Psychologists’ Desk

Reference,
Second Edition

Gerald P. Koocher
John C. Norcross
Sam S. Hill III,
Editors

OXFORD UNIVERSITY PRESS

PSYCHOLOGISTS’ DESK REFERENCE
This page intentionally left blank
PSYCHOLOGISTS’
DESK REFERENCE
Second Edition
Editors
Gerald P. Koocher
John C. Norcross
Sam S. Hill III

1
2005
 1
Oxford New York
Auckland Bangkok Buenos Aires Cape Town Chennai
Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata
Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi
São Paulo Shanghai Taipei Tokyo Toronto

Copyright © 2005 by Gerald P. Koocher and John C. Norcross

First edition © 1998 by Gerald P. Koocher, John C. Norcross, and Sam S. Hill III
Published by Oxford University Press, Inc.
198 Madison Avenue, New York, New York 10016
www.oup.com
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.

Library of Congress Cataloging-in-Publication Data

Psychologists’ desk reference / editors, Gerald P. Koocher,
John C. Norcross, Sam S. Hill, III.—2nd ed.
p. cm.
Includes bibliographical references and index.
ISBN 0-19-516606-X
1. Clinical psychology—Handbooks, manuals, etc. I. Koocher, Gerald P.
II. Norcross, John C., 1957 – III. Hill, Sam S.
RC467.2.P78 2004
616.89—dc22 2004046937

1 3 5 7 9 8 6 4 2
Printed in the United States of America
on acid-free paper
We dedicate this volume to
Robin C. Koocher
Nancy A. Caldwell
and
Betty Ann Pratt Hill
This page intentionally left blank
 PREFACE

The Psychologists’ Desk Reference is intended • An accompanying Web site containing hy-
as an authoritative and indispensable companion perlinks, graphics, PowerPoint presentations,
of mental health practitioners of all theoretical illustrations, tables, primary sources, exten-
orientations and professional disciplines. This sive bibliographies, and much more
volume compiles, organizes, and presents key
guides and essential information that clinicians, A brief history of the Psychologists’ Desk
from practicum students to seasoned practition- Reference places our objectives and the revised
ers, want on their desks. It contains diagnostic contents into proper perspective. In 1994, we
codes, test information, report checklists, prac- sent letters to directors of psychology training
tice guidelines, treatment principles, ethics re- programs requesting their thoughts on the con-
freshers, legal regulations, special-population tents of such a desk reference. In 1995, we sur-
materials, professional resources, practice man- veyed members of the American Psychological
agement tips, and related data that all clinicians Association’s (APA) Division of Clinical Psy-
need at their fingertips. chology. Over 500 practicing psychologists re-
When asked what the Psychologists’ Desk sponded to the question, “All clinicians seem to
Reference includes, we reply, “Everything es- have a file in which they place useful checklists,
sential but the tissue box.” When asked who guidelines, and summaries. If you had such a
should purchase it, we reply, “Every clinician.” collection at your desk, what topics would you
This new edition features: want in it?” In addition to providing hundreds
of nominations and a healthy consensus on the
• Thoroughly revised chapters by the field’s contents, the vast majority agreed that a Psy-
leaders chologists’ Desk Reference would be both a
• 29 new chapters, now totaling 140 very practical and a very popular manual for the
• Elimination of 14 chapters that readers practicing clinician. In 1996 and 1997, we in-
deemed dated or of too-limited utility ventoried the desk contents of several colleagues
• Sections reorganized into smaller and more and interviewed dozens of practitioners regard-
specific chunks, making topics easier to find ing their preferences for a functional desk refer-
• A listing of valuable Internet sites in many ence. In sum, the project began with an ambi-
chapters tious idea, was sharpened by program directors’
• Increased emphasis on evidence-based prac- responses, was strengthened by nominations of
tices (broadly defined) clinical psychologists across the nation, and was
viii preface

shaped by field observation and collegial feed- We also present a computer icon in the text—
back. in the table of contents and again at the ends of
This second edition continues the years of individual chapters (typically next to the “Ref-
sequential research and development. The final erences” heading)— to indicate that additional
page of the first edition of the Psychologists’ relevant material is available on the Psycholo-
Desk Reference cordially invited readers to in- gists’ Desk Reference Web site. This material
form us of what they would like to be included may include detailed strategies, forms, figures,
in future editions. Many excellent ideas were practice guidelines, or items useful in making
offered in response. Published reviews of the presentations on topics germane to the material
first edition and five reviewers secured by Ox- in the particular chapter noted. The Web site can
ford University Press further helped to sharpen be accessed at www.oup.com/us/psychdeskref,
our focus. And if imitation is indeed the sincer- and the in-text icon appears as follows:

est form of flattery, then we are flattered that This volume is the culmination of lengthy
the Psychologists’ Desk Reference has spawned labors and multitudinous contributions; in the
several imitators; not nearly as good as this best sense of the term, it has been a “group ef-
volume, but imitators nonetheless. fort.” Although we are, of course, ultimately
The positive reception to the first edition responsible for the book, we genuinely hope
convinced us to vigorously maintain our origi- that the second edition of the Psychologists’
nal emphasis on a compact and user-friendly Desk Reference does justice to all those who
resource. In the words of one reviewer, “The have assisted us.
coverage is broad but not superficial; it is com- From its inception, Joan Bossert, editor ex-
prehensive yet focused.” As a consequence, all traordinaire at Oxford University Press, nur-
140 contributions are concisely written, designed tured the book. In selecting the contents, direc-
as summaries or thumbnail guides. We chose tors of training programs, members of APA’s
only authors who possessed special expertise in Division of Clinical Psychology, dozens of col-
particular subject areas and who manifested an leagues, and the editorial board of Oxford Text-
ability to synthesize the material in 10 manu- books in Clinical Psychology provided invalu-
script pages or less. The text is a combination of able assistance. We appreciate the affirming
narrative text, numbered or bulleted points, evaluations and constructive suggestions of the
tables, and checklists. The chapter titles are reviewers of the previous edition, as we do the
succinct and descriptive; subtitles were largely nine colleagues who recommended new chap-
abandoned. The references accompanying each ters that appear in this edition. More than 150
contribution are not intended as an exhaustive authors participated generously and adhered to
listing but, rather, as documentation of key a challenging writing format. These authors
sources and recommendations for additional represent, in the words of another reviewer, “a
reading. veritable Who’s Who in psychology.” Not to be
The format of the Psychologists’ Desk Refer- outdone, our spouses and children endured our
ence contributes to its ease of use. These entail: absences and preoccupations with grace. Fi-
nally, we acknowledge each other for the col-
• A detailed table of contents laborative spirit and the interpersonal pleasures
• A coherent organization into 11 parts, in of coediting this volume. Both the process and
which the chapters are arranged both chrono- the product have improved over the years.
logically (according to how a treatment or a
consultation would proceed) and topically Gerald P. Koocher, Ph.D.
• Running heads that identify the part number Chestnut Hill, Massachusetts
and title on the left-hand page and the chap-
ter number and title on the right-hand page John C. Norcross, Ph.D.
• Cross-references within contributions to re- Clarks Summit, Pennsylvania
lated chapters in the book
• A comprehensive index at the end of the Sam S. Hill III, Psy.D.
book Corpus Christi, Texas
 CONTENTS

1 Contributors xvii 6 Developmental Neuropsychological

Assessment 28
PART I: ASSESSMENT AND DIAGNOSIS jane holmes bernstein,
betsy kammerer, penny a. prather,
1 Lifetime Prevalence of Mental Disorders in & celiane rey-casserly
the General Population 3
christie p. karpiak & 7 Adult Neuropsychological Assessment
john c. norcross 33
aaron p. nelson &
2 Mental Status Examination 7 margaret o’connor
robert w. baker &
paula t. trzepacz 8 Assessment and Intervention for
Executive Dysfunction 38
3 Improving Diagnostic and Clinical robert m. roth,
Interviewing 13 peter k. isquith, &
rhonda s. karg & gerard a. gioia
arthur n. wiens
9 Child and Adolescent Diagnosis With
4 The Multimodal Life History Inventory DSM-IV 41
16 stuart m. goldman
arnold a. lazarus &
clifford n. lazarus 10 Formulating Diagnostic Impressions
With Ethnic and Racial Minority
5 Increasing the Accuracy of Clinical Children Using the DSM-IV-TR 45
Judgment (and Thereby Treatment ronn johnson
Effectiveness) 23
david faust 11 Medical Evaluation of Children With
Behavioral or Developmental Disorders
50
james l. lukefahr
x contents

12 Interviewing Parents 55 23 Publishers of Psychological and

carolyn s. schroeder & Psychoeducational Tests 108
betty n. gordon thomas p. hogan

13 Attention-Deficit/Hyperactivity Disorder 24 Types of Test Scores and Their Percentile

Through the Life Span 60 Equivalents 111
robert j. resnick thomas p. hogan

14 Assessment of Suicidal Risk 63 25 Assessing the Quality of a Psychological

kenneth s. pope & Testing Report 117
melba j. t. vasquez gerald p. koocher

15 Assessment of Malingering on 26 Child Behavior Observations 119

Psychological Measures 67 janice ware
richard rogers
27 Measures of Children’s Psychological
16 Identification and Assessment of Alcohol Development 124
Abuse 71 sam s. hill iii
linda carter sobell &
mark b. sobell 28 Assessing MMPI-2 Profile Validity 128
james n. butcher
17 Measures of Acculturation 77
juan carlos gonzalez 29 Clinical Scales of the MMPI-2 132
john r. graham
18 DSM-IV-TR Classification System 80
american psychiatric 30 Supplementary Scales of the MMPI-2
association 137
roger l. greene
19 A Practical Guide for the Use of the
Global Assessment of Functioning (GAF) 31 Characteristics of High and Low Scores
Scale of the DSM-IV-TR 91 on the MMPI-2 Clinical Scales 141
american psychiatric john r. graham
association
32 Empirical Interpretation of the MMPI-2
20 Assessment of Character Strengths 93 Codetypes 149
christopher peterson, james n. butcher
nansook park, &
martin e. p. seligman 33 Millon Clinical Multiaxial Inventory
(MCMI-III) 153
theodore millon &
seth d. grossman
PART II: PSYCHOLOGICAL TESTING
34 Millon Adolescent Clinical Inventory
21 50 Widely Used Psychological Tests (MACI) 159
101 theodore millon &
thomas p. hogan seth d. grossman

22 Sources of Information About 35 Thumbnail Guide to the Rorschach

Psychological Tests 105 Method 166
thomas p. hogan barry a. ritzler
 contents xi

36 Rorschach Assessment: Questions and 46 Stages of Change: Prescriptive Guidelines

Reservations 169 226
howard n. garb, james o. prochaska,
james m. wood, & john c. norcross, &
scott o. lilienfeld carlo c. diclemente

37 Rorschach Assessment: Scientific Status 47 Psychotherapy Treatment Plan Writing

and Clinical Utility 173 232
irving b. weiner arthur e. jongsma, jr.

48 Key Principles in the Assessment of

PART III: INDIVIDUAL PSYCHOTHERAPY Psychotherapy Outcome 236
AND TREATMENT michael j. lambert,
bruce w. jasper, &
38 Patients’ Rights in Psychotherapy 181 joanne white
dorothy w. cantor
49 Treatment and Management of the
39 Compendium of Empirically Supported Suicidal Patient 240
Therapies 183 bruce bongar &
dianne l. chambless glenn r. sullivan

40 Compendium of Psychotherapy 50 Crisis Intervention 245

Treatment Manuals 192 kenneth france
michael j. lambert,
51 Impact of Disasters 249
taige bybee, ryan houston,
eric m. vernberg &
matthew bishop,
r. enrique varela
a. danielle sanders,
ron wilkinson, & sara rice
52 Principles in the Treatment of Borderline
Personality Disorder 255
41 Compendium of Empirically Supported
john f. clarkin &
Therapy Relationships 202
pamela a. foelsch
john c. norcross &
clara e. hill 53 Psychotherapy With Reluctant and
Involuntary Clients 257
42 Enhancing Adherence 208 stanley l. brodsky
m. robin dimatteo
54 Treatment Matching in Substance Abuse
43 Methods to Reduce and Counter 263
Resistance in Psychotherapy 212 carlo c. diclemente
albert ellis
55 Motivational Interviewing 267
44 Repairing Ruptures in the Therapeutic william r. miller &
Alliance 216 theresa b. moyers
jeremy d. safran
56 Anxiety/Anger Management Training 271
45 Systematic Assessment and Treatment richard m. suinn
Matching 220
oliver b. williams, 57 Psychological Interventions in Adult
larry e. beutler, & Disease Management 274
kathryn yanick carol d. goodheart
xii contents

58 Assessing and Treating Normative Male 69 Parent Management Training for

Alexithymia 278 Childhood Behavior Disorders 327
ronald f. levant laura j. schoenfield &
sheila m. eyberg
59 Assessing and Treating Male Sexual
Dysfunction 282 70 Hypnosis and Relaxation Scripting 332
joseph lopiccolo & douglas flemons
lynn m. van male
71 Working With the Religiously
60 Assessing and Treating Female Sexual Committed Client 338
Dysfunction 286 p. scott richards &
joseph lopiccolo & kari a. o’grady
lynn m. van male
72 Psychotherapy With Cognitively
61 Assessing and Reducing Risk of Infection Impaired Adults 342
With the Human Immunodeficiency kathleen b. kortte,
Virus 291 felicia hill-briggs, &
michael p. carey stephen t. wegener

62 Guidelines for Treating Women in 73 Early Termination and Referral of Clients

Psychotherapy 295 in Psychotherapy 346
laura s. brown & manferd d. koch
felicia a. mueller
74 Guidelines for Relapse Prevention 350
63 Assessment and Treatment of Lesbians, katie witkiewitz &
Gay Men, and Bisexuals 299 g. alan marlatt
robin a. buhrke &
douglas c. haldeman 75 Guidelines for Terminating
Psychotherapy 354
64 Psychotherapy With Older Adults 305 oren m. shefet &
margaret gatz & rebecca c. curtis
bob g. knight

65 Refusal Skills Training 308 PART IV: COUPLES, FAMILY, AND GROUP
robert h. woody & TREATMENT
jennifer k. h. woody
76 Choice of Treatment Format 363
66 Sexual Feelings, Actions, and Dilemmas john f. clarkin
in Psychotherapy 313
kenneth s. pope 77 Genograms in Assessment and Therapy
366
67 Six Steps to Improve Psychotherapy sueli s. petry &
Homework Compliance 319 monica mcgoldrick
michael a. tompkins
78 Guidelines for Conducting Couple and
68 Stimulus Control Instructions for the Family Therapy 373
Treatment of Insomnia 325 jay l. lebow
richard r. bootzin
79 Treating High-Conflict Couples 378
susan heitler
 contents xiii

80 Treatment of Marital Infidelity 384 90 Use of Height and Weight Assessment

don-david lusterman Tools 445
nancie h. herbold &
81 Group Psychotherapy: An Interpersonal sari edelstein
Approach 388
victor j. yalom 91 Medical Conditions That May Present as
Psychological Disorders 447
82 Psychoeducational Group Treatment william j. reed
393
gary m. burlingame & 92 Adult Psychopharmacology 1:
nathanael w. ridge Common Usage 454
joseph k. belanoff,
charles debattista, &
PART V: CHILD AND ADOLESCENT alan f. schatzberg
TREATMENT
93 Adult Psychopharmacology 2: Side
83 Principles of Treatment With the Effects and Warnings 460
Behaviorally Disordered Child 401 elaine orabona mantell
esther j. calzada,
arwa aamiry, & 94 Pediatric Psychopharmacology 466
sheila m. eyberg timothy e. wilens,
thomas j. spencer, &
84 Psychological Interventions in Childhood joseph biederman
Chronic Illness 406
robert j. thompson, jr. & 95 Dietary Supplements and Psychological
kathryn e. gustafson Functioning 476
sari edelstein &
85 Methods to Engage the Reluctant nancie h. herbold
Adolescent 410
alice k. rubenstein 96 Common Drugs of Abuse 481
christopher j. correia &
86 The APSAC Study Guides 416 james g. murphy
jeannie baker & sam s. hill iii

87 Interviewing Children When Sexual PART VII: SELF-HELP RESOURCES

Abuse Is Suspected 423
karen j. saywitz & 97 Top Internet Sites for Psychologists and
joyce s. dorado Their Clients 491
john m. grohol
88 Treatment of Child Sexual Abuse 430
kathryn kuehnle 98 Highly Rated Self-Help Books and
Autobiographies 494
john c. norcross &
PART VI: BIOLOGY AND jennifer a. simansky
PHARMACOTHERAPY
99 Popular Films Portraying Mental
89 Normal Medical Laboratory Values and Disorders 497
Measurement Conversions 439 danny wedding
gerald p. koocher &
samuel z. goldhaber
xiv contents

100 Facilitating Client Involvement in 111 Glossary of Legal Terms of Special

Self-Help Groups 502 Interest in Mental Health Practice 572
elena klaw & gerald p. koocher
keith humphreys
112 Fifteen Hints on Money Matters and
101 National Self-Help Groups and Related Ethical Issues 577
Organizations 506 gerald p. koocher &
dennis e. reidy & sam s. hill iii
john c. norcross
113 How to Confront an Unethical
102 Known and Unproven Herbal Colleague 579
Treatments for Psychological patricia keith-spiegel
Disorders 517
paula j. biedenharn 114 Confidentiality and the Duty to Protect
584
tiffany chenneville
PART VIII: ETHICAL AND LEGAL ISSUES

103 Ethical Principles of Psychologists and PART IX: FORENSIC MATTERS

Code of Conduct (2002) 525
american psychological 115 Forensic Evaluations and Testimony
association 591
stanley l. brodsky
104 Privacy, Confidentiality, and Privilege
545 116 Forensic Evaluation Outline 593
gerald p. koocher david l. shapiro

105 Involuntary Psychiatric Hospitalization 117 Forensic Referrals Checklist 595

(Civil Commitment): Adult and Child geoffrey r. mckee
548
stuart a. anfang & 118 Expert Testimony in Depositions 599
paul s. appelbaum geoffrey r. mckee

106 Physical Restraint and Seclusion: 119 Forensic Assessment Instruments 603
Regulations and Standards 553 randy borum
thomas p. graf
120 Evaluation of Competency to Stand
107 Basic Principles for Dealing With Legal Trial 607
Liability Risk Situations 558 paul d. lipsitt
gerald p. koocher
121 A Model for Clinical Decision Making
108 Defending Against Legal Complaints With Dangerous Patients 612
560 leon vandecreek
robert h. woody
122 Principles for Conducting a
109 Dealing With Licensing Board and Comprehensive Child Custody
Ethics Complaints 566 Evaluation 615
gerald p. koocher & barry bricklin
patricia keith-spiegel
123 Recognizing, Assisting, and Reporting
110 Dealing With Subpoenas 570 the Impaired Psychologist 620
gerald p. koocher gary r. schoener
 contents XV

124 Essential Features of Professional 134 Establishing a Consultation Agreement

Liability Insurance 625 666
bruce e. bennett len sperry

135 Computerized Billing and Office

PART X: PRACTICE MANAGEMENT Management Programs 670
edward l. zuckerman
125 Sample Psychotherapist-Patient
Contract 635
eric a. harris & PART XI: PROFESSIONAL RESOURCES
bruce e. bennett
136 Therapist Self-Care Checklist 677
126 Fundamentals of the HIPAA Privacy john c. norcross &
Rule 640 james d. guy, jr.
jason m. bennett
137 Conducting Effective Clinical
127 Basic Elements of Consent 645 Supervision 682
gerald p. koocher nicholas ladany

128 Basic Elements of Release Forms 647 138 Guide to Interacting With the Media
gerald p. koocher 686
lilli friedland &
129 Prototype Mental Health Records 649 florence w. kaslow
gerald p. koocher
139 Common Clinical Abbreviations and
130 Utilization Review Checklist 652 Symbols 691
gerald p. koocher john c. norcross

131 Contracting With Managed Care 140 Major Professional Associations 697
Organizations 653
stuart l. koman & john c. norcross
eric a. harris
Index 701
132 Billing Issues 657
gerald p. koocher What Do You Want in the Next Edition?
735
133 Psychologists’ Fees and Incomes 662
john c. norcross
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 CONTRIBUTORS

Gerald P. Koocher, Ph.D., is Professor and Dean of versity Press), Authoritative Guide to Self-Help
the School for Health Studies at Simmons College in Resources in Mental Health, the fifth edition of Sys-
Boston. He also serves as a lecturer on the faculties tems of Psychotherapy: A Transtheoretical Analysis,
of Boston College and Harvard Medical School. A and the Insider’s Guide to Graduate Programs in
diplomate of the American Board of Professional Clinical and Counseling Psychology. He is president
Psychology in clinical, clinical child and adolescent of the International Society of Clinical Psychology,
health, family, and forensic psychology, Dr. Koocher past president of the APA Division of Psychotherapy,
is former editor of the Journal of Pediatric Psychol- Council Representative of the APA, and a director of
ogy and The Clinical Psychologist. He serves on the the National Register of Health Service Providers in
editorial boards of several scholarly journals and Psychology. Dr. Norcross has also received numerous
currently edits the journal Ethics & Behavior. A past awards, including the Pennsylvania Professor of the
president of the Massachusetts and New England Year from the Carnegie Foundation, the Rosalee Weiss
Psychological Associations as well as three divisions Award from the American Psychological Foundation,
of the American Psychological Association (APA), he and election to the National Academies of Practice.
is currently a member of the Board of Directors and John lives in northeastern Pennsylvania with his
Treasurer of the APA. Dr. Koocher is the author or wife, two children, and deranged cat.
coauthor of more than 160 articles and chapters, in
addition to nine books. His text (with Patricia Keith- Sam S. Hill III, Psy.D., is associate professor of psy-
Spiegel) Ethics in Psychology: Professional Stan- chology at Texas A&M University–Corpus Christi
dards and Cases is the best-selling textbook in its and a clinical psychologist in part-time practice of pe-
field. He has won research grant support from fed- diatric psychology at the Driscoll Children’s Hospital
eral and foundation sources totaling more than $3 in Corpus Christi, where he is associate director of
million. Gerry lives in Chestnut Hill, Massachu- medical education for psychology. Dr. Hill conducts
setts, with his wife, daughter, and an assortment of and reviews research on the psychological aspects of
vociferous psittacines. pediatric cancer and other chronic illnesses. He is an
analytic candidate of the Interregional Society of Jun-
John C. Norcross, Ph.D., is professor of psychology gian Analysts. He is director of the Division for the
at the University of Scranton, editor of In Session: Psychological Study of Diverse Populations of the
Journal of Clinical Psychology, and a clinical psy- Texas Psychological Association, and is a former chair
chologist in part-time independent practice. Author of the Multicultural Affairs Committee of the APA’s
of more than 150 scholarly publications, Dr. Norcross Division of Psychotherapy. Sam lives in Corpus
has cowritten or edited 12 books, most recently Psy- Christi with his wife and their best friends Schatzie,
chotherapy Relationships That Work (Oxford Uni- Gus, and Pippin— the family dachshunds.

xvii
xviii contributors

Arwa Aamiry, Ph.D. Chief of Pediatric Psychopharmacology,

Pediatric Child Clinical Psychologist Massachusetts General Hospital, Boston, MA
Faculty of Arts and Sciences, American University
Matthew Bishop, B.S.
of Beirut, Lebanon
Department of Psychology, Brigham Young
Stuart A. Anfang, M.D. University, Provo, UT
Western Massachusetts Area Medical Director,
Bruce Bongar, Ph.D., ABPP, FAPM
Massachusetts Department of Mental Health
Pacific Graduate School of Psychology–Stanford
Assistant Professor of Psychiatry, University of
Psy.D. Consortium, Palo Alto, CA
Massachusetts Medical School, Worcester, MA
Department of Psychiatry and Behavioral Services,
Paul S. Appelbaum, M.D. Stanford University School of Medicine,
A. F. Zeleznik Distinguished Professor of Stanford, CA
Psychiatry and Chair, Department of Psychiatry,
Richard R. Bootzin, Ph.D.
University of Massachusetts Medical School,
Professor of Psychology, Department of
Worcester, MA
Psychology, University of Arizona
Jeannie Baker, M.A. Director, Insomnia Clinic, University of Arizona
Licensed Psychological Associate, Licensed Sleep Disorders Center
Specialist in School Psychology, Driscoll
Children’s Hospital, Corpus Christi, TX Randy Borum, Psy.D.
Associate Professor, Department of Mental Health
Robert W. Baker, M.D. Law and Policy, University of South Florida,
Associate Director, U.S. Neurosciences, Eli Lilly Tampa, FL
and Company
Clinical Associate Professor of Psychiatry and Barry Bricklin, Ph.D.
Pharmacology, University of Mississippi Medical President, Bricklin Associates, Wayne, PA
School, Jackson, MS Adjunct Associate Professor, Widener University,
Chester, PA
Joseph K. Belanoff, M.D.
Chief Executive Officer, Corcept Therapeutics, Stanley L. Brodsky, Ph.D.
Menlo Park, CA Professor, Department of Psychology, University of
Alabama, Tuscaloosa, AL
Bruce E. Bennett, Ph.D.
Chief Executive Officer, American Psychological Laura S. Brown, Ph.D., ABPP
Association Insurance Trust, Washington, DC Professor, Washington School of Professional
Psychology at Argosy University, Seattle,
Jason M. Bennett, J.D. WA
American Psychological Association Insurance
Trust, Washington, DC Robin A. Buhrke, Ph.D.
Staff Psychologist, Counseling and Psychological
Jane Holmes Bernstein, Ph.D. Services, and Assistant Clinical Professor in
Director, Neuropsychology Program, Children’s Psychiatry and Behavioral Sciences, Duke
Hospital, Boston, MA University, Durham, NC
Associate Clinical Professor, Harvard Medical
School, Boston, MA Gary M. Burlingame, Ph.D.
Professor of Psychology, Brigham Young
Larry E. Beutler, Ph.D., ABPP University, Provo, UT
William McInnes, SJ, Distinguished Professor of
Psychology, Pacific Graduate School of James N. Butcher, Ph.D.
Psychology, Palo Alto, CA Professor of Psychology, University of Minnesota,
Consulting Professor of Psychiatry, Stanford Minneapolis, MN
University School of Medicine, Stanford, CA
Taige Bybee, B.S.
Paula J. Biedenharn, Ph.D. Department of Psychology, Brigham Young
Department of Psychology, Texas A&M University, Provo, UT
University, Corpus Christi, TX
Esther J. Calzada, Ph.D.
Joseph Biederman, M.D. Assistant Professor of Psychiatry, Child Study
Professor of Psychiatry, Harvard Medical School, Center, New York University School of
Boston, MA Medicine, New York, NY
 contributors xix

Dorothy W. Cantor, Psy.D. Sheila M. Eyberg, Ph.D., ABPP

Independent practice, Westfield, NJ Professor of Clinical and Health Psychology,
University of Florida, Gainesville, FL
Michael P. Carey, Ph.D.
Professor or Psychology and Director, Center for David Faust, Ph.D.
Health and Behavior, Syracuse University, Professor of Psychology, University of Rhode
Syracuse, NY Island, Kingston, RI
Adjunct Professor of Medicine, Upstate Medical
Douglas Flemons, Ph.D.
University (Syracuse) and University of
Professor of Family Therapy and Director of the
Rochester School of Medicine and Dentistry
Brief Therapy Institute, Nova Southeastern
Dianne L. Chambless, Ph.D. University, Fort Lauderdale, FL
Merriam Term Professor of Psychology,
Pamela A. Foelsch, Ph.D.
Department of Psychology, University of
Weill Medical College of Cornell University,
Pennsylvania, Philadelphia, PA
White Plains, NY
Tiffany Chenneville, Ph.D. Adjunct Assistant Professor, Smith College School
Pinellas County Schools, St. Petersburg, FL of Social Work, Northampton, MA
Independent practice, St. Petersburg, FL
Kenneth France, Ph.D.
John F. Clarkin, Ph.D. Professor of Psychology, Shippensburg University,
Professor of Clinical Psychology in Psychiatry, Shippensburg, PA
Weill Medical College of Cornell University and Lead Online Mentor, New Hope Crisis Counseling
New York Presbyterian Hospital, New York, NY Center
Christopher J. Correia, Ph.D. Lilli Friedland, Ph.D., ABPP
Assistant Professor of Psychology, Auburn President, Executive Advisors, Los Angeles, CA
University, Auburn, AL
Howard N. Garb, Ph.D.
Rebecca C. Curtis, Ph.D. Chief, Psychology Research Service, Wilford Hall
Professor, Gordon F. Derner Institute, Adelphi Medical Center, Lackland Air Force Base, San
University, Garden City, NY Antonio, TX
William Alanson White Institute of Psychiatry,
Margaret Gatz, Ph.D.
Psychology, and Psychoanalysis, New York,
Professor of Psychology, University of Southern
NY
California, Los Angeles, CA
Charles DeBattista, M.D.
Gerard A. Gioia, Ph.D.
Associate Professor of Psychiatry, Stanford
Pediatric Neurology Program, Children’s National
University, Stanford, CA
Medical Center, Washington, DC
Carlo C. DiClemente, Ph.D. Associate Professor, Departments of Pediatrics and
Professor and Chair, Department of Psychology, Psychiatry, George Washington University
University of Maryland, Baltimore County, School of Medicine, Washington, DC
Baltimore, MD
Samuel Z. Goldhaber, M.D.
M. Robin DiMatteo, Ph.D. Staff Cardiologist, Brigham and Women’s Hospital,
Professor of Psychology, University of California, Boston, MA
Riverside, CA Associate Professor of Medicine, Harvard Medical
School, Boston, MA
Joyce S. Dorado, Ph.D.
Co-Director of Clinical Training, Department of Stuart M. Goldman, M.D.
Psychiatry, University of California, San Director, Affective Disorders Clinic, Children’s
Francisco/San Francisco General Hospital, San Hospital, Boston, MA
Francisco, CA Assistant Professor of Psychiatry, Harvard Medical
School, Boston, MA
Sari Edelstein, Ph.D., R.D.
Registered Dietitian and Assistant Professor of Juan Carlos Gonzalez, Ph.D.
Nutrition, Simmons College, Boston, MA Children’s Psychiatric Center, Miami, FL
Albert Ellis, Ph.D. Carol D. Goodheart, Ed.D.
President, Albert Ellis Institute, New York, NY Independent practice, Princeton, NJ
xx contributors

Betty N. Gordon, Ph.D. Ryan Houston, B.S.

Associate Professor Emerita, University of North Department of Psychology, Brigham Young
Carolina at Chapel Hill, Chapel Hill, NC University, Provo, UT
Thomas P. Graf, Ph.D Keith Humphreys, Ph.D.
Driscoll Children’s Hospital, Corpus Christi, TX Associate Professor of Psychiatry, Stanford
University, Stanford, CA
John R. Graham, Ph.D.
Director, Veterans Affairs Program Evaluation and
Professor of Psychology, Kent State University,
Resource Center, Menlo Park, CA
Kent, OH
Peter K. Isquith, Ph.D.
Roger L. Greene, Ph.D.
Pediatric Neuropsychology, Department of
Professor of Psychology, Pacific Graduate School of
Psychiatry, Dartmouth Medical School
Psychology, Palo Alto, CA
Bruce W. Jasper, B.S.
John M. Grohol, Psy.D. Department of Psychology, Brigham Young
International Society for Mental Health Online, University, Provo, UT
PsychCentral.com
Ronn Johnson, Ph.D.
Seth D. Grossman, Psy.D. Child and Adolescent Services Research Center,
Institute for Advanced Studies on Personology and Children’s Hospital, San Diego, CA
Psychopathology, Coral Gables, FL
Arthur E. Jongsma, Jr., Ph.D.
James D. Guy, Jr., Ph.D. Psychological Consultants, Grand Rapids, MI
Headington Institute, Pasadena, CA
Betsy Kammerer, Ph.D.
Kathryn E. Gustafson, Ph.D. Children’s Hospital, Boston, MA
Assistant Professor of Medical Psychology, Duke Harvard Medical School, Boston, MA
University, Durham, NC
Rhonda S. Karg, Ph.D.
Douglas C. Haldeman, Ph.D. Research Triangle Institute, Research Triangle
University of Washington, Seattle, WA Park, NC
Independent practice, Seattle, WA
Christie P. Karpiak, Ph.D.
Eric A. Harris, J.D., Ed.D. Department of Psychology, University of Scranton,
Risk Management Consultant, American Scranton, PA
Psychological Association Insurance Trust,
Washington, DC Florence W. Kaslow, Ph.D., ABPP
Legal Counsel, Massachusetts Psychological Director, Florida Couples and Family Institute,
Association, Wellesley, MA West Palm Beach, FL
Visiting Professor of Medical Psychology, Duke
Susan Heitler, Ph.D. University Medical School, Durham, NC
Independent practice, Denver, CO
Patricia Keith-Spiegel, Ph.D.
Nancie H. Herbold, Ed.D., R.D., L.D.N. Professor of Psychology Emerita, Ball State
Registered Dietitian and Ruby Winslow Linn University, Muncie, IN
Professor of Nutrition, Simmons College, Visiting Professor of Psychology, Harvard Medical
Boston, MA School, Boston, MA
Clara E. Hill, Ph.D. Elena Klaw, Ph.D.
Professor of Psychology, University of Maryland, Department of Psychology, San José State
College Park, MD University, San Jose, CA
Felicia Hill-Briggs, Ph.D. Bob G. Knight, Ph.D.
Department of Physical Medicine and Merle H. Bensinger Professor of Gerontology, Professor
Rehabilitation, Johns Hopkins University School of Psychology and Director of Clinical Training,
of Medicine, Baltimore, MD University of Southern California, Los Angeles, CA
Thomas P. Hogan, Ph.D. Manferd D. Koch, Ph.D.
Professor of Psychology, University of Scranton, Department of Psychology, Texas A&M
Scranton, PA University, Corpus Christi, TX
 contributors xxi

Stuart L. Koman, Ph.D. Elaine Orabona Mantell, Ph.D.

Koman Associates, Winchester, MA Prescribing Psychologist, Lt. Colonel, United
States Air Force
Kathleen B. Kortte, Ph.D.
Neuropsychology Service, National Rehabilitation G. Alan Marlatt, Ph.D.
Hospital, Washington, DC Addictive Behaviors Research Center, University
of Washington, Seattle, WA
Kathryn Kuehnle, Ph.D.
Assistant Professor, University of South Monica McGoldrick, M.S.W.
Florida, Florida Mental Health Institute The Multicultural Family Institute, Highland Park,
Department of Mental Health Law and Policy, NJ
Tampa, FL
Geoffrey R. McKee, Ph.D., ABPP
Independent practice, Tampa, FL
University of South Carolina School of Medicine,
Nicholas Ladany, Ph.D. Columbia, SC
Department of Psychology, Lehigh University,
William R. Miller, Ph.D.
Bethlehem, PA
Center on Alcoholism, Substance Abuse, and
Michael J. Lambert, Ph.D. Addictions, University of New Mexico,
Professor of Psychology, Brigham Young Albuquerque, NM
University, Provo, UT
Theodore Millon, Ph.D., D.Sc.
Arnold A. Lazarus, Ph.D., ABPP Institute for Advanced Studies on Personology and
Professor Emeritus of Psychology, Rutgers Psychopathology, Coral Gables, FL
University
Theresa B. Moyers, Ph.D.
President, Center for Multimodal Psychological
Center on Alcoholism, Substance Abuse, and
Services, Princeton, NJ
Addictions, University of New Mexico,
Clifford N. Lazarus, Ph.D. Albuquerque, NM
Director, Comprehensive Psychological Services,
Felicia A. Mueller, B.A.
Princeton, NJ
Washington School of Professional Psychology at
Jay L. Lebow, Ph.D., ABPP Argosy University, Seattle, WA
Family Institute at Northwestern and Adjunct
James G. Murphy, M.S.
Associate Professor, Northwestern University,
Brown Center for Alcohol and Addiction Studies,
Evanston, IL
Auburn University, Auburn, AL
Ronald F. Levant, Ed.D., ABPP
Aaron P. Nelson, Ph.D., ABPP
Dean, Center for Psychological Studies, Nova
Chief of Neuropsychology, Brigham and Women’s
Southeastern University, Fort Lauderdale, FL
Hospital, Boston, MA
Scott O. Lilienfeld, Ph.D. Instructor in Psychology, Harvard Medical School,
Associate Professor, Department of Psychology, Boston, MA
Emory University, Atlanta, GA
Margaret O’Connor, Ph.D.
Paul D. Lipsitt, LL.B., Ph.D. Division of Behavioral Neurology, Beth
Student Health Service, Boston University, Boston, Israel Deaconess Medical Center, Boston,
MA MA
Harvard Medical School, Boston, MA
Joseph LoPiccolo, Ph.D.
Professor of Psychology, University of Missouri, Kari A. O’Grady, B.S.
Columbia, MO Department of Psychology, Brigham Young
Director of Psychological Services, Sexual University, Provo, UT
Medicine Center of Missouri, Columbia, MO
Nansook Park, Ph.D.
James L. Lukefahr, M.D. Department of Psychology, University of Rhode
Professor of Pediatrics, University of Texas Medical Island, Kingston, RI
Branch, Galveston, TX
Christopher Peterson, Ph.D.
Don-David Lusterman, Ph.D., ABPP Professor of Psychology, University of Michigan,
Independent practice, Baldwin, NY Ann Arbor, MI
xxii contributors

Sueli S. Petry, M.A., Ed.S. Alice K. Rubenstein, Ed.D.

The Multicultural Family Institute, Highland Park, Monroe Psychotherapy and Consultation Center,
NJ Pittsford, NY
Seton Hall University, South Orange, NJ
Jeremy D. Safran, Ph.D.
Kenneth S. Pope, Ph.D., ABPP Professor, Department of Psychology, New School
Independent practice, Norwalk, CT University, New York, NY
Penny A. Prather, Ph.D. A. Danielle Sanders, B.S.
Educational Enhancement Center, Newton Center, Department of Psychology, Brigham Young
MA University, Provo, UT
Harvard Medical School, Boston, MA
Karen J. Saywitz, Ph.D.
James O. Prochaska, Ph.D. Professor, UCLA School of Medicine, Division of
Professor of Psychology, University of Rhode Child and Adolescent Psychiatry, Los Angeles,
Island, Kingston, RI CA

William J. Reed, M.D., F.A.A.P Alan F. Schatzberg, M.D.

Associate Professor of Pediatrics, Texas Kenneth T. Norris, Jr., Professor and Chairman,
A&M College of Medicine, Corpus Christi, Department of Psychiatry and Behavioral
TX Sciences, Stanford University Medical School,
Clinical Assistant Professor of Pediatrics, Stanford, CA
University of Texas Medical Branch Gary R. Schoener, B.A.
Adjunct Professor of Psychology, Texas A&M Walk-in Counseling Center, Minneapolis, MN
University, Corpus Christi, TX
Laura J. Schoenfield, B.A.
Dennis E. Reidy, B.S. Department of Clinical and Health Psychology,
Department of Psychology, University of Scranton, University of Florida, Gainesville, FL
Scranton, PA
Carolyn S. Schroeder, Ph.D.
Robert J. Resnick, Ph.D., ABPP Adjunct Professor, Clinical Child Psychology
Professor of Psychology, Randolph-Macon College, Program, University of Kansas, Lawrence, KS
Ashland, VA
Martin E. P. Seligman, Ph.D.
Celiane Rey-Casserly, Ph.D., ABPP Fox Professor of Psychology and Director, Positive
Children’s Hospital, Boston, MA Psychology Center, University of Pennsylvania,
Harvard Medical School, Boston, MA Philadelphia, PA
Sara Rice, B.S. David L. Shapiro, Ph.D.
Department of Psychology, Brigham Young Nova Southeastern University, Fort Lauderdale, FL
University, Provo, UT
Oren M. Shefet, M.A.
P. Scott Richards, Ph.D. The Derner Institute of Advanced Psychological
Professor of Counseling Psychology, Brigham Studies, Adelphi University, Garden City, NY
Young University, Provo, UT
Jennifer A. Simansky, B.S.
Nathanael W. Ridge, B.S. University of Scranton, Scranton, PA
Department of Psychology, Brigham Young
Linda Carter Sobell, Ph.D., ABPP
University, Provo, UT
Professor, Center for Psychological Studies, Nova
Barry A. Ritzler, Ph.D., ABPP Southeastern University, Fort Lauderdale, FL
Long Island University and Rorschach Workshops,
Mark B. Sobell, Ph.D., ABPP
Inc., Brooklyn, NY
Professor, Center for Psychological Studies, Nova
Richard Rogers, Ph.D., ABPP Southeastern University, Fort Lauderdale, FL
Professor of Psychology, University of North
Thomas J. Spencer, M.D.
Texas, Denton, TX
Assistant Director, Pediatric Psychopharmacology,
Robert M. Roth, Ph.D. Massachusetts General Hospital, Boston, MA
Neuropsychology and Neuroimaging Program, Assistant Professor, Harvard Medical School,
Dartmouth Medical School, Hanover, NH Boston, MA
 contributors xxiii

Len Sperry, M.D., Ph.D, ABPP Stephen T. Wegener, Ph.D., ABPP

Clinical Professor of Psychiatry and Behavioral Department of Physical Medicine and
Medicine, Medical College of Wisconsin, Rehabilitation, Johns Hopkins University School
Milwaukee, WI of Medicine, Baltimore, MD
Richard M. Suinn, Ph.D., ABPP Irving B. Weiner, Ph.D.
Professor of Psychology Emeritus, Colorado State Professor of Psychology, University of South
University, Fort Collins, CO Florida, Tampa, FL
Glenn R. Sullivan, M.S. Joanne White, B.S.
Pacific Graduate School of Psychology, Palo Alto, CA Department of Psychology, Brigham Young
University, Provo, UT
Robert J. Thompson, Jr., Ph.D.
Dean of Trinity College and Professor of Arthur N. Wiens, Ph.D., ABPP
Psychology: Social and Health Sciences, Duke Professor Emeritus of Medical Psychology,
University, Durham, NC Oregon Health Sciences University, Portland,
OR
Michael A. Tompkins, Ph.D.
Director of Training, San Francisco Bay Area Timothy E. Wilens, M.D.
Center for Cognitive Therapy, Oakland, CA Director of Substance Abuse Services,
Associate Clinical Professor, Department of Massachusetts General Hospital, Pediatric
Psychology, University of California, Berkeley, Psychopharmacology, Boston, MA
CA Associate Professor, Harvard Medical School,
Boston, MA
Paula T. Trzepacz, M.D.
Medical Director, U.S. Neurosciences, Eli Lilly and Ron Wilkinson, J.D.
Company Brigham Young University, Provo, UT
Clinical Professor of Psychiatry, University of
Oliver B. Williams, Ph.D.
Mississippi Medical School, Jackson, MS
Center for Behavioral HealthCare Technologies,
Leon VandeCreek, Ph.D., ABPP Inc., Oxnard, CA
School of Professional Psychology, Wright State
Katie Witkiewitz, Ph.D.
University, Dayton, OH
Addictive Behaviors Research Center, University
Lynn M. Van Male, M.A. of Washington, Seattle, WA
Doctoral Candidate, Department of Psychology,
James M. Wood, Ph.D.
University of Missouri, Columbia, MO
Associate Professor of Psychology, University of
R. Enrique Varela, Ph.D. Texas at El Paso, El Paso, TX
Assistant Professor of Psychology, Tulane
Jennifer K. H. Woody, M.S.
University, New Orleans, LA
Omaha, NE
Melba J. T. Vasquez, Ph.D., ABPP
Robert H. Woody, J.D., Sc.D., Ph.D., ABPP
Independent practice, Austin, TX
University of Nebraska, Omaha, NE
Eric M. Vernberg, Ph.D. Private practice of law, Omaha, NE
Professor of Psychology, University of Kansas,
Victor J. Yalom, Ph.D.
Lawrence, KS
President, Psychotherapy.net
Janice Ware, Ph.D. Independent practice, San Francisco, CA
Associate Director, Developmental Medicine
Kathryn Yanick, B.A., A.D.R.N.
Center, Children’s Hospital, Boston, MA
Pacific Graduate School of Psychology, Palo Alto,
Assistant Professor of Psychology, Harvard
CA
Medical School, Boston, MA
Edward L. Zuckerman, Ph.D.
Danny Wedding, Ph.D., MPH
Independent practice, Armbrust, PA
Missouri Institute of Mental Health, St. Louis, MO
University of Missouri –Columbia School of
Medicine, Columbia, MO
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PART I
Assessment and Diagnosis
This page intentionally left blank
 LIFETIME PREVALENCE OF
1 MENTAL DISORDERS IN THE
GENERAL POPULATION

Christie P. Karpiak & John C. Norcross

The following table summarizes the approxi- obviously vary as a result of the different sam-
mate lifetime prevalence rates of mental disor- ple compositions, diagnostic criteria, and as-
ders in the general population. These rates will sessment methods employed in each study.

table 1. Lifetime Prevalence of Mental Disorders in the General Population

National Diagnostic and Statistical Epidemiological International

Comorbidity Manual of Mental Catchment Consortium in
Study Disorders, rev. 4th ed. Area Psychiatric Epi-
Disorder (NCS) (DSM-IV-TR) (ECA) demiology (ICPE)

Adjustment disorders 2.0 –8.0%

Agoraphobia without panic 5.3% overall 2.1–3.4% overall
disorder 3.5% of men 0.8 –1.9% of men
7.0% of women 3.0–4.9% of women
Alcohol abuse 9.4% overall
12.5% of men
6.4% of women
Alcohol dependence 14.1% overall 15.0% 13.8% overall
20.1% of men 23.8% of men
8.2% of women 4.6% of women
Alzheimer’s 0.6% of men age 65
0.8% of women age 65
11.0% of men age 85
14.0% of women age 85
21.0% of men age 90
25.0% of women age 90
(continued)

3
4 part i • assessment and diagnosis

table 1. Lifetime Prevalence of Mental Disorders in the General Population (continued)

National Diagnostic and Statistical Epidemiological International

Comorbidity Manual of Mental Catchment Consortium in
Study Disorders, rev. 4th ed. Area Psychiatric Epi-
Disorder (NCS) (DSM-IV-TR) (ECA) demiology (ICPE)

Amphetamine dependence/abuse 1.5%

Anorexia nervosa 0.05% of men
0.5% of women
Antisocial personality disorder 3.5% overall 2.6% overall
5.8% of men 3.0% of men 4.5% of men
1.2% of women 1.0% of women 0.08% of women
Anxiety disorder, any typea 5.6 –25.0% overalla
5.6% in Mexico;
7.4% in Turkey;
9.8% in Germany;
17.4% in Brazil;
20.1% in the
Netherlands;
21.3% in Canada;
25.0% in the
United States
Attention-deficit/hyperactivity
disorder 3.0 –7.0%
Autism 0.02–0.2%
Avoidant personality disorder 0.5 –1.0%
Bipolar I disorder 0.4 –1.6% 1.0 –1.8%
Bipolar II disorder 0.5%
Borderline personality disorder 2.0%
Bulimia nervosa 0.1–0.3% of men 0.2–0.3% of men
1.0 –3.0% of women 1.1–2.4% of
women
Conduct disorder <1.0 –>10.0%
Cyclothymic disorder 0.4 –1.0%
Delirium 0.4% age 18 and older
1.1% age 55 and older
Delusional disorder 0.05 –0.1%
Dementia 1.4 –1.6% age 65 –69
16.0 –25.0% over age 85
Dissociative fugue 0.2%
Dissociative identity disorder Subject of controversy
Drug abuse 4.4% overall
5.4% of men
3.5% of women
Drug dependence 7.5% overall 6.2% overall
9.2% of men 7.7% of men
5.9% of women 4.8% of women
Dysthymic disorder 6.4% overall 6.0% 3.3% overall 4.3 –6.3%
4.8% of men 2.2% of men
8.0% of women 4.1% of women
Encopresis 1.0% of 5-year-olds
Enuresis 5.0 –10.0% 5-year-olds
3.0 –5.0% 10-year-olds
1.0% age 15 and older
Gender identity disorder 0.003% of men
0.001% of womenb
Generalized anxiety disorder 5.1% overall 5.0% 5.8% overall 1.9 –5.3% overall
3.6% of men 4.5% of men 1.4 –3.5% of men
6.6% of women 6.8% of women 2.4 –7.3% of
women
 1 • lifetime prevalence of mental disorders 5

table 1. Lifetime Prevalence of Mental Disorders in the General Population (continued)

National Diagnostic and Statistical Epidemiological International

Comorbidity Manual of Mental Catchment Consortium in
Study Disorders, rev. 4th ed. Area Psychiatric Epi-
Disorder (NCS) (DSM-IV-TR) (ECA) demiology (ICPE)

Histrionic personality disorder 2.0 –3.0%

Learning disorders 2.0 –10.0%
5.0% of students in public
schools
4.0% reading disorder
1.0% mathematics disorder
Major depressive disorder 17.1% overall 6.4% overall 15.4–16.8% overall
12.7% of men 5.0 –12.0% of men 3.6% of men 10.9–13.5% of men
21.3% of women 10.0 –25.0% of women 8.7% of women 19.2–20.1% of
women
Manic episode 1.6% overall 0.8% overall
1.6% of men 0.7% of men
1.7% of women 0.9% of women
Mental retardation 1.0%
Mood disorder, any typec 7.3 –19.4% overallc
7.3% in Turkey;
9.2% in Mexico;
10.2% in Canada;
15.5% in Brazil;
17.1% in Germany;
18.9% in the
Netherlands;
19.4% in the
United States
Narcissistic personality
disorder <1.0%
Narcolepsy 0.02–0.16%
Nonaffective psychosis 0.7% overall 0.4 –1.9% overall
(also see schizophrenia)b 0.6% of men 0.4 –1.7% of men
0.8% of women 0.3 –2.0% of
women
Obsessive-compulsive 2.5% adults 2.6% overall
disorder 1.0 –2.3% children and 2.0% of men
adolescents 3.0% of women
Obsessive-compulsive
personality disorder 1.0%
Oppositional defiant disorder 2.0 –16.0%
Panic disorder 3.5% overall 1.0 –3.5% 1.6% overall 1.6 –3.8% overall
2.0% of men 1.0% of men 0.7 –1.9% of men
5.0% of women 2.1% of women 2.3 –5.7% of
women
Paranoid personality disorder 0.5 –2.5%
Pathological gambling 0.4 –3.4% adults in the
United States, up to 7.0%
adults international,
2.8 –8.0% adolescents
and students
Phobia (general) 14.3% overall
10.0% of men
17.4% of women
Posttraumatic stress disorder 8.0%
Schizophrenia (also see 0.5 –1.5% 1.5% overall
nonaffective psychosis)d 1.2% of men
1.7% of women
(continued)
6 part i • assessment and diagnosis

table 1. Lifetime Prevalence of Mental Disorders in the General Population (continued)

National Diagnostic and Statistical Epidemiological International

Comorbidity Manual of Mental Catchment Consortium in
Study Disorders, rev. 4th ed. Area Psychiatric Epi-
Disorder (NCS) (DSM-IV-TR) (ECA) demiology (ICPE)

Schizotypal personality disorder 3.0%

Selective mutism <1.0%
Separation anxiety disorder 4.0% children and
adolescents
Sleep terror disorder unknown
Episodes 1.0 –6.0% children
<1.0% adults
Sleepwalking disorder 1.0 –5.0% of children
Episodes 10.0 –30.0% of children
1.0 –7.0% adults
Social phobia 13.3% overall 3.0 –13.0% 3.5 –7.8% overall
11.1% of men 2.9 –5.9% of men
15.5% of women 3.5 –9.7% of
women
Somatization disorder 0.2–2.0% of women 0.1% overall
<0.2% of men 0.02% of men
0.23% of women
Specific/simple phobia 11.3% overall 7.2–11.3% 4.8 –10.1% overall
6.7% of men 2.2–6.6% of men
15.7% of women 6.7 –13.6% of
women
Stuttering 1.0% children
0.8% adolescents
Substance abuse/dependence, 0.0 –28.2% overalle
any typee 0.0% in Turkey;
9.6% in Mexico;
16.1% in Brazil;
18.7% in the
Netherlands;
19.7% in Canada;
21.5% in Germany;
28.2% in the
United States
Tourette’s disorder 0.05 –0.3% children
0.01–0.02% adults
Trichotillomania 0.6%

aAny anxiety disorder = panic disorder, agoraphobia, simple phobia, social phobia, and/or generalized anxiety disorder.
bInformation obtained from a survey conducted in smaller European countries.
cAny mood disorder = depression, dysthymia, and/or mania.
dIncludes schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, and atypical psychosis.
eAny substance = alcohol and/or drug abuse or dependence.

Four data sources are presented: the Na- Epidemiology (ICPE; World Health Organiza-
tional Comorbidity Study (NCS; Kessler et al., tion, 2000). The NCS reports prevalence rates
1994); the text revision of the fourth edition of of mental disorders from a national probability
the Diagnostic and Statistical Manual of Men- sample of noninstitutionalized civilians across
tal Disorders (DSM-IV-TR; American Psychi- the 48 continental United States and uses
atric Association, 2000); the NIMH Epidemio- DSM-III-R diagnostic criteria. The DSM-IV-
logical Catchment Area (ECA) study (Robins TR extracts its prevalence rates from various
& Reiger, 1991); and the World Health Organi- epidemiological and clinical studies reported in
zation International Consortium in Psychiatric the literature. The ECA bases its prevalence
 2 • mental status examination 7

rates on structured interviews of more than Kessler, R. C., Andrade, L. H., Bijl, R. V., Offord,
20,000 adults in five cities across the United D. R., Demler, O. V., & Stein, D. J. (2002). The ef-
States and uses DSM-III criteria. fects of co-morbidity on the onset and persistence
The first three data sources are largely based of generalized anxiety disorder in the ICPE sur-
veys. Psychological Medicine, 32, 1213 –1225.
on the population of the United States of Amer-
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson,
ica; in contrast, the fourth data source is interna-
C. B., Hughes, M., Eshleman, S., et al. (1994).
tional in scope. The ICPE studies employ a ver- Lifetime and 12-month prevalence of DSM-
sion of the WHO Composite International Diag- III-R psychiatric disorders in the United States:
nostic Interview, a structured diagnostic that Results from the National Comorbidity Study.
encompasses criteria from both the International Archives of General Psychiatry, 51, 8 –19.
Classification of Diseases (ICD) and the DSM. National Institute of Mental Health (NIMH). (n.d.).
The international prevalence estimates in the Statistics. Retrieved 2004 from http://www.
table are based on published data from participat- nimh.nih.gov/stats.cfm
ing countries, with between two and seven coun- Reiger, D. A., Myers, J. K., Kramer, M., Robins,
tries contributing to the reported prevalence L. N., Blazer, D. G., Hough, R. L., et al. (1984).
The NIMH Epidemiologic Catchment Area
ranges. The WHO efforts to generate cross-
program. Archives of General Psychiatry, 41,
national information on mental disorders are on-
934 – 941.
going, with data currently being gathered from Robins, L. N., Helzer, J. E., Weissman, M. M., Or-
general populations in more than 20 countries. vaschel, H., Gruenberg, E., Burke, J. D., Jr., et
al. (1984). Lifetime prevalences of specific psy-
References, Readings, & Internet Sites chiatric disorders in three sites. Archives of
General Psychiatry, 41, 949 – 958.
American Psychiatric Association. (2000). Diagnos- Robins, L. N., & Reiger, D. A. (Eds.). (1991). Psychi-
tic and statistical manual of mental disorders atric disorders in America: The Epidemiologi-
(4th ed., rev.). Washington, DC: Author. cal Catchment Area Study. New York: Free Press.
Andrade, L., Walters, E. E., Gentil, V., & Laurenti, R. World Health Organization. (n.d.). Mental health
(2002). Prevalence of ICD-10 mental disorders links page. Retrieved 2004 from http://www.
in a catchment area in the city of São Paulo, who.int/health_topics/mental_health/en
Brazil. Social Psychiatry and Psychiatric Epi- World Health Organization (WHO) International
demiology, 37, 316 –325. Consortium of Psychiatric Epidemiology. (2000).
Bijl, R. V., Ravelli, A., & van Zessen, G. (1998). Cross-national comparisons of the prevalences
Prevalence of psychiatric disorder in the gen- and correlates of mental disorders. Bulletin of the
eral population: Results of the Netherlands World Health Organization, 78, 413 – 426.
Mental Health Survey and Incidence Study
(NEMESIS). Social Psychiatry and Psychiatric
Epidemiology, 33, 587 – 595. Related Topic
International Consortium in Psychiatric Epidemiol- Chapter 18, “DMS-IV-TR Classification System”
ogy. (n.d.). Home page. Retrieved 2004 from
http://www.hcp.med.harvard.edu/icpe

2 MENTAL STATUS EXAMINATION

Robert W. Baker & Paula T. Trzepacz

In conjunction with history taking, mental sta- for psychiatric assessment and differential di-
tus examination (MSE) provides the database agnosis. It comprises the observed and objec-
8 part i • assessment and diagnosis

tive portion of the evaluation, along with re- unshaven, disheveled, clothing torn, mis-
sults of laboratory and radiological testing. Al- matched socks.
though the MSE is part of a thorough physical • Abnormal physical traits are noted, such as
examination, it is usually more comprehensive skin lesions or tattoos, body odor, sweating,
when performed by a psychiatrist than when amputations, and Down’s syndrome facies.
performed by other physicians. Except for the • Eye contact can be described as “good” or
cognitive and language portions of the MSE, “poor” or is described quantitatively (e.g.,
which usually are administered in a structured “made normal eye contact about half of the
fashion, much of the MSE is semistructured, time”).
and information is obtained throughout an in-
terview. Attitude describes the patient’s approach to
The following material describes a standard the interview:
format for documenting the MSE, along with
some advice for its performance. During as- • Degree and type of cooperativeness: Use-
sessments for follow-up, only particular por- ful terms are cooperative/uncooperative,
tions of the MSE may be emphasized. This out- friendly, open, hostile, guarded, suspicious,
line for the MSE has six sections and is derived or regressed.
from our textbook, The Psychiatric Mental • Resistance, if any, is noted here, such as “He
Status Examination. refused to answer any questions about his
family.” Resistance may be nonverbal, such
as avoiding eye contact, muteness, or fist
APPEARANCE, ATTITUDE, shaking.
AND ACTIVITY
Activity describes physical movement. Five
Appearance is ascertained by direct observa- aspects to consider are as follows:
tion of physical characteristics. The following
items should be considered: • Voluntary movement and its intensity: In-
creased movement is described directly (“He
• Level of consciousness: Normally patients was pacing/fidgety/restless”) or is labeled
are attentive and respond to stimuli; when “psychomotor agitation.” Decreased move-
this is not the case, the examiner may try to ment is localized (e.g., paresis or masked fa-
rouse the patient, such as by speaking cies) or general, known as bradykinesia or
loudly or shaking the patient’s arm. “Hyper- (especially if mentation also is slowed or de-
arousal” or “hypervigilance” is sometimes layed) psychomotor retardation.
seen, such as in mania or stimulant intoxica- • Involuntary movements are observed at
tion. A decreased level of consciousness can rest, during motion, and, if relevant, with
be described in rough order of increasing provocative maneuvers, such as having the
severity with the following terms: drowsy, patient stand with eyes closed and arms out-
lethargic, obtunded, stuporous, comatose. stretched. Tremors are regular or rhythmic.
• Apparent age is judged by vigor, mode of Resting tremor improves during action,
dress, mannerisms, and condition of hair and whereas intention tremor is worst during
skin. the most demanding phase of an action.
• Position/posture records where the patient is Chorea is sudden and irregular, while athe-
(e.g., in bed, on a chair, or on the floor) and toid movements are irregular and writh-
pertinent abnormalities, such as the “waxy ing. Dystonias are sustained, like a muscle
flexibility” of catatonia or the use of leather spasm.
restraints. • Automatic movements may appear sponta-
• Attire/grooming is reported in nonjudg- neously during partial seizures. Common
mental, descriptive terms, such as casually examples are chewing, lip smacking, or
dressed, neat, clean, meticulously groomed, clumsy limb movements. Movements may
 2 • mental status examination 9

be more complex, such as walking or pulling usually variable over the course of an inter-
at buttons, but purposeful action is not char- view, whereas mood usually is sustained for
acteristic of automatism. Typically the pa- relatively longer periods. The following pa-
tient has decreased alertness during auto- rameters of affect can be recorded:
matic movement; if repetitive, automatisms
usually are stereotyped, that is, the same • Type of affect: Types of affect seen during
movement is repeated. the interview are reported, using the same
• Tics are sudden, stereotyped, brief, abrupt, list of terms outlined for mood above.
and sometimes (temporarily) consciously • Intensity of affect: When increased, affect is
mitigated or suppressed. They may increase described as “heightened” or “exaggerated”;
if topic matter is stressful. Most noticeable reduced is “blunted”; no emotional expres-
are facial tics, but other body areas can be af- sion is “flat” (flat affect has no intensity,
fected, and tics can be verbal utterances, such range, or mobility).
as in Tourette’s disorder. • Reactivity of affect is assessed in the re-
• Compulsions may be reported by the patient sponse to emotional cues from the examiner.
or observed by the examiner. Screen by ask- Normally the examiner should see reaction
ing about repeated or undesired activities. to very subtle cues, such as smiling or com-
Patients should recognize that the behavior miserating.
is unreasonable, but they may become anx- • Range of affect is measured in the variety of
ious if the action is resisted. Common com- emotions expressed during an interview. In-
pulsions include hand washing or checking ability to express both happy and negative
(locks, stove, wallet, etc.). feelings is “restricted” affective range.
• Appropriateness or congruence of affect is
monitored by comparing emotional expres-
MOOD AND AFFECT sion to the subject matter. For example, the
examiner should expect a frightened appear-
Mood is a person’s predominant feeling state at ance when anyone is describing being pur-
a given time. It is judged primarily by self- sued or poisoned by the CIA.
report but also by observation throughout the • Mobility is the changeability of affect. Rapidly
interview. Individuals with “alexithymia” have changing affect, especially if precipitous and
diminished awareness and inability to describe unprovoked, is “labile” or “volatile.” Slowness
their mood state; nonverbal expression is in- in change of affective expression can be called
hibited. Listed below are six categories of mood “constricted” or “phlegmatic” affect; unchang-
states that are used to describe the predomi- ing affect is “fixed” or “immobile.”
nant mood:

• Normal: calm, euthymic, pleasant, unre- SPEECH AND LANGUAGE

markable
• Angry: belligerent, frustrated, hostile, irri- Careful examination can differentiate types of
table, sullen aphasia (demonstrated in Figure 4.2 and Table
• Euphoric: cheerful, elated, happy 4.2 of Trzepacz and Baker, 1993) or other lan-
• Apathetic: bland, dull guage disorders. Major psychiatric disorders
• Dysphoric: despondent, distraught, hopeless, (e.g., mania) can affect speech or language.
overwhelmed, sad Eight speech and language parameters should
• Apprehensive: anxious, fearful, frightened, be considered:
panicky, tense, worried
• Fluency is the initiation and flow of speech
Affect describes external manifestations of a in conversation; its description is based on
person’s emotional state. Unlike mood, descrip- the smoothness of the speech rather than its
tion of affect is entirely objective, and affect is communicativeness. Fluency is assessed in
10 part i • assessment and diagnosis

spontaneous speech, its initiation and main- questions throughout the interview. This part
tenance, pauses between words, use of con- of the MSE is objective in that it is based on ob-
nectors, and grammatical correctness. Ab- servation only, but it requires significant reflec-
normalities include nonfluent aphasia, scan- tion and judgment by the clinician, such as
ning, stuttering, and cluttering. “How clear was the communication?”; “Was I
• Comprehension: Spoken and written com- frequently confused by the patient?”; “Did he
prehension is tested by increasingly complex jump from subject to subject, or keep returning
commands (such as “open your mouth” and to one subject?”; “Did words or ideas keep
“touch your right ear with your left hand”). coming ‘out of the blue’?” The following two
Deafness, paresis, or apraxia may falsely elements should be included in the MSE report:
suggest impaired comprehension.
• Repetition: Tested by asking the patient to • Connectedness of thought is how logically
repeat words and phrases. or smoothly statements and ideas flow from
• Naming: Assessed by confronting with an each other and how relevant answers are to
object or picture and asking the patient for questions. Decreased connectedness is de-
the name. Other approaches include request- scribed (in terms for increasing severity) as
ing the patient to generate a list of words tangentiality, loosening of associations, or
starting with a given letter or testing in non- word salad. Circumstantiality is talking
visual modalities (e.g., naming a small object around a subject. Flight of ideas is quick and
by touch alone). frequent tangentiality.
• Writing: Assessed by giving dictation and • Peculiar thought processes: neologisms, per-
also by requesting spontaneous composition. severation, clanging, or blocking.
• Reading: Assessed by requesting patient to
read aloud (visual impairment should be ex- Thought content also is described. Sponta-
cluded). neous speech is important, especially in identi-
• Prosody: Assessed by monitoring intona- fying predominant themes, but it is helpful to
tion, rate, rhythm, and musicality of speech specifically inquire about the following:
and relationship of intonation to content of
speech. With deficient prosody, speech is • Delusions may be clear-cut and sponta-
monotonous. Prosody underlies much of the neously divulged or may appear only on
emotional expressiveness of speech, such as questioning. For example, when persecutory
sarcasm (consider the different ways to say psychosis is suspected, gentle probes such as
“you’re really smart”). Abnormally fast or “How safe do you feel?”; “How are people
slow speech is recorded here. Irrespective of treating you?”; or “Do strangers seem to be
rate, speech that is persistently difficult to noticing you?” may be revealing. Reality
interrupt is “pressured.” testing similarly can be assessed: “How cer-
• Quality of speech: Assessed in pitch, vol- tain are you of that?”; “What do you think
ume, articulation, and amount. Articulation is the reason for that?”; or “Do you think it
is tested with phrases like “no ifs, ands, or could have been a coincidence?” Behavioral
buts.” Dysarthrias reduce clarity. Manics impact determines the severity or danger-
often speak loudly, and depressed individuals ousness of delusions. The type of delusion is
may speak softly, with prolonged latency and recorded, such as persecutory, grandiose,
reduced spontaneity. referential, somatic, religious, or nihilistic.
• Overvalued ideas are illogical or objectively
false beliefs, but compared with delusions
THOUGHT PROCESS, THOUGHT they are held less tenaciously or with better
CONTENT, AND PERCEPTION recognition that they may be wrong.
• Obsessions are undesired and unpleasant
Thought process (or “form”) is assessed in (“ego-dystonic”); at times difficult to distin-
spontaneous communication and in answers to guish from delusions, obsessions are recog-
 2 • mental status examination 11

nized by the patient as unreasonable or un- to talk to the unseen. Voices that talk to each
warranted. Ask about any ideas or thoughts other or make running commentary on the
that keep repeating; specifically query for patient’s behavior are particularly severe,
common obsessions like losing control, do- but perhaps most important is the impact of
ing something dangerous or embarrassing, hallucinations on behavior (e.g., obeying
or being contaminated by germs. “command” hallucinations that require vio-
• Rumination is persistent mulling over of an lence). Hallucinations of a visual, olfactory,
unpleasant thought or theme. tactile, or gustatory nature further raise sus-
• Preoccupation is an unduly prominent re- picion of an identifiable organic etiology.
current topic that is not a delusion or an • Other perceptual abnormalities include illu-
obsession. sions, derealization, depersonalization, déjà
• Suicidal ideation may be expressed sponta- vu, and so on.
neously; if not, probe directly by asking
about thoughts of death and indirectly by
discussing future plans. Questions about COGNITION
suicidality include “Have you thought about
dying?”; “Would you be better off/hap- This section of the MSE describes higher corti-
pier/more comfortable dead?”; “Would you cal functions, such as the ability to use intel-
like to die?”; “Have you thought about lect, reason, attentiveness, logic, and memory.
killing yourself?”; “Are you going to kill It is an important part of most screening exams
yourself?” Other potentially relevant infor- and many follow-up exams, especially when
mation includes intent, past suicidality, steps neuropsychiatric dysfunction is likely. Some
taken to settle affairs, means for suicide, al- examination may be indirect, such as evaluating
ternatives to suicide, barriers to suicide, and memory by discussion of past conversations,
so on. names of medicines, or last week’s football game.
• Other violent ideas: Self-harm ideation may Cognitive functions can be categorized into a
be less severe than suicidality, such as lacer- number of main areas. Definitions vary, how-
ation, mutilation, or intentional neglect. ever, for different types of declarative memory.
Ideation of violence to others can be of vary- MSE usually does not include testing of proce-
ing urgency and intensity (e.g., “I’d like to dural memory. Testing each of the following
punch him” versus “I’d like to shoot him”). areas is a reasonable screen for cognitive im-
Some important issues are identification of a pairment.
specific intended victim, availability of a
weapon, and barriers to violent action. • Orientation: Orientation to time, place, and
• Phobias: Agoraphobia, social phobia, and person usually are assessed.
relevant simple phobias are recorded here if • Attention and concentration: Attentiveness
the patient manifests such symptoms while or distractibility can be monitored in the in-
being observed by the examiner. terview itself or formally tested. Digit span
is a measure of attention. Tests of concentra-
Perceptual Abnormalities tion include backward recitation of months
or weekdays, spelling backward, or serial
• Hallucinations may be of any sensory subtraction.
modality, but auditory hallucinations are • Registration: The capacity to immediately
most characteristic of primary psychiatric repeat a very short list of information, such
illness. Helpful inquiries include asking as three to five words.
whether people are talking about the patient, • Short-term memory: Memory over the
the patient hears voices without seeing any- course of a few minutes. It can be saturated
one, or there has been communication from and is not permanent. A common approach is
God or spirits. Auditory hallucinations may testing recollection of three unrelated items
be behaviorally evident if the patient appears after two to three minutes. More detailed
12 part i • assessment and diagnosis

approaches include story recall, word list stamped, unmailed envelope on the street?”)
learning tasks, or testing other modalities are relatively insensitive.
such as visual memory. Insight and judgment are impacted by de-
• Long-term memory: More permanent mem- fense mechanisms. These are less frequently
ory stores that cannot be saturated. May be cited in mental status reports than in the past,
recent, such as days or weeks ago, or remote, but, if included, they belong here. One catego-
such as years or decades ago. “Episodic” rization of defense mechanisms is mature
memory is personal and time tagged; a cor- types—altruism, humor, sublimation, suppres-
roborative source is needed to exclude con- sion; neurotic types—repression, displacement,
fabulation. “Semantic” memory tests gen- dissociation, reaction formation, intellectual-
eral information, such as names of recent ization; immature types — splitting, external-
presidents. ization, idealization, projection, acting out;
• Visuoconstructional ability: Visuospatial psychotic types—denial, distortion.
abilities are necessary for everyday func-
tions like driving or preparing a meal. Draw-
ing or copying figures, such as a cube, inter- References & Readings
secting pentagons, a clock, or a map of the
state or country, or making a puzzle can test American Psychiatric Association. (1994). Diagnos-
tic and statistical manual of mental disorders
this function.
(4th ed.). Washington, DC: Author.
• Executive functions: These are higher level Campbell, R. J. (1989). Psychiatric dictionary (6th
cognitive functions that include abstracting ed.). New York: Oxford University Press.
ability. Abstraction can be assessed in the in- Cutting, J. (1990). The right cerebral hemisphere
terview through general conversation or by and psychiatric disorders. New York: Oxford
formal testing. For example, cognitively con- University Press.
crete individuals may respond literally to Kaplan, H. I., & Sadock, B. J. (1995). Psychiatric re-
questions such as “What brought you to the port, and typical signs and symptoms of psy-
hospital?” Formal testing includes identify- chiatric illness. In H. I. Kaplan & B. J. Sadock
ing similarities between pairs of objects (Eds.), Comprehensive textbook of psychiatry
(e.g., table/chair, orange/apple, painting/ (6th ed., pp. 531– 544). Baltimore: Williams &
Wilkins.
poem) or meanings of well-known proverbs.
Strauss, G. D. (1995). The psychiatric interview,
history, and mental status examination. In H. I.
Kaplan & B. J. Sadock (Eds.), Comprehensive
INSIGHT AND JUDGMENT textbook of psychiatry (6th ed., pp. 521– 531).
Baltimore: Williams & Wilkins.
Insight is awareness of internal and external Trzepacz, P. T., & Baker, R. W. (1993). The psychi-
realities. For the MSE, assess the patient’s recog- atric mental status examination. New York:
nition of illness, how it impacts other people, Oxford University Press.
and the role of treatment. Vaillant, G. E. (1977). Adaptation to life: How the
Assessment of judgment considers the abil- best and brightest come of age. Boston: Little,
ity to weigh different aspects of an issue. The Brown.
examiner can discuss important past choices
(marriage, work, retirement, big purchases)
and recent choices (e.g., how did the patient Related Topics
come to clinical attention?) to demonstrate the Chapter 3, “Improving Diagnostic and Clinical In-
degree of judgment used by the patient in de- terviewing”
cision making. Traditional tests for judgment Chapter 5, “Increasing the Accuracy of Clinical Judg-
(e.g., “What would you do if you found a ment (and Thereby Treatment Effectiveness)”
 IMPROVING DIAGNOSTIC
3 AND CLINICAL
INTERVIEWING

Rhonda S. Karg & Arthur N. Wiens

First and foremost, the purpose of a clinical in- tives. For example, should the client be consid-
terview is to give clients the opportunity to pre- ered incompetent? Should this patient be re-
sent their unique perspectives on the reasons leased from the hospital?
they have sought help. From the standpoint of 3. Convey the purpose and parameters of
the interviewer, the purposes of a clinical inter- the interview: Present the rationale for the in-
view are to gather information about the client terview and describe what information you ex-
and his or her problems, to establish a relation- pect the client (or other informant) to provide.
ship with the client that will facilitate assess- The intent is to give the interviewee a “set” or
ment and treatment, and to support and direct an expectation of what will occur during the in-
the client in his or her search for relief. Toward terview and why this time is important. De-
these goals, the following list describes empiri- scribe the amount of available time, the type of
cally supported and clinically tested guidelines questions you will ask, the limits of privileged
to improve the efficacy and efficiency of inter- information, and to whom the interview find-
views. ings may be reported. Monumental misunder-
1. Prepare for the interview: Before the ini- standings can occur when clinician and client
tial meeting, carefully review the referral re- are not “on the same page.”
quest and other available data. Clients become 4. Use a collaborative interview style: Put
understandably annoyed by being asked for in- two minds to work and explore problems with
formation contained in the record and fre- the client. A collaborative interview style not
quently feel slighted by interviewers who did only helps build rapport but also sets the tone
not take the time to review their files. In a sim- for working together during the course of treat-
ilar vein, interview preparation should involve ment. By sharing the responsibilities of their
becoming well-informed regarding the prob- assessment and treatment, clients gain a sense
lem areas presented by the client, such as of control, and are thereby more likely to ad-
substance use, attention-deficit/hyperactivity here to recommendations and are less likely to
disorder, or depression (Wiens & Tindall, complain if their progress is bumpy.
1995). 5. Hear what the interviewee has to say:
2. Determine the purpose of the interview: Clients often express their appreciation that
Before proceeding with an interview, the clini- someone was willing to hear them. Give clients
cian should have a clear understanding of what (or other informants) sufficient time to talk and
he or she desires to accomplish in the inter- tell their story in their own ways and words.
view. Ask yourself: What are the objectives of Listen profoundly; devote 100% of yourself to
this interview? For example, is the purpose to the interview, hearing not only what the indi-
make a diagnosis, to plan treatment, to initiate vidual is saying (content) but also what mean-
psychotherapy, or all three? In other cases, the ing lies beneath the words (process and emo-
interview will accomplish more detailed objec- tion). Truly listening to interviewees is vital to

13
14 part i • assessment and diagnosis

developing rapport and encourages the expres- 10. Include a comprehensive analysis of
sion of valid diagnostic information. the problem behaviors: Begin the functional
6. Use structured interviews: By ensuring analysis of behavior by probing for the three
coverage of critical areas of functioning and by dimensions of problematic behavior: frequency
standardizing the diagnostic assessment, struc- (how often?), duration (how long?), and inten-
tured interviews enhance diagnostic reliability sity (how severe?). Thoroughly examine the
and validity (Rogers, 2001; Wiens, 1990). Ex- contexts in which the problem behaviors devel-
amples of these include the Structured Clinical oped and in what contexts they are most likely
Interview for the Diagnostic and Statistical to manifest themselves. For example, what was
Manual of Mental Disorders, or DSM-IV (SCID-I happening in the life of the person just prior to
and SCID-II; First, Spitzer, Gibbon, & Wil- the onset of symptoms? What internal and ex-
liams, 1996), the Schedule for Affective Disor- ternal events appear to trigger or exacerbate the
ders and Schizophrenia (SADS; Endicott & symptoms? What appears to strengthen or
Spitzer, 1978), the Clinician-Administered weaken the problem behaviors? Giving serious
PTSD Scale (CAPS; Blake et al., 1995), and the consideration to environmental or situational
Composite International Diagnostic Interview determinants can assist us in making a multi-
(CIDI) (World Health Organization, 1997). axial diagnosis (particularly Axis IV, Psychoso-
7. Administer screening instruments: To cial and Environmental Problems) and might
increase efficiency and improve the accuracy of reduce the chance of committing the funda-
the clinical interview, administer psychometri- mental attribution error.
cally sound screening instruments immedi- 11. Integrate the use of behavioral refer-
ately prior to the structured interview. Two of ents: Anchoring verbal assessments with be-
our favorites are the Psychiatric Diagnostic havioral referents will supply greater reliabil-
Screening Questionnaire (Zimmerman & Mat- ity and validity to individualized assessments.
tia, 1999) and the SCID Screen Patient Ques- Employing this strategy will also help teach
tionnaire (First et al., 1996). clients to describe and conceptualize their prob-
8. Complement the interview with other as- lems in concrete, behavioral terms (versus
sessment methods: Clinicians who rely exclu- vague, general terms, like “I have a drinking
sively on the clinical interview are prone to miss problem”). Ask questions such as “Can you
important information. The comprehensiveness give me an example of what you mean when
and validity of an interview are enhanced by the you say ‘drinking problem’?” or “On a scale of
use of psychological testing, behavioral or situa- 0 –100, with 0 being ‘no desire to use alcohol’
tional observations, and family or social reports. and 100 being ‘the strongest desire to use alco-
In fact, research consistently demonstrates that hol I have ever experienced just prior to using,’
objective psychological testing (especially actu- how would you rate your current craving to
arially driven) should be used in practically all drink?”
diagnostic interviews (e.g., Dawes, Faust, & 12. Differentiate between skill and motiva-
Meehl, 1989; Meyer et al., 2001). tion: Traditional interviews frequently confuse
9. Ensure that the interviewee comprehends a person’s skill and motivation. Ask: Is this be-
the questions: Clients are often unfamiliar with havior within the person’s behavioral reper-
psychiatric nomenclature and the constructs toire? In other words, does he or she have the
underlying the symptoms. Thus, take pains to skills to perform the behavior in question? Or
ensure that the interviewee comprehends the is it a motivational deficit: Is he or she suffi-
content of the questions. Speak in terms inter- ciently motivated? What consequences are
viewees can understand. Assess their under- maintaining his or her behavior? While inter-
standing by soliciting examples of the symptoms related, the two have differing diagnostic and
they endorse and by providing examples of the treatment implications and thus should be
symptoms they deny. Rephrasing questions clearly delineated.
using more concrete or lay terms will often help 13. Consider base rates of behaviors: Base
interviewees grasp the underlying constructs. rates should guide, in part, the prediction of be-
 3 • improving diagnostic and clinical interviewing 15

haviors and the establishment of diagnostic de- tible to prematurely terminating data collec-
cisions (Finn & Kamphuis, 1995). A corollary tion.
is to consider base rates when conducting the 17. Provide a proper termination: Antici-
clinical interview. Acquire some knowledge of pate the termination of the interview and pre-
the frequencies of psychiatric symptoms and pare the client accordingly. Point out when
disorders in the population from which the time is running short (usually 5 to 10 minutes
client is drawn. For example, what is the base prior to ending the interview). One can com-
rate of committing suicide among older Cau- bine this forewarning with a brief recapitula-
casian males? Consult the extant literature on tion, followed by eliciting the client’s reactions
prevalence rates of psychiatric disorders across to the interview and asking if there is any ad-
client characteristics, paying particular atten- ditional topic he or she would like to discuss be-
tion to those relevant to your professional set- fore ending. Communicate your diagnostic im-
ting. pressions and your treatment recommenda-
14. Avoid common biases: Although for- tions, if applicable. End the interview with a
mulating hypotheses is an integral component concluding statement expressing your appreci-
of interviews, one must guard against biases ation and your interest.
that might result in skewing information and
in making incorrect decisions. As described by References, Readings, & Internet Sites
Meehl (1977), examples of such biases include
a tendency to perceive people very unlike our- Arkes, H. R. (1981). Impediments to accurate clini-
cal judgment and possible ways to minimize
selves as being sick (the “sick-sick fallacy”),
their impact. Journal of Consulting and Clini-
denying the diagnostic significance of an event
cal Psychology, 49, 323 –330.
because it has also happened to us (the “me-too Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek,
fallacy”), and the idea that understanding D. G., Gusman, F. D., Charney, D. S., & Keane,
clients’ behaviors strip them of their signifi- T. M. (1995). The development of a clinician-
cance (the “understanding-it-makes-it-normal administered PTSD scale. Journal of Traumatic
fallacy”). Stress, 8, 75 – 90.
15. Employ debiasing strategies: Our nat- Cormier, W. H., & Cormier, L. S. (1998). Interview-
ural tendency is to search for supporting evi- ing strategies for helpers (4th ed.). Pacific
dence for our expectations. To help combat this Grove, CA: Brooks/Cole.
bias, employ a disconfirmation strategy, hunt- Dawes, R. M., Faust, D., & Meehl, P. E. (1989). Clin-
ical versus actuarial judgment. Science, 243,
ing for information that will disprove initial
1668 –1674.
impressions. What in this protocol disputes the
Elstein, A. S., Shulman, A. S., & Sprafka, S. A.
evidence for, say, schizophrenia? Another debi- (1978). Medical problem solving: An analysis
asing strategy is to make yourself think about of clinical reasoning. Cambridge, MA: Harvard
alternatives after you have generated an initial University Press.
impression (Arkes, 1981). If we find ourselves Endicott, J., & Spitzer, R. L. (1978). A diagnostic in-
unable to generate alternatives, it is time to terview: The Schedule for Affective Disorders
seek consultation with colleagues. Again, we and Schizophrenia. Archives of General Psy-
suggest using base rates and other objective chiatry, 35, 837 – 844.
means to help avoid biases and expectations. Finn, S. E., & Kamphuis, J. H. (1995). What a clini-
16. Delay reaching decisions while the in- cian needs to know about base rates. In J. N.
Butcher (Ed.), Clinical personality assessment
terview is being conducted: Research has gen-
(pp. 224 –235). New York: Oxford University
erally shown that the most accurate clinical de-
Press.
cision makers tend to arrive at their conclusions First, M. B., Spitzer, R. L, Gibbon, M., & Williams,
later than do less accurate clinicians (e.g., El- J. B. W. (1996). Structured Clinical Interview
stein, Shulman, & Sprafka, 1978). The clinical for DSM-IV Axis I Disorders, Clinician Version
implication of these findings is to reserve your (SCID-CV). Washington, DC: American Psy-
diagnostic judgments until after the interview chiatric Press.
has been completed so that you are less suscep- Meehl, P. E. (1977). Why I do not attend case confer-
16 part i • assessment and diagnosis

ences. In P. E. Meehl (Ed.), Psychodiagnosis: M. Hersen (Eds.), Handbook of psychological

Selected papers (pp. 225 –302). New York: assessment (pp. 108 –125). New York: Perga-
Norton. mon.
Meyer, G. J., Finn, S. E., Eyde, L. D., Kay, G. G., More- Wiens, A. N. & Tindall, A. G. (1995). Interviewing.
land, K. L., Dies, R. R., Eisman, E. J., Kubiszyn, In L. Heiden & M. Hersen (Eds.), Introduction
T. W., & Read, G. M. (2001). Psychological test- to clinical psychology (pp. 173 –190). New
ing and psychological assessment: A review of York: Plenum.
evidence and issues. American Psychologist, 56, World Health Organization. (1997). Composite In-
128 –165. ternational Diagnostic Interview (CIDI), Ver-
Morrison, J. R. (1995). The first interview: Revised sion 2.1. Geneva, Switzerland: Author.
for the DSM-IV. New York: Guilford Press. Zimmerman, M., & Mattia, J. L. (2001). A self-
Rogers, R. (2001). Handbook of diagnostic and report scale to help make psychiatric diagnoses:
structured interviewing. New York: Guilford The Psychiatric Diagnostic Screening Ques-
Press. tionnaire. Archives of General Psychiatry, 58,
Structured Clinical Interview for DSM-IV. (2001). 787 – 794.
SCID resource page. Retrieved 2004 from http://
cpmcnet.columbia.edu/dept/scid/
Wiens, A. N. (1990). Structured clinical interviews
Related Topics
for adults. In G. Goldstein & M. Hersen (Eds.),
Comprehensive textbook of psychiatry (6th ed., Chapter 2, “Mental Status Examination”
pp. 521–531). Baltimore: Williams & Wilkins. Chapter 4, “The Multimodal Life History Inven-
Wiens, A. N., & Brazil, P. J. (2000). Structured clin- tory”
ical interviews for adults. In G. Goldstein & Chapter 18, “DSM-IV-TR Classification System”

THE MULTIMODAL LIFE

4 HISTORY INVENTORY

Arnold A. Lazarus & Clifford N. Lazarus

Arnold Lazarus in Wolpe and Lazarus (1966) compiled appeared in Wolpe and Lazarus (1966,
wrote: “Anamnestic interviews may be consid- pp. 165 –169). Five years later, the initial Life
erably shortened with literate individuals by History Questionnaire had been revised and
asking them to complete, at their leisure, a Life considerably amplified and was published in
History Questionnaire. . . . Using the com- 1971 (Lazarus, 1971, pp. 239 –251). A new ver-
pleted questionnaire as a guide, patient and sion, one that had benefited from further field
therapist may quite rapidly obtain a compre- testing, appeared in 1981 (Lazarus, 1981, pp.
hensive picture of the patient’s past experiences 239 –251). Prepared in collaboration with Clif-
and current status” (p. 26). One of the first Life ford N. Lazarus, the most recent version, now
History Questionnaires that Arnold Lazarus referred to as the Multimodal Life History In-
 4 • the multimodal life history inventory 17

ventory, appeared in 1997 (Lazarus, 1997, pp. — early development, family interactions, and
127 –142). This 15-page inventory is copy- educational, sexual, occupational, and other ex-
righted and sold by Research Press, 2612 North periences.
Mattis Avenue, Champaign, IL 61821. Clients are advised not to try to complete
The use of the Multimodal Life History In- the inventory in a single sitting, but to space it
ventory facilitates treatment by out over several days. When the completed
form is received, the therapist peruses it in his
• Encouraging clients to focus on specific or her own time, making notations and queries
problems, their sources, and attempted solu- that are discussed during the next and perhaps
tions; subsequent sessions. Items that have been
• Providing focal antecedents, presenting prob- omitted also become grist for the mill.
lems, and relevant historical data; and We tend to read through the brief section
• Generating a valuable perspective regarding “Expectations Regarding Therapy” before any-
a client’s style and treatment expectations. thing else because it gives clues to the patient’s
expectations, as well as the type of therapeutic
Basically, the inventory provides a therapeutic style and cadence to which he or she may best
“road map” that aids in clinical decision making respond. For example, a client who sees therapy
by helping patients, and hence therapists, iden- as an opportunity to ventilate and to be heard
tify a wide range of potentially salient problems by a good listener will require a different treat-
within all the major spheres of biopsychosocial ment trajectory than one who expects to be
functioning. Typically, the Multimodal Life coached and reeducated. We also zero in on the
History Inventory is handed to patients at the 15 questions at the end of the section titled
end of the initial interview, and they are asked “Thoughts” that appear as a 5-point rating scale
to fill it out and bring it with them to their sec- on the inventory. This section immediately
ond session. Seriously disturbed (e.g., deluded, alerts the therapist to dysfunctional thoughts
deeply depressed, highly agitated) clients will and irrational ideas the client may harbor.
obviously not be expected to comply, but most We instruct clients to omit their names, ad-
psychiatric patients who are reasonably literate dresses, or any other identifying information if
will find the exercise useful for speeding up this will lead them to answer the inventory
routine history taking, thus readily providing more honestly and completely.
the therapist with significant data to generate a We now present the items that constitute
viable treatment plan. For individuals who can- the inventory. The actual forms, of course, are
not or will not complete it, the inventory may laid out differently, with adequate space for
be used as a guide during the sessions to obtain different answers and room for clients to elab-
a thorough overview of the client’s background orate should they so desire.

Multimodal Life History Inventory

The purpose of this inventory is to obtain a comprehensive picture of your back-
ground. In psychotherapy, records are necessary since they permit a more thorough
dealing with one’s problems. By completing these questions as fully and as accurately
as you can, you will facilitate your therapeutic program. You are requested to an-
swer these routine questions in your own time instead of using up your actual con-
sulting time (please feel free to use extra sheets if you need additional answer space).
It is understandable that you might be concerned about what happens to the in-
formation about you because much or all of this information is highly personal.
Case records are strictly confidential.
(continued)
18 part i • assessment and diagnosis

General Information
Name: Remarried? How many times?
Address: With whom do you live?
Telephone numbers: Day, Evening What sort of work are you doing now?
Age: Does your present work satisfy you?
Occupation: If no, please explain:
Sex: What kind of jobs have you held in the
Date of birth: past?
Place of birth: Have you been in therapy before or received
Religion: any professional assistance for your prob-
Height: lems?
Weight: Have you ever been hospitalized for
Does your weight fluctuate? psychological/psychiatric problems?
If yes, by how much? If yes, when and where?
Do you have a family physician? Have you ever attempted suicide?
Name of family physician: Does any member of your family suffer from
Telephone number: an “emotional” or “mental” disorder?
By whom were you referred? Has any relative attempted or committed
Marital status: suicide?

Personal and Social History

Father: In what ways were you disciplined or pun-
Name: ished by your parents?
Age: Give an impression of your home atmo-
Occupation: sphere (i.e., the home in which you grew
Health: up). Mention state of compatibility be-
If deceased, give his age at time of death: tween parents and between children.
How old were you at the time? Were you able to confide in your parents?
Cause of death: Basically, did you feel loved and respected
Mother: by your parents?
Name: If you have a stepparent, give your age when
Age: your parent remarried:
Occupation: Has anyone (parents, relatives, friends) ever
Health: interfered in your marriage, occupation,
If deceased, give her age at time of death: etc.?
How old were you at the time? Scholastic strengths:
Cause of death: Scholastic weaknesses:
Siblings: What was the last grade completed (or high-
Age(s) of brother(s): est degree)?
Age(s) of sister(s): Check any of the following that applied
Any significant details about siblings: during your childhood/adolescence:
If you were not brought up by your Happy childhood; Unhappy childhood;
parents, who raised you and between what Emotional/behavior problems; Legal trou-
years? ble; Death in family; Medical problems;
Give a description of your father’s (or father Ignored; Not enough friends; Sexually
substitute’s) personality and his attitude abused; School problems; Severely bullied
toward you (past and present): or teased; Financial problems; Eating dis-
Give a description of your mother’s (or order; Strong religious convictions; Drug
mother substitute’s) personality and her use; Used alcohol; Severely punished
attitude toward you (past and present):
 4 • the multimodal life history inventory 19

Description of Presenting Problems

State in your own words the nature of your What have you tried that has been helpful?
main problems: How satisfied are you with your life as a
Please estimate the severity of your whole these days?
problem(s): Not satisfied 1 2 3 4 5 6 7 Very
Mildly upsetting; Moderately upsetting; satisfied
Very severe; Extremely severe; Totally in- How would you rate your overall level of
capacitating tension during the past month?
When did your problems begin? Relaxed 1 2 3 4 5 6 7 Tense
What seems to worsen your problems?

Expectations Regarding Therapy

In a few words, what do you think therapy is What personal qualities do you think the
all about? ideal therapist should possess?
How long do you think your therapy should
last?

Modality Analysis of Current Problems

The following section is designed to help you describe your current problems in
greater detail and to identify problems that might otherwise go unnoticed. This will
enable us to design a comprehensive treatment program and tailor it to your specific
needs. The following section is organized according to the seven modalities of Be-
haviors, Feelings, Physical sensations, Images, Thoughts, Interpersonal relation-
ships, and Biological factors.

Behaviors
Check any of the following behaviors that often apply to you:
Overeat; Loss of control; Phobic avoidance; Crying; Take drugs; Suicidal attempts;
Spend too much money; Outbursts of temper; Unassertive; Compulsions; Can’t
keep a job; Odd behavior; Smoke; Insomnia; Drink too much; Withdrawal; Take
too many risks; Work too hard; Nervous tics; Lazy; Procrastination; Concentra-
tion difficulties; Eating problems; Impulsive reactions; Sleep disturbance; Aggres-
sive behavior; Others:
What are some special talents or skills that you feel proud of?
What would you like to start doing?
What would you like to stop doing?
How is your free time spent?
What kind of hobbies or leisure activities do you enjoy or find relaxing?
Do you have trouble relaxing or enjoying weekends and vacations? If yes, please explain:
If you could have any two wishes, what would they be?

Feelings
Check any of the following feelings that often apply to you:
Angry; Fearful; Happy; Hopeful; Bored; Optimistic; Annoyed; Panicky; Con-
flicted; Helpless; Restless; Tense; Sad; Energetic; Shameful; Relaxed; Lonely; De-
(continued)
20 part i • assessment and diagnosis

pressed; Envious; Regretful; Jealous; Contented; Anxious; Guilty; Hopeless; Un-

happy; Excited; Others:
List your five main fears:
What are some positive feelings you have experienced recently?
When are you most likely to lose control of your feelings?
Describe any situations that make you feel calm or relaxed:

Physical sensations
Check any of the following physical sensations that often apply to you:
Abdominal pain; Bowel disturbances; Hear things; Pain or burning with urina-
tion; Tingling; Watery eyes; Menstrual difficulties; Numbness; Flushes; Head-
aches; Stomach trouble; Nausea; Dizziness; Tics; Skin problems; Palpitations; Fa-
tigue; Dry mouth; Muscle spasms; Twitches; Burning or itching skin; Tension;
Back pain; Chest pains; Sexual disturbances; Tremors; Rapid heartbeat; Unable to
relax; Fainting spells; Don’t like to be touched; Blackouts; Excessive sweating; Vi-
sual disturbances; Hearing problems; Others:
What sensations are pleasant for you? Unpleasant for you?

Images
Check any of the following that apply to you. I picture myself:
Being happy; Being talked about; Being trapped; Being hurt; Being aggressive;
Being laughed at; Not coping; Being helpless; Being promiscuous; Succeeding;
Hurting others; Losing control; Being in charge; Being followed; Failing; Oth-
ers:
I have:
Pleasant sexual images; Seduction images; Unpleasant childhood images; Images
of being loved; Negative body image; Unpleasant sexual images; Lonely images;
Others:
Describe a very pleasant image, mental picture, or fantasy:
Describe a very unpleasant image, mental picture, or fantasy:
Describe your image of a completely “safe place”:
Describe any persistent or disturbing images that interfere with your daily func-
tioning:
How often do you have nightmares?

Thoughts
Check each of the following that you might use to describe yourself:
Intelligent; Confident; A nobody; Inadequate; Useless; Confused; Worthwhile;
Evil; Ambitious; Sensitive; Crazy; Worthless; Ugly; Stupid; Can’t make decisions;
Morally degenerate; Naive; Suicidal ideas; Loyal; Considerate; Trustworthy; De-
viant; Full of regrets; Unattractive; Honest; Incompetent; Concentration difficul-
ties; Memory problems; Attractive; Persevering; Deviant; Good sense of humor;
Horrible thoughts; Hardworking; Unlovable; Conflicted; Undesirable; Lazy; Un-
trustworthy; Dishonest; Others:
What do you consider to be your craziest thought or idea?
 4 • the multimodal life history inventory 21

Are you bothered by thoughts that occur over and over again? If yes, what are these
thoughts?
What worries do you have that may negatively affect your mood or behavior?
On each of the following items, please circle the number that most accurately re-
flects your opinions:
[On the actual inventory, this appears as a scale ranging from “1,” Strongly Dis-
agree, to a “5,” Strongly Agree.] I should not make mistakes; I should be good at
everything I do; When I do not know something, I should pretend that I do; I
should not disclose personal information; I am a victim of circumstances; My life
is controlled by outside forces; Other people are happier than I am; It is very im-
portant to please other people; Play it safe, don’t take any risks; I don’t deserve to
be happy; If I ignore my problems, they will disappear; It is my responsibility to
make other people happy; I should strive for perfection; Basically, there are two ways
of doing things— the right way and the wrong way; I should never be upset.

Interpersonal relationships
Do you make friends easily? Do you keep them?
Did you date much during high school? College?
Were you ever bullied or severely teased?
Describe any relationship that gives you: Joy; Grief
Rate the degree to which you generally feel relaxed and comfortable in social situations:
Very relaxed 1 2 3 4 5 6 7 Very anxious
Do you have one or more friends with whom you feel comfortable sharing your
most private thoughts?
Marriage (or a committed relationship):
How long did you know your spouse before your engagement?
How long were you engaged before you got married?
How long have you been married?
What is your spouse’s age? His/her occupation?
Describe your spouse’s personality:
What do you like most about your spouse?
What do you like least about your spouse?
What factors detract from your marital satisfaction?
How satisfied are you with your marriage?
How do you get along with your partner’s friends and family?
How many children do you have?
Please give their names and ages:
Do any of your children present special problems? If yes, please describe:
Any significant details about a previous marriage(s)? Sexual relationships?
Describe your parents’ attitude toward sex. Was sex discussed in your home?
When and how did you derive your knowledge of sex?
When did you first become aware of your own sexual impulses?
Have you ever experienced any anxiety or guilt arising out of sex or masturbation?
Relevant details regarding your first or subsequent sexual experiences?
Is your present sex life satisfactory? If no, please explain:
Provide information about any significant homosexual reactions or relationships:
Are there any problems in your relationships with people at work? If yes, please describe:
(continued)
22 part i • assessment and diagnosis

Please complete the following:

One of the ways people hurt me is; I could shock you by; My spouse (or
boyfriend/girlfriend) would describe me as; My best friend thinks I am; People
who dislike me:
Are you currently troubled by any past rejections or loss of a love relationship?

Biological factors
Do you have any current concerns about your physical health?
List any medications you are currently taking:
Do you eat three well-balanced meals each day?
Do you get regular physical exercise? If yes, what type and how often?
Please list any significant medical problems that apply to you or to members of your
family:
Please describe any surgery you have had (give dates):
Please describe any physical handicap(s) you have:

Menstrual history
Age at first period:
Were you informed? Did it come as a shock?
Are you regular? Duration: Do you have pain?
Do your periods affect your moods? Date of last period:
Check any of the following that apply to you:
Muscle weakness; Tranquilizers; Diuretics; Diet pills; Marijuana; Hormones;
Sleeping pills; Aspirin; Cocaine; Painkillers; Narcotics; Stimulants; Hallucinogens
(e.g., LSD); Laxatives; Cigarettes; Tobacco (specify); Coffee; Alcohol; Birth control
pills; Vitamins; Undereat; Overeat; Eat junk foods; Diarrhea; Constipation; Gas;
Indigestion; Nausea; Vomiting; Heartburn; Dizziness; Palpitations; Fatigue; Al-
lergies; High blood pressure; Chest pain; Shortness of breath; Insomnia; Sleep too
much; Fitful sleep; Early morning awakening; Earaches; Headaches; Backaches;
Bruise or bleed easily; Weight problems; Others:

Structural Profile
[On the actual inventory, clients are asked to rate the following items on a 7-point
scale.]
Behaviors: Some people may be described as “doers”— they are action oriented;
they like to busy themselves, get things done, take on various projects. How much
of a doer are you?
Feelings: Some people are very emotional and may or may not express it. How emo-
tional are you? How deeply do you feel things? How passionate are you?
Physical sensations: Some people attach a lot of value to sensory experiences, such
as sex, food, music, art, and other “sensory delights.” Others are very much
aware of minor aches, pains, and discomforts. How “tuned in” to your sensations
are you?
Mental images: How much fantasy or daydreaming do you engage in? This is sepa-
rate from thinking or planning. This is “thinking in pictures,” visualizing real or
imagined experiences, letting your mind roam. How much are you into imagery?
 5 • increasing the accuracy of clinical judgment 23

Thoughts: Some people are very analytical and like to plan things. They like to rea-
son things through. How much of a “thinker” and “planner” are you?
Interpersonal relationships: How important are other people to you? This is your
self-rating as a social being. How important are close friendships to you, the ten-
dency to gravitate toward people, the desire for intimacy? The opposite of this is
being a “loner.”
Biological factors: Are you healthy and health conscious? Do you avoid bad habits
like smoking, too much alcohol, drinking a lot of coffee, overeating, and so on? Do
you exercise regularly, get enough sleep, avoid junk foods, and generally take care
of your body?

Please describe any significant childhood (or other) memories and experiences you
think your therapist should be aware of.

References & Readings Wolpe, J., & Lazarus, A. A. (1966). Behavior ther-
apy techniques. Oxford: Pergamon Press.
Lazarus, A. A. (1971). Behavior therapy and be-
yond. New York: McGraw-Hill.
Lazarus, A. A. (1981). The practice of multimodal Related Topics
therapy. New York: McGraw-Hill. Chapter 2, “Mental Status Examination”
Lazarus, A. A. (1997). Brief but comprehensive psy- Chapter 3, “Improving Diagnostic and Clinical In-
chotherapy. New York: Springer. terviewing”
Lazarus, A. A. (2002). The Multimodal Assessment Chapter 5, “Increasing the Accuracy of Clinical Judg-
Therapy approach. In F. Kaslow (Series Ed.) & ment (and Thereby Treatment Effectiveness)”
J. L. Lebow (Ed.), Comprehensive handbook of psy- Chapter 77, “Genograms in Assessment and Ther-
chotherapy: Vol. 4, Integrative/eclectic (pp. 241– apy”
254). New York: Wiley.

INCREASING THE ACCURACY

OF CLINICAL JUDGMENT
5 (AND THEREBY TREATMENT
EFFECTIVENESS)

David Faust

Increased predictive accuracy improves clinical presumes prediction. Our interventions are
practice. This is not only because patients may guided by our expectations (predictions) of
seek guidance about the likelihood of various their effects and effectiveness. After all, we
outcomes (e.g., “Am I in a relationship with a would not say, “Let’s try this, although I don’t
future?”) but also because intervention usually have the slightest idea how well it’s going to
24 part i • assessment and diagnosis

work, and who cares anyway, because what’s tion of two conditions and that there are
going to happen next is of no concern,” but roughly equal costs and benefits for both types
rather, “I think what’s most likely to help is . . .” of correct and incorrect judgments (i.e., cor-
Similarly, therapeutic interpretation is guided rectly identifying Condition A versus missing
by predicted impact or what is expected to ben- Condition A; correctly identifying Condition B
efit the patient. versus missing Condition B). Of course, such
There is much useful knowledge and meth- relatively clean examples are not that common,
odology for increasing predictive accuracy, al- and often there is an imbalance across one or
though, unfortunately, this information usu- both of these dimensions. This does not negate
ally is not provided in the training of mental the underlying principle, that is, that fre-
health professionals (see Dawes, 1988; Faust, quency data or base rates are often among the
1984; Meehl, 1973). A few of the more impor- most important guides to decision making, but
tant principles are conveyed in the “rules of it does call for adjustments.
thumb” that follow. Suppose, for example, that a set of signs in-
dicate posttraumatic stress disorder (PTSD)
versus major depression (MD) at a 2:1 ratio,
GO WITH THE MORE FREQUENT EVENT but that in the setting of application MD occurs
four times more often than PTSD. Under such
Principle circumstances, most individuals with the sign
Assume the evidence points about equally to- will still have MD. One can think of this as the
ward two alternatives and that the potential 4:1 ratio (or base rate) in favor of MD more
disadvantages of misidentifying both condi- than offsetting the 2:1 ratio (the sign) in favor
tions or outcomes are about the same. Under of PTSD. It is simply a matter of one indicator
such circumstances, you should guess that the pointing to MD and the other to PTSD, with
more frequent of the two conditions is present. the former indicator being a more powerful or
To the extent the frequency of the two condi- accurate one. However, there is a partial offset
tions or outcomes varies, such a strategy will of the 4:1 ratio, and the base rate will not be as
enhance predictive accuracy. In fact, not un- strong an indicator of MD as it would be were
commonly, the frequency of an event (i.e., the the sign neutral or not indicative of the alter-
base rate) is the single most predictive variable native diagnosis. The point is that deviations
or useful piece of information. from clean examples change the operating
characteristics, although not the underlying
principles, and call for certain steps to deter-
Illustration
mine, for example, shifts in the relative proba-
To illustrate, suppose that Alzheimer’s disease bilities of alternative outcomes.
occurs about 10 times more often than Pick’s These adjustments can be difficult to make
disease and that the manifestations of these dis- impressionistically, especially as the differences
orders, at least initially, are often very similar. among alternatives become less extreme. Fortu-
If one guesses Alzheimer’s disease every time, nately, exact determinations can be made using
one will be correct about 9 in 10 times. For ex- relatively simple formalisms (see Meehl &
ample, if, across a series of 100 cases, there are Rosen, 1973). Steps can also be taken to deal
91 cases of Alzheimer’s disease and 9 cases of with gaps in information about frequencies or
Pick’s disease, and if one guesses Alzheimer’s base rates and to consider utilities or the costs
every time, one will achieve a 91% accuracy and benefits of different types of correct and in-
rate. correct decisions (see Faust & Nurcombe, 1989).

Elaboration Summary of the First Principle

This guide, as narrowly stated above, assumes In summary, the frequency of a condition or
that evidence points about equally in the direc- event is often among the most useful, if not
 5 • increasing the accuracy of clinical judgment 25

the single best, predictor of that event or out- with each other. Consequently, they are not
come. The extreme case illustrates this point: If carving out unique pieces of the predictive pie
something never occurs or always occurs, know- but are re-covering the same ground. To illus-
ing this alone would lead to 100% predictive trate, if we are trying to obtain a proper phy-
accuracy. Indeed, as events become more or less sical description of a person and measure the
frequent, or more or less frequent than one an- person’s weight first in pounds and then in kilo-
other, greater and greater predictive accuracy grams, the second measurement really adds
can be achieved by playing the base rates, that nothing new. We have only measured the same
is, by guessing that the event that is less fre- dimension twice. Similarly, two depression in-
quent will not occur or that the event that is ventories may both measure roughly the same
more frequent will occur. Under such circum- thing.
stances, the rate of accurate decisions can in- Starting with the first predictor (and for
crease 10-fold or more by utilizing base rates purposes of this discussion bypassing the issue
versus contrary diagnostic or predictive signs of reliability), additional predictors are valu-
or indicators, even those that, in conditions of able to the extent they are both valid and non-
equal frequency, perform reasonably well. redundant. In many domains in clinical psy-
chology, once one combines about three to five
of the most valid and independent variables,
INCLUDING A BAD PREDICTOR IS adding a new variable often does little or noth-
USUALLY MUCH WORSE THAN ing to increase predictive accuracy, even if it
EXCLUDING A GOOD PREDICTOR has a very respectable level of validity (owing
to its redundancy). However, combining or in-
Principle
tegrating a weaker or invalid variable cannot
For technical reasons to be described, mistak- help matters and will often decrease judgmen-
enly including a weak or invalid variable in the tal accuracy.
predictive mix usually does considerably more Suppose, for example, that sexual abuse has
harm than mistakenly overlooking or disre- not occurred and that the three best predictors
garding a good predictor. Therefore, in most of possible abuse are negative. Three other
situations, especially when other predictors of variables, which, unfortunately and unbe-
known value are available, if in doubt, exclude knownst to the clinician, are really weak or
rather than include; in other words, avoid in- poor predictors, indicate otherwise. Obviously,
corporating additional variables into the deci- a correct conclusion might be overturned, and
sion process. in the long run, the inclusion of weak or invalid
variables will have a detrimental overall effect.
Explanation of Principle
Further Elaboration
Clinicians are commonly advised to integrate
most or all the data, a strategy that flows from Precisely determining alterations in predictive
mistaken beliefs about validity and is almost accuracy as variables are combined in different
sure to decrease overall accuracy. The miscon- ways or are added or subtracted is very difficult
ception is that validity is cumulative, and hence to do via observation or experientially. For ex-
the more (data or predictors) the better. It is not ample, even an astute observer is rather un-
uncommon, for example, for authors to call for likely to get it just right when subjectively
the integration of dozens, if not hundreds, of “calculating” the figure for shared variance or
test scores and data points. Were validity strictly redundancy across two variables. Proper devel-
cumulative, then, if one could identify 15 pre- opment of decision procedures through formal
dictors that each accounted for 10% of the research includes analysis of predictive accu-
variance, their combination would account for racy, level of redundancy, and the impact of
150% of the variance! This does not hold be- adding new variables to the predictive mix.
cause predictors are often redundant or overlap This is clearly a situation in which human in-
26 part i • assessment and diagnosis

genuity, via the development of scientific and tempt, we might direct most of our efforts to-
analytic methods, has gone a long way toward ward the most probable event (e.g., access to a
solving tasks that place unrealistic demands on means). However, it is instructive to examine
the unaided human mind, much like the tele- the consequences of this strategy using the hy-
scope has extended human senses. pothetical figures stated above. If I reduce
Also contrary to common belief, the exact Event B by .10, or from .90 to .80, the result is
weighting of variables is often of much lesser .20 ⫻ .80 = .16, or a minimal reduction in risk.
importance than selecting which variables to In contrast, if I decrease A by .10, or from .20
use and which to exclude. Indeed, in many situ- to .10, the result is .10 ⫻ .90 = .09; that is, I
ations, weighting the relevant variables equally have cut the risk in half.
results in the same, or about the same, predic- The results or proportionate impact can be
tive accuracy as optimal weighting, and the even more dramatic as the probability of the
“optimal” weights derived in one situation are least likely event decreases below that stated in
often relatively unstable across other situations the hypothetical, especially when these proba-
anyway, reducing their potential advantages bilities start out rather low. For example, as-
(Dawes, 1979; Dawes & Corrigan, 1974; Dawes, sume that the probability of A is now .06 and
Faust, & Meehl, 1989). All these considerations that B is still at .90, and that we could reduce
lead to the same prescription: Identify (prefer- either A or B by .05. Before intervention, we
ably through well-conducted research) the lim- start at .06 ⫻ .90 = .054. If we reduce B by .05,
ited set of variables that are most valid and the result is .06 ⫻ .85 = .051; but if we reduce A
nonredundant and then be conservative, that is, by .05, the result is .01 ⫻ .90 = .009. By inter-
worry much more about adding questionable vening in the right place, rather than achieving
variables to the mix than overlooking addi- a very minor decrease in risk, we have reduced
tional valid variables. it almost sixfold, or from about 1 in 18 to about
1 in 100. The obverse also holds and tends to
align more closely with intuition; that is, when
TO REDUCE RISK OF A BAD OUTCOME, one wants a positive outcome to occur, all other
START WITH THE LEAST LIKELY things being equal, bolster the least likely link
EVENT IN THE CHAIN OR SET in the chain.
Principle and Explanation
Cautionary Note
When a set of events all must occur for some-
thing bad to happen, the greatest proportionate It is of utmost importance to recognize that this
reduction in risk occurs when one lowers the principle of risk reduction assumes that all
probability of the least likely link. Consider the events in the set must occur for the event to
following example. Suppose two things, Event occur. (Technically, it is better to use the term
A and Event B, must take place for a bad out- set rather than chain because no particular se-
come to occur. Suppose that the probability of quence needs to be assumed.) Also, as with base
Event A is .20 and of Event B is .90, making the rates, the conditions stated here (i.e., all other
probability of the outcome .20 ⫻ .90 = .18. Now things being equal) often will not hold, and ad-
suppose for practical reasons that you can inter- justments will have to be made (e.g., What if I
vene with either A or B but not both, perhaps can reduce A, the less frequent event, by .10 and
because of limited time or resources. Suppose B by .20?). However, the mathematics are usu-
further that you can decrease the probability of ally simple because one need only multiply the
either of the variables by .10. probabilities of each relevant variable by the
In attempting to reduce risk, intuition usu- others (i.e., A ⫻ B ⫻ C, etc.). The main point is
ally leads one to focus first on the segment of that the tendency to focus time and effort on
the chain that appears most likely to occur. For the most likely event is often misdirected and
example, if we are trying to avoid a suicide at- opposite to the more effective approach.
 5 • increasing the accuracy of clinical judgment 27

BEFORE DECIDING, GENERATE information (because one feels one already

REASONS TO DECIDE OTHERWISE knows); and (c) to not learn or implement the
many useful methods that scientific research
Principle and Explanation
and work in decision making, such as those dis-
The simple exercise of generating reasons to cussed in this chapter, have uncovered.
decide otherwise or of actively considering or
bringing to mind contrary evidence tends to References & Readings
counter a number of problematic judgment
tendencies. For one, once individuals formulate Arkes, H. R. (1981). Impediments to accurate clini-
cal judgment and possible ways to minimize
hypotheses or tentative conclusions, they tend
their impact. Journal of Consulting and Clini-
to look for possible confirming evidence more cal Psychology, 49, 323 –330.
so than contrary evidence, or, given a certain Dawes, R. M. (1979). The robust beauty of improper
mental set, supportive evidence may be more linear models in decision making. American
salient or noticeable. This may skew the evi- Psychologist, 34, 571– 582.
dence that is gathered or considered in favor of Dawes, R. M. (1988). Rational choice in an uncertain
supportive evidence, resulting in premature world. New York: Harcourt Brace Jovanovich.
termination of data collection, erroneous con- Dawes, R. M., & Corrigan, B. (1974). Linear models
clusions, and overconfidence. Active attempts in decision making. Psychological Bulletin, 81,
to recognize and consider contrary evidence 95 –106.
tend to rebalance the scales. Dawes, R. M., Faust, D., & Meehl, P. E. (1989). Clin-
ical versus actuarial judgment. Science, 243,
1668 –1674.
Further Explanation Faust, D. (1984). The limits of scientific reasoning.
Minneapolis: University of Minnesota Press.
Given the variability of human behavior over Faust, D., & Nurcombe, B. (1989). Improving the ac-
time and place, as well as error in our measur- curacy of clinical judgment. Psychiatry, 52,
ing devices, a plausible but false, or mainly false, 197 –208.
conclusion will often still find considerable sup- Meehl, P. E. (1973). Psychodiagnosis: Selected papers.
portive evidence. For example, if one concludes Minneapolis: University of Minnesota Press.
that the patient has more than expectable levels Meehl, P. E., & Rosen, A. (1973). Antecedent prob-
of interpersonal conflict, when the patient actu- ability and the efficiency of psychometric
ally is a little better than average on this score, signs, patterns, and cutting scores. In P. E.
Meehl, Psychodiagnosis: Selected papers (pp.
thorough probing of his or her history ought to
32– 62). Minneapolis: University of Minnesota
uncover many instances in which interpersonal Press.
conflicts occurred. If alternative or contrary ev- Slovic, P., Fischhoff, B., & Lichtenstein, S. (1982).
idence becomes more salient, the false initial Facts versus fears: Understanding perceived
impression may be overturned. risk. In D. Kahneman, P. Slovic, & A. Tversky
Confidence that is unduly inflated by the (Eds.), Judgment under uncertainty: Heuristics
tendency to focus on one side of the coin, or ev- and biases (pp. 463 – 489). New York: Cam-
idence consistent with one’s conclusions, can bridge University Press.
lead to many secondary, damaging judgment
practices. For example, when one is more confi- Related Topics
dent than is justified, there is a tendency (a) to Chapter 3, “Improving Diagnostic and Clinical In-
make overly extreme or risky predictions (“I terviewing”
know he won’t commit murder when on pa- Chapter 48, “Key Principles in the Assessment of
role”); (b) to fail to gather important sources of Psychotherapy Outcome”
 DEVELOPMENTAL
6 NEUROPSYCHOLOGICAL
ASSESSMENT

Jane Holmes Bernstein, Betsy Kammerer,

Penny A. Prather, & Celiane Rey-Casserly

FUNDAMENTAL ASSUMPTIONS behavior. Models of relatively static, modu-

OF NEUROPSYCHOLOGICAL (NP) lar adult behavioral function should be ap-
ASSESSMENT OF CHILDREN plied to children with extreme caution.

• Clinical assessment in neuropsychology, as

in psychology, involves extracting diagnostic ASSUMPTIONS OF
meaning from an individual’s history, from DEVELOPMENTAL ANALYSIS
direct and indirect observations of behavior,
and from performance on targeted tests. • Development implies a dynamic interaction
• NP assessment requires analysis of both between an organism and its environment.
neurological and psychological (behavioral) The principles at the core of a developmental
variables. Observed behavior is a function of NP analysis of behavior are those of the de-
the interaction of the brain with the envi- velopmental sciences: structure, context, pro-
ronment. cess, and experience.
• NP assessment is situated within a wider so- • In the developing child the contribution of
cial context, requiring sensitivity to issues of “brain” to observed behavior cannot be
culture, language, and diversity. meaningfully assessed without reference to
• The goal of NP assessment is optimal adapta- the child’s developmental course, matura-
tion in all aspects of “real life”—by promot- tional status, immediate environmental de-
ing the child’s psychosocial and intellectual mands, and wider sociocultural context.
development. • Knowledge of normal development and its
• The practice of neuropsychology is based on variation is a prerequisite for all develop-
knowledge of the brain as a necessary, but not mental analysis.
sufficient, substrate for behavior relation- • A disturbance of the brain at any point in
ships. Its goal is to explicate brain-behavior time is necessarily incorporated into the
relationships. Neuropsychology is not de- subsequent developmental course. Both neu-
fined by a set of tests, no matter how exten- rological and behavioral development will
sive or well organized the cognitive domains proceed in a different fashion around the
tapped by the tests. new brain organization.
• The practice of neuropsychology requires • A brain insult will have differential impact
formal and rigorous training of the clinician. on behavioral outcome as a function of the
• Children are not small adults. Comprehen- developmental status of the disrupted brain
sive assessment models for children must in- system at the time of the insult.
corporate development in their analysis of • The behaviors or “symptoms” that prompt
28
 6 • developmental neuropsychological assessment 29

referral occur in the context of the expected • NP assessment provides important informa-
competencies of the child at a given develop- tion to aid in the better understanding and
mental stage. Thus, the same underlying management of behavioral consequences of
neuropsychological problem will be mani- childhood disorders— such as (but not lim-
fest in different ways at different points in ited to) the role of executive functions in spina
development. bifida, prematurity, or attentional disorders;
the prediction of behavioral late effects in
treated brain tumor and leukemias; the im-
INDICATIONS FOR NP ASSESSMENT pact of seizure activity and/or medications
in epilepsy; the contribution of language-
• In contrast to adults, children undergo fre- processing variables to reading disorders; the
quent psychological and/or educational test- interplay of social and cognitive factors in the
ing. “Overtesting” is thus of serious con- outcome of traumatic brain injury; the poten-
cern. Referral questions should be carefully tial brain substrates for deficits in processing
reviewed. NP consultation, rather than com- socially relevant information; or the elucida-
prehensive NP assessment, should be consid- tion of NP deficits associated with psychiatric
ered where appropriate. disorders (such as schizophrenia or obsessive-
• NP assessment should be considered when a compulsive disorder).
child unexpectedly fails to meet environ- • NP services are provided in the form of (a)
mental demands in either academic or psycho- comprehensive individual assessments (out-
social contexts, and/or when psychological, patient); (b) consultation — to educational,
psychiatric, psychoeducational, or multi- psychiatric, social work, medicine, and reha-
disciplinary assessment does not provide bilitation professionals — including review
an adequate explanation for presenting be- of records, analysis of behavioral data, in-
havior or sufficient information to guide terpretation of neurological data in the be-
intervention planning. havioral arena, application of neurologically
• NP assessment is indicated (a) when behav- relevant information to everyday settings
ioral change is seen in the context of known (home, school), and assistance in diagnostic
or suspected neurological disorders; known or formulation and intervention strategies; (c)
suspected systemic disorders with impact on inpatient assessment or consultation to local-
the central nervous system (CNS); treatment ize function (seizures), monitor behavioral
regimens with potentially deleterious impact change in the intraoperative setting, and
on CNS status; degenerative, metabolic, or document behavioral functioning in psychi-
specific genetic disorders; and disorders associ- atric patients; and (d) forensic evaluation to
ated with structural CNS abnormalities; (b) to provide a comprehensive description of de-
clarify the relationship of behavioral change velopmental status, cognitive functioning,
to specific medical/neurological/psychiatric academic achievement, and psychosocial ad-
diagnoses or to specific neural substrates; (c) justment and to address future risks/needs in
to provide a baseline profile to monitor recov- forensic situations.
ery, effects of treatment, and/or the impact of
developmental change on behavioral func-
tion; (d) to provide ongoing monitoring of DIAGNOSTIC STRATEGY
neurobehavioral status in the context of de-
velopmental change, recovery, and/or treat- • Diagnosis in neuropsychology is not a func-
ment— particularly in the case of specific in- tion of test performance. It is the result of a
jury and/or medical or surgical intervention formal assessment strategy that is ideally
(e.g., epilepsy surgery, medication trials or formulated as an experiment with an N of 1,
changes, radiation therapy) and in the context theoretically driven, with hypotheses that
of the use of medications; and (e) for clinical are systematically tested and with a design
research in neurological, psychiatric, and and methodology that include appropriate
psychological populations. controls for variability and bias.
30 part i • assessment and diagnosis

• The diagnostic strategy not only should ad- • Domains include regulatory and goal-directed
dress the referral questions but also should executive capacities (arousal, attention, mem-
be framed within the biopsychosocial con- ory, learning, mood, affect, emotion, reason-
text of the child’s life. It should incorporate ing, planning, decision making, monitoring,
adaptive competence, emotional well-being, initiating, sustaining, inhibiting, and shift-
and functional processing style, as well as ing abilities); skills and knowledge bases
cognitive and academic abilities. (sensory and perceptual processing in [pri-
• The diagnostic strategy must integrate the marily] visual and auditory modalities,
“vertical” dimension of development with motor capacities, communicative compe-
the “horizontal” dimension of the child’s tence, social cognition, linguistic processing,
current neurobehavioral repertoire. speech functions, spatial cognition); and
• Relevant diagnostic data are derived from achievement (academic skills, adaptive func-
the individual’s history, direct and indirect tioning, social comportment, societal adjust-
observations of behavior, and performance ment).
on psychological tests.
• The diagnostic formulation is the basis for
referencing the child’s profile to categories of SOURCES OF DATA
neurological, psychological, and/or educa-
tional disorders. • The history is typically obtained from inter-
• Diagnostic categories can be framed in terms views of the child, parent(s)/guardian(s),
of neuropsychological or neurodevelopmen- teacher(s), psychologist, and physician; from
tal variables, specific psychological (cognitive, medical/educational records; and from ques-
perceptual, information processing) factors, tionnaires. The goal of the history is to
primary academic deficits, and/or specific determine the child’s heritage (genetic, med-
nosological schemes (e.g., DSM-IV). ical, socioeconomic, cultural, educational) de-
• The diagnostic formulation is the basis for rived from the family history and to assess
determination of risk (prediction of future the child’s ability to take advantage of this
response to expectable challenges, both psy- heritage (the child’s developmental, medical,
chosocial and intellectual) and for the design psychological, and educational history). The
and implementation of the comprehensive, interviews also provide important informa-
individualized management strategy that tion on the attributions given by others as to
addresses the pattern of risks faced by this the nature and source of the child’s present-
child in this family with this history, this ing difficulties.
profile of skills, and these goals (both short- • Observational data are derived from exami-
and long-term). nation of the child’s appearance and behavior,
from information obtained from question-
naires and interviews completed with people
BEHAVIORAL DOMAINS familiar with the child in nonclinical con-
texts, from direct observation of the child-
• In NP assessment, behavioral domains rather parent interaction during the clinical inter-
than test performance are the units of analy- view, from analysis of the examiner-child
sis. dyad, and from observation of the child’s be-
• Behavioral domains tapped can be organized havior and problem-solving style under spe-
in a number of ways — and labeled differ- cific performance demands (including both
ently by clinicians with differing theoretical specific tests and the activities of the natural
perspectives. What they have in common, environment).
however, is that they are sufficiently wide- • Tests provide psychometric data relating level
ranging to address both the behavioral rep- of performance to that of age peers; behav-
ertoire of the individual being assessed and ioral data on behaviors elicited under differ-
the referral question(s). ent problem-solving demands and problem-
 6 • developmental neuropsychological assessment 31

solving strategies for reaching solutions; and • No test measures just one thing. All behav-
task analysis data such as information re- ior, including test responses, is the result of a
garding complexity of task demands, alloca- complex interaction of executive, cognitive,
tion of resources, systemic relationships in and perceptual variables, motor and sensory
task/situation. capacities, and emotional factors.
• Psychological tests have limitations with re-
spect to NP assessment. They can provide in-
THE USE OF PSYCHOLOGICAL TESTS terchild rating and cognitive profiling. Used
alone, they cannot model the neural sub-
• Psychological tests are designed to tap spe- strate or explicate childhood neuropathol-
cific aspects of behavioral function. They are ogy.
constructed according to sound psychomet-
ric principles, administered rigorously, and
scored according to standard guidelines. COMMUNICATION OF FINDINGS
Their normative data should be up to date,
reliable, valid, and appropriate in terms of • Communication of findings is undertaken
age and/or cultural or language group for by means of a written report and an inform-
the population under study. ing session. These are complementary: The
• NP assessment protocols require a core of informing session provides a forum for dis-
population-based standardized psychological cussion of the findings and their meaning, as
test instruments. These typically include a well as an opportunity for parents to discuss
measure of general mental/cognitive abili- and reframe their understanding of the
ties, appropriate to the child’s age and gen- child. The report provides details of the as-
eral competency, which serves to “anchor” sessment process, the scores derived from
the clinician by referencing this child’s per- standardized measures, the diagnostic for-
formance to that of other children of the mulation, and the management and recom-
same age. It also provides a context of gen- mendations.
eral ability against which specific neuropsy- • The goal of the report and informing session
chologically relevant skills and weaknesses is to educate the child, parents/guardians,
can be evaluated. Additional tests are then and teachers/other professionals about the
selected to address the full range of behav- nature of children’s neurobehavioral devel-
ioral domains and to provide more detailed opment in general; to explain how brain-
analysis of specific psychological processes. behavior relationships in children are exam-
These may have population-based or research- ined in the evaluation; to “normalize” this
based norms. The latter typically have less child’s NP performance by situating it in the
extensive normative bases but can target larger context of neurobehavioral develop-
specific skills more precisely. ment; to relate observed behaviors to the
• Tests provide samples of observed behavior specific medical/neurological condition (where
under structured conditions; they comple- relevant); and to demonstrate the relation-
ment, but do not substitute for, observations ship of the diagnostic formulation to the
(direct or elicited) of the child in the natural management plan proposed.
environment. • The written report should present a clear
• Test performance varies in response to con- statement of the referral question(s); sum-
textual variables, including the nature of the marize relevant history, observations, and
test setting, rapport with the clinician, age of test findings organized so that the weight of
the child, test format/materials, and test con- the findings is clear; integrate the findings
struction/scoring criteria. No test can be ren- into a clear diagnostic statement (not a list of
dered so “objective” that the interaction be- what the child “can” and “cannot” do); dis-
tween child and examiner is eliminated as an cuss the relationship of the diagnostic for-
important source of diagnostic information. mulation to the child’s real-world function-
32 part i • assessment and diagnosis

ing; address the referral question specifi- additional services/evaluation from medical,
cally; reference the findings to the med- psychological, physical, and/or educational-
ical/neurological condition where relevant vocational specialists as indicated.
(noting specifically when data are, or are not,
consistent with a known disorder and locus); References & Readings
identify areas of concern (risks) based on or
referenced to the diagnostic statement; and Baron, I. S. (2003). Neuropsychological evaluation
of the child. New York: Oxford University
outline the management plan and recom-
Press.
mendations to maximize the child’s func-
Bernstein, J. H. (2000). Developmental neuropsy-
tioning in the real-world contexts of family, chological assessment. In K. O. Yeates, M. D.
school, and society at large. Ris, & H. G. Taylor (Eds.), Pediatric neuropsy-
chology: Research, theory, and practice (pp.
401– 422). New York: Guilford Press.
THE MANAGEMENT PLAN Rey-Casserly, C. (1999). Neuropsychological as-
sessment of preschool children. In E. V. Nuttall,
• A management plan has two important com- I. Romero, & J. Kalesnik (Eds.), Assessing and
ponents: education and recommendations. screening preschoolers (2nd ed.). Boston: Allyn
• The goal of the educational component is to and Bacon.
Reynolds, C. R., & Fletcher-Janzen, E. (1997).
inform the child, parents/guardians, and
Handbook of clinical child neuropsychology
other involved professionals about neurobe- (2nd ed.). New York: Plenum Press.
havioral development in children; to relate Rourke, B. P., van der Vlugt, H., & Rourke, S. B.
this child’s performance to that of other chil- (2002). Practice of child-clinical neuropsychol-
dren (with and without a similar diagnosis); ogy. Lisse, The Netherlands: Swets & Zeit-
and to provide detailed information about linger.
this child’s individual style, expectable risks Taylor, H. G. (1988). Neuropsychological testing:
(both short- and long-term), and educational Relevance for assessing children’s learning dis-
and psychosocial/emotional needs. The clin- abilities. Journal of Consulting & Clinical Psy-
ician will also address issues of medical and chology, 56(6), 795 – 800.
psychological health, as well as development Yeates, K. O., Ris, M. D., & Taylor, H. G. (2000). Pe-
diatric neuropsychology: Research, theory, and
and achievement in academic/vocational and
practice. New York: Guilford Press.
psychosocial spheres.
• Recommendations should respond to the
specific risks that the child faces now and in Related Topics
the future; be tailored to different contexts Chapter 7, “Adult Neuropsychological Assessment”
as necessary; provide general guidelines for Chapter 8, “Assessment and Intervention for Execu-
maximizing behavioral adjustment in both tive Dysfunction”
social and academic settings; foster specific Chapter 11, “Medical Evaluation of Children With
cognitive, social, and academic skills; and ad- Behavioral or Developmental Disorders”
dress psychosocial development and emo- Chapter 12, “Interviewing Parents”
tional well-being. Recommendations include Chapter 13, “Attention-Deficit/Hyperactivity Dis-
specific interventions involving accommoda- order Through the Life Span”
tions, compensatory strategies, remedial in- Chapter 27, “Measures of Children’s Psychological
Development”
struction, rehabilitation programming, and/or
assistive technologies, as well as referral for
 ADULT NEUROPSYCHOLOGICAL
7 ASSESSMENT

Aaron P. Nelson & Margaret O’Connor

GENERAL CONSIDERATIONS 8. As with any psychological intervention,

the neuropsychological evaluation should
Fundamental Assumptions of
proceed in a sensitive manner and with ex-
Clinical Neuropsychological
plicit communications regarding the use of
Assessment
clinical information.
1. It is possible to make valid inferences re- 9. A dynamic developmental life span per-
garding the integrity of the brain through spective is critical in the evaluation of each
the observation of behavior. Such inferences patient.
require a firm grasp of brain-behavior rela- 10. All behavior should be viewed within a so-
tionships and characteristic neurobehav- ciocultural context.
ioral syndromes.
2. Observable behavior is frequently the most
Uses of Neuropsychological
sensitive manifestation of brain pathology.
Assessment
3. Observable behavior, including “test be-
havior,” is a reflection of the interaction 1. Neuropsychological assessment is indicated
between the domains of person and envi- for questions of differential diagnosis and
ronment; variables from each domain must prognosis.
be assessed in order to arrive at an under- 2. Neuropsychological assessment should be
standing of the clinical significance of a considered in the setting of a deterioration
given behavior. in neuropsychological status or when there
4. A neuropsychological test is simply one is a history of neurological disease, injury,
means of eliciting a sample of behavior, or developmental abnormality affecting
under standardized conditions, which is cerebral functions.
then to be observed and analyzed. 3. Neuropsychological assessment is used to
5. Test performance and “real-life” behavior clarify the significance of known or sus-
are imperfectly correlated. Proceed with pected pathology for “real-life” functioning
caution in using test data to predict behavior. in day-to-day activities, relationships, edu-
6. Most behaviors are multifactorial and de- cation, and work.
pend on a complex interplay of cognitive, 4. Neuropsychological assessment provides
perceptual, emotional, and environmental information relevant to management, reha-
factors. bilitation, and treatment planning for iden-
7. Most neuropsychological tests are multi- tified cognitive problems.
factorial and depend on a confluence of cog- 5. Baseline (pretreatment) status and mea-
nitive and perceptual functions for their surement of treatment response (medica-
performance. tion, neurosurgery, behavioral intervention,

33
34 part i • assessment and diagnosis

electroconvulsive therapy) can be monitored servations of family members or close friends,

with serial neuropsychological testing. medical records, and prior evaluations from
6. Neuropsychological consultation is fre- academic or work situations. Information is ob-
quently critical in determination of legal/ tained regarding the following:
forensic issues, including need for guard-
ianship, neuropsychological damages, crim- 1. Developmental background, including cir-
inal responsibility, and competence to stand cumstances of gestation, birth/delivery, ac-
trial. quisition of developmental milestones, and
7. Neuropsychological research investigations early socialization skills
enhance the understanding of brain-behav- 2. Social development, including major autobi-
ior relationships and neurobehavioral syn- ographical events and relationships (a three-
dromes. These studies are of tremendous generational genogram is highly useful in
value to the understanding of neurological gaining relevant family information)
disease and normal brain function. 3. Past medical history, including illnesses, in-
juries, surgeries, medications, hospitaliza-
Approach to Neuropsychological
tions, substance abuse, and relevant familial
Evaluation
medical history
4. Psychiatric history, including hospitaliza-
1. Evaluation should be individually tailored tions, medications, and outpatient treatment
to each patient. 5. Educational background, including early
2. Test data are viewed from both qualitative school experiences and academic perfor-
and quantitative perspectives. mance during high school, college, post-
3. Assessment proceeds in a hypothesis testing graduate study, and other educational and
manner. Tests are selected to answer specific technical training
questions, some of which emerge during the 6. Vocational history, including work perfor-
evaluation process. mance, work satisfaction, and relationships
4. Standardized tests can be modified to test with supervisors and coworkers
limits and produce richer qualitative data. 7. Recreational interests and hobbies
5. Task performance is analyzed to determine
component processes, with the goal of iden-
Behavioral Observation
tification of dissociations between such pro-
cesses. Physical appearance is inspected, including sym-
metry of gross anatomic features, facial expres-
sion, manner of dress, and attention to personal
CLINICAL METHOD hygiene. The patient is asked specific questions
Referral Question regarding unusual sensory or motor symp-
toms. Affect and mood are assessed with re-
The chief complaint and presenting problems spect to range and modulation of felt/expressed
are reviewed to produce a clear description of emotions and their congruence with concurrent
their onset and course, as well as information ideation and the contemporaneous situation.
regarding the medical and social context in Interpersonal comportment is assessed in the
which the problem(s) emerged. The patient’s context of the interview. Does the patient’s be-
overall understanding of his or her current cir- havior reflect a normal awareness of self and
cumstances and the reason for the consultation other in interaction? The patient’s motivation
are sought. and compliance with examination requests, in-
structions, and test procedures are observed
History with respect to the validity of test findings.

Information is obtained from a variety of

sources, including the patient’s self-report, ob-
 7 • adult neuropsychological assessment 35

Domains of Neuropsychological should be assessed through either direct in-

Function quiry or a formal handedness questionnaire.
A sufficiently broad range of neuropsycholog- Motor speed, dexterity, and programming
ical functions is evaluated using tests and other are tested with timed tasks, some of which
assessment techniques. involve repetition of a specific motor act
(e.g., finger tapping, peg placement) and oth-
1. General intellectual ability: Intelligence en- ers of which involve more complex move-
compasses a broad array of capacities, many ments (e.g., finger sequencing, sequential
of which are not directly assessed in the tra- hand positions). Manual grasp strength can
ditional clinical setting. The estimate of be assessed with a hand dynamometer. Vari-
general intellectual ability is based on both ous forms of verbally guided movement or
formal assessment methods and a survey of praxis are examined.
demographic factors and life accomplish- 4. Attention/concentration: The capacity to
ments. Particular care must be exercised in selectively maintain and shift attentional
the evaluation of patients from varying ed- focus forms the basis of all cognitive activ-
ucational and sociocultural backgrounds. In ity. Evaluation of attention includes obser-
cases of known or suspected impairment, vations of a broad array of interrelated be-
premorbid ability is surmised from perfor- haviors. General level of arousal or alertness
mance on measures presumed less sensi- is determined through clinical observation.
tive to cerebral dysfunction (i.e., vocabu- An appraisal is made of the extent to which
lary), so-called best performance methods, environmental or diurnal factors modify
educational/professional accomplishment, arousal. Attentional functions are assessed
avocational interests and pursuits, and dem- in both auditory/acoustic and visual modal-
ographic variables. The level of general abil- ities. Attention span is measured by deter-
ity provides a reference point from which to mining the number of unrelated “bits” of
view performance on other measures. information that can be held on line at a
2. Sensation and perception: It is important to given moment in time. Sustained attention
establish to what degree primary sensation is assessed with tests that require the pa-
and perception are intact prior to initiation tient to maintain focused attention over
of testing. Significant impairment of sen- longer periods. Selective attention is mea-
sory function (auditory, visual, kinesthetic) sured with tasks requiring the patient to
is usually obvious and points to a need for shift focus from one event to another. Resis-
specialized assessment procedures. Unusual tance to interference is assessed with tasks
or abnormal gustatory and olfactory experi- requiring the patient to inhibit overlearned
ences should be sought through direct ques- responses or other distractions that could
tioning. Simple auditory function can be as- undermine a desired response.
sessed by finger-rub stimuli to each ear. Vi- 5. Learning and memory: The assessment of
sion is examined with tests of acuity, memory function is perhaps the most com-
tracking, scanning, depth perception, color plex endeavor of the neuropsychological ex-
perception, and attention/neglect for visual amination. Memory is assessed with respect
field quadrants. Kinesthetic perception is as- to time of initial exposure (anterograde vs.
sessed with tests of graphesthesia and stere- retrograde), modality of presentation (acous-
ognosis. Double simultaneous stimulation tic vs. visual), material (linguistic vs. fig-
can be used in auditory, visual, and kines- ural), and locus of reference (personal vs.
thetic modalities to determine whether nonpersonal). The evaluation of memory
hemiextinction occurs. should include measures that allow the neu-
3. Motor functions: Naturalistic observations ropsychologist to parse out the component
of the patient’s gait and upper and lower ex- processes (encoding, consolidation, retrieval)
tremity coordination are an important part entailed in the acquisition and later recall of
of the motor examination. Hand preference information. To this end, measures are used
36 part i • assessment and diagnosis

to assess performance with respect to length Left/right orientation can be assessed by

of interval between exposure and demand for having the patient point to specific body
recall (none vs. short vs. long delay) and ex- parts on himself or herself or the examiner.
tent of facilitation required to demonstrate Topographic orientation can be tested in
retention (free recall vs. recognition). The most patients by instructing them to indi-
assessment of retrograde memory function cate well-known locales on a blank map.
poses a special problem insofar as it is diffi- Graphic reproduction of designs and assem-
cult to know with certainty what informa- bly of patterns using sticks, blocks, or other
tion was contained at one time in the remote media are used to assess visual organization
memory of a particular patient. Although a and constructional abilities.
number of formal tests can be used for this 8. Executive functions: Executive functions
purpose, we also assess this aspect through comprise the capacity of the patient to pro-
asking for personal information that pre- duce cognitive behavior in a planned, orga-
sumably is or had been well known at one nized, and situationally responsive manner.
time by the patient (e.g., names of family The assessment of executive functions is ac-
members, places of prior employment). complished in an ongoing fashion through
6. Language: Language is the medium through observation of the patient’s approach to all
which much of the neuropsychological ex- types of tests and via his or her comport-
amination is accomplished. Language func- ment within the consultation. Although few
tion is assessed both opportunistically, as tests assess these functions directly or specif-
during the interview, and via formal test in- ically, the clinician looks for evidence of
struments. Conversational speech is ob- flexibility versus perseveration, initiation
served with respect to fluency, articulation, versus abulia, self-awareness versus obliv-
and prosody. The patient’s capacity to re- iousness, planfulness versus impulsivity,
spond to interview questions and test in- and capacity to assume an abstract attitude
structions provides an informal index of re- versus concreteness.
ceptive language ability or comprehension. 9. Psychological factors and emotion: Stan-
Visual confrontation naming is carefully as- dardized measures of mood, personality, and
sessed so that word-finding problems and psychopathology can be used to explore the
paraphasic errors may be elicited. Repetition role of these issues in the patient’s presenta-
is measured with phrases of varying length tion and diagnosis. It is important to note,
and phonemic complexity. Auditory com- however, that neurological and other med-
prehension is evaluated by asking the pa- ical conditions can skew performance on cer-
tient questions that vary in length and tain personality tests; hence, interpretation
grammatical complexity. Reading measures must take this into account through the use
include identification of individual letters, of “correction” methods where available and
common words, irregularly spelled words, in exercising caution in drawing diagnostic
and nonwords, as well as measures of read- conclusions.
ing speed and comprehension. Spelling can
be assessed in both visual and auditory
Diagnostic Formulation
modalities. A narrative handwriting sample
can be obtained by instructing the patient to Data from the history, observation, and testing
describe a standard stimulus scene. of the patient are analyzed collectively to pro-
7. Visuospatial functions: After basic visuo- duce a concise understanding of the patient’s
perceptual status is established, the assess- symptoms and neuropsychological diagnosis.
ment of visuospatial function commences A configuration of abilities and limitations is
with the evaluation of the spatial distribu- developed and used both diagnostically and as a
tion of visual attention. Visual neglect is framework for the elucidation of goals for
examined by way of tasks entailing scan- treatment. When possible, the diagnostic for-
ning across all quadrants of visual space. mulation should identify the neuropathological
 7 • adult neuropsychological assessment 37

factors giving rise to the patient’s clinical pre- Heilman, K., & Valenstein, E. (Eds.) (1993). Clinical
sentation, including underlying anatomy and neuropsychology (3rd ed.). New York: Oxford
disease process. University Press.
Kaplan, E. (1983). Process and achievement revis-
ited. In S. Wapner & B. Kaplan (Eds.), Toward a
holistic developmental psychology (pp. 143 –
Recommendations and Feedback
156). Hillsdale, NJ: Erlbaum.
Consultation concludes with feedback, in which Kaplan, E. (1988). A process approach to neuropsy-
findings and recommendations are reviewed chological assessment. In T. Boll & B. Bryant
with relevant individuals (e.g., referring physi- (Eds.), Clinical neuropsychology and brain
cian, patient, family, treatment team mem- function: Research, measurement, and prac-
tice. Washington, DC: American Psychological
bers). A variety of treatment plans may be ad-
Association.
vised, including pharmacological intervention,
Kolb, B., & Wishaw, I. Q. (Eds.) (1990). Fundamen-
psychiatric consultation, psychotherapy, voca- tals of human neuropsychology (3rd ed.). New
tional guidance, and cognitive-behavioral re- York: Freeman.
mediation. Recommendations should be prag- Lezak, M. (1995). Neuropsychological assessment
matic and individually tailored to each patient’s (3rd ed.). New York: Oxford University Press.
specific needs. Strategies for optimizing perfor- Mesulam, M. M. (Ed.) (1985). Principles of behav-
mance in personal, educational, and occupa- ioral neurology. Philadelphia: F. A. Davis.
tional spheres are identified and discussed in Spreen, O., & Strauss, E. (1991). A compendium of
lay language that the patient and family mem- neuropsychological tests: Administration, norms,
ber can comprehend. Where possible, specific and commentary. New York: Oxford Univer-
sity Press.
behaviorally based suggestions are made for
Walsh, K. W. (1987). Neuropsychology: A clinical
remediation of identified problems. Further
approach (2nd ed.). Edinburgh: Churchill Liv-
clinical evaluations and other neurodiagnostic ingstone.
procedures are suggested when appropriate in Walsh, K. W. (1992). Some gnomes worth knowing.
order to provide more information relevant to Clinical Neuropsychologist, 6, 119 –133.
differential diagnosis, response to treatment,
and functional status over time. Appropriate
Related Topics
neuropsychological follow-up is also arranged.
Chapter 8, “Assessment and Intervention for Execu-
tive Dysfunction”
References & Readings Chapter 13, “Attention-Deficit/Hyperactivity Dis-
order Through the Life Span”
Feinberg, T., & Farrah, M. (Eds.) (1997). Behavioral
neurology and neuropsychology. New York:
McGraw-Hill.
 ASSESSMENT AND
8 INTERVENTION FOR
EXECUTIVE DYSFUNCTION

Robert M. Roth, Peter K. Isquith, & Gerard A. Gioia

Executive functions are interrelated control • Sustain: Stay with or stick to an activity for
processes involved in the selection, initiation, ex- an age-appropriate amount of time
ecution, and monitoring of cognitive function- • Plan: Anticipate future events, set goals, and
ing, as well as aspects of motor and sensory func- develop appropriate steps ahead of time
tioning. They are self-regulatory functions that • Organize: Establish or maintain order in in-
organize and direct cognitive activity, emotional formation, an activity or place; carry out
responses, and overt behaviors. Neisser (1967) tasks in a systematic manner
described executive functions as the orchestra- • Self-monitor: Check on one’s own actions
tion of basic cognitive processes during goal- during, or shortly after, finishing a task to
oriented problem-solving, differentiating “basic” assure appropriate attainment of goal;
cognitive functions from “executive” cognitive awareness of one’s cognitive, physical, and
control functions. In this metaphor, the executive emotional abilities or state
serves as the conductor of the orchestra by mak- • Problem solving: Ability to think abstractly
ing intentional decisions regarding the final out- and form or develop concepts necessary to
put of the music and recruiting the necessary achieve a goal
components in reaching the intended goal (Gold-
berg, 2002). The “instruments” are the domain- Individuals with executive dysfunction can ex-
specific functions, such as language, visual/non- hibit a broad range of problems such as acting
verbal reasoning, and memory. inappropriately due to difficulty inhibiting im-
The specific cognitive processes subsumed pulses, quickly losing track of what they are
under the “executive” umbrella include: thinking or doing, making poor financial or
other personal decisions, or having consider-
• Inhibit: Ability to not act on an impulse, stop able difficulty getting started on tasks. Difficul-
one’s own activity at the proper time, and ties with executive functions are often mani-
suppress distracting information from inter- fested in more than one specific cognitive do-
fering with ongoing mental or behavioral ac- main, such that inhibitory control deficits can
tivity be expressed as verbal disinhibition, behavioral
• Shift: Move flexibly from one situation, ac- impulsivity, attentional distractibility, emo-
tivity, or aspect of a problem to another as tional reactivity, or social inappropriateness.
the situation demands Historically, executive functions have been
• Emotional control: Control one’s emotional closely associated with the integrity of the
response as appropriate to the situation or frontal lobes of the brain. Much of the evi-
stressor; maintain an optimal level of arousal dence supporting a role for the frontal lobes in
• Initiate: Begin a task or activity executive functions has come from studies of
• Working memory: Hold information ac- patients with acquired focal damage to this re-
tively in mind over time gion (Luria, 1966; Stuss & Levine, 2002).

38
 8 • assessment and intervention for executive dysfunction 39

More recently, studies using advanced brain The precise nature of the executive dysfunc-
imaging techniques such as positron emission tion observed in such conditions varies. For ex-
tomography (PET) and functional magnetic ample, some disorders have been commonly,
resonance imaging (fMRI) have shown that but not exclusively, associated with deficits in
the frontal lobes play an intimate role in exec- inhibitory control (e.g., ADHD-combined
utive functions (Cabeza & Nyberg, 2000). type, OCD, TS), while others appear to involve
However, neuroimaging studies have also prominent deficits in working memory (e.g.,
clearly shown that executive functions are not ADHD-inattentive type, schizophrenia, multi-
subserved by the frontal lobes alone, but ple sclerosis).
rather by distributed neural circuitry that in-
cludes other cortical regions such as the tem-
poral and parietal lobes, subcortical structures ASSESSMENT OF EXECUTIVE
such as the hippocampus and basal ganglia, DYSFUNCTION
and the cerebellum. Furthermore, studies of
patients with acquired focal lesions in non- Numerous measures have been designed to as-
frontal brain regions such as the basal ganglia sess subdomains of executive function (Rabbitt,
have provided further support for a distrib- 1997). Some of the most commonly employed
uted circuitry model of executive functions. performance measures are the Wisconsin Card
Damage to any given component of this cir- Sorting Test, the Stroop Task, Verbal Fluency
cuitry may result in executive dysfunction. tests, Tower tasks (e.g., Tower of London,
Executive functions are mediated by a num- Tower of Hanoi), and Trail Making tests (Le-
ber of neurochemicals, particularly dopamine, zak, 1995; Spreen & Strauss, 1998). Establish-
serotonin, and norepinephrine (Robbins, ing that an individual has executive dysfunc-
2000). Roles for other neurochemicals such as tion usually includes not only such psychome-
glutamate, acetylcholine, and GABA are being tric tests but also a clinical interview and
increasingly investigated. Disruption of one or behavioral observations, at times supplemented
more of these neurochemical systems may in by reports from informants familiar with the
part account for executive dysfunction in con- individual. Confirming that executive dysfunc-
ditions where there is no obvious structural tion is present also requires that problems in
brain damage. the basic cognitive, sensory, and motor func-
The following list includes some of the more tions be ruled out as accounting for the appear-
common disorders with executive deficits: ance of executive dysfunction. These include
basic attention, language, visuospatial skills,
• Attention-deficit/hyperactivity disorder sensory inputs (e.g., hearing, vision), periph-
(ADHD) eral motor function, and learning and memory.
• Autism spectrum disorders Assessment of executive function is thus
• Tourette’s syndrome (TS) complicated. It is difficult to tease apart deficits
• Learning disabilities in executive from domain-specific functions,
• Traumatic brain injury given that most neuropsychological tests are
• Epilepsy multifactorial in nature. Highly structured
• Brain tumors testing may be providing the organization,
• Multiple sclerosis and other disorders affect- guidance, and cuing necessary for optimal per-
ing white matter connectivity formance on tests of executive function, which
• Parkinson’s disease, Huntington’s disease, would generally not be available in naturalis-
and other movement disorders tic settings. Many tests of executive functions
• Alzheimer’s disease and other dementias are susceptible to practice effects. That is, once
• Psychiatric disorders such as schizophrenia, a person figures out how to successfully com-
major depressive disorder, obsessive-com- plete the test, he or she often performs much
pulsive disorder (OCD), and bipolar disorder better on repeat testing or on similar tests. This
• Alcoholism and substance abuse disorders is consistent with evidence that executive dys-
40 part i • assessment and diagnosis

function is more readily observed when pa- • Goal-setting: An initial decision about or
tients are faced with novel tasks or stimuli, choice of a goal to pursue (What do I need to
rather than familiar or routine tasks. accomplish?)
Despite these limitations, performance tests • Self-awareness of strengths/weaknesses:
of executive function can be useful in discrimi- Recognition of one’s stronger and weaker
nating between clinical and normal samples, abilities, and a decision about how easy or
and exhibit good sensitivity but not necessarily difficult it will be to accomplish the goal
high specificity for specific disorders (Gioia, (How easy or difficult is this task/goal?
Isquith, & Guy, 2001; Grant & Adams, 1996; Have I done this type of task before?)
Pennington & Ozonoff, 1996). Increased atten- • Organization/planning: Development of an
tion has been devoted to developing instru- organized plan (What materials do we need?
ments with greater ecological validity, includ- Who will do what? In what order do we need
ing: to do these things? How long will it take?)
• Flexibility/strategy use: As complications or
• Performance tests that require patients to obstructions arise, planned (e.g., staff mem-
complete “real-world” type tasks in the lab- bers ensure that problems arise) or un-
oratory, such as the Test of Everyday Atten- planned coaching of the students in flexible
tion (TEA), Test of Everyday Attention for problem solving/strategic thinking (When/
Children (TEA-Ch), and the Behavioural if a problem arises, what other ways should
Assessment of the Dysexecutive Syndrome I think about to reach the goal? Should I ask
(BADS) for assistance?)
• Structured clinician rating scales such as the • Monitoring: A review of the goal, plan, and
Frontal Behavioral Inventory accomplishments at the end (How did I do?)
• Patient and/or informant completed ques- • Summarizing: What worked and what didn’t;
tionnaires such as the Behavior Rating In- what was easy and what was difficult and why
ventory of Executive Function (BRIEF), Dys-
executive Questionnaire (DEX), and Frontal For individuals just starting to learn executive
Systems Behavioral Scale (FrSBe) control behaviors, young children, or individu-
als with extreme executive dysfunction, the
focus of intervention often needs to be more
INTERVENTION FOR EXECUTIVE externalized or environmental, such as orga-
DYSFUNCTION nizing and structuring the external environ-
ment for them, and cuing strategies and behav-
An understanding of the executive components ioral routines. They often need help to know
of an individual’s functioning can lead to tar- when and how to apply the appropriate problem-
geted pharmacological, behavioral, cognitive, solving behavioral routine. Direct rewards and
or other therapeutic interventions. Such strate- positive incentives are often necessary to mo-
gies may be specifically targeted toward one tivate the individual to attend to and practice
area of executive functions, such as antecedent new behavioral routines. Once behavioral rou-
management for children with inhibitory con- tines have become established, positive cuing
trol deficits, or may be more programmatic, becomes the crucial factor; cuing can then be
such as the comprehensive cognitive rehabilita- faded, as a function of the individual’s increas-
tion programs. ing autonomy.
An executive system intervention focus is
possible in most daily activities involving more
than one step for completion, including class- References, Readings, & Internet Sites
room, therapy, social/recreational, and activi- Cabeza, R., & Nyberg, L. (2000). Imaging cognition
ties of daily living at home (Ylvisaker & II: An empirical review of 275 PET and fMRI
Feeney, 1998). For example, any of these activ- studies. Journal of Cognitive Neuroscience, 12,
ities can include: 1– 47.
 9 • child and adolescent diagnosis with DSM - IV 41

Gioia, G. A., Isquith, P. K., & Guy, S. C. (2001). As- Pennington, B. F., & Ozonoff, S. (1996). Executive
sessment of executive function in children with functions and developmental psychopathology.
neurological impairments. In R. Simeonsson & Journal of Child Psychology and Psychiatry
S. Rosenthal (Eds.), Psychological and develop- and Allied Disciplines, 37, 51– 87.
mental assessment (pp. 317 –356). New York: Rabbitt, P. (Ed.). (1997). Methodology of frontal
Guilford Press. and executive function. Hove, UK: Psychology
Goldberg, E. (2002). The executive brain: Frontal Press.
lobes and the civilized mind. New York: Ox- Robbins, T. W. (2000). Chemical neuromodulation
ford University Press. of frontal-executive functions in humans and
Grant, I., & Adams, K. M. (Eds.). (1996). Neuropsy- other animals. Experimental Brain Research,
chological assessment of neuropsychiatric dis- 133, 130 –138.
orders (2nd ed.). New York: Oxford University Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive
Press. rehabilitation: An integrative neuropsycholog-
Krasnegor, N. A., Lyon, G. R., & Goldman-Rakic, ical approach. New York: Guilford Press
P. S. (1997). Development of the prefrontal cor- Spreen, O., & Strauss, E. (1998). A compendium of
tex: Evolution, neurobiology, and behavior. neuropsychological tests (2nd ed.). New York:
Baltimore: Paul H. Brookes. Oxford University Press.
Lezak, M. D. (1995). Neuropsychological assess- Stuss, D. T., & Levine, B. (2002). Adult clinical neu-
ment (3rd ed.). New York: Oxford University ropsychology: Lessons from studies of the
Press. frontal lobes. Annual Review of Psychology,
Luria, A. R. (1966). Higher cortical functions in 53, 401– 433.
man. New York: Basic Books. Ylvisaker, M., & Feeney, T. J. (1998). Collaborative
National Academy of Neuropsychology. (n.d.). brain injury intervention: Positive everyday
Home page. Retrieved 2004 from http://www. routines. San Diego: Singular.
nanonline.org
Neisser, U. (1967). Cognitive psychology. New
Related Topics
York: Appleton-Century-Crofts.
Neuropsychology Central. (n.d.). Home page. Re- Chapter 6, “Developmental Neuropsychological As-
trieved 2004 from http://www.neuropsychology sessment”
central.com Chapter 7, “Adult Neuropsychological Assessment”

CHILD AND ADOLESCENT

9 DIAGNOSIS WITH DSM-IV

Stuart M. Goldman

The fourth edition of the Diagnostic and Statis- scriptive assessment based primarily on his-
tical Manual of Mental Disorders (DSM-IV) tory. It provides a five-axis system of evalua-
follows the approach to diagnosis established by tion, each of which covers a different realm of
DSM-III and DSM-III-R of an atheoretical, de- information.
42 part i • assessment and diagnosis

• Axis I refers to the majority of the primary No: Move on to adjustment disorder.
psychiatric disorders. Yes: What has been the duration (Question 4)?
• Axis II refers to personality disorders and
Less than 1 month? Acute stress disorder.
mental retardation.
• Axis III covers general medical conditions. More than 1 month? Is there reexperiencing,
• Axis IV provides a scale of psychosocial avoidance, or numbing and increased arousal?
stressors from 1 (none) to 6 (catastrophic). Yes: PTSD (all three must be present).
• Axis V details, utilizing the Global Assess- No: Adjustment disorder, which is modified by
ment Scale of Functioning, the patient’s level the affected area (Question 3) to include distur-
of functioning on a scale of 1 (worst) to 100 bance of mood (anxiety, depression), conduct,
(best). or mixed.

This multiaxial, multidimensional system en- 3. What basic area or areas are affected?
hances the clinician’s capacity for assessment, As one gathers history, are the primary
planning, and prognosis. In addition to its clin- symptoms behavioral, mood, body parts or
ical utility, it was designed to be interrater re- functions, disconnection, multiple/pan, or exter-
liable, compatible with ICD-9CM, and consis- nally induced? This refers to the predominant
tent with and suitable for research studies. areas of concern as one is undertaking the diag-
In practice, most clinicians want a practical nostic evaluation. Each area, when answered in
and succinct approach to arrive at a working the affirmative, leads to a short decision tree cul-
DSM-IV diagnosis. It must include both child- minating in DSM-IV diagnosis. There may be
hood and general diagnosis, since almost all diag- more than one area of significant concern, lead-
noses are applicable to a child or adolescent pop- ing to several diagnoses. When there are con-
ulation. To this end, we have developed an easy- cerns in almost every area, the multiple/pan cat-
to-use schema utilizing four questions to arrive egory should be considered first.
rapidly at a working diagnosis, which then must Behavioral disorders are characterized by
be confirmed against the full DSM criteria. either an inability or an unwillingness to be-
have and/or follow social or societal rules.
1. Where is the problem primarily located?
Does the child appear to deliberately misbe-
If it is within the child (such as attention-
have?
deficit/hyperactivity disorder [ADHD]), con-
tinue with the next set of questions. Yes: Does he or she break societal rules (things
that would lead to arrest in adults)? Likely con-
If it is not within the child, is it between the
duct disorder.
parent and the child? V-codes.
Yes: Breaks mostly social rules (hard, unpleas-
In the parent? Consider adjustment disorders
ant to manage or get along with)? Likely oppo-
for the child and a primary diagnosis for the
sitional defiant disorder.
parent.
No: Is the child inattentive, hyperactive, or im-
Between the child and the school? Consider a
pulsive? Likely ADHD.
systems-based etiology and intervention.
If the child is hyperactive, inattentive, impul-
sive, and deliberately misbehaves, likely both
2. Is the problem reactive to an identifiable ADHD and either oppositional defiant or con-
stressor or event? duct disorder.
No: Move on to Question 3.
Mood disorders are characterized by a pre-
Yes: The child has either an adjustment disorder dominance of unpleasant or inappropriate
or posttraumatic stress disorder (PTSD). moods and may include anxiety, depression,
Did the event include actual or threatened se- mania, irritability, or some combination. They
rious injury or death with intense affects? must be sufficiently intense to cause some dys-
 9 • child and adolescent diagnosis with DSM - IV 43

function. Each leads to a symptom-focused de- No: Return to schema.

cision tree. Yes: Name the part or dysfunction, and the
disorder follows.
Which affect is primarily involved?
Does the trouble center on eating?
Anxiety? Too little: Anorexia nervosa.
Is the child anxious in almost all ways? Too much: Bulimia nervosa.
Generalized anxiety disorder.
Not food: Pica.
If specific, is it fear of being away from fam-
Regurgitation: Rumination disorder.
ily/home? Separation anxiety disorder.
Bowel or bladder problems (specify if never
Fear or difficulty being in places? Agora-
controlled [primary] versus regression [sec-
phobia.
ondary])?
Fear with multiple incapacitating somatic
Bladder: Enuresis.
symptoms? Panic attacks.
Bowel: Encoporesis.
Anxiety with unremitting worries or persis-
tent useless behaviors? Obsessive-compul- Unwanted movements or sounds?
sive disorder. Less than a year? Transient tic disorder.
Fear of a certain circumscribed thing? Sim- More than a year?
ple phobia reflecting the specific item. Muscles: Motor tic.
Depression (may present as sadness, irritability)? Sounds: Vocal tic.
Is this a clinically significant depression Both: Tourette’s syndrome.
with dysphoria, isolation, boredom, or irri-
Sleep problems?
tability?
Dramatic awakening with morning memo-
No: Return to other categories.
ries? Nightmares.
Yes: What is the duration of symptoms?
Dramatic awakening without morning
Greater than 1 year, with disruption of func- memories? Likely night terrors.
tioning? Likely dysthymic disorder.
Genitalia, gender complaints?
Greater than 2 weeks, with major somatic
symptoms (sleep, weight, concentration) With complaints or confusion about physi-
and/or suicidal elements (ideation, plan, at- cal parts, roles, and so on: Gender identity
tempts)? Likely major depressive disorder. dx.
Elements of both? Dysthymic and major Complaints about other body parts?
depressive disorder. One part not working: Conversion disorder.
Have there been periods of elation, increased Many things (13) not working: Somato-
activity, racing thoughts, out-of-control ac- form disorder.
tions, decreased sleep, hypersexuality, or ex- Parts working but very worried: Hypochon-
treme irritability? driasis.
No: Unipolar major depression. Language trouble?
Yes: Mild? Likely cyclothymia. Severe? Input: Receptive language.
Manic-depressive disorder.
Output: Expressive.
Body part or function disorders are character- Both: Mixed.
ized by specific troubles in carrying out a daily
bodily function or by complaints about a spe- Decreased output but normal capability: Se-
cific body part or parts. lective mutism.
Is there a body part or function that the Learning trouble?
clinical difficulties center upon? Specific area? Reading, writing, math.
44 part i • assessment and diagnosis

General cognition? No: Return to earlier on the decision tree.

Mild to profound retardation on Axis II. Yes: Possibly borderline character of child-
hood Axis II (trouble with relationships,
Disconnection disorders appear around a rage, identity concerns/confusion, self-
discontinuity in sense of self or in functioning destructive, all in a shifting framework of
that is not deliberate on the part of the patient. functioning).
They are relatively uncommon and should raise
the suspicion of abuse or maltreatment. Externally induced disorders are caused by
an external substance such as alcohol, mari-
Many selves? Dissociative identity disorder. juana, tobacco, or cocaine. Each of these disor-
ders is diagnosed by a significant involvement
Travel? (How did I get here? Where am I?)
with the substance in question and then named
Fugue disorder.
accordingly. Although they are far more com-
Forgetting? Amnestic disorder. mon in adolescents, they are seen in younger
Unreal? Depersonalization disorder. children as well. They are commonly seen as
comorbid disorders with a wide range of other
Multiple or pan disorders present with major psychiatric diagnoses.
disruptions in all spheres of the patient’s func-
tioning, including school, home, peers, and self. Is there substantial involvement with a sub-
Generally patients’ impairments are quite ob- stance?
vious, even if their diagnosis is not. Yes: Give the child a substance disorder
(naming the substance in question).
Has the child’s ability to interact with others
been the major area of concern since early child- 4. Are the symptoms in question longstanding
hood? and ego-syntonic? If yes, then consider the rel-
evant Axis II diagnosis, except for antisocial
No: Continue below.
personality disorder.
Yes: Is language capacity mostly spared,
even if collaborative communication is not?
No: Likely autism (must consider other di- SUMMARY
agnoses, such as major language disorders).
Yes: Probably Asperger’s syndrome. The schema just described is designed to help
Has the child been related but developed major clinicians in a time- and energy-sensitive man-
dysfunctioning with odd or bizarre behaviors? ner to focus their diagnostic efforts and come to
a probable DSM-IV diagnosis. Each diagnosis
No: Continue below.
should be confirmed by applying the full DSM-
Yes: There is bizarre or odd behavior, but IV criteria. The diagnosis must then be placed
there is minimal affective component. Prob- in the context of a multidimensional formula-
ably childhood schizophrenia. tion to ensure that an optimal treatment plan is
Yes: Is there a major ongoing component of implemented.
depression or of elation, increased activity,
or irritability?
References & Readings
Yes: Depression? Probably major depressive
disorder (likely with psychotic features). American Psychiatric Association. (1994). Diagnos-
Yes: Elation, activity, and so on, or a combi- tic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
nation of depression and elation? Manic-
Beitman, B., & Goldfried, M. (1989). The movement
depressive disorder.
toward integration of the psychotherapies.
Does the child have marked shifts in his or her American Journal of Psychiatry, 146, 138 –
level of functioning dependent upon the context? 147.
 10 • formulating diagnostic impressions 45

Goodman, A. (1991). Organic unity theory: The and adolescent psychiatry. Washington, DC:
mind-body revisited. American Journal of Psy- American Psychiatric Association.
chiatry, 148, 553 –563.
Sperry, L., Gudeman, J. E., Blackwell, B., & Faulkner,
L. R. (1992). Psychiatric case formulations. Related Topic
Washington, DC: American Psychiatric Associ-
ation. Chapter 10, “Formulating Diagnostic Impressions
Weiner, J. M. (1997). Diagnostic classification in With Ethnic and Racial Minority Children
DSM-IV. In J. Weiner (Ed.), Textbook of child Using the DSM-IV-TR”

FORMULATING DIAGNOSTIC
IMPRESSIONS WITH ETHNIC
10 AND RACIAL MINORITY
CHILDREN USING THE
DSM-IV-TR

Ronn Johnson

The Diagnostic and Statistical Manual of Men- dorsed by the American Psychological Associa-
tal Disorders (text rev., or DSM-IV-TR; Amer- tion (APA). The APA emphasized the relevance
ican Psychiatric Association, 2000) is a primary of culture by developing a set of guidelines for
clinical reference assessment tool used in the psychological practice with culturally diverse
psychodiagnostic process with children. It in- populations. One example included addressing
cludes information critical for rendering diag- the cultural issues within the Ethical Principles
nostic impressions across ethnoracial groups. of Psychologists and Code of Conduct (APA,
Yet, while the inclusion of cultural factors 2002). Attention to cultural issues is also a guid-
within the DSM-IV-TR is a noteworthy devel- ing principle in determining APA accreditation
opment in psychiatric nosology, it represents a for all clinical, counseling, and school psychol-
somewhat turbulent milestone. For example, ogy training programs. In spite of such profes-
there is more of an extensive coverage of cul- sional attention, there are persistent concerns
ture within the DSM-IV-TR than was the case about how culture is being integrated within
in previous editions of the Diagnostic and Sta- the diagnostic classification of mental illness.
tistical Manual. In many respects, the DSM- The DSM’s cultural infusion occurs in a dis-
IV-TR reinforces the need to assess ethnoracial jointed, uneven manner. It could be argued by
factors while in the diagnostic process. In this some that it is beyond the scope of the DSM-
case, the DSM-IV-TR seemed to follow the cross- IV-TR to completely establish the role of cul-
cultural momentum that was seemingly en- ture within the diagnostic process. Despite the
46 part i • assessment and diagnosis

lengthy debates that could occur in this area, it lar group. This includes their worldview, be-
is important to recognize and examine three liefs, ethics, values, norms of conduct, and so
central issues related to the use of the DSM-IV- forth. These meanings must be accounted
TR with ethnic minority children. for when formulating a diagnostic impres-
sion with ethnic minority children or the di-
1. Culture must be viewed as a relevant factor agnosis will be invalid (Johnson, 1993).
when developing diagnostic impressions re- • The clinician is the largest source of error in
lated to the mental illness in children. How- the reliability and validity of DSM-IV-TR
ever, the DSM-IV-TR does not provide diagnosis with ethnic minority children.
enough guidance in how to cogently inte- Three factors associated with that error are
grate cultural influences with specific diag- discussed below.
nostic questions. • The clinician must competently assess the
2. The huge variance in the cultural competen- child’s level of acculturation and the child’s
cies of clinicians working with ethnic-racial transition distress from the home culture to
minority children is also often reflected in another cultural experience. “Transition dis-
their diagnostic skills. While it is obvious tress” refers to a child’s reluctance or strug-
that ethnoracial factors are important for gle to successfully move from one activity or
clinical work, only within the past decade setting to another. To do so, the clinician
have they emerged as a consistent topic must (minimally) establish credibility (Sue
within mainstream training programs. & Sue, 1990) with the child as well as with
3. Since cultural factors influence the way eth- the adult caretakers and must conduct an ap-
nic minority children present themselves propriate interview addressing these issues.
(e.g., patterns of cultural characteristics as- • The clinician must accept the client’s lan-
sociated with behavior or shared meanings), guage, socioeconomic status, and attitude to-
it is the objective of this chapter to introduce ward mental health treatment as irrelevant
some of the cultural elements that are often to any psychopathology diagnosis that is to
relevant to the diagnosis of ethnic minority be established.
children. • The clinician must remain supremely aware
of his or her impact on the interviewee.
The goal of this chapter is to provide a start- There is some indication that less obvious
ing place for clinicians as they perform diag- and unintentional discrimination by a clini-
nostic work using the DSM-IV-TR with ethnic cian can affect the assessment data presented
minority children. Because all ethnic groups by ethnic minority patients.
cannot be considered here individually, some • The use of assessment tools to measure ac-
ethnoracial African American and Hispanic culturation should be considered.
children are used as illustrative examples, but • The clinician must collect a culturally rele-
it is hoped that the guidelines presented here vant history that includes an assessment of
can serve as a conceptual diagnostic framework the child’s racial identity. An informed ex-
when working with any ethnic minority chil- amination of all the cultural influences on
dren. It is important to recognize that cultural the child’s identity may not be readily ob-
factors associated with African American and servable by the clinician, and some issues of
Hispanic children are different from those pre- racial identity development may contribute
sented by children of other ethnic minority to the child’s negative reaction to the clini-
groups, and that the examples provided here do cian. One preferred method of determining a
not exhaust the content base necessary for child’s racial identity development involves
working effectively with African American and studying the various racial identity models
Hispanic children. (e.g., Cross, 1991; Ponterotto, 1988). Unfor-
tunately, this approach relies too heavily on
• By definition, “culture” generally refers to the competencies that the clinician brings
the meanings held by members of a particu- into the diagnostic process.
 10 • formulating diagnostic impressions 47

• The more mainstream the clinician’s own relevant for the development of treatment
cultural identification, the more likely is the plans for ethnic minority children. Histori-
clinician to overlook certain salient cultural cally, the DSM has been ripe for ethnocentric
frameworks. In this case, cultural sensitivity criticisms. Many of its diagnostic criteria have
is not synonymous with cross-cultural com- limited cross-cultural utility, and diagnosis
petency. Cross-cultural training and requi- with the DSM-IV-TR is too dependent on clin-
site supervision are highly recommended for icians who often are not adequately cross-
the clinician involved with an ethnic minor- culturally trained. In addition, the tools or
ity child. methods typically used to arrive at a DSM di-
• Finally, the clinician’s knowledge of ethnora- agnostic impression for ethnic minority chil-
cial oppression and rejection may offer a crit- dren are inappropriate (Berry, Poortinga,
ical insight into the patient’s response to the Segall, & Dasen, 1992).
diagnostic process. For example, African Johnson (1993) points out the restricted clin-
Americans have historically been the targets ical utility of certain diagnostic categories with
of undesirable attributes or stereotypes (e.g., these children (e.g., conduct disorder, opposi-
low intelligence, sexual prowess, criminal tional disorder, and posttraumatic stress dis-
behaviors). African Americans also carry order). For example, there is an undesirable
into the diagnostic process significant experi- tendency for the DSM-IV-TR to be overly in-
ences of exploitation, discrimination, and clusive (i.e., yield increased false-positive diag-
generally bad treatment within the mental noses). This characteristic is likely to have a
health service system. Consequently, many more damaging effect on ethnic minority chil-
children are taught by adult caretakers to be dren. For example, under conduct disorder the
wary of their disclosures to mainstream psychologist is strongly encouraged to consider
clinicians. That is, part of the cultural will a child’s “reaction to the immediate social con-
passed on from generation to generation is text.” Despite this DSM-IV-TR warning, some
aimed at insulating and protecting children ethnic minority children displaying externaliz-
from what is often perceived as service- ing behaviors related to poverty or exposure to
related hostility. violence may be inappropriately labeled as hav-
ing a conduct disorder. Anderson (1991) demon-
It is only logical to presume these children’s strates that stress is underdiagnosed in some of
cultural expectations and experiences may these ethnoracial populations.
cloud a clinician’s ability to develop a more ac- The most common mental disorders of
curate diagnostic impression, so knowledge of childhood and adolescence listed in the DSM-
those expectations and experiences is critical. IV-TR include adjustment disorders, behavior
One way a mainstream clinician may start to disorders, attention-deficit/hyperactivity dis-
learn more about ethnoracial oppression and order, oppositional defiant disorder, conduct
rejection could involve reading history and de- disorder, depressive disorders, anxiety disor-
voting part of the clinical interview to discus- ders, substance-related disorders, and eating
sion of racism experiences. Consultation with disorders.
more culturally competent clinicians is also One of the strengths of the DSM-IV-TR is
recommended. the fact that it is empirically based. It was de-
veloped in conjunction with the World Health
Organization’s publication of the 10th edition
TREATMENT PLANNING of the International Classification of Diseases
(ICD-10). It is at least minimally sensitive to
In a cautionary statement, the DSM warns culturally relevant issues and represents a con-
clinicians that the manual is not intended to siderable improvement over the DSM-III-R in
encompass all mental health conditions. Unfor- terms of cultural factors. Cultural considera-
tunately, there is no such warning that infor- tions are now mentioned in a significant man-
mation available in the DSM-IV-TR may be ir- ner, in contrast to the scant allusion made to
48 part i • assessment and diagnosis

culture in the introductory sections of the prescribed set of behaviors just to accommo-
DSM-III-R. In the DSM-IV-TR, the criteria for date to the mainstream. On the other hand,
many disorders are accompanied by descriptive some children feel a need to display differ-
sections on culture, age, and gender, reflecting ent sets of behavior due to some discomfort
an understanding of mental disorders in a con- or other reasons. Diagnostically, the way
text broader than their symptoms. Extending the child presents under either of these con-
this thinking, the clinician can take the follow- ditions influences the clinical picture as as-
ing steps to use the DSM-IV-TR more effec- sessed by the psychologist.
tively with ethnic minority children: 4. The clinician should also recognize that di-
agnostically relevant behaviors might be
1. Clinicians should become as familiar as pos- cloaked by the stage of racial identity devel-
sible with the sections that specifically ad- opment. This may be important with bira-
dress childhood diagnostic issues. The DSM- cial children who can have a more dichoto-
IV-TR’s classification of disorders usually mous racial identity. Some empirical evi-
diagnosed in infancy, childhood, and adoles- dence suggests that biracial children move
cence is based on empirical findings and through racial identity development in dif-
is developmentally relevant. For example, ferent ways than children from more
mental retardation, attention-deficit/hyper- racially homogeneous backgrounds.
activity disorder to stereotypic movement 5. The DSM-IV-TR’s 11 appendixes should be
disorder, and other childhood-onset dis- utilized fully. While Appendix I’s outline
orders may occur within the context of for cultural formulation and glossary of
poverty, racial trauma, generational differ- culture-bound syndromes examination ap-
ences, immigration stress, and acculturation pears to be most relevant to the issues being
(Johnson, 1993), though they are not caused addressed here, each appendix has the po-
by cultural factors. tential to influence the effective use of the
2. Clinicians must recognize that cultural con- DSM-IV-TR with ethnic minority children.
ditions can have an impact on the presenta- These appendixes require the clinician to
tion of these disorders. For example, an Afri- take a proactive stance in using culture as a
can American foster child was diagnosed as factor in the diagnostic process.
having oppositional defiant disorder, but it
was never disclosed that he had experienced For example, Appendix A presents decision
several episodes on a school bus in which he trees for six diagnostic categories. The decision
was racially taunted by other riders. tree framework allows the culturally skilled
3. Understanding of acculturation problems is clinician to inject culturally relevant questions
a key when an ethnic minority child comes at appropriate decision points before arriving
to the attention of the psychologist. Accul- at a diagnosis. One of the question points for
turation reflects the extent to which ethnic clarifying an anxiety diagnosis, for instance,
minority children completely release, mod- regards anxiety concerning attachment figures
ify, and retain aspects of both their home with the onset in childhood. Some Hispanic
environment and the mainstream culture girls are brought up to rely on and value a
(Locke, 1992). Acculturation may occur in close-knit family. In their case, it is culturally
at least two ways. External acculturation appropriate to experience some distress when
may be assessed through behavioral pat- placed in situations away from the immediate
terns (e.g., dress, language use). Internal ac- family (e.g., distant sleepover or leaving home
culturation involves the extent to which to attend college). The culturally informed
children articulate their experiences accord- clinician will question whether the distress
ing to the home culture versus the more represents a true anxiety disorder or more
mainstream culture. There may in fact be simply a culturally appropriate response to
no reportable difference. In this case, the separation.
child may feel less compelled to display a Appendix I describes cultural influences on
 10 • formulating diagnostic impressions 49

pathology and defines culturally based syn- is challenged to more fully understand the be-
dromes. It also presents cultural issues salient havior of children from diverse backgrounds.
to diagnosis (e.g., cultural identity, cultural
explanations of the individual’s illness) and
encourages the clinician to generate narrative References & Readings
summaries for these same categories. The American Psychiatric Association. (1987). Diagnos-
brevity of this section might erroneously lead tic and statistical manual of mental disorders
some clinicians to believe there is little to (3rd ed., rev.). Washington, DC: Author.
know regarding cultural issues, but the intent American Psychiatric Association. (1994). Diagnos-
of this appendix is clearly the opposite. It tic and statistical manual of mental disorders
makes passing mention of indigenous clini- (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnos-
cians’ capability of formulating their own di-
tic and statistical manual of mental disorders
agnostic systems for some of the more com- (4th ed., rev.). Washington, DC: Author.
monly occurring North American idioms of American Psychological Association. (2002). Ethical
distress (e.g., anorexia nervosa, dissociative principles of psychologists and code of conduct.
disorders). Johnson (1993) has shown that Washington, DC: Author.
some single-entity disorders (e.g., posttrau- Anderson, L. P. (1991). Acculturative stress: A the-
matic stress disorder) may be sorted into sev- ory of relevance to black Americans. Clinical
eral subcategories, such as racial trauma or Psychology Review, 11, 685 – 702.
racial encounter distress disorder. Other exten- Berry, J. W., Poortinga, Y. H., Segall, M. H., &
sions of Appendix I include consideration of Dasen, P. R. (1992). Cross-cultural psychology:
certain ethnoracial factors such as cultural will Research and applications. Cambridge, UK:
Cambridge University Press.
in assigning a global adaptive functioning rat-
Cross, W. E. (1991). Shades of black: Diversity in
ing on Axis V. African-American identity. Philadelphia:
The DSM-IV-TR’s attempt to be culturally Temple University Press.
appropriate makes it reasonably responsive to Hardiman, R. (1982). White identity development:
practical clinical issues while allowing room for A process oriented model for describing the
culturally competent practice (Tucker, 2002). racial conscious of white Americans. Unpub-
This article was guided by an assumption that lished doctoral dissertation, University of Mas-
cultural patterns affect the presentation of psy- sachusetts, Amherst.
chopathology and the diagnostic process. A cul- Helms, J. E. (1984). Toward a theoretical explanation
turally relevant diagnosis is at the heart of ef- of the effects of race on counseling: A black 137
fective therapeutic interventions and outcome and white model. Counseling Psychologist, 12,
153 –165.
assessment. Communication between clini-
Johnson, R. (1993). Clinical issues in the use of the
cians is enhanced when practitioners can share DSM-III with African American children: A
treatment information that includes cultural diagnostic paradigm. Journal of Black Psychol-
nuances. ogy, 19, 447 – 460.
A culturally competent clinician must iden- Locke, D. C. (1992). Increasing multicultural under-
tify clearly the subtle interactions between the standing: A comprehensive model. Newbury
child, the clinician, and the DSM-IV-TR in Park, CA: Sage.
order to yield the most useful clinical assess- Ponterotto, J. G. (1988). Racial consciousness devel-
ment. Quintana, Castilllo, and Zamarripa (2000) opment among white counselor trainees: A
offer cultural and linguistic competencies an stage model. Journal of Multicultural Counsel-
assessing clinician should possess in this re- ing and Development, 16, 146 –156.
Quintana, S. M., Castillo, E. M., & Zamarripa,
gard. It is also worth noting that some practi-
M. X. (2000). Assessment of ethnic and lin-
tioners have misgivings or serious doubts guistic minority children. In S. Shapiro & T. R.
about the presumptions within the DSM-IV- Kratchochwill (Eds.), Behavioral assessment in
TR. Others might argue the need to extend the schools: Theory, research and clinical founda-
DSM-IV-TR axes to include identification of tions (2nd ed., pp. 435 – 463). New York: Guil-
cultural and gender factors. Here, the clinician ford Press.
50 part i • assessment and diagnosis

Sue, D. W., & Sue, D. (1990). Counseling the cultur- Related Topics
ally different: Theory and practice (2nd ed.).
Chapter 9, “Child and Adolescent Diagnosis With
New York: Wiley.
DSM-IV”
Tucker, C. M. (2002). Expanding pediatric psychol-
Chapter 18, “DSM-IV-TR Classification System”
ogy beyond hospital walls to meet the health
needs of ethnic minority children. Journal of
Pediatric Psychology, 27, 315 –323.
World Health Organization. (1992). International
classification of diseases and related health
problems (10th ed.). Geneva: Author.

MEDICAL EVALUATION OF
11 CHILDREN WITH BEHAVIORAL
OR DEVELOPMENTAL DISORDERS

James L. Lukefahr

This chapter is designed to familiarize the psy- retardation (IUGR), also referred to as small
chologist with the diagnostic medical evalua- for gestational age, refers to conditions that
tion of children with disordered development impair fetal growth, so that birth size is dis-
or behavior. The three components of a com- proportionately small for the gestational age.
prehensive medical evaluation (history, physi- IUGR is a particularly important risk factor
cal examination, and laboratory evaluation) because its presence indicates significant
will be described, with emphasis on those con- toxic, nutritional, or infectious insult to the
siderations pertinent to children with behav- developing fetus. A partial list of causes of
ioral or developmental disorders. IUGR is shown in Table 1.
For example, congenital infection with cy-
tomegalovirus (CMV) affects 1% of U.S.
MEDICAL HISTORY newborns (about 40,000 infants every year).
Although most of these newborns are
Birth History
asymptomatic, 6% have severe disease evi-
• Prenatal factors: Prematurity (birth prior to dent at birth with IUGR, psychomotor retar-
37 weeks of gestation) and low birth weight dation, microcephaly, and multiple organ in-
are risk factors for developmental and cogni- volvement. Another 14% of CMV-infected
tive delays, as well as for some behavior dis- infants do not have obvious disease at birth
orders, such as attention-deficit/hyperactiv- but are later found to have sensorineural
ity disorder (ADHD). Intrauterine growth hearing loss (making CMV infection the
 11 • medical evaluation of children with disorders 51

table 1. Common Causes of Intrauterine seizure disorders, and asthma often have
Growth Retardation concurrent behavioral and developmental
Fetal
problems. For example, children with severe
Chromosomal disorders (e.g., Down syndrome [trisomy congenital heart disease often experience
21], trisomies 18 or 13) developmental delays due to the cerebral ef-
Chronic fetal infection (e.g., human immunodeficiency fects of chronic hypoxemia. Similarly, severe
virus [HIV], cytomegalovirus [CMV], syphilis) chronic renal disease may also cause cogni-
Severe congenital anomalies or syndrome complexes
Radiation injury
tive or developmental compromise as a result
Multiple gestation of growth failure and high levels of circulat-
ing toxic metabolic products. Children with
Placental cancer may have cognitive impairments due
Decreased placental size to either the malignancy itself or the toxic ef-
Placental infection or tumor fects of the cancer treatment. Severe seizure
Twin-to-twin transfusion
disorders are often associated with brain le-
sions or malformation syndromes with de-
Maternal
Hypertension or preeclampsia
velopmental and cognitive implications.
Renal disease Children with chronic illnesses fre-
Hypoxemia (chronic lung or cardiac disease) quently experience concurrent behavioral
Malnutrition or anemia problems. For example, small children with
Drugs (e.g., tobacco, alcohol, cocaine, narcotics) severe asthma may experience separational
difficulties as a result of parental overprotec-
tion. Adolescents with diabetes or epilepsy
often rebel against their dependency on med-
most common noninherited cause of deaf- ical treatment regimens and refuse to comply
ness). with prescribed therapy—frequently result-
• Perinatal factors: Complications during labor ing in serious complications.
and delivery appear to cause developmental • Other chronic conditions: The United States
and learning disabilities less often than pre- and other developed countries are experienc-
viously believed. However, very premature ing an epidemic of obesity affecting children
infants and infants with severe perinatal com- as well as adults. Severely overweight chil-
plications remain at risk if they sustain epi- dren manifest a variety of physical, psy-
sodes of hypoxemia or intracerebral hemor- chosocial, and economic dysfunctions. Famil-
rhage. Advances in neonatal intensive care ial and community factors typically exert
have diminished the impact of respiratory strong influences in the development of obe-
distress syndrome (or hyaline membrane sity in children and greatly complicate ther-
disease) on later development for most pre- apy.
mature infants. • Recurrent illnesses: Children with recurrent
Neonatal jaundice (hyperbilirubinemia) otitis media during the first few years of life
is an extremely common condition, reported may sustain speech and language delays due
to affect as many as 60% of all infants. De- to prolonged periods of decreased hearing.
velopmental sequelae appear to occur only in Frequent episodes of asthma may affect
those infants who experience extremely high physical and social development by inhibit-
serum bilirubin levels or (more often) when ing normal childhood activities.
the jaundice is a result of a severe perinatal • Family history: The clinician should inquire
illness. about heritable conditions known to occur
within the family. Examples of congenital fa-
milial conditions with developmental conse-
Complete Past Medical History
quences include tuberous sclerosis, which is
• Chronic severe illnesses: Children with often associated with severe seizures and
chronic illnesses such as diabetes mellitus, mental retardation, and fragile X syndrome,
52 part i • assessment and diagnosis

the most common cause of mental retarda- growth, and physicians routinely maintain
tion in boys. Acquired conditions can also standardized growth charts for their child pa-
have familial occurrence patterns. Thyroid tients. These growth charts allow comparison
disease, collagen-vascular disease (e.g., sys- of children’s length or height, weight, and head
temic lupus or juvenile rheumatoid arthri- circumference to national norms for those
tis), and inflammatory bowel disease (e.g., growth parameters and are reproduced on the
Crohn’s disease) commonly cluster within accompanying Web site. A child with any
families. These may first present with growth parameter less than the 5th percentile
changes in behavior or school performance, for age (or greater than the 95th percentile)
or with chronic pain that initially may ap- should undergo thorough medical evaluation.
pear to be functional in nature. Head circumference is particularly important
• Body mass index (BMI): This is the most in evaluating developmentally delayed chil-
widely accepted parameter for detecting and dren, since this growth parameter is closely
monitoring childhood obesity. Standardized correlated with brain growth.
growth charts for calculating and plotting In recent years there has been increased
BMI for age are now available and are also recognition of a hereditary or familial compo-
included on the accompanying Web site. nent in the development of several behavioral
• Social history: Physicians recognize the im- disorders. The role of heredity has been most
portance of psychosocial factors in disease strongly established in schizophrenia, bipolar
states and are accustomed to exploring these disorder, and ADHD. Other conditions in
concerns with parents of young children. Di- which heredity may play a role include ob-
rect discussion of psychosocial issues with sessive-compulsive disorder and the autistic
older children and adolescents during a disorders.
single medical encounter is often more dif-
ficult. A brief structured interview tech-
nique, commonly utilized with adolescents,
General Physical Examination
is the HEADSSS interview, summarized in
Table 2. • Vital signs: Temperature, pulse, blood pres-
sure, and respiratory rate.
• Head: Malformations of the skull, external
PHYSICAL EXAMINATION ears, and other structures (often the most
visible signs of major malformation syn-
Growth Parameters dromes). Microcephaly, small palpebral fis-
Many chronic developmental and somatic dis- sures, and short, flat upper lips are the classic
orders are accompanied by disordered physical physical findings of fetal alcohol syndrome.
• Eyes, ears, nose, and throat: Abnormalities
of the iris, pupil, lens, or retina; middle-ear
table 2. The HEADSSS Psychosocial Interview fluid or tympanic membrane abnormality;
Technique malformations of the nose and throat (such
as cleft or high arched palate).
H Home environment (e.g., relations with parents and • Neck: Enlargement of the thyroid gland
siblings)
(goiter) or lymph nodes.
E Education/employment (e.g., school performance)
A Activities (e.g., sports participation, after-school • Chest: Malformations of the chest wall; heart
activity, peer relations) murmur or other evidence of cardiac malfor-
D Drug, alcohol, or tobacco use mation; lung abnormalities.
S Sexuality (e.g., is the patient sexually active; does • Abdomen: Enlarged liver, spleen, or kidneys
he/she use condoms or contraception)
(associated with congenital infection or
S Suicide risk or symptoms of depression or other
mental disorder metabolic disorders); abnormal masses;
S “Savagery” (e.g., violence or abuse in home environ- cachexia or obesity.
ment or in neighborhood) • Back: Evidence of spina bifida or scoliosis.
 11 • medical evaluation of children with disorders 53

• Genitalia and anus: Malformations of sexual Vision and Hearing Testing

organs or perineum; testicular enlargement Accurate assessment of visual and auditory
(common in fragile X syndrome). function should be performed in all children
• Extremities: Signs of limb malformation; de- with behavioral or developmental disorders.
creased or asymmetrical muscle mass. Several technologies, such as auditory and vi-
• Skin: Pigmentation abnormalities, such as sual brain stem evoked potentials, are now
the café au lait spots of neurofibromatosis, available that allow such testing even in new-
ash-leaf spots of tuberous sclerosis, hyper- borns or children with severe communication
pigmentation of incontinentia pigmenti, and impairment.
acanthosis nigricans associated with type II
diabetes.
• Neurological examination: Neurological ex- LABORATORY TESTS AND
amination is a critical element in the evalua- IMAGING PROCEDURES
tion of children with behavioral or develop-
mental disorders. It includes cranial nerve Table 3 provides a partial listing of laboratory
function, tendon reflexes, muscle tone, mus- tests commonly obtained during evaluation of
cle strength, cerebellar function (such as children with developmental or behavioral dis-
stereognosis and proprioception), gait abnor- orders. Developmental disorders presenting in
malities, and presence of persistent or abnor- early infancy are usually more severe and
mal infantile reflexes (such as the startle and often warrant extensive evaluation for meta-
glabellar reflexes). bolic disorders or congenital infection. Studies

table 3. Selected Laboratory Tests and Their Indications in Evaluating Behavioral or Developmental
Disorders

Laboratory Test Indication

Alpha-fetoprotein, serum Abnormal in maternal serum or fetal amniotic fluid in

Down syndrome and neural tube defects
Amino or organic acids, serum or urine Elevated in some congenital metabolic diseases
Ammonia, blood Elevated in some congenital metabolic diseases
Antinuclear antibody (ANA), serum Elevated in collagen-vascular diseases (e.g., systemic lupus
erythematosus)
Bilirubin, serum Elevated in neonatal jaundice and in liver disease
Chromosome evaluation (karyotype) Abnormal in many major malformation syndromes (e.g.,
Down syndrome, trisomy 18)
Creatinine, serum Elevated in chronic renal diseases
DNA testing Detection of fragile X syndrome and numerous other
hereditary conditions
Electrolytes, serum Abnormal in some congenital metabolic diseases
Erythrocyte sedimentation rate (ESR), blood Elevated in chronic inflammatory diseases, such as
systemic lupus erythematosus and Crohn’s disease
Gamma-glutamyltransferase (GGT), serum Elevated in chronic liver disease
Glucose, blood or serum Abnormal in diabetes mellitus and in some inborn errors
of metabolism
Glycosylated hemoglobin (hemoglobin A1C), serum Elevated in diabetes mellitus with undertreatment or poor
compliance with treatment
Hemoglobin electrophoresis, blood Detects abnormal hemoglobin types, such as in sickle-cell
disease
Lead, blood Elevated in chronic lead exposure
Thyroid function tests (thyroxine, triiodothyronine, Used to detect abnormal thyroid function
thyroid-stimulating hormone, T4, T3, TSH), serum
Transaminases (AST, ALT, SGOT, SGPT), serum Elevated in acute or chronic liver disease
Urea nitrogen (BUN), serum Elevated in acute or chronic renal disease
54 part i • assessment and diagnosis

aimed at detecting infectious agents that may References & Readings

cause fetal injury and subsequent developmen-
Behrman, R. E., Kliegman, R. M., & Jenson, H. B.
tal delay include urine for CMV culture and (Eds.). (2000). Nelson textbook of pediatrics
serum antibody titers for congenital infection (16th ed.). Philadelphia: W. B. Saunders.
by organisms such as toxoplasmosis and syph- Brodsky, M., & Lombroso, P. J. (1998). Molecular
ilis. Skull and extremity X rays are often ob- mechanisms of developmental disorders. De-
tained to detect metabolic or infectious damage velopment and psychopathology, 10(1), 1–20.
to skeletal structures. Computed tomography Burke, W. (2002). Genetic testing. New England
(CT) or magnetic resonance imaging (MRI) of Journal of Medicine, 347(23), 1867 –1875.
the brain may be ordered to identify congenital Jones, K. L. (1997). Smith’s recognizable patterns of
malformations. Chromosome determination human malformation (5th ed.). Philadelphia:
W. B. Saunders.
(karyotype) is ordered if a major malformation
Kimm, S. Y. S., & Obarzanek, E. (2002). Childhood
syndrome (e.g., Down syndrome or Turner
obesity: A new pandemic of the new millen-
syndrome) is suspected. Specific DNA testing nium. Pediatrics, 110(5), 1003 –1007.
for a variety of disorders with developmental Kuban, K. C. K., & Leviton, A. (1994). Cerebral
or behavioral implications is now available. palsy. New England Journal of Medicine,
These include fragile X syndrome, Hunting- 330(3), 188 –195.
ton’s disease, and Duchenne’s muscular dystro- Parker, S., & Zuckerman, B. S. (Eds.). (1995). Behav-
phy, with DNA tests for other conditions being ioral and developmental pediatrics: A hand-
announced regularly. book for primary care. Philadelphia: Lippincott
Laboratory evaluation of behavior disorders Williams & Wilkins
and learning disabilities presenting later in Pass, R. F. (2002). Cytomegalovirus infection. Pedi-
atrics in Review, 23(5), 163 –170.
childhood is usually not as extensive. In the
Rapin, I. (1997). Autism. New England Journal of
typical case, where a child has a long and rela-
Medicine, 337(2), 97 –104.
tively stable symptomatology with a diagnosis Roberts, M. C. (Ed.). (1995). Handbook of pediatric
such as reading disability or ADHD, laboratory psychology (2nd ed.). New York: Guilford
evaluation is usually not helpful. However, a Press.
child who was previously thriving and over a Schwartz, I. D. (2000). Failure to thrive: An old
short time begins to do poorly in school is more nemesis in the new millennium. Pediatrics in
likely to have a treatable medical condition. Review, 21(8), 257 –264.
Electroencephalography (EEG) should be per-
formed if a child’s abnormal behaviors show a
discrete episodic pattern that may represent Related Topics
seizure activity. Otherwise, the EEG is not rou- Chapter 9, “Child and Adolescent Diagnosis With
tinely indicated for the evaluation of learning DSM-IV”
and behavior problems. Thyroid function tests Chapter 89, “Normal Medical Laboratory Values
may be indicated, particularly in girls with re- and Measurement Conversions”
cent changes in cognitive performance or if there
is a family history of thyroid disease.
 12 INTERVIEWING PARENTS

Carolyn S. Schroeder & Betty N. Gordon

Parents are usually the primary referral source content and process of the interview. Some
when a child is brought to the attention of a other problems with unstructured interviews
mental health professional. They have a unique include collecting information selectively, a
knowledge and understanding of the child and lack of a systematic way to combine different
thus are an integral part of the assessment and types of information, and a tendency to make a
treatment process. During the initial interview judgment or diagnosis based on what is famil-
with the parent(s), the information-gathering iar to the clinician (McClellan & Werry, 2000).
process begins, essential preliminary clinical Given the limited psychometric support for
decisions are made, and the parents become en- structured interviews and the uniqueness of
gaged in a collaborative working relationship each child, family, and environment, we think
with the therapist. A successful parent inter- the unstructured interview has more advan-
view will ultimately determine treatment goals tages than disadvantages over the structured in-
and their priority and will ensure that parents terview format. Thus, this discussion will focus
will cooperate in carrying out these goals. on unstructured parent interviews. The reader
Parent interviews can be structured or un- is referred to McClellan and Werry (2000) for a
structured. Both methods have advantages and description and critique of structured parent
disadvantages. Structured interviews involve a interviews.
prearranged set of questions to be asked in se- One format for gathering and organizing
quential order that usually focus on gathering information using an unstructured interview
information about a specific DSM disorder. Al- is called the Comprehensive Assessment-to-
though providing a more standardized format, Intervention System (CAIS; Schroeder & Gor-
structured interviews generally give more don, 2002). The CAIS focuses on the specifics
global information about the existence of a dis- of the behavior of concern and the characteris-
order rather than specific details about a par- tics of the child, family, and environment that
ticular child, family, or peer group that are potentially influence the behavior. It helps the
needed for planning an intervention program. interviewer decide which questions need to be
An unstructured interview, on the other hand, asked and ensures that essential information is
allows the clinician more freedom to explore gathered quickly and efficiently (Schroeder &
the nature and context of a particular problem, Gordon, 2002).
as well as the opportunity to investigate poten-
tial contributing factors, such as stimuli that
may elicit the problem behaviors. Moreover, SETTING THE STAGE
this type of interview allows the clinician to
begin to delineate acceptable behavioral alter- Prior to interviewing parents, it is helpful to
natives, as well as other potential problem have them complete a general questionnaire
areas for the child or family. Unstructured in- about the child and family (see Schroeder &
terviews, however, assume that the interviewer Gordon, 2002, for an example), as well as a rat-
has the necessary knowledge about the nature ing scale that screens for problem behavior and
of the specific presenting problem to guide the compares the child’s behavior to a normative

55
56 part i • assessment and diagnosis

sample. Examples of useful behavior rating ily’s life can improve as a result of professional
scales are the Child Behavior Checklist (Achen- help. Characteristics of a good interviewer can
bach, 1991, 1992), the Parenting Stress Index contribute to a positive tone. These include
(Abidin, 1995), the Eyberg Child Behavior In- warmth, empathy, a sensitive and nonjudgmen-
ventory (Eyberg & Pincus, 1999), and the Be- tal approach that respects others’ feelings and
havior Assessment System for Children (Rey- cultures, and an ability to keep the interview
nolds & Kamphaus, 1992). Each parent should moving along in a smooth, purposeful fashion
be asked to complete the selected behavior rat- (Kanfer, Eyberg, & Krahn, 1992). The ability to
ing scale; if they are separated or divorced, each listen also is an essential skill. Listening helps
should be asked to complete a general parent parents focus on the problem, and reflecting or
questionnaire. The information gained from paraphrasing lets the parents know that they
the completed questionnaires permits the clin- have been heard. Recognizing the parents’ dis-
ician to generate preliminary hypotheses about tress as they discuss areas of concern encour-
the nature and causes of the problem, as well as ages them to share their fears and beliefs about
to plan for and focus the parent interview. the problem(s).
It is important to include both parents in the It is helpful to begin the interview by briefly
initial interview if they both are actively in- summarizing what is already known about the
volved in the child’s life. If they are unable or situation and explaining the purpose of the in-
unwilling to participate in a joint interview, an terview (i.e., to get a better understanding of
attempt should be made to interview them sep- their concerns in order to help determine what,
arately, even if this is done by telephone. Each if any, intervention is necessary). This gives
parent brings his or her own perspective on the parents some initial information on what is ex-
problem and also will provide the clinician with pected of them, as well as on what they can ex-
information about his or her willingness to pect from the interviewer. Further, it helps them
support the child’s treatment. We routinely in- start talking about their concerns. Whereas it is
clude preschool children in the initial parent important to get a thorough understanding of
interview, with age-appropriate toys and activ- the nature and context of the problematic be-
ities provided to keep the child occupied. Al- havior, it is not possible or advisable to assess
though some clinicians may find this difficult, everything in the child’s or family’s back-
we have discovered that the information being ground. Background information is important,
discussed is rarely new to the child. Moreover, but the goal is to be selective in pursuing a par-
the opportunity to observe the child and the ticular topic. It should also be remembered that
parent-child interaction firsthand far outweighs working with children almost always involves
any disadvantages. If necessary, later inter- an ongoing relationship with the parents; if a
views can be conducted with the parents alone, relevant area is missed initially, it is very likely
to go over more sensitive information or to re- to be discussed in future meetings. Problems
ceive information or provide information to the with parent interviews include inaccurate re-
parents without the distraction of a particularly call, conflicting perceptions of the child be-
disruptive child. Parents of school-age children tween parents, and a tendency to describe the
are typically interviewed alone, before the child in unrealistically positive and precocious
child is seen; parents of adolescents are first terms (Kanfer et al., 1992). Parents also may
seen with the adolescent present or absent, de- describe their child’s behavior in excessively
pending on the nature of the problem. negative terms when they are under personal
Interviewing parents is an interactive stress (e.g., marital discord, depression). Focus-
process that sets the tone for future interven- ing on the current situation — that is, current
tion efforts. To promote collaboration, it is im- behavior, current child management tech-
portant for the interviewer to create an atmo- niques, and current family strengths and
sphere that puts the parents at ease in dis- weaknesses — can help increase the reliability
cussing their child’s problems and gives them of parental reports.
some sense of optimism that the child’s or fam-
 12 • interviewing parents 57

COMPREHENSIVE ASSESSMENT-TO- other mother, however, is extremely upset, fear-

INTERVENTION SYSTEM ful, and unable to view the problem objectively.
Each of these parents presents a different focus
The following is a logical and systematic guide for the assessment/intervention process.
to assuring that information in important areas The family’s sociocultural characteristics
is gathered. The information does not have to can play an important role in the planning and
be obtained in any particular order, and al- implementation of a treatment program (Gar-
though it may be gathered during the parent cía Coll & Meyer, 1993). Questions such as the
interview, a variety of other sources and meth- following can help the clinician get a better un-
ods could be used (e.g., parent or teacher ques- derstanding of the parent’s perspective: What
tionnaires, psychometric testing, observation do you think has caused your child’s problem?
of parent-child interaction). The CAIS is very Why do you think it started when it did? How
useful for complex cases, but it also provides a does the problem affect you or your child?
framework to assist the clinician in quickly How severe do you feel your child’s problem
gathering essential information for brief as- is? Do you expect it will have a short- or long-
sessment cases. term course? What kind of treatment do you
think your child should receive? Who can help
with the treatment? What are the most impor-
Clarifying the Referral Question
tant results that you hope your child will re-
Although the need to clarify the referral ques- ceive from treatment? What is your greatest
tion seems obvious, its importance cannot be fear about your child (García Coll & Meyer,
overemphasized. After the parent has de- 1993)? Asking the parents about their expecta-
scribed the problem, the clinician should be tions, hopes, and fears in coming to a mental
certain that he or she and the parent are think- health professional helps in both gathering and
ing about the same problem. This can be done interpreting the material, especially if the clin-
by simply reflecting what the parent has said: ician’s recommendations are contrary to the
“It sounds like you are concerned about your parents’ expectations or confirm their worst
child refusing to go to school, as well as the dif- fears. This information also can help the clini-
ferent ways you and your husband are han- cian develop a treatment program that is sensi-
dling the situation.” This gives the parent the tive to sociocultural influences.
opportunity to restate his or her concerns until
there is a mutual understanding of the concerns
that are to be addressed. Assessing General Areas
Information about the characteristics of the
child and the family is important in putting
Determining the Social Context
problems or concerns in perspective and deter-
A child is referred because someone is con- mining the resources the family has or will
cerned. This does not necessarily mean that the need to carry out a successful intervention
child needs treatment or that the child’s behav- plan. Asking parents to briefly describe a typi-
ior is the problem. The clinician should ask: cal day for their child (when he or she gets up;
Who is concerned about the child? Why is this the morning, daily, and evening routines; when
person concerned? Why is this person con- he or she goes to bed, etc.) usually gives a great
cerned now as opposed to some other time? The deal of information about how the family and
parents’ affect in describing the problems is also child functions, their stresses and limitations,
significant. Are they overwhelmed, anxious, de- and, in general, the context in which they live.
pressed, or nonchalant? Two mothers, for ex- The following general areas are important to
ample, describe their 3-year-old daughters as assess:
being anxious and fearful. One mother is calm,
in control of herself, and using good judgment • Developmental status: Knowledge of the
in attempting to deal with the problem. The child’s developmental status (physical/motor,
58 part i • assessment and diagnosis

cognitive, language, social, personality/emo- about child development in general, may

tional, psychosexual) allows the clinician to have emotional problems, or may be experi-
evaluate the child’s behavior in comparison encing stress, all of which can distort his or
with that of other children of the same age her perception of the child’s behavior. In addi-
or developmental level. Behavior that may tion, parenting styles, techniques, and mod-
be considered a significant problem at one els; marital status; and the presence of psy-
stage in development or at one age may be chopathology in parents and other family
quite normal at another. The job of the clini- members are especially important areas to
cian is to judge whether the behavior of con- assess, as are sibling relationships and the
cern is less or more than one would expect of availability and use of social support.
any child at that age and in that environ- • Environment: Recent stressful life events, so-
ment. A 3-year-old who wets the bed, for ex- cioeconomic status, and subculture norms and
ample, may be considered “normal” for that values can provide important information
age, whereas a 10-year-old who wets the bed about the problems the child is experiencing
is viewed as having a significant problem. and the intervention strategies that may be
Behavior also changes over the course of de- most helpful. The child’s environment pro-
velopment, and some problem behaviors vides the setting conditions for the behavior
change in the appropriate or desired direc- and in some cases may be a more appropriate
tion without intervention. Thus, the time at focus for intervention than the behavior itself.
which a behavior occurs in a child’s life is as The setting conditions can include very spe-
important as the behavior itself. Further- cific antecedents to the behavior (repeated
more, knowledge of early development is commands, teasing, criticism, or hunger), so-
important when assessing children in the cioeconomic status, or major events such as
preschool years, since this is a critical time parental divorce, a death in the family, a
for identification of and intervention in de- chronic illness, or an impending move.
velopmental problems. • Consequences of the behavior: Information
• Characteristics of parents and extended fam- in this area includes the ways in which the
ily: Although it is difficult to identify causal parents are currently handling the behavior
mechanisms in the development of childhood problem; the techniques that have been tried
disorders, and equally difficult to delineate in the past and the “payoff” for the child;
the specific factors contributing to or mediat- the impact of the problem behavior on the
ing outcome, the child development and child child, parents, and environment; and the
clinical literature does provide evidence for prognosis with and without treatment. Lack
certain parent characteristics and parenting of careful assessment of these factors usually
practices that facilitate development, as well leads to parents’ responding to suggestions
as those that make the child more vulnerable by saying, “Yes, but we’ve tried that and it
(Schroeder & Gordon, 2002). Moreover, doesn’t work.”
these factors affect how parents view their • Medical/health status: This area should in-
children. It is generally accepted, for exam- clude information on the family’s history of
ple, that low parental tolerance, high expec- medical/genetic problems, chronic illnesses of
tations for child behavior, marital stress, and the child, current health and medications, pre-
family problems influenced parents’ percep- natal history, and early development. Much of
tion of their child’s behavior. Similarly, this information can be gathered in a general
Wahler’s (1980) work shows that a mother’s parent questionnaire with specific areas of
perception of her child’s behavior is highly concern followed up in the interview.
correlated with the type of environmental in-
teractions (positive or coercive) she has just
Assessing Specific Areas
experienced. Thus, the perspective of the re-
ferring person must be taken into account. In addition to the general areas already men-
The referring person may lack information tioned, it is important to gather information on
 12 • interviewing parents 59

the specific behaviors or concerns, including (a) area, one could (a) teach new parenting tech-
the persistence of the behavior (how long has it niques; (b) focus on the emotional atmosphere
been going on?); (b) changes in behavior (is it in the home or school; (c) treat (or refer for
getting worse?); (c) severity (is the behavior treatment) marital problems or parent psy-
very intense or dangerous or low-level but chopathology; or (d) change parental expecta-
“annoying”?); (d) frequency (has the behavior tions, attitudes, or beliefs. Environmental in-
occurred only once or twice or many times?); terventions might involve (a) changing the
(e) situation specificity (does the behavior occur specific cues that elicit inappropriate behavior
only at home or in a variety of settings?); and or prevent appropriate behavior from occur-
(f) the type of problem (is the problem a dis- ring; (b) focusing on the emotional atmosphere
crete behavior or a set of diffuse problems?). in the home by helping parents build support
networks and deal with the stresses of daily
life; (c) helping the child/family cope with life
Determining the Effects of
events such as a death; or (d) changing the
the Problem
physical environment where the problem be-
It is important to note who is suffering from havior most often occurs. Focusing interven-
the referral problem(s). It may be that the tion on the consequences of the behavior
child’s behavior is bothering one parent but not might involve (a) changing the responses of the
the other or is annoying to the teacher but is parents; (b) changing the responses of other
not a problem for the parents. In other cases, significant adults such as teachers; or (c) chang-
although the behavior may be interfering with ing the behavior of the child by focusing on a
some aspect of the child’s development, it may more appropriate payoff for the child (e.g., pro-
not be seen as a problem to the parents or other viding reinforcers). Intervening in the med-
adults and without intervention may lead to a ical/health area may involve (a) referral for
poor outcome for the child. For example, a treatment of the cause of the problem (e.g.,
learning disability may not be seen as a prob- persistent ear infections) or (b) treating the ef-
lem for the parents, but the child is likely to fect of the problem (e.g., teaching relaxation
suffer negative consequences in school and in skills to a child with cerebral palsy).
future opportunities.

CLOSING THE INTERVIEW

Determining Areas for Intervention
After assessing each of these areas, the clini- Time should be allowed at the end of the initial
cian should have a good idea about the nature parent interview to summarize and integrate
of the problem and should know what addi- the information gathered. This lets the parents
tional information is needed to conceptualize know that their concerns have been accurately
the problem. It should be possible at this time heard and gives them feedback on the clinician’s
to formulate plans for further assessment initial conceptualization of the problem. An ex-
and/or intervention strategies. Although it is planation should be given for any additional in-
not possible to answer every question and/or to formation that is needed (e.g., school visit, be-
intervene effectively in every situation, inter- havioral rating scales, psychometric testing of
vention strategies follow naturally from the the child, child interviews, further interviews
assessment, if the child’s development and be- with the parents, observations of parent-child
havior and the emotional, physical, and socio- interactions, medical evaluation) and how this
cultural context in which he or she lives have information will be gathered. If possible, po-
been examined systematically. For example, in- tential treatment strategies should be dis-
terventions in the developmental area could cussed, as well as the estimated length of time
include (a) teaching new responses; (b) provid- and cost for that treatment. While it might not
ing appropriate stimulation; or (c) increasing or be possible to give all this information without
decreasing specific behaviors. In the parental further assessment, it is important that the
60 part i • assessment and diagnosis

parents have some understanding of the clini- Eyberg, S. M., & Pincus, D. (1999). The Eyberg
cian’s thoughts regarding treatment and a sense Child Behavior Inventory and Sutter-Eyberg
of hope that something can be done to help Student Behavior Inventory: Professional
them and their child. Early in the interview, manual. Odessa, FL: Psychological Assessment
Resources.
the clinician should have asked about the par-
García Coll, C. T., & Meyer, E. C. (1993). The socio-
ents’ expectations, and at the end of the inter-
cultural context of infant development. In C. H.
view, their expectations can be discussed in re- Zeanah, Jr. (Ed.), Handbook of infant mental
lation to the gathered information. A collabora- health (pp. 56 – 70). New York: Guilford Press.
tive relationship with parents is developed by Kanfer, F., Eyberg, S. M., & Kahn, G. L. (1992). In-
sharing information with them and allowing terviewing strategies in child assessment. In
them choices in how to proceed. Asking the C. E. Walker & M. C. Roberts (Eds.), Handbook
parents what they think (or feel) about what of clinical child psychology (2nd ed., pp.
they have heard and engaging them in the 49 –62). New York: Wiley Interscience.
process of setting treatment goals encourage Reynolds, C. R., & Kamphaus, R. W. (1992). Behav-
them to be part of this process and maximize ioral Assessment System for Children (BASC).
Circle Pines, MN: American Guidance Services.
the chances that they will support the child’s
Schroeder, C. S., & Gordon, B. N. (2002). Assess-
treatment.
ment and treatment of childhood problems: A
clinician’s guide (2nd ed.). New York: Guilford
Press.
References & Readings
Wahler, R. G. (1980). The insular mother: Her prob-
Abidin, R. R. (1995). Parenting Stress Index man- lems in parent-child treatment. Journal of Ap-
ual (3rd ed.). Odessa, FL: Psychological Assess- plied Behavior Analysis, 13, 207 –219.
ment Resources.
Achenbach, T. M. (1991). Manual for the Child Be-
Related Topics
havior Checklist/4-18 and 1991 Profile. Bur-
lington: University of Vermont, Department of Chapter 9, “Child and Adolescent Diagnosis With
Psychiatry. DSM-IV”
Achenbach, T. M. (1992). Manual for the Child Be- Chapter 11, “Medical Evaluation of Children With
havior Checklist/2-3 and 1992 Profile. Bur- Behavioral or Developmental Disorders”
lington: University of Vermont, Department of
Psychiatry.

ATTENTION-DEFICIT/
13 HYPERACTIVITY DISORDER
THROUGH THE LIFE SPAN

Robert J. Resnick

Attention-deficit/hyperactivity disorder (ADHD) with ADHD in every classroom. This disorder

is the most frequent reason children access is not outgrown in adolescence, and up to 70%
health care. On average there are two children of children so diagnosed will have discernible
 13 • attention-deficit/hyperactivity disorder through the life span 61

symptoms into adulthood. It is estimated that will be learning disabled because of the ADHD,
3 – 5% of children and 10 –20 million adults and in others the learning disability is a paral-
have symptoms of ADHD. Boys outnumber lel process. The former type of learning disabil-
girls by about 4 to 1, and they may present in ity shows much more improvement with treat-
different ways: boys tend to be more external- ment of the ADHD than the latter.
izing and aggressive, whereas girls tend to be With adults, depressive disorders as well as
more internalizing, showing more difficulties bipolar disorders can present as ADHD. Anxiety
with emotion and much less assertiveness disorders, schizophrenia, borderline and schizo-
along with oversocializing and being overly typal personality disorders, intellectual retar-
talkative. ADHD is not caused by poor parent- dation, and learning disabilities may also mask
ing, diet, excess sugar, or inadequate schools, as ADHD. It would be unusual for an adult to
but all of these may exacerbate the ADHD be- have had a seizure undiagnosed since child-
haviors. hood. Academic and vocational underachieve-
According to the DSM-IV (1994), the two ment, multiple marriages, and problems in so-
primary symptom clusters are inattention and cial relationships should raise the question of
impulsivity and hyperactivity. The diagnostic ADHD. Disorganization, procrastination, prob-
rubrics are attention-deficit/hyperactivity dis- lems handling everyday stress, moodiness, and
order: predominantly inattentive type (note hair-trigger temper, usually with quick offset,
there is no hyperactivity of significance); atten- all can be related to ADHD. In both adolescents
tion-deficit/hyperactivity disorder: predomi- and adults, alcohol and substance abuse are not
nantly hyperactive-impulsive type; attention- unusual cofindings.
deficit/hyperactivity disorder: combined type
(incorporating both clusters); and attention-
deficit/hyperactivity disorder: not otherwise THE EVALUATION
specified, for individuals who exhibit symp-
toms of ADHD but do not meet full criteria. • History: A rigorous psychological, develop-
For adolescents and adults who currently have mental, and social history must be taken. In-
symptoms but no longer meet full criteria, the clude employment and educational history
notation “in partial remission” should be added. for adults.
Onset of symptoms occurs before age 7, lasts at • School records: A complete copy of school
least 6 months, and is observed in more than records, including report cards, achievement
one setting (e.g., home, school, church, work, tests, teacher/school commentaries, and spe-
neighborhood, day care). Symptoms must be at cial services/special education testing along
an age-inappropriate level, with significant im- with individualized educational plans (IEPs),
pairment in social, occupational, or academic should be obtained. These provide an invalu-
functioning. able view of the person over time in school.
Appropriate “rule outs” need to be consid- For older children, look for a downward spi-
ered because they can present as ADHD. In ral of grades, especially starting in third or
children and adolescents, mood disorders, anx- fourth grade.
iety, autism and other developmental disorders, • Teacher ratings: Teacher rating scales are
intellectual retardation, learning disabilities, helpful at baseline and treatment points.
hearing loss, and poor vision can mask as They are commercially available.
ADHD. Similarly, seizure disorders (especially • Parent ratings: Parents should fill out rat-
brief but frequent seizures known as “absence” ings separately because they, like teachers,
and petit mal) need to be considered as well. frequently have different thresholds of tol-
Because of the nature of the symptoms, con- erance for the child’s behavior.
duct disorders and oppositional defiant disor- • Computerized assessments: These measure
ders are common comorbid conditions. Simi- inattention, distractibility, and impulsivity.
larly, many children will carry a dual diagno- Continuous performance tests (CPTs) are the
sis of ADHD and learning disabilities; some most common and are commercially available
62 part i • assessment and diagnosis

(e.g., Conner’s Continuous Performance www.add.org, and Additude magazine at

Test). www.additudemag.com.
• Mental status exam: Observe the person for • Bibliotherapy for child and parents. Connect
ADHD symptoms and behaviors while rul- them to ADD Warehouse (800-233-9273)
ing out other diagnoses by appropriate ques- for free catalog.
tioning/observation.
• In adults, information from spouse/signifi-
Adults
cant other is most helpful.
• Thorough explanation of the life course of
the ADHD to adult and significant other.
TREATMENT • Cognitive and behavioral interventions at
home and at work to decrease disorganiza-
School-Age Children
tion, inattention, and distractibility.
• Thorough explanation to parents and child of • Use of prompts such as Voice It, a personal
the nature of ADHD, including etiology, audio-reminder, and/or organizers such as
treatment, and outcome. Significant under- the Franklin Planner.
standing of ADHD by family and child is • Focused trial on stimulant medication or
imperative. other pharmacological agents.
• School-based behavioral strategies to ensure • Individual psychotherapy as needed for is-
homework, class work, and school participa- sues around ADHD and/or other comorbid
tion are at an acceptable level. Strategies are conditions.
also aimed at increasing compliance (on task) • Marital/couples psychotherapy focusing on
and decreasing inappropriate and frequently the relationship and ways of coping with
aggressive behaviors. Referral to the school ADHD within that relationship.
system for special education screening and • Bibliotherapy to augment understanding, in-
evaluation may be necessary so that the tervention skills, and interpersonal relation-
ADHD child can be identified as qualifying ships (e.g., Katie Kelly and Peggy Ramundo’s
for special education services. Academic tu- You Mean I’m Not Lazy, Stupid or Crazy?!
toring may also be necessary. and Lynn Weiss’s Attention Deficit Disor-
• Home-based behavioral interventions simi- ders in Adulthood: Practical Help for Suffer-
lar to the end points in school (i.e., ensuring ers and Their Spouses). Connect the person
completion and turning in of all schoolwork); to the ADD Warehouse for a catalog.
additional intervention around household • Provide information about CHADD and/or
chores, siblings, and play/recreation. The ADDA.
goal again is to increase compliance with
rules in the household and community. A number of federal statutes have a bearing
Parental skills training may be necessary. on treatment of ADHD and therefore on the
• Stimulant medication is most often, and outcome. A school-age population with ADHD
appropriately, used in conjunction with the can be affected by Section 504 of the Rehabili-
above strategies. Other pharmacological tation Act of 1973 and the Individuals With
agents can be used as well (i.e., antidepres- Disabilities Education Act of 1990 (IDEA),
sants). which was reauthorized in 1997. Both can re-
• Individual therapy around issues of ADHD quire specific interventions when a school-age
and/or comorbid features. Therapy may be person has been identified as having ADHD. A
intermittent over the course of time. person at any age with ADHD may have legal
• Connect family to local, state, and national standing under the Americans with Disabilities
parents’ support group, such as Children and Act (ADA) of 1990 if education or employment
Adults with Attention Deficit Disorder as a “major life activity” is “substantially lim-
(CHADD) at www.chadd.org, Attention ited.”
Deficit Disorders Association (ADDA) at
 14 • assessment of suicidal risk 63

References & Readings peractivity disorder. Journal of Clinical Psy-

chology, 54, 425 – 436.
Abikoff, H. (2001). Tailored psychosocial treatment
Ingersoll, B., & Goldstein, S. (1993). Attention def-
for AD/HD: The search for a good fit. Journal
icit disorder and learning disabilities. New
of Clinical Psychology, 30, 122–125.
York: Doubleday.
American Psychiatric Association. (1994). Diagnos-
Resnick, R. J. (2000). The hidden disorder: A clini-
tic and statistical manual of mental disorders
cian’s guide to attention deficit hyperactivity
(4th ed.). Washington, DC: Author.
disorder in adults. Washington, DC: American
Barkley, R. (1995). Taking charge of ADHD: The
Psychological Association.
complete authoritative guide for parents. New
Root, R. W., & Resnick, R. J. (2003). An update on
York: Guilford Press.
the diagnosis and treatment of attention deficit
Barkley, R. A. (1998). Attention-deficit/hyperactiv-
hyperactivity disorder in children. Professional
ity disorder: A handbook for diagnosis and
Psychology: Theory and Practice, 14, 34 – 41.
treatment (2nd ed.). New York: Guilford Press.
Spencer, T., Biederman, J., Wilens, T., Harding, M.,
Connors, C. K., March, J. S., Frances, A., Wells,
O’Donnell, D., & Griffin, B. (1996). Pharma-
K. C., & Ross, R. (2001). Treatment of atten-
cotherapy of attention-deficit hyperactivity
tion deficit/hyperactivity disorder: Expert con-
disorder across the life cycle. Journal of the
sensus guidelines. Journal of Attention Disor-
American Academy of Child and Adolescent
ders, 4, 7 –128.
Psychiatry, 35, 409 – 432.
Gaub, M., & Carlson, C. L. (1997). Gender differ-
ences in ADHD: A meta-analysis and critical
Related Topics
review. Journal of Child and Adolescent Psy-
chiatry, 36, 1036 –1045. Chapter 6, “Developmental Neuropsychological As-
Gingerich, K. J., Turncock, P., Litfin, J. K., & Rosen, sessment”
L. A. (1998). Diversity and attention deficit hy- Chapter 7, “Adult Neuropsychological Assessment”

ASSESSMENT OF
14 SUICIDAL RISK

Kenneth S. Pope & Melba J. T. Vasquez

Evaluating suicidal risk is one of the most chal- ness of such factors as they emerge from the
lenging aspects of clinical work, in part because research and clinical literature may be helpful
it is literally a life-or-death matter. False posi- in assessing suicidal risk.
tives and false negatives are frequent because Among the essential qualifications are the
of such issues as suicide’s low base rate (Pope, following. First, space limitations allow men-
Butcher, & Seelen, 2000). The following list, tioning these factors only in a very general
adapted from Pope and Vasquez (1998), notes way. There may be many exceptions to the
some factors that are widely accepted as signif- trends outlined here, and various factors may
icantly associated with suicide attempts. Aware- interact with one another. The purpose is solely
64 part i • assessment and diagnosis

to call attention to some areas that clinicians 4. Indirect statements and behavioral signs:
should be aware of in assessing risk. Second, People planning to end their lives may com-
this list is merely a snapshot of some current municate their intent indirectly through
trends. Emerging research continues to correct their words and actions—for example, talk-
false assumptions and refine our understand- ing about “going away,” speculating on
ings, as well as reflect changes. For example, what death would be like, giving away their
there are indications of an increase in the sui- most valued possessions, wondering aloud
cide rate for women, bringing it closer to that what it might be like to attend their own fu-
for men. Third, this list is by no means com- neral, or acquiring lethal instruments.
prehensive. It provides examples only of some 5. Depression: As might be expected, the re-
of the kinds of factors statistically associated search suggests that the suicide rate for those
with suicide attempts or completed suicides. with clinical depression is much higher—
Fourth, this list is meant to increase awareness perhaps as much as 20 times greater— than
of factors empirically associated with suicidal the suicide rate for the general population.
risk, but it should never be used in an unthink- 6. Hopelessness: The sense of hopelessness
ing, mechanical manner. Awareness of such fac- appears to be closely associated with suici-
tors can serve as an important aspect of — but dal intent (see, e.g., Kazdin, 1983; Petrie &
never a substitute for — a careful, informed, Chamberlain, 1983; Wetzel, 1976; how-
comprehensive evaluation of suicidal risk. ever, see also Nimeus, Traskman-Bendz, &
Alsen, 1997).
1. Direct verbal warning: A direct statement of 7. Intoxication: The research suggests that
intention to commit suicide often precedes a many suicides are associated with alcohol
suicide attempt. Such statements deserve as a contributing factor; an even greater
careful attention and adequately compre- number may be associated with the pres-
hensive exploration. It is crucial to resist the ence of alcohol (without clear indication of
temptation to reflexively dismiss such its contribution to the suicidal process and
warnings as “a hysterical bid for attention,” lethal outcome).
“a borderline manipulation,” “a clear ex- 8. Special clinical populations: Some clinical
pression of negative transference,” “an at- populations such as clients who have been
tempt to provoke the therapist,” or “yet an- sexually involved with a prior therapist
other grab for power in the interpersonal (Pope, 1994), who have AIDS (Pope &
struggle with the therapist.” It is possible Morin, 1990), or who have been victims of
that the statement may reflect issues other torture (Pope & Garcia-Peltoniemi, 1991)
than an actual increase in suicidal risk, but may be at increased risk for suicide.
such a working hypothesis should be set 9. Sex: The suicide rate for men tends to be
forth only after a respectful, careful, open- about three times that for women. For
minded evaluation. youths, the rate is closer to 5:1 (see, e.g.,
2. Plan: The presence of a plan frequently re- Safer, 1997). The rate of suicide attempts
flects an increased suicidal risk. The more for women is about three times that for
specific, detailed, lethal, and feasible the men.
plan, the more likely it may be that the per- 10. Age: The risk for suicide tends to increase
son will attempt suicide. over the adult life cycle. Attempts by older
3. Past attempts: The research suggests that people are much more likely to be lethal.
most completed suicides have been preceded The ratio of attempts to completed suicides
by a prior attempt. Schneidman (1976) for those up to age 65 is about 7:1 but is 2:1
found that the clients with the greatest sui- for those over 65. Assessing suicidal risk
cidal rate were those who had entered into differs according to whether the client is an
treatment with a history of at least one at- adult or minor. Safer’s review of the litera-
tempt. ture found that the “frequent practice of
 14 • assessment of suicidal risk 65

combining adult and adolescent suicide and 16. Health status: The research suggests that
suicide behavior findings can result in mis- illness and somatic complaints tend to be
leading conclusions” (1997, p. 61). associated with increased suicidal risk, as
11. Race: Generally in the United States, are disturbances in patterns of sleeping and
Whites tend to have one of the highest sui- eating. Clinicians who are helping people
cide rates. Gibbs (1997) highlights the ap- with AIDS, for example, need to be sensi-
parent cultural paradox: “African-Ameri- tive to this risk (Pope & Morin, 1990).
can suicide rates have traditionally been 17. Impulsivity: Those with poor impulse con-
lower than White rates despite a legacy of trol are at increased risk for taking their
racial discrimination, persistent poverty, own lives (see, e.g., Patsiokas, Clum, &
social isolation, and lack of community re- Luscumb, 1979).
sources” (p. 68). EchoHawk (1997) ob- 18. Rigid thinking: Suicidal individuals often
served that the Native-American suicide display a rigid, all-or-none way of think-
rate is “greater than that of any other eth- ing (see, e.g., Neuringer, 1964). A typical
nic group in the U.S., especially in the age statement might be: “If I don’t find work
range of 15 –24 years” (p. 60). within the next week, then the only real
12. Religion: Suicide rates among Protestants alternative is suicide.”
tend to be higher than those among Jews 19. Stressful events: Excessive numbers of
and Catholics. undesirable events with negative out-
13. Living alone: The research suggests that comes have been associated with increased
suicidal risk tends to be reduced if someone suicidal risk (Cohen-Sandler, Berman, &
is not living alone; it is reduced more if he King, 1982; Isherwood, Adam, & Horn-
or she is living with a spouse and even fur- blow, 1982). Bagley, Bolitho, and Bertrand
ther if there are children. (1997), in a study of 1,025 adolescent
14. Bereavement: Brunch, Barraclough, Nel- women in grades 7 –12, wrote that “15
son, and Sainsbury (1971) found that 50 of percent of . . . women who experienced fre-
those in their sample who had committed quent, unwanted sexual touching had
suicide had lost their mothers within the ‘often’ made suicidal gestures or attempts
last three years (compared with a 20% rate in the previous 6 months, compared with 2
among controls matched for age, sex, mar- percent of . . . women with no experience of
ital status, and geographic location). Fur- sexual assault” (p. 341; see also McCauley
thermore, 22 of the suicides, compared et al., 1997). Some types of recent events
with only 9 of the controls, had experi- may place clients at extremely high risk.
enced the loss of their father within the For example, Ellis, Atkeson, and Calhoun
past five years. Krupnick’s (1984) review of (1982) found that 52 of their sample of
studies revealed a link between childhood multiple-incident victims of sexual assault
bereavement and suicide attempts in adult had attempted suicide.
life, perhaps doubling the risk for depres- 20. Release from hospitalization: Some clini-
sives who had lost a parent compared with cians use voluntary or involuntary hospi-
depressives who had not experienced the talization to address severe suicidal risk.
death of a parent. Klerman and Clayton However, even when it has been deter-
(1984; see also Beutler, 1985) found that mined that a person may safely leave the
suicide rates are higher among the wid- hospital setting, suicidal risk cannot be
owed than the married (especially among ignored. Research suggests that suicidal
elderly men) and that, among women, the risk may increase — sometimes sharply —
suicide rate is not as high for widows as for when a person leaves the hospital, for ex-
the divorced or separated. ample, for a family visit, during a weekend
15. Unemployment: Unemployment tends to pass, or at discharge.
increase the risk for suicide.
66 part i • assessment and diagnosis

References & Readings nal of the American Medical Association, 277,

1367 –1368.
Bagley, C., Bolitho, F., & Bertrand, L. (1997). Sexual Neuringer, C. (1964). Rigid thinking in suicidal in-
assault in school, mental health, and suicidal dividuals. Journal of Consulting Psychology,
behaviors in adolescent women in Canada. 28, 54 – 58.
Adolescence, 32, 341–366. Nimeus, A., Traskman-Bendz, L., & Alsen, M.
Beutler, L. E. (1985). Loss and anticipated death: (1997). Hopelessness and suicidal behavior.
Risk factors in depression. In H. H. Goldman & Journal of Affective Disorders, 42, 137 –144.
S. E. Goldston (Eds.), Preventing stress-related Patsiokas, A. T, Clum, G. A., & Luscumb, R. L.
psychiatric disorders (pp. 177 –194). Rockville, (1979). Cognitive characteristics of suicidal at-
MD: National Institute of Mental Health. tempters. Journal of Consulting and Clinical
Brunch, J., Barraclough, B., Nelson, M., & Sains- Psychology, 47, 478 – 484.
bury, P. (1971). Suicide following death of par- Petrie, K., & Chamberlain, K. (1983). Hopelessness
ents. Social Psychiatry, 6, 193 –199. and social desirability as moderator variables in
Cohen-Sandler, R., Berman, A. L., & King, R. A. predicting suicidal behavior. Journal of Con-
(1982). Life stress and symptomatology: Deter- sulting and Clinical Psychology, 51, 485 – 487.
minants of suicidal behavior in children. Jour- Pope, K. S. (1994). Sexual involvement with thera-
nal of the American Academy of Child Psychi- pists: Patient assessment, subsequent therapy,
atry, 21, 178 –186. forensics. Washington, DC: American Psycho-
EchoHawk, M. (1997). Suicide: The scourge of Na- logical Association.
tive American people. Suicide & Life-Threaten- Pope, K. S., Butcher, J. N., & Seelen, J. (2000). The
ing Behavior, 27, 60 – 67. MMP1, MMPI-2, and MMPI-A in court: A
Ellis, E. M., Atkeson, B. M., & Calhoun, K. S. practical guide for expert witnesses and attor-
(1982). An examination of differences between neys (2nd ed.). Washington, DC: American
multiple- and single-incident victims of multi- Psychological Association.
ple sexual assault. Journal of Abnormal Psy- Pope, K. S., & Garcia-Peltoniemi, R. E. (1991). Re-
chology, 91, 221–224. sponding to victims of torture: Clinical issues,
Gibbs, J. T. (1997). African-American suicide: A cul- professional responsibilities, and useful re-
tural paradox. Suicide & Life-Threatening Be- sources. Professional Psychology: Research
havior, 27, 68 –79. and Practice, 22, 269 –276. http://kspope.com.
Isherwood, J., Adam, K. S., & Hornblow, A. R. Pope, K. S., & Morin, S. E. (1990). AIDS and HIV
(1982). Life event stress, psychosocial factors, infection update: New research, ethical respon-
suicide attempt, and auto-accident proclivity. sibilities, evolving legal frameworks, and pub-
Journal of Psychosomatic Research, 26, lished resources. Independent Practitioner, 10,
371–383. 43 – 53.
Kazdin, A. E. (1983). Hopelessness, depression, and Pope, K. S., & Vasquez, M. J. T. (1998). Ethics in
suicidal intent among psychiatrically disturbed psychotherapy and counseling (2nd ed.) San
inpatient children. Journal of Consulting and Francisco: Jossey-Bass.
Clinical Psychology, 51, 504 – 510. Safer, D. J. (1997). Adolescent/adult differences in
Klerman, G. L., & Clayton, E. (1984). Epidemiologic suicidal behavior and outcome. Annals of Clin-
perspectives on the health consequences of be- ical Psychiatry, 9, 61– 66.
reavement. In M. Osterweis, G. Solomon, & M. Schneidman, E. (1976). Suicidology: Contemporary
Green (Eds.), Bereavement: Reactions, conse- developments. New York: Grune and Stratton.
quences, and care (pp. 15 – 44). Washington, Wetzel, R. (1976). Hopelessness, depression, and
DC: National Academy Press. suicide intent. Archives of General Psychiatry,
Krupnick, J. L. (1984). Bereavement during child- 33, 1069 –1073.
hood and adolescence. In M. Osterweis, E.
Solomon, & M. Green (Eds.), Bereavement:
Reactions, consequences, and care (pp. Related Topic
99 –141). Washington, DC: National Academy Chapter 49, “Treatment and Management of the
Press. Suicidal Patient”
McCauley, J., Kern, D. E., Kolodner, K., Dill, L., et al.
(1997). Clinical characteristics of women with a
history of child abuse: Unhealed wounds. Jour-
 ASSESSMENT OF
15 MALINGERING ON
PSYCHOLOGICAL MEASURES

Richard Rogers

Psychologists vary considerably in their under- mates that accounted for an appreciable per-
standing of malingering and their sophistica- centage of assessment cases (7.4% and
tion at its detection. As a prelude to this synop- 7.8%). Even if the premise were true, psy-
sis, the standard definition of malingering is chologists should not equate infrequency
the deliberate fabrication or gross exaggeration with inconsequentiality. As an analogue,
of psychological or physical symptoms for suicide attempts are very rare in certain clin-
some external goal (American Psychiatric As- ical populations but no responsible psychol-
sociation, 2000). Critical decision points in- ogist would argue against their examination.
clude (a) the deliberateness of the presentation • Because malingering is a global response
(e.g., somatoform disorder vs. malingering), (b) style, it is easy to detect. This premise is eas-
the magnitude of the dissimulation (e.g., minor ily assailable. Psychological practice with
embellishment vs. gross exaggeration), and (c) veteran populations, for example, provides
the identification of the goal and its primary ample evidence of how some malingerers be-
source (e.g., internal vs. external). Rogers come very targeted in their feigned posttrau-
(1997) provides a comprehensive resource for matic stress disorder (PTSD). The implicit
addressing these issues. message of this misconception is that malin-
The focus of this synopsis is twofold. First, gering is relatively easy to detect because of
I address common misconceptions about malin- its obviousness. At least with feigned cogni-
gering that are likely to influence professional tive deficits, the available literature (for a
practice. Second, I distill the empirical litera- review, see Rogers, Harrell, & Liff, 1993)
ture relative to the clinical detection of malin- suggests that many simulators remain unde-
gering. This distillation is necessarily selective tected, unless specific measures of malinger-
and concentrates on the more robust clinical ing are employed.
indicators for feigned mental disorders and • If psychologists pay attention to Diagnostic
cognitive impairment. and Statistical Manual of Mental Disorders
(DSM-IV-TR) indices, they are likely to be
effective at identifying malingerers. This
COMMON MISCONCEPTIONS viewpoint disregards the nature of DSM-IV-
TR indices. Unlike inclusion criteria found
• Because malingering is very infrequent, it with most disorders, these indices are in-
should not be a cause of diagnostic concern. tended merely to raise the index of suspicion.
Survey data strongly question the premise Moreover, the only available data suggest
of this fallacy. Two extensive surveys of that the use of these indices may result in a
clinical practice yielded almost identical esti- false-positive rate in the range of 80%. In ad-

67
68 part i • assessment and diagnosis

dition, the DSM-IV-TR emphasis on crimi- derreporting of substance abuse) is the polar
nality (i.e., medicolegal evaluation and anti- opposite of malingering in the denial and
social personality disorder) is largely unwar- minimization of mental disorders.
ranted (see Rogers, 1990) and may lead to
misclassifications in both forensic (false-pos-
itives) and nonforensic (false-negatives) cases. ASSESSMENT OF FEIGNED
• Inconsistencies are the hallmark of malin- MENTAL DISORDERS
gerers. Although inconsistencies are found
among many malingerers, the equating of in- The assessment of feigned psychopathology in-
consistencies with malingering is a grievous volves the use of well-validated measures in a
error. For example, research on the MMPI-2 multimethod evaluation. Although a number
has demonstrated convincingly that inconsis- of brief self-report measures have been re-
tent profiles may result from psychosis, in- cently published, these measures lack the dis-
ability to attend, and inadequate comprehen- criminability and extensive cross-validation for
sion (Greene, 1997). Data from structured their use in the determination of malingering
interviewing (Structured Interview of Re- (see Smith, 1997); however, they may serve a
ported Symptoms [SIRS]; Rogers, Bagby, & useful screening function. The two best estab-
Dickens, 1992) further illustrates this point. lished measures are the MMPI-2 and the SIRS.
Although malingerers tend to be inconsistent Each will be summarized separately.
in their symptom presentation, a substantial Meta-analysis of the MMPI (Berry, Baer, &
minority of the clinical population is also in- Harris, 1991) and the MMPI-2 (Rogers,
consistent. Depending on the prevalence rate Sewell, Martin, & Vitacco, 2003; Rogers,
for malingering in a particular setting, an in- Sewell, & Salekin, 1994) underscore (a) its
consistent presentation may have a greater general usefulness in the evaluation of feigning
likelihood of being a genuinely disordered and (b) the marked variability in optimum cut-
patient than a malingerer. ting scores. For example, Rogers et al. (2003)
• Mental illness and malingering are mutu- found cut scores for F that ranged from 9 to 30.
ally exclusive. Most psychologists are not The following guidelines are proposed:
likely to embrace openly this false di-
chotomy. However, many clinical evalua- 1. Is the profile consistent? A random or in-
tions appear to be concluded once malinger- consistent profile likely will be indistin-
ing is determined. I also suspect that the es- guishable from a feigned profile on fake-bad
tablishment of a bona fide disorder reduces indicators. One benchmark is to exclude
the scrutiny given to the genuineness of profiles with VRIN > 14.
other presented symptoms. Unquestionably, 2. Are the standard validity indicators ex-
neither malingering nor mental illness of- tremely elevated? Psychologists should
fers any natural immunity to the other. have greater confidence in scores that exceed
• Deceptive persons are likely to be malinger- all or nearly all studies in a meta-analysis.
ers. The mislogic that “if you lie, you will As a benchmark of malingering, is F > 30?
malinger” is readily apparent. While malin- Please note that persons with schizophrenia
gerers are deceptive persons, the obverse is or PTSD are likely to have marked eleva-
not necessarily true. The sustained effort in- tions on F and Fb.
volved in successful feigning, the stigmatiza- 3. Are specialized indicators markedly ele-
tion of mental disorders, and the often severe vated? The best overall indicator of feigned
penalties for detection are likely to militate mental disorders is a Fp raw score > 9. A
against widespread malingering. Moreover, second useful indicator is Ds raw score > 35.
Ford, King, and Hollender (1988) cogently 4. Caution should be exercised in applying these
describe the numerous genuine disorders for results to minority populations. For instance,
which deception is commonplace. Finally, nonclinical populations (African Americans
much deception in clinical practice (e.g., un- and Hispanic Americans) score higher on F
 15 • assessment of malingering on psychological measures 69

than their Anglo-American counterparts. put forward a suboptimal effort with an ap-
Likewise, Spanish-language and audiotaped pearance of sincerity. Because of the disparate-
versions have not been validated. ness between types of malingering, different
strategies are recommended for its detection.
The SIRS is a structured interview that has As an important caution, the MMPI-2 is fre-
been extensively validated with clinical, com- quently recommended in neuropsychological
munity, and correctional samples. Unlike the consults where malingering is suspected; how-
numerous cutting scores generated for multi- ever, it is unlikely to be effective in detecting
scale inventories, the SIRS has employed stan- markedly suboptimal performances on cogni-
dard cutting scores throughout its development tive tasks. Nonetheless, the MMPI-2 may be
and validation. Its results combine data from useful in those cases of global malingering
both simulation and known-groups compar- when feigning encompasses both psycho-
isons. Guidelines (see Rogers, 1997; Rogers et pathology and cognitive functioning.
al., 1992) for its use are straightforward: Rogers et al. (1993) summarized detection
strategies for feigned cognitive impairment.
• Any SIRS scale in the definite feigning Importantly, most strategies are useful in
range: Any extreme elevations on the pri- screening for feigned impairment, but not for
mary scales designate feigning and have a making the actual determination. The detection
negligible false-positive rate (1.0%). strategies include the following:
• Three or more scales in the probable feign-
ing range: The most robust measure of 1. Floor effect: Some malingerers fail on ex-
feigning is the combination of markedly ele- ceptionally simple questions that even very
vated primary scales; again, the false positive impaired persons are able to answer cor-
rate appears to be very small (<3.0%). rectly. For example, “Who is older, a mother
• Total SIRS score (all scores except Repeated or her child?” The most common use of the
Inquiries): In indeterminant cases, a summa- floor-effect strategy is found in the presen-
tion of endorsed items represents a supple- tation of Rey’s 15-Item Memory Test that
mentary criterion; Rogers et al. (1992) found has only modest sensitivity.
no false-positives. 2. Performance curve: Many malingerers do
not take into account item difficulty. While
Further research is needed on the use of the they fail more difficult than easy items, the
SIRS with adolescents and persons with neu- decline based on item difficulty is generally
ropsychological impairment. As clearly articu- more gradual than found with genuine pa-
lated in the test manual (Rogers et al., 1992), tients. Frederick (1997) has successfully ap-
the SIRS is designed to assess the feigning of plied this strategy to the Validity Indicator
psychopathology and mental disorders; en- Profile (VIP). It has also been successfully
tirely different strategies are needed with per- applied to Ravens Progressive Matrices.
sons faking cognitive impairment. 3. Symptom validity testing (SVT): Pankratz
(1988) championed this method for the de-
tection of feigned sensory or memory
ASSESSMENT OF FEIGNED deficits through the presentation of a large
COGNITIVE IMPAIRMENT number of trials. Based on probability, some
malingering cases can be identified based on
Unlike simulated mental disorders, feigned performance worse than chance. The best
cognitive impairment does not require the validated measure for this purpose is the
complex generation believable symptoms and Portland Digit Recognition Test (PDRT;
associated features with concomitant data on Binder, 1993). More recent efforts to estab-
the onset and course of the simulated disorder. lish performance below expectations (called
Rather, persons that malinger intellectual or “forced choice testing”); it lacks the certi-
neuropsychological impairment must simply tude of SVT’s below-chance results.
70 part i • assessment and diagnosis

4. Magnitude of error: Some malingerers are utilizes specific measures well-validated for
theorized to make very atypical mistakes, malingering and related response styles.
either in terms of gross errors or near
misses, akin to the Ganser syndrome. Mar-
References & Readings
tin, Franzen, and Orey (1998) demonstrated
the efficacy of this approach. American Psychiatric Association. (2000). Diagnos-
5. Psychological sequelae: An important issue tic and statistical manual of mental disorders
is the effectiveness of persons feigning cog- (4th ed., rev.). Washington, DC: Author.
nitive impairment at describing both decre- Berry, D. T. R., Baer, R. A., & Harris, M. J. (1991).
Detection of malingering on the MMPI: A
ments to their daily functioning and psy-
meta-analysis. Clinical Psychology Review, 11,
chological symptoms that are likely to arise 585 – 598.
from their purported impairment. Recent Berry, D. T. R., Wetter, M. W., & Baer, R. A. (1995).
research would suggest that untrained per- Assessment of malingering. In J. N. Butcher
sons are likely to recognize symptoms asso- (Ed.), Clinical personality assessment: Practi-
ciated with post-concussion syndrome and cal approaches (pp. 236 –248). New York: Ox-
mild brain injury. What remains to be in- ford University Press.
vestigated is whether such persons can accu- Binder, L. M. (1993). Assessment of malingering
rately depict psychological sequelae (e.g., after mild head trauma with the Portland Digit
depression and anxiety) that frequently fol- Recognition Test. Journal of Clinical and Ex-
low such injuries. perimental Neuropsychology, 15, 170 –183.
Frederick, R. I. (1997). The Validity Indicator Pro-
6. Inconsistent or atypical presentations:
file. Minneapolis: National Computer Systems.
Many clinicians believe that variable perfor- Greene, R. L. (1997). Assessment of malingering
mance or an atypical pattern of test scores and defensiveness by multiscale personality in-
signify malingering. Many factors argue ventories. In R. Rogers (Ed.), Clinical assess-
against any facile conclusions: (a) no cutting ment of malingering and deception (2nd ed.,
scores are established for making this deter- pp. 169 –207). New York: Guilford Press.
mination; (b) patients with neuropsycho- Martin, R. C., Franzen, M. D., & Orey, S. (1998).
logical impairment often have variable per- Magnitude of error as a strategy to detect
formances; and (c) personality changes, as a feigned memory impairment. The Clinical
result of brain injury, are likely to affect Neuropsychologist, 12, 84 – 91.
performance. Pankratz, L. (1988). Malingering on intellectual and
neuropsychological measures. In R. Rogers (Ed.),
Clinical assessment of malingering and decep-
In closing, determinations of malingering tion (pp. 169 –192). New York: Guilford Press.
are complex, multimethod evaluations. Conclu- Rogers, R. (1990). Models of feigned mental illness.
sions should never be based on a single symp- Professional Psychology, 21, 182–188.
tom, scale, or measure. When data are incon- Rogers, R. (Ed.). (1997). Clinical assessment of ma-
clusive but suggestive of feigning, the response lingering and deception (2nd ed.). New York:
style may be described as “inconsistent” or Guilford Press.
“unreliable.” To misclassify a genuine patient Rogers, R., Bagby, R. M., & Dickens, S. E. (1992).
as a malingerer may have devastating conse- Structured Interview of Reported Symptoms
quences to that individual’s future treatment, (SIRS) and professional manual. Odessa, FL:
financial well-being, and legal status. To mis- Psychological Assessment Resources, Inc.
Rogers, R., Harrell, E. H., & Liff, C. D. (1993).
classify a malingerer as a genuine patient may
Feigning neuropsychological impairment: A
have grave consequences for other concerned critical review of methodological and clinical
parties (e.g., insurance companies, employers, considerations. Clinical Psychology Review, 13,
or criminal justice system). Psychologists 255 –274.
shoulder a heavy responsibility to minimize Rogers, R., Sewell, K. W., & Goldstein, A. (1994).
both types of misclassification in their assess- Explanatory models of malingering: A proto-
ment of malingering. They must base their typical analysis. Law and Human Behavior, 18,
findings on a comprehensive evaluation that 543 – 552.
 16 • identification and assessment of alcohol abuse 71

Rogers, R., Sewell, K. W., Martin, M. A., & Vitacco, Smith, G. (1997). Assessment of malingering with
M. J. (2003). Detection of feigned mental disor- self-report instruments. In R. Rogers (Ed.),
ders: A meta-analysis of the MMPI-2 and ma- Clinical assessment of malingering and decep-
lingering. Assessment, 10, 160 –177. tion (2nd ed., pp. 351–370). New York: Guil-
Rogers, R., Sewell, K. W., & Salekin, R. (1994). A ford Press.
meta-analysis of malingering on the MMPI-2.
Assessment, 1, 227 –237.
Related Topic
Schretlen, D. J. (1988). The use of psychological
tests to identify malingered symptoms of men- Chapter 28, “Assessing MMPI-2 Profile Validity”
tal disorder. Clinical Psychology Review, 8,
457 – 476.

IDENTIFICATION AND ASSESSMENT

16 OF ALCOHOL ABUSE

Linda Carter Sobell & Mark B. Sobell

A well-formulated assessment is fundamental gain their cooperation by explaining the nature

to successful treatment planning. The follow- of each instrument, why it is being used, and
ing brief overview is intended to help health what feedback, if any, they might expect from
care practitioners better identify, assess, and the instrument. Early discussion of how long
treat individuals with alcohol problems, both treatment will take and what treatment will
those with only primary alcohol problems, as entail will also help establish a good therapeu-
well as those with comorbid disorders. tic relationship that will gain the client’s trust
1. Setting clients at ease: Because there is a and cooperation. One way to help ensure that
social stigma related to having an alcohol prob- accurate information is gathered is to assure
lem, making the first call to a treatment pro- clients that what is discussed in treatment is
gram can be highly stressful. Similarly, arriv- confidential and to explain the conditions under
ing for the first appointment can provoke con- which confidentiality would have to be broken.
siderable anxiety. Individuals who are thinking 2. Choosing assessment instruments/mea-
of changing their drinking have probably made sures: When choosing an assessment instru-
a decision to seek treatment only after careful ment, health care practitioners should consider
consideration and with some degree of ambiva- the following questions: (a) What purpose will
lence. For these reasons, it is very important for it serve (e.g., screening, diagnosis, triage, treat-
anyone working with individuals with alcohol ment planning, goal setting, monitoring, eval-
problems to set clients at ease by establishing uating treatment)? (b) Is it clinically useful
rapport and being empathetic and supportive. (i.e., Will it help develop a better course of
Because clients are often asked to complete sev- treatment?)? (c) Is it user-friendly for clients
eral assessment instruments, it is important to (e.g., easy to complete, relevant)? (d) How long
72 part i • assessment and diagnosis

does it take to administer and score, and over hol (Sobell, Tonneato, & Sobell, 1994), and if so,
what time interval can information be collected the assessment should be rescheduled.
(e.g., one month, one year)? (e) What costs are 6. Key measures in assessing alcohol use
involved, if any? and abuse: There is no shortage of instru-
3. Value of an assessment: Good assess- ments, scales, and questionnaires for assessing
ments have several clinical benefits: (a) They individuals with alcohol problems (for a review
can serve as the basis for treatment planning and sample copies of instruments, see Allen &
and goal setting (e.g., determining intensity of Wilson, 2003). For health care practitioners the
treatment; focusing on motivation or action; key question is “What will I learn from the in-
matching clients to treatments; identifying strument/measure that I will not otherwise
high-risk triggers for use); (b) they can help in know from a routine clinical interview?” To
formulating diagnoses; (c) the results can be assist health care practitioners in assessing a
used to give clients feedback or advice about person’s alcohol use and related problems, a
their past drinking and related behaviors; such listing of one or two key measures in each of
advice can enhance or strengthen motivation for several areas and a brief description of the mea-
change (Miller & Rollnick, 2002; Sobell et al., sure is presented in Table 1. These measures
2002); and (d) because assessments are dynamic were selected because they are user-friendly,
and ongoing throughout treatment, they can require minimal time and resources, are psy-
determine whether treatment is working (e.g., chometrically sound, and, whenever possible,
self-monitoring of alcohol use during treat- provide meaningful feedback to clients.
ment), and, if not, what the next step should be 7. Motivational interviewing: Interviewing
to modify the course of treatment (i.e., stepped style is very important for obtaining accurate
care; Sobell & Sobell, 2000b). information about an individual’s alcohol use
4. Alcohol problem severity: When evalu- (Miller & Rollnick, 2002). The way questions
ating a client’s use of alcohol, it is important to are asked can also affect a client’s answers. Mo-
assess problem severity because such informa- tivational interviewing is an interviewing style
tion is relevant to goal setting and treatment designed to minimize resistance, a helpful strat-
planning (Sobell & Sobell, 1993). Problem egy when interviewing clients who are ambiva-
severity can be viewed as lying on a continuum lent about changing. There are several impor-
ranging from mild (e.g., problem drinkers) to tant considerations when conducting assess-
severe (e.g., chronic alcohol abuse). Table 1 lists ments with individuals who might have alcohol
a good measure (AUDIT) that can be used to problems.
evaluate problem severity.
5. Alcohol abusers’ self-reports are gener- • Empathy: Empathy helps health care
ally accurate: Health care practitioners must practitioners gain the acceptance and trust
rely on their clients’ self-reports for a consider- of clients and is associated with decreased
able amount of assessment and treatment plan- client resistance and improved outcomes.
ning information. Contrary to folklore, several A key way of expressing empathy is re-
studies have shown that alcohol abusers’ self- flective listening, in which the practi-
reports are generally accurate if they are inter- tioner forms a reasonable guess about
viewed when (a) alcohol-free, (b) given assur- what the client has said and shares it with
ances of confidentiality, and (c) in a clinical or re- the client. Reflective listening helps mini-
search setting (Babor, Sterling, Anton, & Del mize resistance.
Boca, 2000; Sobell, Sobell, Connors, & Agrawal, • Periodic summary: Frequent summariz-
2003). When individuals with alcohol problems ing throughout the interview allows
have been drinking, however, their self-reports health care practitioners to synthesize the
may not be accurate. In this regard, a portable information gathered and solicit a client’s
breath alcohol tester can be used to determine feedback about the accuracy of the thera-
whether a person is under the influence of alco- pist’s understanding.
 16 • identification and assessment of alcohol abuse 73

table 1. Key Measures for Assessing Alcohol Use and Related Problems

Area Measure and Brief Description

Adverse consequences Alcohol Use Disorders Identification Test (AUDIT): 10-item, self-administered
of use/problem severity questionnaire addressing past and recent alcohol consumption and alcohol-related problems;
identifies high-risk drinkers as well as those experiencing consequences. It is available in sev-
eral languages, including Spanish.a,b,c
Alcohol use Timeline Followback (TLFB; for alcohol use before treatment): Using memory aids, individ-
uals are asked to recall their estimated daily drinking for intervals ranging from 30 to 360
days; the TLFB can be used in treatment as an advice-feedback tool to analyze clients’ drink-
ing and to increase their motivation to change. It is available in Spanish.a,b,c,d,e,f
Self-Monitoring (SM; for alcohol use during treatment): Requires clients to record aspects
of their alcohol use or urges (e.g., amount, frequency, mood, consequences); SM has several
clinical advantages including identifying situations that pose a high-risk of excessive drink-
ing and providing feedback about changes in drinking. Available in Spanish.a,b,c,e,f
Drug use other than Drug Use History Questionnaire (DUHQ): Captures lifetime and recent information (e.g.,
alcohol years used, route of administration, year last used, frequency of use) about the use of differ-
ent drugs.c,f,g
Drug Abuse Screening Test (DAST-10): 10-item, self-administered measure of drug-use con-
sequences in past 12 months; assesses severity of drug problems. Available in Spanish.c,f,h
Cigarette use Time to the First Cigarette: A Single question—“How many minutes upon waking until the
first cigarette is smoked?”— is strongly predictive of nicotine dependence.c,i
Cognitive functioning Trails A and B: A brief, sensitive, nonspecific, age-adjusted screening test for assessing prob-
able signs of organic brain dysfunction that may be related to severe alcohol problems.c,j
Mini Mental Status Exam: A standardized 8-item questionnaire for assessing current cogni-
tive functioning.j
High-risk triggers for use Brief Situational Confidence Questionnaire (BSCQ): An 8-item variant of the SCQ,k the
BSCQ assesses situational self-efficacy, in other words, how confident people are at the pres-
ent time that they would be able to resist the urge to drink heavily in 8 major relapse situa-
tional categories (BSCQ can also assess drug use situations).a,b,f,l
Motivation/readiness Decisional Balance Exercise: A Brief exercise that asks clients to evaluate their perceptions of
to change the costs and benefits of continuing to drink problematically versus changing; it is intended
to make more salient the costs and benefits of changing and to identify obstacles to
change.f,m,n
Readiness to Change Ruler: A simple method for determining clients’ readiness to change
by asking where they are on a scale of 1 to 10 (0 = not ready to change to 10 = very ready to
change). Depending on clients’ readiness to change, discussions may take different directions
(e.g., for clients who are unsure, with ratings from 4 to 7, explore the pros and cons of treat-
ment). As clients continue their treatment, the ruler can be used periodically to see how mo-
tivation changes over treatment.m,o,p
Pyschiatric comorbidity Symptom Checklist 90-R (SCL-90-R): 90-item self-report questionnaire that reflects psy-
chiatric symptoms that occurred in the past week; items are rated on 5-point scales of dis-
comfort; the SCL-90-R takes about 15 minutes to complete and has been widely used as an
outcome measure in psychotherapy; three global scores of distress can be derived as well as
scores for nine primary symptom dimensions (e.g., somatization, depression, anxiety, anger,
paranoid ideation, psychoticism); this instrument reflects patterns of psychological distress
currently being experienced by clients.q,r

Note: Information and reviews about and/or copies of the measures/instruments can be found in the footnoted publication after each mea-
sure.

aAllen & Wilson, 2003. jLezak, 1995.

bhttp://www.niaaa.nih.gov/publications/guide.htm. kAnnis & Davis, 1989.
cSobell, Sobell, & Toneatto, 1994. lBreslin, Sobell, Sobell, & Agrawal, 2000.
dSobell & Sobell, 2000a. mSubstance Abuse and Mental Health Administration, 1999.
eSobell, Sobell, Connors, & Agrawal, 2003. nSobell et al., 1996.
fhttp://ww.nova.edu/~gsc. oRollnick, 1998.
gSobell, Kwan, & Sobell, 1995. pRollnick, Mason, & Butler, 1999.
hSkinner, 1982. qSeidner & Kilpatrick, 1988.
iHeatherton, Kozlowski, Frecker, & Robinson, 1989. rDerogatis, 1983.
74 part i • assessment and diagnosis

• Flexibility: When a health care practi- drinking upon waking to avoid with-
tioner senses that a client finds the inter- drawal symptoms, is different than
view threatening, is ambivalent, or is re- drinking before noon while on a fishing
luctant to discuss issues, it is important to trip. Morning drinking and DTs are sig-
“roll with resistance” by using reflective nificant because they are associated with
listening rather than confronting the re- severe dependence on alcohol.
sistance directly. It is also important to
emphasize to clients that it is their choice 8. Measures complementary to self-reports:
whether a matter will be discussed. There has been a tendency to view biochemical
• Avoid confrontation: Confrontation and measures such as liver function and urinalysis
arguments should be avoided whenever and collateral (e.g., friends or family) reports as
possible because confrontational strategies superior to a client’s report of his or her drink-
can be counterproductive. Miller, Benefield, ing (Sobell & Sobell, 1990). However, several
and Tonigan (1993), for example, found major comparative evaluations have revealed
that alcohol abusers randomly assigned to problems with biochemical measures and col-
confrontational counseling had higher lev- lateral reports (reviewed in Babor et al., 2002;
els of resistance, drank more during treat- Maisto & Connors, 1992; Sobell et al., 1994).
ment, and had poorer outcomes than clients Consequently, at the present time, biological
assigned to motivational counseling. markers and collateral reports should be seen as
• Avoid labeling: Clients are generally re- complementing rather than replacing self-re-
luctant to be labeled as “alcoholic.” This ports of alcohol use.
especially applies to individuals whose 9. Psychiatric comorbidity: Psychiatric co-
problems are not severe (i.e., problem and morbidity among alcohol abusers has been well
heavy drinkers). Labeling should be documented (Modesto-Lowe & Kranzler, 1999;
avoided because it has no clinical advan- Schuckit, 1996). Because of the high prevalence
tages and because it has been associated of psychiatric comorbidity among alcohol
with alcohol abusers’ delaying or avoiding abusers (rates range from 7% to 75%), diag-
entry into treatment (Sobell & Sobell, nostic formulations involve a two-step process:
2000b). Asking about an individual’s alco- document the extent and nature of the alcohol
hol use in the past year and any concerns problem and establish whether other psychi-
he or she may have is more likely to get a atric disorders are present; if so, determine
client to engage in an open dialogue about whether the alcohol use disorder is primary or
drinking than asking, “How many years secondary. Because of the lack of empirical
have you had an alcohol problem?” or guidelines about how to treat alcohol abusers
“How long have you been an alcoholic?” who have other clinical disorders (Drake &
• Terminology: Explaining the meaning of Mueser, 2000; Smyth, 1996), decisions about
key terms to clients is an important part treating alcohol and psychiatric problems si-
of the interviewing process. Health care multaneously or sequentially need to be made
practitioners need to know how to prop- on a case-by-case basis.
erly ask questions in relation to the fol- 10. Comorbidity of other drug problems, in-
lowing terms: blackouts, delirium tremens cluding nicotine: For alcohol abusers who use or
(DTs), morning drinking, and cirrhosis. abuse other drugs, including nicotine, it is im-
All these terms reflect the severity of the portant to gather a profile of their psychoactive
disorder, but their meaning can be easily substance use (e.g., see DUHQ in Table 1). Also,
misunderstood (reviewed in Sobell et al., drug use patterns may change over the course
1994). For example, DTs, which must in- of treatment (e.g., decreased alcohol use, in-
clude actual delirium, are often confused creased smoking; decreased alcohol use, in-
with minor withdrawal symptoms (e.g., creased cannabis use). Three issues are impor-
psychomotor agitation). Similarly, the tant when assessing alcohol abusers who use
term morning drinking, which refers to other drugs: (a) pharmacological synergism (i.e.,
 16 • identification and assessment of alcohol abuse 75

a multiplicative effect of similarly acting drugs SUMMARY

taken concurrently); (b) cross-tolerance (i.e., de-
creased effect of a drug due to previous or cur- A careful and ongoing assessment is an impor-
rent heavy use of pharmacologically similar tant part of the treatment process for individu-
drugs); and (c) cigarette use (80 –90% of alcohol als with alcohol problems. Accurate evaluation
abusers report having at some time smoked cig- of alcohol problems and other concurrent disor-
arettes; Sobell, Sobell, & Agrawal, 2002). Fi- ders is integral to the assessment process, and
nally, because it appears that continued smok- a good assessment is critical to the development
ing may serve as a trigger for relapse for some of meaningful treatment plans. Assessment in-
alcohol abusers attempting to change their struments and procedures should be user-
drinking (Sobell et al., 2002), the smoking be- friendly and relevant to treatment planning
havior of alcohol abusers should be a part of the and goal setting. Various interviewing strate-
assessment and treatment planning process. gies can be used to enhance the accuracy of in-
11. Motivation for change: An important formation obtained from clients and to increase
assessment issue is the need to evaluate a clients’ motivation for change.
client’s motivation for and commitment to
change. Motivation can be conceptualized as a
References & Readings
state of readiness to change that may fluctuate
over time and can be influenced by several vari- Allen, J. P., & Wilson, V. (2003). Assessing alcohol
ables, including the therapist’s behavior and problems (2nd ed.; NIH Publication no. 03-
treatment procedures. For a thorough descrip- 3745). Rockville, MD: National Institute on Al-
tion of motivational interviewing, see Miller cohol Abuse and Alcoholism.
Annis, H. M., & Davis, C. S. (1989). Relapse pre-
and Rollnick (2002). Table 1 lists a measure
vention. In R. K. Hester & W. R. Miller (Eds.),
(Readiness to Change Ruler) that can be used
Handbook of alcoholism treatment ap-
to assess readiness for change and an exercise proaches: Alternative approaches (pp. 170 –
(Decisional Balance) that can be used to en- 182). New York: Pergamon Press.
hance or strengthen motivation for change. Babor, T. F., Steinberg, K., Anton, R., & Del Boca, F.
The most important issue regarding motiva- (2000). Talk is cheap: Measuring drinking out-
tion is that treatment of clients who are as- comes in clinical trials. Journal of Studies on
sessed as weakly committed to changing their Alcohol, 61(1), 55 – 63.
drinking should initially focus on increasing Breslin, F. C., Sobell, L. C., Sobell, M. B., & Agra-
their motivation rather than on methods for wal, S. (2000). A comparison of a brief and long
achieving change. Use of a motivational inter- version of the Situational Confidence Ques-
tionnaire. Behaviour Research and Therapy,
viewing style can be helpful for increasing
38(12), 1211–1220.
clients’ motivation (Miller & Rollnick, 2002;
Derogatis, L. R. (1983). SCL-90 Revised Version
Resnicow, Dilorio, Soet, Borrelli, & Ernst, Manual-1. Baltimore, MD: Johns Hopkins
2002; Sobell & Sobell, 2000b). University School of Medicine.
12. Base conclusions on a convergence of in- Drake, R. E., & Mueser, K. T. (2000). Psychosocial
formation: While alcohol abusers’ self-reports approaches to dual diagnosis. Schizophrenia
are generally accurate if gathered under the con- Bulletin, 26(1), 105 –118.
ditions noted earlier, a small proportion of re- Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., &
ports will be inaccurate. To deal with this poten- Robinson, J. (1989). Measuring the heaviness
tial problem, it is advisable to obtain informa- of smoking: Using self-reported time to the
tion from several sources when possible (e.g., first cigarette of the day and number of ciga-
rettes smoked per day. British Journal of Addic-
psychological tests, family, friends, probation
tion, 84, 791– 800.
officers, medical records, biochemical tests). Bas-
Lezak, M. D. (1995). Neuropsychological assess-
ing conclusions on a convergence of information ment (3rd ed.). New York: Oxford University
should result in increased confidence in that in- Press.
formation (Sobell & Sobell, 1990). Maisto, S. A., & Connors, G. J. (1992). Using subject
and collateral reports to measure alcohol con-
76 part i • assessment and diagnosis

sumption. In R. Z. Litten & J. Allen (Eds.), sues in alcohol abuse: State of the art and fu-
Measuring alcohol consumption: Psychosocial ture directions. Behavioral Assessment, 12,
and biological methods (pp. 73 – 96). Towota, 91–106.
NJ: Humana Press. Sobell, L. C., & Sobell, M. B. (2000a). Alcohol
Miller, W. R., & Rollnick, S. (2002). Motivational Timeline Followback (TLFB). In American Psy-
interviewing: Preparing people to change (2nd chiatric Association (Ed.), Handbook of psychi-
ed.). New York: Guilford. atric measures (pp. 477 – 479). Washington,
Modesto-Lowe, V., & Kranzler, H. R. (1999). Diag- DC: American Psychiatric Association.
nosis and treatment of alcohol-dependent pa- Sobell, L. C., Sobell, M. B., Connors, G., & Agrawal,
tients with comorbid psychiatric disorders. Al- S. (2003). Is there one self-report drinking
cohol Health & Research World, 23(2), 144 – measure that is best for all seasons? Alco-
149. holism: Clinical and Experimental Research,
Resnicow, K., Dilorio, C., Soet, J. E., Borrelli, B., 27, 1661–1666.
Hecht, J., & Ernst, D. (2002). Motivational in- Sobell, L. C., Sobell, M. B., Leo, G. I., Agrawal, S.,
terviewing in health promotion: It sounds like Johnson-Young, L., & Cunningham, J. A.
something is changing. Health Psychology, (2002). Promoting self-change with alcohol
21(5), 444 – 451. abusers: A community-level mail intervention
Rollnick, S. (1998). Readiness, importance, and con- based on natural recovery studies. Alcoholism:
fidence. In W. R. Miller & N. Heather (Eds.), Clinical and Experimental Research, 26, 936 –
Treating addictive behaviors (2nd ed., pp. 49 – 948.
60). New York: Plenum. Sobell, L. C., Toneatto, T., & Sobell, M. B. (1994).
Schuckit, M. A. (1996). Alcohol, anxiety, and de- Behavioral assessment and treatment planning
pressive disorders. Alcohol Health & Research for alcohol, tobacco, and other drug problems:
World, 20(2), 81–85. Current status with an emphasis on clinical ap-
Seidner, A. L., & Kilpatrick, D. G. (1988). Derogatis plications. Behavior Therapy, 25, 533 – 580.
symptom checklist 90-R. In M. Hersen & A. S. Sobell, M. B., & Sobell, L. C. (1993). Problem
Bellack (Eds.), Dictionary of behavioral assess- drinkers: Guided self-change treatment. New
ment techniques (pp. 174 –175). New York: York: Guilford Press.
Pergamon Press. Sobell, M. B., & Sobell, L. C. (2000b). Stepped care
Skinner, H. A. (1982). The Drug Abuse Screening as a heuristic approach to the treatment of alco-
Test. Addictive Behaviors, 7, 363 –371. hol problems. Journal of Consulting and Clini-
Smyth, N. J. (1996). Motivating persons with dual cal Psychology, 68(4), 573 – 579.
disorders: A stage approach. Families in Soci- Substance Abuse and Mental Health Administra-
ety: The Journal of Contemporary Human tion. (1999). Enhancing motivation for change
Services, 77, 605 –614. in substance abuse treatment (Treatment Im-
Sobell, L. C., Cunningham, J. A., Sobell, M. B., provement Protocol Series). Rockville, MD:
Agrawal, S., Gavin, D. R., Leo, G. I., et al. U.S. Department of Health and Human Ser-
(1996). Fostering self-change among problem vices.
drinkers: A proactive community intervention.
Addictive Behaviors, 21(6), 817 – 833.
Related Topics
Sobell, L. C., Kwan, E., & Sobell, M. B. (1995). Re-
liability of a Drug History Questionnaire Chapter 54, “Treatment Matching in Substance
(DHQ). Addictive Behaviors, 20(2), 233 –241. Abuse”
Sobell, L. C., & Sobell, M. B. (1990). Self-report is- Chapter 55, “Motivational Interviewing”
 17 MEASURES OF ACCULTURATION

Juan Carlos Gonzalez

The importance of cultural awareness and re- NEGATIVE EFFECTS OF

spect in the provision of psychological services ACCULTURATIVE STRESS
to individuals from other countries or subcul-
tures has been clearly outlined in the APA The process of acculturation has been hypoth-
Guidelines for Providers of Psychological Ser- esized to lead to a deterioration in physical, so-
vices to Ethnic, Linguistic, and Culturally Di- cial, and emotional well-being (Berry, Kim,
verse Populations (American Psychological As- Minde, & Mok, 1987). Elevations in anxiety,
sociation, 1990). Acculturation is highlighted in depression, identity confusion, and somatic com-
these guidelines as one of the factors that all plaints have been associated with elevated lev-
psychologists should be familiar with when els of acculturative stress (Williams & Berry,
working with individuals from nonmajority 1991). Psychologists assess the individual’s ac-
groups. The ability to differentiate between psy- culturation experience in order to ascertain
chopathology and the effects of acculturative how this stressful process may contribute to
stress is essential for psychologists who assess the presenting symptomatology. In general, in-
and treat individuals from different cultures. dividuals who are able to find a balance be-
tween the majority culture and their own tend
to exhibit fewer negative consequences (Berry
DEFINITION et al., 1987; Pawliuk et al., 1996; Szapocznik,
Kurtines, & Fernandez, 1980). However, mul-
Acculturation is the stressful and complex pro- tiple variables (i.e., race, education, language
cess that individuals undergo in adjusting to a proficiency, reason for immigration, premorbid
new culture. A useful structure of four distinct adjustment, similarity between culture of ori-
acculturation styles is commonly used to help gin, and new culture) often serve to ameliorate
categorize and understand an individual’s re- or exacerbate the effects of acculturation.
sponse to this difficult adaptational process
(Berry, 1984):
BRIEF LINGUISTIC MEASURES OF
• Assimilation: Embracing the characteristics ACCULTURATION
of the majority culture while rejecting the
characteristics of the culture of origin. Psychologists practicing in clinical settings
• Integration: Embracing the majority culture may find brief linguistic measures of accultur-
while maintaining a strong culture-of- ation particularly useful for determining an in-
origin identity. dividual’s general level of acculturation. The
• Rejection: Maintaining own culture while proponents of these circumscribed measures
rejecting both assimilation and integration. have argued persuasively that language usage
• Deculturation: Eventual rejection of both the and proficiency may serve as accurate estimates
majority culture and the culture of origin. of overall acculturation (Epstein, Botvin, Dusen-
bury, Diaz, & Kerner, 1996; Marin & Marin,
1991; Marin, Sabogal, Marin, Otero-Sabogal,

77
78 part i • assessment and diagnosis

& Perez-Stable, 1987). When using these mea- • How does the individual define his or her
sures, it is also important to keep in mind that own cultural, linguistic, and/or ethnic iden-
lack of English proficiency may exacerbate ac- tity in relation to the majority culture?
culturative stress by limiting employment op-
tions and other important economic and social
domains (Westermeyer & Her, 1996). Al- STANDARDIZED MEASURES OF
though research regarding these brief strate- ACCULTURATION
gies has focused primarily on Hispanic adoles-
cents, it is likely that the general findings may Most measures of acculturation have been de-
apply to other groups. In general, individuals signed by researchers studying the accultura-
from non-English-speaking groups who report tion process. The following encompasses a small
using their native language in all or most in- sampling of the measures available for assessing
terpersonal settings are less likely to be signif- acculturation in various nonmajority groups.
icantly assimilated or integrated into the ma- These measures are available directly from the
jority culture. The following multiple-choice authors.
questions may be useful in helping to deter-
mine linguistic acculturation (suggested an- • The Acculturation Rating Scale for Mexican
swer choices adapted from Epstein et al., 1996, Americans-II (ARSMA-II; Cuellar, Arnold,
are only English, mostly English, English and & Maldonado, 1995) is a behavioral measure
my native language, mostly my native lan- designed to yield five levels of acculturation
guage, only my native language): (from a very Mexican orientation to very
assimilated or Anglicized). It also has two
subscales that measure the individual’s ori-
• What language do you usually use with
entation toward Anglo culture and toward
your (parents, children, spouse, friends)?
Mexican culture.
• In what language do you (think, dream, de-
• The African American Acculturation Scale
scribe emotional experiences)?
(AAAS; Landrine & Klonoff, 1994) is de-
• In what language do you (listen to the radio,
signed to assess eight dimensions: tradi-
watch TV, read)?
tional family structure, preference for things
African American, traditional food prefer-
ences, interracial attitudes/cultural mistrust,
SELF-REPORT OF ACCULTURATION religious beliefs, traditional health beliefs,
AND ACCULTURATIVE STRESS traditional child-rearing practices, and su-
perstitions.
Another useful strategy in clinical settings is to • The Bicultural Involvement Scale (Sza-
simply ask about the individual’s perception of pocznik, Kurtines, & Fernandez, 1980) is de-
his or her own degree of acculturation and the signed to assess general cultural involve-
stressors associated with this adaptational ment (i.e., comfort with majority language,
process. Allow the individual to educate you preference for recreational activities). This
about his or her culture of origin, as well as scale was originally used with Cuban-Amer-
goals, wishes, and fears concerning the new en- icans, but it may easily be adapted for use
vironment. with other groups (Pawliuk et al., 1996).
• The Brief Acculturation Scale for Hispan-
• What has the process of adapting to a new en- ics (Norris, Ford, & Bova, 1996) is a four-
vironment (i.e., language, diet, culture, rules, item linguistic measure of acculturation
expectations) been like for the individual? for Hispanics.
• What is the individual’s perception of the • The Minority-Majority Relations Survey
benefits and risks of embracing the majority (Sodowsky, Lai, & Plake, 1991) is a 38-item
culture? questionnaire designed to assess the atti-
 17 • measures of acculturation 79

tudes of Hispanics and Asians along three (2002). Acculturation: Advances in theory,
subscales: perceived prejudice, language usage, measurement, and applied research. Washing-
and acculturation. ton, DC: American Psychological Association.
• The Suinn-Lew Asian Self-Identity Accul- Cuellar, I., Arnold, B., & Maldonado, R. (1995). Ac-
culturation Rating Scale for Mexican Ameri-
turation Scale (Suinn, Ahuna, & Khoo,
cans-II: A revision of the original ARSMA
1992) is a 21-item questionnaire that focuses
scale. Hispanic Journal of Behavioral Sciences,
on attitudes, identity, language, friendships, 17, 275 –304.
behaviors, and geographic background. It is Epstein, J. A., Botvin, G. J., Dusenbury, L., Diaz, T.,
used to rate individuals along an accultura- & Kerner, J. (1996). Validation of an accultura-
tion continuum (low acculturation to high tion measure for Hispanic adolescents. Psycho-
acculturation) and in terms of being “Asian- logical Reports, 76, 1075 –1079.
identified” or “Western-identified.” Landrine, H., & Knonoff, E. A. (1994). The African
American Acculturation Scale: Development,
reliability, and validity. Journal of Black Psy-
chology, 20, 104 –127.
ADDITIONAL RESOURCES
Marin, G., & Marin, B. V. (1991). Research with
Hispanic populations (Applied Social Research
Those interested in a comprehensive review of Methods Series, Vol. 23). Newbury Park, CA:
theoretical and applied developments in the Sage.
measurement of acculturation— particularly for Marin, G., Sabogal, R., Marin, B. V., Otero-Sabogal,
African Americans, Asian Americans, American R., & Perez-Stable, E. J. (1987). Development of a
Indians, and Hispanics— will find the text Ac- short acculturation scale for Hispanics. Hispanic
culturation: Advances in Theory, Measurement, Journal of Behavioral Sciences, 9, 183 –205.
and Applied Research (Chun, Organista, & Norris, A. E., Ford, K., & Bova, C. A. (1996). Psy-
Marin, 2002) to be an up-to-date and invaluable chometrics of a brief acculturation scale for
resource. Hispanics in a probability sample of urban His-
panic adolescents and young adults. Hispanic
Further information regarding the process of
Journal of Behavioral Sciences, 18, 29 –38.
acculturation for various nonmajority groups
Pawliuk, N., Grizenko, N., Chan-Yip, A., Gantous,
can be found in the Gale Encyclopedia of Mul- P., Mathew, J., & Nguyen, D. (1996). Accultur-
ticultural America (Vecoli & Galens, 1995). Ad- ation style and psychological functioning in
ditional measures of acculturation may be children of immigrants. American Journal of
found by using the frequently updated ERIC/ Orthopsychiatry, 66, 111–121.
AE Test Locator service on the Internet (http:// Sodowsky, G. R., Lai, E. W., & Plake, B. S. (1991).
ericae.net/testcol.htm), as well as by consulting Moderating effects of sociocultural variables on
the psychological research literature. acculturation attitudes of Hispanics and Asian
Americans. Journal of Counseling and Devel-
opment, 70, 194 –204.
References, Readings, & Internet Sites Suinn, R., Ahuna, C., & Khoo, G. (1992). The
Suinn-Lew Asian Self-Identity Acculturation
American Psychological Association. (1990). APA Scale: Concurrent and factorial validation. Edu-
guidelines for providers of psychological ser- cational and Psychological Measurement, 52,
vices to ethnic, linguistic, and culturally di- 1041–1046.
verse populations. Washington, DC: Author. Szapocznik, J., Kurtines, W. M., & Fernandez, T.
http://www.apa.org/pi/guide.html (1980). Bicultural involvement and adjustment
Berry, J. W. (1984). Multicultural policy in Canada: in Hispanic-American youths. International
A sociopsychological analysis. Canadian Jour- Journal of Intercultural Relations, 4, 353 –365.
nal of Behavioral Sciences, 16(4), 353 –370. Vecoli, R. J., & Galens, J. (Eds.). (1995). Gale ency-
Berry, J. W., Kim, U., Minde, T., & Mok, M. (1987). clopedia of multicultural America (2 vols.).
Comparative studies of acculturative stress. In- Detroit: St. James Press.
ternational Migration Review, 21, 491–511. Westermeyer, J., & Her, C. (1996). English fluency
Chun, K. M., Organista, P. B., & Marin, G. (Eds.). and social adjustment among Hmong refugees
80 part i • assessment and diagnosis

in Minnesota. Journal of Nervous and Mental Related Topic

Disease, 184(2), 130 –132.
Chapter 10, “Formulating Diagnostic Inpressions
Williams, C. L., & Berry, J. W. (1991). Primary pre-
With Ethnic and Racial Minority Children
vention of acculturative stress among refugees:
Using the DSM-IV-TR”
Application of psychological theory and prac-
tice. American Psychologist, 46, 632– 641.

DSM-IV-TR CLASSIFICATION
18 SYSTEM

American Psychiatric Association

Since the last edition of the Psychologists’ Desk • Mild

Reference, there have been two revisions of the • Moderate
Diagnostic and Statistical Manual composed • Severe
by the American Psychiatric Association. Those
• If criteria are no longer met, one of the fol-
changes have been noted below, and all the
lowing specifiers may be noted:
codes are produced here for the reader’s conve-
nience and with permission from the Diagnos- • In Partial Remission
tic and Statistical Manual of Mental Disorders • In Full Remission
(4th ed., rev.; copyright 2000 American Psychi- • Prior History
atric Association).
The following notes are offered for the con-
venience of the user in navigating the DSM
and for a better understanding of the taxon- DSM-IV-TR CLASSIFICATION
omy.
Disorders Usually First Diagnosed
in Infancy, Childhood, or
• NOS = Not Otherwise Specified
Adolescence
• An x appearing in a diagnostic code indicates
that a specific code number is required. Mental Retardation
• An ellipsis ( . . . ) is used in the names of cer- Note: These are coded on Axis II.
tain disorders to indicate that the name of a
specific mental disorder or general medical 317 Mild Mental Retardation
condition should be inserted when recording 318.0 Moderate Mental
the name (e.g., 293.0 Delirium Due to Hy- Retardation
pothyroidism). 318.1 Severe Mental Retardation
• If criteria are currently met, one of the fol- 318.2 Profound Mental Retardation
lowing severity specifiers may be noted after 319 Mental Retardation, Severity Un-
the diagnosis: specified
 18 • DSM - IV-TR classification system 81

Learning Disorders Other Disorders of Infancy, Childhood, or

315.00 Reading Disorder Adolescence
315.1 Mathematics Disorder 309.21 Separation Anxiety Disorder
315.2 Disorder of Written Expression 313.23 Selective Mutism
315.9 Learning Disorder NOS
Reactive Attachment Disorder of Infancy or
Motor Skills Disorder Early Childhood (Specify: Inhibited
315.4 Developmental Coordination Type/Disinhibited Type)
Disorder 307.3 Stereotypic Movement Disorder
(Specify if: With Self-Injurious
Communication Disorders Behavior)
315.31 Expressive Language Disorder 313.9 Disorder of Infancy, Childhood,
315.32 Mixed Receptive-Expressive or Adolescence NOS
Language Disorder
15.39 Phonological Disorder
Delirium, Dementia, and Amnestic
307.0 Stuttering
and Other Cognitive Disorders
307.9 Communication Disorder NOS

Pervasive Developmental Disorders Delirium

299.00 Autistic Disorder 293.0 Delirium Due to . . . [Indicate the
299.80 Rett’s Disorder General Medical Condition]
299.10 Childhood Disintegrative ——.— Substance Intoxication Delirium
Disorder (Refer to Substance-Related Dis-
299.80 Pervasive Developmental orders for substance-specific
Disorder NOS codes)
——.— Substance Withdrawal Delirium
Feeding and Eating Disorders of Infancy or (Refer to Substance-Related Dis-
Early Childhood orders for substance-specific
307.52 Pica codes)
307.53 Rumination Disorder ——.— Delirium Due to Multiple Etiolo-
307.59 Feeding Disorder of Infancy or gies (Code each of the specific eti-
Early Childhood ologies)
780.09 Delirium NOS
Tic Disorders
307.23 Tourette’s Disorder Dementia
307.22 Chronic Motor or Vocal Tic 294.xx* Dementia of the Alzheimer’s
Disorder Type, With Early Onset (Also
307.21 Transient Tic Disorder (specify if: code 331.0 Alzheimer’s disease on
Single Episode/Recurrent) Axis III)
307.20 Tic Disorder NOS .10 Without Behavioral Disturbance
.11 With Behavioral Disturbance
Elimination Disorders 294.xx* Dementia of the Alzheimer’s
——.— Encopresis Type, With Late Onset (Also
787.6 With Constipation and Overflow code 331.0 Alzheimer’s disease on
Incontinence Axis III)
307.7 Without Constipation and Over- .10 Without Behavioral
flow Incontinence Disturbance
307.6 Enuresis (Not Due to a General .11 With Behavioral Disturbance
Medical Condition) (Specify type: 290.xx Vascular Dementia
Nocturnal Only/Diurnal .40 Uncomplicated
Only/Nocturnal and Diurnal) .41 With Delirium
82 part i • assessment and diagnosis

.42 With Delusions Other Cognitive Disorders

.43 With Depressed Mood 294.9 Cognitive Disorder NOS
(Specify if: With Behavioral
Disturbance) Mental Disorders Due to a General
Medical Condition Not Elsewhere
Code presence or absence of a behavioral dis-
Classified
turbance in the fifth digit for Dementia Due
to a General Medical Condition: 293.89 Catatonic Disorder Due to . . .
[Indicate the General Medical
0 = Without Behavioral Disturbance
Condition]
1 = With Behavioral Disturbance
310.1 Personality Change Due to . . .
294.1x* Dementia Due to HIV Disease [Indicate the General Medical
(Also code 042 HIV on Axis III) Condition]
294.1x* Dementia Due to Head Trauma Specify type: Labile Type/Disin-
(Also code 854.00 on Axis III) hibited Type/Aggressive
294.1x* Dementia Due to Parkinson’s Dis- Type/Apathetic Type/Paranoid
ease (Also code 332.0 Parkinson’s Type/Other Type/Combined
disease on Axis III) Type/Unspecified Type
294.1x* Dementia Due to Huntington’s 293.9 Mental Disorder NOS Due to . . .
Disease (Also code 333.4 Hunt- [Indicate the General Medical
ington’s disease on Axis III) Condition]
294.1x* Dementia Due to Pick’s Disease
(Also code 331.1 Pick’s disease on
Substance-Related Disorders
Axis III)
294.1x* Dementia Due to Creutzfeld- The following specifiers apply to Substance
Jakob Disease (Also code 046.1 Dependence as noted:
Creutzfeld-Jakob disease on aWith Physiological Dependence/Without

Axis III) Physiological Dependence

294.1x* Dementia Due to . . . [Indicate bEarly Full Remission/Early Partial Remis-

the General Medical Condition sion/Sustained Full Remission/Sustained Par-

not listed above] (Code the tial Remission
general medical condition on cIn a Controlled Environment

Axis III) dOn Agonist Therapy

——— Substance-Induced Persisting The following specifiers apply to Substance-

Dementia (Refer to Substance- Induced Disorders as noted:
Related Disorders for substance IWith Onset During Intoxication

specific codes) WWith Onset During Withdrawal

——— Dementia Due to Multiple Etiolo-

gies (Code each of the specific eti- Alcohol-Related Disorders
ologies) Alcohol Use Disorders
294.8 Dementia NOS 303.90 Alcohol Dependencea,b,c
305.00 Alcohol Abuse
Amnestic Disorders
294.0 Amnestic Disorder Due to . . . Alcohol-Induced Disorders
[Indicate the General Medical 303.00 Alcohol Intoxication
Condition] (Specify if: Transient/ 291.81 Alcohol Withdrawal (Specify if:
Chronic) With Perceptual Disturbances)
——— Substance-Induced Persisting 291.0 Alcohol Intoxication Delirium
Amnestic Disorder (Refer to 291.0 Alcohol Withdrawal Delirium
Substance-Related Disorders for 291.2 Alcohol-Induced Persisting Dementia
substance-specific codes) 291.1 Alcohol-Induced Persisting
294.9 Amnestic Disorder NOS Amnestic Disorder
 18 • DSM - IV-TR classification system 83

291.x Alcohol-Induced Psychotic Cannabis-Related Disorders

Disorder Cannabis Use Disorders
.5 With DelusionsI,W 304.30 Cannabis Dependence
.3 With HallucinationsI,W 304.20 Cannabis Abuse
291.89 Alcohol-Induced Mood
DisorderI,W Cannabis-Induced Disorders
291.89 Alcohol-Induced Anxiety 292.89 Cannabis Intoxication (Specify if:
DisorderI,W With Perceptual Disturbances)
291.89 Alcohol-Induced Sexual 292.81 Cannabis Intoxication Delirium
DysfunctionI,W 292.xx Cannabis-Induced Psychotic Dis-
291.89 Alcohol-Induced Sleep order
DisorderI,W .11 With DelusionsI
291.0 Alcohol-Related Disorder .12 With HallucinationsI
NOS 292.89 Cannabis-Induced Anxiety Disor-
derI
Amphetamine (or Amphetamine-Like)- 292.89 Cannabis-Related Disorder NOS
Related Disorders
Amphetamine Use Disorders Cocaine-Related Disorders
304.40 Amphetamine Dependencea,b,c Cocaine Use Disorders
305.70 Amphetamine Abuse 304.20 Cocaine Dependence
304.60 Cocaine Abuse
Amphetamine-Induced Disorders
292.89 Amphetamine Intoxication Cocaine-Induced Disorders
(Specify if: With Perceptual 292.89 Cocaine Intoxication (Specify if:
Disturbances) With Perceptual Disturbances)
292.0 Amphetamine Withdrawal 292.0 Cocaine Withdrawal
292.81 Amphetamine Intoxication 292.81 Cocaine Intoxication Delirium
Delirium 292.xx Cocaine-Induced Psychotic
292.xx Amphetamine-Induced Psychotic Disorder
Disorder .11 With DelusionsI
.11 With DelusionsI .12 With HallucinationsI
.12 With HallucinationsI 292.84 Cocaine-Induced Mood
292.84 Amphetamine-Induced Mood DisorderI,W
DisorderI,W 292.89 Cocaine-Induced Anxiety
292.89 Amphetamine-Induced Anxiety DisorderI,W
DisorderI 292.89 Cocaine-Induced Sexual
292.89 Amphetamine-Induced Sexual DysfunctionI
DysfunctionI 292.89 Cocaine-Induced Sleep
292.89 Amphetamine-Induced Sleep DisorderI,W
DisorderI,W 292.9 Cocaine-Related Disorder NOS
292.0 Amphetamine-Related Disorder
NOS Hallucinogen-Related Disorders
Hallucinogen Use Disorders
Caffeine-Related Disorders 304.50 Hallucinogen Dependenceb,c
Caffeine-Induced Disorders 305.30 Hallucinogen Abuse
305.90 Caffeine Intoxication
292.89 Caffeine-Induced Anxiety Hallucinogen-Induced Disorders
DisorderI 292.89 Hallucinogen Intoxication
292.89 Caffeine-Induced Sleep 292.89 Hallucinogen Persisting Percep-
DisorderI tion Disorder (Flashbacks)
292.9 Caffeine-Related Disorder 292.81 Hallucinogen Intoxication
NOS Delirium
84 part i • assessment and diagnosis

292.xx Hallucinogen-Induced Psychotic 292.84 Opioid-Induced Mood DisorderI

Disorder 292.89 Opioid-Induced Sexual
.11 With DelusionsI DysfunctionI
.12 With HallucinationsI 292.89 Opioid-Induced Sleep
292.84 Hallucinogen-Induced Mood DisorderI,W
DisorderI 292.9 Opioid-Related Disorder NOS
292.89 Hallucinogen-Induced Anxiety
DisorderI Phencyclidine (or Phencyclidine-Like)-
292.9 Hallucinogen-Related Disorder Related Disorders
NOS Phencyclidine Use Disorders
304.60 Phencyclidine Dependenceb,c
Inhalant-Related Disorders 305.90 Phencyclidine Abuse
Inhalant Use Disorders
304.60 Inhalant Dependenceb,c Phencyclidine-Induced Disorders
305.90 Inhalant Abuse 292.89 Phencyclidine Intoxication (Spec-
ify if: With Perceptual Distur-
Inhalant-Induced Disorders bances)
292.89 Inhalant Intoxication 292.81 Phencyclidine Intoxication
292.81 Inhalant Intoxication Delirium Delirium
292.82 Inhalant-Induced Persisting 292.xx Phencyclidine-Induced Psychotic
Dementia Disorder
292.xx Inhalant-Induced Psychotic .11 With DelusionsI
Disorder .12 With HallucinationsI
.11 With DelusionsI 292.84 Induced Mood DisorderI
.12 With HallucinationsI 292.89 Induced Anxiety DisorderI
292.84 Inhalant-Induced Mood DisorderI 292.9 Phencyclidine-Related Disorder
292.89 Inhalant-Induced Anxiety NOS
DisorderI
292.9 Inhalant-Related Disorder NOS Sedative-, Hypnotic-, or Anxiolytic-
Related Disorders
Nicotine-Related Disorders Sedative, Hypnotic, or Anxiolytic Use
Nicotine Use Disorders Disorders
305.1 Nicotine Dependence 304.10 Sedative, Hypnotic, or Anxiolytic
Dependence
Nicotine-Induced Disordersa,b 305.40 Sedative, Hypnotic, or Anxiolytic
292.00 Nicotine Withdrawal Abuse
292.9 Nicotine-Related Disorder NOS
Sedative, Hypnotic, or Anxiolytic-Induced
Opioid-Related Disorders Disorders
Opioid Use Disorders 292.89 Sedative, Hypnotic, or Anxiolytic
304.00 Opioid Dependence Intoxication
305.50 Opioid Abuse 292.0 Sedative, Hypnotic, or Anxiolytic
Withdrawal (Specify if: With Per-
Opioid-Induced Disorders ceptual Disturbances)
292.89 Opioid Intoxication (Specify if: 292.81 Sedative, Hypnotic, or Anxiolytic
With Perceptual Disturbances) Intoxication Delirium
292.0 Opioid Withdrawal 292.81 Sedative, Hypnotic, or Anxiolytic
292.81 Opioid Intoxication Delirium Withdrawal Delirium
292.xx Opioid-Induced Psychotic Disorder 292.82 Sedative, Hypnotic, or Anxiolytic-
.11 With DelusionsI Induced Persisting Dementia
.12 With HallucinationsI 292.83 Sedative, Hypnotic, or Anxiolytic-
 18 • DSM - IV-TR classification system 85

Induced Persisting Amnestic 292.89 Other (or Unknown) Substance-

Disorder Induced Sexual DysfunctionI
292.xx Induced Psychotic Disorder 292.89 Other (or Unknown) Substance-
.11 With DelusionsI Induced Sleep DisorderI,W
.12 With HallucinationsI 292.9 Other (or Unknown) Substance-
292.84 Sedative, Hypnotic, or Anxiolytic- Related Disorder NOS
Induced Mood DisorderI,W
292.89 Sedative, Hypnotic, or Anxiolytic-
Schizophrenia and Other
Induced Anxiety DisorderI,W
Psychotic Disorders
292.89 Sedative, Hypnotic, or Anxiolytic-
Induced Sexual DysfunctionI 295.xx Schizophrenia
292.89 Sedative, Hypnotic, or Anxiolytic- The following Classification of Longitudinal
Induced Sleep DisorderI,W Course applies to all subtypes of Schizophre-
292.9 Sedative, Hypnotic, or Anxiolytic- nia:
Related Disorder NOS
Episodic
Polysubstance-Related Disorder With Interepisode Residual Symptoms (Spec-
304.80 Polysubstance Dependencea,b,c,d ify if: With Prominent Negative Symp-
toms)/Episodic
Other (or Unknown) Substance-Related With No Interepisode Residual Symptoms
Disorders Continuous (Specify if: With Prominent Neg-
Other (or Unknown) Substance Use Disorders ative Symptoms)
Single Episode in Partial Remission (Specify
304.90 Other (or Unknown) Substance if: With Prominent Negative Symptoms)/
Dependencea,b,c,d Single Episode in Full Remission
305.90 Other (or Unknown) Substance Other or Unspecified Pattern
Abuse
.30 Paranoid Type
Other (or Unknown) Substance-Induced .10 Disorganized Type
Disorders .20 Catatonic Type
292.89 Other (or Unknown) Substance .90 Undifferentiated Type
Intoxication (Specify if: With Per- .60 Residual Type
ceptual Disturbances) 295.40 Schizophreniform Disorder
292.0 Other (or Unknown) Substance (Specify if: Without Good Prog-
Withdrawal nostic Features/With “Good
292.81 Other (or Unknown) Substance- Prognostic Features)
Induced Delirium 295.70 Schizoaffective Disorder (Specify
292.82 Other (or Unknown) Substance- type: Bipolar type/Depressive
Induced Persisting Dementia Type)
292.82 Other (or Unknown) Substance- 297.1 Delusional Disorder (Specify
Induced Persisting Amnestic Dis- type: Erotomanic Type/Grandiose
order Type/Jealous Type/Persecutory
292.xx Other (or Unknown) Substance- Type/Somatic Type/Mixed
Induced Psychotic Disorder Type/Unspecified Type)
292.11 With DelusionsI,W 298.8 Brief Psychotic Disorder (Specify
292.12 With HallucinationsI,W if: With Marked
292.84 Other (or Unknown) Substance- Stressor(s)/Without Marked
Induced Mood DisorderI,W Stressor(s)/With Postpartum
292.89 Other (or Unknown) Substance- Onset)
Induced Anxiety DisorderI,W 298.3 Shared Psychotic Disorder
86 part i • assessment and diagnosis

293.xx Psychotic Disorder Due to . . . Bipolar Disorders

[Indicate the General Medical 296.xx Bipolar I Disorder
Condition] .0x Single Manic Episodea,c,f (Specify
.81 With Delusions if: Mixed)
.82 With Hallucinations .40 Most Recent Episode Hypo-
——.— Substance-Induced Psychotic manicg,h,i
Disorder (Refer to Substance- .4x Most Recent Episode Manica,c,f,g,h,i
Related Disorders for substance- .6x Most Recent Episode Mixeda,c,f,g,h,i
specific codes; specify if: With .5x Most Recent Episode
Onset During Intoxication/With Depresseda,b,c,d,e,f,g,h,i
Onset During Withdrawal) .7 Most Recent Episode Unspeci-
298.9 Psychotic Disorder NOS fiedg,h,i
296.89 Bipolar II Disordera,b,c,d,e,f,g,h,I
(Specify current or most recent
Mood Disorders
episode: Hypomanic/Depressed)
Code current state of Major Depressive Dis- 301.13 Cyclothymic Disorder
order or Bipolar I Disorder in fifth digit: 296.80 Bipolar Disorder NOS
1 = Mild 293.83 Mood Disorder Due to . . . [Indi-
2 = Moderate cate the General Medical Condi-
3 = Severe Without Psychotic Features tion] (Specify type: With Depres-
4 = Severe With Psychotic Features sive Features/With Major
(Specify: Mood-Congruent Psychotic Depressive-Like Episode/With
Features/Mood-Incongruent Psy- Manic Features/With Mixed Fea-
chotic Features) tures. Specify if: With Onset
5 = In Partial Remission During Intoxication/With Onset
6 = In Full Remission During Withdrawal)
0 = Unspecified 296.90 Mood Disorder NOS
The following specifiers apply (for current or
most recent episode) to Mood Disorders as Anxiety Disorders
noted: 300.01 Panic Disorder Without Agora-
aSeverity/Psychotic/Remission Specifiers phobia
bChronic 300.21 Panic Disorder With Agoraphobia
cWith Catatonic Features 300.22 Agoraphobia Without History of
dWith Melancholic Features Panic Disorder
eWith Atypical Features 300.29 Specific Phobia (Specify type: An-
fWith Postpartum Onset imal Type/Natural Environment
The following specifiers apply to Mood Disor- Type/Blood-Injection-Injury
ders as noted: Type/Other Type)
gWith or Without Full Interepisode Recovery 300.23 Social Phobia (Specify if: Gener-
hWith Seasonal Pattern alized)
iWith Rapid Cycling 300.3 Obsessive-Compulsive Disorder
(Specify if: With Poor Insight)
Depressive Disorders 309.81 Post Traumatic Stress Disorder
296.xx Major Depressive Disorder (Specify if: Acute/Chronic. Spec-
.2x Single Episodea,b,c,d,e,f ify if: With Delayed Onset)
.3x Recurrenta,b,c,d,e,f,g,h 308.3 Acute Stress Disorder
300.4 Dysthymic Disorder (Specify if: 300.02 Generalized Anxiety Disorder
Early Onset/Late Onset; Specify: 293.84 Anxiety Disorder Due to . . . [In-
With Atypical Features) dicate the General Medical Con-
311. Depressive Disorder NOS dition] (Specify if: With General
 18 • DSM - IV-TR classification system 87

Anxiety/With Panic 300.6 Depersonalization Disorder

Attacks/With Obsessive Compul- 300.15 Dissociative Disorder NOS
sive Symptoms)
——— Substance-Induced Anxiety
Sexual and Gender Identity
Disorder (Refer to Substance
Disorders
Related Disorders for substance-
specific codes; specify if: With
Generalized Anxiety/With Panic Sexual Dysfunctions
Attacks/With Obsessive The following specifiers apply to all primary
Compulsive Symptoms/With Sexual Dysfunctions:
Phobic Symptoms. Specify if: Lifelong Type/Acquired Type
With Onset During Intoxica- Generalized Type/Situational Type
tion/With Onset During Due to Psychological Factors/Due to Com-
Withdrawal) bined Factors
300.00 Anxiety Disorder NOS
Sexual Desire Disorders
Somatoform Disorders 302.71 Hypoactive Sexual Desire Disor-
300.81 Somatization Disorder der
300.82 Undifferentiated Somatoform 302.79 Sexual Aversion Disorder
Disorder
300.11 Conversion Disorder (Specify Sexual Arousal Disorders
type: With Motor Symptom or 307.72 Female Sexual Arousal Disorder
Deficit/With Sensory Symptom 307.72 Male Erectile Disorder
or Deficit/With Seizures or Con-
vulsions/With Mixed Presenta- Orgasmic Disorder
tion) 302.73 Female Orgasmic Disorder
307.xx Pain Disorder 302.74 Male Orgasmic Disorder
.80 Associated With Psychological 302.75 Premature Ejaculation
Factors and a General Medical
Condition (Specify if Sexual Pain Disorders
Acute/Chronic) 302.76 Dyspareunia (Not Due to a Gen-
300.7 Hypochondriasis (Specify if: eral Medical Condition)
With Poor Insight) 302.51 Vaginismus (Not Due to a Gen-
300.7 Body Dysmorphic Disorder eral Medical Condition)

Factitious Disorders Sexual Dysfunction Due to General Medical

300.xx Factitious Disorder Condition
.16 With Predominantly Psychologi- 625.8 Female Hypoactive Sexual
cal Signs and Symptoms Desire Disorder Due to . . .
.19 With Predominantly Physical [Indicate the General Medical
Signs and Symptoms Condition]
.19 With Combined Psychological 608.89 Male Hypoactive Sexual Desire
and Physical Signs and Symp- Disorder Due to . . . [Indicate the
toms General Medical Condition]
300.19 Factitious Disorder NOS 607.84 Male Erectile Disorder Due to . . .
[Indicate the General Medical
Dissociative Disorders Condition]
300.12 Dissociative Amnesia 625.0 Female Dyspareunia Due to . . .
300.13 Dissociative Fugue [Indicate the General Medical
300.14 Dissociative Identity Disorder Condition]
88 part i • assessment and diagnosis

608.89 Male Dyspareunia Due to . . . [In- Eating Disorders

dicate the General Medical Con- 307.1 Anorexia Nervosa (Specify if: Re-
dition] stricting Type; Binge-
302.70 Sexual Dysfunction NOS Eating/Purging Type)
625.8 Other Female Sexual Dysfunction 307.51 Bulimia Nervosa (Specify type:
Due to . . . [Indicate the General Purging Type/Non-Purging
Medical Condition] Type)
608.89 Other Male Sexual Dysfunction 307.50 Eating Disorder NOS
Due to . . . [Indicate the General
Medical Condition]
——— Substance-Induced Sexual Dys- Sleep Disorders
function NOS (Refer to
Substance-Related Disorders for Primary Sleep Disorders
substance-specific codes; specify Dyssomnias
if: With Impaired Desire/With 307.42 Primary Insomnia
Impaired Arousal/With Impaired 307.44 Primary Hypersomnia (Specify
Orgasm/With Sexual Pain. if: Recurrent)
Specify if: With Onset During 347 Narcolepsy
Intoxication) 780.59 Breathing-Related Sleep Disorder
302.70 Sexual Dysfunction NOS 307.45 Circadian Rhythm Sleep Disorder
(Specify type: Delayed Sleep
Paraphilias Phase Type/Jet Lag Type/Shift
302.4 Exhibitionism Work Type/Unspecified Type)
302.81 Fetishism 307.47 Dyssomnia NOS
302.89 Frotteurism
302.2 Pedophilia (Specify if: Sexually Parasomnias
Attracted to Males/Sexually 307.47 Nightmare Disorder
Attracted to Females/Sexually 307.46 Sleep Terror Disorder
Attracted to Both. Specify if: 307.46 Sleepwalking Disorder
Limited to Incest. Specify Type: 307.47 Parasomnia NOS
Exclusive Type/Nonexclusive
Type) Sleep Disorders Related to Another Mental
302.83 Sexual Masochism Disorder
302.84 Sexual Sadism 307.42 Insomnia Related to . . . [Indicate
302.3 Transvestic Fetishism the Axis I or Axis II Disorder]
302.82 Voyeurism 307.44 Hypersomnia Related to . . . [In-
302.9 Paraphilia NOS dicate the Axis I or Axis II Disor-
der]
Gender Identity Disorders
302.xx Gender Identity Disorder Other Sleep Disorders
.6 in Children 780.xx Sleep Disorder Due to . . .
.85 in Adolescents or Adults (Specify [Indicate the General Medical
if: Sexually Attracted to Condition]
Males/Sexually Attracted to .52 Insomnia Type
Females/Sexually Attracted to .54 Hypersomnia Type
Both/Sexually Attracted to .59 Parasomnia Type
Neither) .59 Mixed Type
302.6 Gender Identity Disorder ——— Substance-Induced Sleep Disorder
NOS (Refer to Substance-Related Dis-
302.9 Sexual Disorder NOS orders for substance-specific
 18 • DSM - IV-TR classification system 89

codes; specify type: Insomnia Other Conditions That May Be a

Type/Hypersomnia Type/Mixed Focus of Clinical Attention
Type. Specify if: With Onset
During Intoxication/With Onset Psychological Factors Affecting Medical
During Withdrawal) Condition
316 . . . (Specified Psychological Fac-
tor) Affecting . . . [Indicate the
Impulse-Control Disorders Not
General Medical Condition].
Elsewhere Classified
Choose name based on nature of
312.34 Intermittent Explosive factors:
Disorder Mental Disorder Affecting Med-
312.32 Kleptomania ical Condition
312.33 Pyromania Psychological Symptoms Affect-
312.31 Pathological Gambling ing Medical Condition
312.39 Trichotillomania Personality Traits or Coping
312.30 Impulse Control Disorder Style Affecting Medical Condi-
NOS tion
Maladaptive Health Behaviors
Affecting Medical Condition
Adjustment Disorders
Stress-Related Physiological Re-
309.xx Adjustment Disorder sponse Affecting Medical Condi-
.0 With Depressed Mood tion
.24 With Anxiety Other or Unspecified Psychologi-
.28 With Mixed Anxiety and cal Factors Affecting Medical
Depressed Mood Condition
.3 With Disturbance of Conduct
.4 With Mixed Disturbance of Medication-Induced Movement Disorders
Emotions and Conduct
.9 Unspecified 332.1 Neuroleptic-Induced Parkinson-
Specify if Acute/Chronic ism
333.92 Neuroleptic Malignant Syndrome
333.7 Neuroleptic-Induced Acute Dys-
Personality Disorders
tonia
Note: These are coded on Axis II. 333.99 Neuroleptic-Induced Acute
301.0 Paranoid Personality Disorder Akathisia
301.20 Schizoid Personality Disorder 333.82 Neuroleptic-Induced Tardive
301.22 Schizotypal Personality Dyskinesia
Disorder 333.1 Medication-Induced Postural
301.7 Antisocial Personality Disorder Tremor
301.83 Borderline Personality 333.90 Medication-Induced Movement
Disorder Disorder NOS
301.50 Histrionic Personality Disorder
301.81 Narcissistic Personality Other Medication-Induced Disorder
Disorder 995.2 Adverse Effects of Medication
301.82 Avoidant Personality Disorder NOS
301.6 Dependent Personality
Disorder Relational Problems
301.4 Obsessive-Compulsive V61.9 Relational Problem Related to a
Disorder Mental Disorder or General Med-
301.9 Personality Disorder NOS ical Condition
90 part i • assessment and diagnosis

V61.20 Parent-Child Relational Problem V71.09 No Diagnosis or Conditions on

V61.10 Partner Relational Problem Axis I
V61.8 Sibling Relational Problem 799.9 Diagnosis or Condition Deferred
V62.81 Relational Problem NOS on Axis I
V71.09 No Diagnosis on Axis II
Problems Related to Abuse or Neglect
Diagnosis Deferred on Axis II
V61.21 Physical Abuse of Child (Code
995.54 if focus of attention is on
victim) MULTIAXIAL SYSTEM
V61.21 Sexual Abuse of Child (Code
995.53 if focus of attention is on Axis I Clinical Disorders and Other
victim) Conditions That May Be a Focus
V61.21 Neglect of Child (Code 995.52 if of Clinical Attention
focus of attention is on victim) Axis II Personality Disorders and Mental
——— Physical Abuse of Adult Retardation
V61.12 (if by partner) Axis III General Medical Conditions
V62.83 (if by person other than partner) Axis IV Psychosocial and Environmental
(Code 995.81 if focus of attention Problems
is on victim) Axis V Global Assessment of Function-
——— Sexual Abuse of Adult ing
V61.12 (if by partner)
V62.83 (if by person other than partner) Source: Reprinted with permission from the Di-
(Code 995.83 if focus of attention agnostic and Statistical Manual of Mental Disor-
is on victim) ders, Fourth Edition, Text Revision, copyright
2004 American Psychiatric Association.
Additional Conditions That May Be a Focus
of Clinical Attention Reference and Internet Site
V15.81 Noncompliance With Treatment
V65.2 Malingering American Psychiatric Association. (2000). The diag-
nostic and statistical manual of mental disor-
V71.01 Adult Antisocial Behavior
ders (4th ed., rev.). Washington, DC: Author.
V62.89 Borderline Intellectual Function- http://www.appi.org
ing
Note: This is coded on Axis II
780.9 Age-Related Cognitive Decline Related Topics
V62.82 Bereavement Chapter 9, “Child and Adolescent Diagnosis With
V62.3 Academic Problem DSM-IV”
V62.2 Occupational Problem Chapter 19, “A Practical Guide for the Use of the
V62.89 Religious or Spiritual Problem Global Assessment of Functioning (GAF) Scale
V62.4 Acculturation Problem of the DSM-IV-TR”
V62.89 Phase of Life Problem

Additional Codes
300.9 Unspecified Mental Disorder
(nonpsychotic)
 A PRACTICAL GUIDE FOR
THE USE OF THE GLOBAL
19 ASSESSMENT OF
FUNCTIONING (GAF) SCALE
OF THE DSM-IV-TR

American Psychiatric Association

One of the criticisms of the Diagnostic and To achieve the best use of this scale, the au-
Statistical Manual of Mental Disorders is that thors provide a four-step process for assigning
it fails to provide an adequate range of descrip- a GAF:
tion to encompass the whole range of human
psychology. While a wider range of description 1. Starting at the top level, evaluate each range
is an admirable goal, it may one that will have by asking, “Is either the individual’s symp-
to wait a long time, if ever, for someone to ac- tom severity or level of functioning worse
complish. The authors of the DSM series have than what is indicated in the range descrip-
attempted to make the best of the task at hand tion?”
by designing a multiaxial system that will re- 2. Keep moving down the scale until the range
flect as many of the individual qualities of the that best matches the individual’s symptom
patient while retaining its meaningful general- severity or the level of functioning is
izability. To this end, Axis V of the DSM was reached, whichever is worse.
provided to allow clinicians to state their im- 3. Look at the next lower range as a double-
pressions of a patient’s overall level of function- check against having stopped prematurely.
ing. The Manual provides the following para- This range should be too severe on both
phrased instruction and warnings. symptom severity and level of functioning.
If it is, the appropriate range has been
• The reporting of the patient’s general overall reached (continue with Step 4). If not, go
condition should not include impairment in back to Step 2 and continue moving down
functioning due to factors other than psy- the scale.
chological in nature, such as one’s physical 4. To determine the specific GAF rating within
or environmental limitations. the selected 10-point range, consider whether
• The scale presents 10 ranges of functioning the individual is functioning at the higher
and the clinician is asked to pick a single or lower end of the 10-point range.
value that best reflects the patient’s adaptive
functioning.
• Each of the 10 ranges has two aspects —
symptoms severity and functioning. The
GAF score should be in the decile that re-
flects either of these aspects.

91
92 part i • assessment and diagnosis

GLOBAL ASSESSMENT OF impairment in several areas, such as

FUNCTIONING (GAF) SCALE work or school, family relations, judg-
ment, thinking, or mood (e.g., depressed
Code
man avoids friends, neglects family, and
Note: Use intermediate codes when appropriate
is unable to work; child frequently beats
(e.g., 45, 68, 72).
up younger children, is defiant at home,
and is failing at school).
100 Superior functioning in a wide range of
30 Behavior is considerably influenced by
activities, life’s problems never seem to
delusions or hallucinations or serious
get out of hand, is sought out by others
impairment in communication or judg-
because of his or her many positive qual-
ment (e.g., sometimes incoherent, acts
ities. No symptoms.
grossly inappropriately, suicidal preoc-
90 Absent or minimal symptoms (e.g., mild
cupation) or inability to function in al-
anxiety before an exam), good function-
most all areas (stays in bed all day; no
ing in all areas, interested and involved
job, home, or friends).
in a wide range of activities, socially ef-
20 Some danger of hurting self or others
fective, generally satisfied with life, no
(e.g., suicide attempts without clear ex-
more than everyday problems or con-
pectation of death; frequently violent;
cerns (e.g., an occasional argument with
manic excitement) or occasionally fails to
family members).
maintain minimal personal hygiene
80 If symptoms are present, they are tran-
(e.g., smears feces) or gross impairment
sient and expectable reactions to psy-
in communication (e.g., largely incoher-
chosocial stressors (e.g., difficulty con-
ent or mute).
centrating after family argument), no
10 Persistent danger of severely hurting self
more than slight impairment in social,
or others (e.g., recurrent violence)
occupational, or school functioning (e.g.,
1 or serious suicidal act with clear expecta-
temporarily falling behind in school-
tion of death.
work).
0 Inadequate information.
70 Some mild symptoms (e.g., depressed
mood and mild insomnia) or some diffi-
Sources: The rating of overall psychological func-
culty in social, occupational, or school
tioning on a scale of 1–100 was operationalized
functioning (e.g., occasional truancy or
by Luborsky in the Health-Sickness Rating Scale
theft within the household), but gener-
(L. Luborsky, “Clinicians’ Judgments of Mental
ally functioning pretty well, has some
Health,” Archives of General Psychiatry 7
meaningful interpersonal relationships.
[1962]: 407 – 417). Spitzer and colleagues devel-
60 Moderate symptoms (e.g., flat affect and
oped a revision of the Health-Sickness Rating
circumstantial speech, occasional panic
Scale called the Global Assessment Scale (GAS)
attacks) or moderate difficulty in social,
(J. Endicott, R. L. Spitzer, J. L. Fleiss, & J. Cohen,
occupational, or school functioning (e.g.,
“The Global Assessment Scale: A Procedure for
few friends, conflicts with peers and co-
Measuring Overall Severity of Psychiatric Dis-
workers).
turbance,” Archives of General Psychiatry 33
50 Serious symptoms (e.g., suicidal ideation, se-
[1976]: 766 – 771). A modified version of the FAS
vere obsessional rituals, frequent shop-
was included in DSM II-R as the “Global Assess-
lifting) or any serious impairment in so-
ment of Functioning (GAF) Scale.” Text for the
cial, occupational, or school functioning
GAF is reprinted with permission from the Diag-
(e.g., no friends, unable to keep a job).
nostic and Statistical Manual of Mental Disor-
40 Some impairment in reality testing or
ders, Fourth Edition, Text Revision, copyright
communication (e.g., speech is at times
2000 American Psychiatric Association.
illogical, obscure, or irrelevant) or major
 20 • assessment of character strengths 93

Reference and Internet Site Related Topics

American Psychiatric Association. (2000). The diag- Chapter 10, “Formulating Diagnostic Impressions
nostic and statistical manual of mental dis- With Ethnic and Racial Minority Children
orders (4th ed., rev.). Arlington, VA: American Using the DSM-IV-TR”
Psychiatric Association. http://www.appi.org Chapter 18, “DSM-IV-TR Classification System”

ASSESSMENT OF CHARACTER
20 STRENGTHS

Christopher Peterson, Nansook Park,

& Martin E. P. Seligman

The new field of positive psychology calls for as Association (1987) has begun by focusing on
much focus on strength as on weakness, as what is right about people and specifically
much interest in building the best things in life about the strengths of character that make the
as in repairing the worst, and as much concern good life possible (Peterson & Seligman, 2004).
with fulfilling the lives of healthy people as Two points frame our discussion of the VIA
healing the wounds of the distressed (Seligman Classification. First, we are not the first psy-
& Csikszentmihalyi, 2000). The past concern of chologists to grapple with character strengths
psychology with human problems is, of course, and how to assess them. We refer the reader to
understandable and will not be abandoned any- Jahoda’s (1958) prescient treatise on positive
time in the foreseeable future, but psycholo- mental health, which made the case for under-
gists interested in promoting human potential standing psychological well-being in its own
need to pose different questions from their pre- right, not simply as the absence of disorder or
decessors who assumed a disease model. Criti- distress. We also refer the reader to other at-
cal tools for positive psychologists include a vo- tempts to measure character strengths with self-
cabulary for speaking about the good life and report inventories: for example, Greenberger,
assessment strategies for investigating its com- Josselson, Knerr, and Knerr’s (1975) measures of
ponents. psychosocial maturity; Ryff and Singer’s (1996)
For the past several years, we have focused dimensions of psychological well-being; and
our attention on positive traits — strengths of Cawley, Martin, and Johnson’s (2000) virtues
character such as curiosity, kindness, and hope. approach to personality assessment.
What are the most important of these, and how Second, we believe that attention to charac-
can they be measured as individual differ- ter strengths is as productive for clinical psy-
ences? Our project — the VIA (Values in Ac- chologists interested in troubled individuals as
tion) Classification of Strengths — means to it is for positive psychologists interested in the
complete what the Diagnostic and Statistical untroubled (Seligman & Peterson, 2003). There
Manual (DSM) of the American Psychiatric are hints in the research literature that certain
94 part i • assessment and diagnosis

strengths of character — for example, hope, sumption that character is plural — and we did
love, and perspective — can buffer the deleteri- so by specifying the separate strengths and
ous effects of stress and trauma, containing or virtues, then devising ways to assess these as
precluding disorders in their wake. And even if individual differences. We recognize the com-
disorder occurs, character strengths often co- ponents of good character as existing at differ-
exist with symptoms of disorder and provide a ent levels of abstraction. Virtues are the core
sturdy foundation on which to base interven- characteristics valued by moral philosophers
tions (cf. social work from a strengths perspec- and religious thinkers: wisdom, courage, hu-
tive; Saleebey, 1992). Furthermore, our own manity, justice, temperance, and transcendence.
research suggests that individuals who recover These six broad categories of virtue emerge
from psychological or physical problems may consistently from historical surveys. We spec-
in the process forge certain character strengths ulate that these are universal, perhaps grounded
such as appreciation of beauty or gratitude. in biology through an evolutionary process
Highlighting these as possible outcomes of suc- that selected for these predispositions toward
cessful therapy might destigmatize the seeking moral excellence as means of solving the im-
of treatment and sustain client motivation. Fi- portant tasks necessary for survival of the
nally, we call on clinical psychologists not only species.
to treat disorder but also to help a client “deal Character strengths are the psychological in-
with it” in the course of treatment. Emphasiz- gredients — processes or mechanisms — that
ing to individuals that they have strengths of define the virtues. Said another way, they are
character in addition to symptoms might lead distinguishable routes to displaying one or an-
them to keep on with their lives, regardless of other of the virtues. For example, the virtue of
the outcome of therapy. We find the examples wisdom can be achieved through such strengths
of Abraham Lincoln and Winston Churchill in- as curiosity, love of learning, open-mindedness,
structive in this regard— profoundly depressed creativity, and what we call perspective — hav-
men and great leaders. How would they (and ing a “big picture” on life. These strengths are
the world) have fared in the contemporary similar in that they all involve the acquisition
mental health system? and use of knowledge, but they are also distinct.
Again, we regard these strengths as ubiqui-
tously recognized and valued, although a given
THE VIA CLASSIFICATION individual will rarely if ever display all of them.
We generated the entries for the VIA Clas-
There are various ways to approach character. sification by reviewing pertinent literatures
A DSM-like approach would talk about it as that addressed good character—from psychia-
unitary and categorical — one either has char- try, youth development, character education,
acter or not. Or one could think about character religion, ethics, philosophy, organizational
in terms of underlying processes like auton- studies, and psychology. From the many candi-
omy or reality orientation. One might wed it date strengths identified, we winnowed the list
to an a priori theory. One could view character by combining redundancies and applying the
as only a social construction, revealing of the criteria in Table 1. (This table and all others
observer’s values but not of who or what is ob- cited in this chapter may be found not only
served. But in all of these respects, the VIA here, but also on the accompanying Web site.)
Classification has taken a different approach. What resulted were 24 positive traits organized
Its stance is in the spirit of personality psychol- under the six broad virtues (see Table 2).
ogy, and specifically modern trait theory, rec-
ognizing individual differences that are stable
and general but also shaped by the individual’s ASSESSING THE VIA STRENGTHS
setting and thus capable of change.
The initial step in our project was to unpack What distinguishes the VIA Classification
the notion of character — to start with the as- from many previous attempts to articulate
 20 • assessment of character strengths 95

table 1. Criteria for the VIA Classification Character Strengths

1. A strength needs to be manifest in the range of an individual’s behavior—thoughts, feelings, and/or actions—in such
a way that it can be assessed.
2. A strength contributes to various fulfillments that comprise the good life, for the self and for others. Although
strengths and virtues determine how an individual copes with adversity, our focus is on how they fulfill an individual.
In keeping with the broad premise of positive psychology, strengths allow the individual to achieve more than the ab-
sence of distress and disorder. They “break through the zero point” of psychology’s traditional concern with disease,
disorder, and failure to address quality of life outcomes.
3. Although strengths can and do produce desirable outcomes, each strength is morally valued in its own right, even in
the absence of obvious beneficial outcomes. To say that a strength is morally valued is an important qualification, be-
cause there exist individual differences that are widely valued and contribute to fulfillment but still fall outside of our
classification. Consider intelligence or athletic prowess. Talents and abilities can be squandered, but strengths and
virtues cannot.
4. The display of a strength by one person does not diminish other people in the vicinity but rather elevates them. On-
lookers are impressed, inspired, and encouraged by their observation of virtuous action.
5. The larger society provides institutions and associated rituals for cultivating strengths and virtues. These can be
thought of as simulations: trial runs that allow children and adolescents to display and develop a valued characteristic in
a safe (as-if) context in which guidance is explicit.
6. Yet another criterion for a character strength is the existence of consensually recognized paragons of virtue.
7. A final criterion is that the strength is arguably unidimensional and not able to be decomposed into other strengths in
the classification. For example, the character strength of “tolerance” meets most of the other criteria enumerated but is
a complex blend of open-mindedness and fairness. The character strength of “responsibility” seems to result from per-
severance and teamwork. And so on.

good character is its simultaneous concern with “contaminated” by a response set of social de-
assessment. Sophisticated social scientists some- sirability; they are socially desirable, especially
times respond with suspicion when they hear when reported with fidelity.
our goal, reminding us of the pitfalls of self- We mention again the previous research
report and the validity threat posed by “social that measured character strengths with self-
desirability” (Crowne & Marlowe, 1964). We report questionnaire batteries. In no case did a
do not dismiss these considerations out of single methods factor order the data. Rather,
hand, but their premise is worth examining. different clusters of strengths always emerged.
We seem to be quite willing, as researchers and External correlates were sensible. These con-
practitioners, to trust what individuals say clusions converge with what we have learned to
about their problems. With notable exceptions, date from our own attempts to measure the
like substance abuse and eating disorders, the VIA strengths among young people and adults
preferred way to measure psychological disor- with self-report questionnaires.
der relies on self-report, in the form of either We have developed two general strategies
symptom questionnaires or structured inter- for assessing character strengths: self-report
views. So why not ascertain wellness in the inventories and structured interviews. Thumb-
same way? nail sketches are found in Table 3 and details in
Suppose that people really do possess moral Peterson and Seligman (2004).
virtues. Most philosophers emphasize that vir- Our measure development is ongoing,
tuous activity involves choosing virtue in light but we can offer some general observations.
of a justifiable life plan (Yearley, 1990). In more First, given our interest in identifying ubiqui-
psychological language, this characterization tous strengths of character, not all possible
means that people can reflect on their own strengths of interest to a psychologist are as-
virtues and talk about them to others. They sessed by our measures. If there is a reason to
may, of course, be misled and/or misleading, ascertain a client’s achievement or autonomy,
but virtues are not the sort of entities that in then the psychologist should ask about such
principle are outside the realm of self-commen- strengths.
tary. Furthermore, character strengths are not Second, our interest as researchers has been
96 part i • assessment and diagnosis

table 2. VIA Classification of Character Strengths

1. Wisdom and knowledge —cognitive strengths that entail the acquisition and use of knowledge
Creativity: Thinking of novel and productive ways to do things; includes artistic achievement but is not limited to it
Curiosity: Taking an interest in all of ongoing experience; finding all subjects and topics fascinating; exploring and dis-
covering
Judgment/critical thinking: Thinking things through and examinng them from all sides; not jumping to conclusions;
being able to change one’s mind in light of evidence; weighing all evidence fairly
Love of learning: Mastering new skills, topics, and bodies of knowledge, whether on one’s own or formally. Obviously re-
lated to the strength of curiosity but goes beyond it to describe the tendency to add systematically to what one knows
Perspective: Being able to provide wise counsel to others; having ways of looking at the world that make sense to the
self and to other people

2. Courage— emotional strengths that involve the exercise of will to accomplish goals in the face of opposition, external
or internal
Bravery: Not shrinking from threat, challenge, difficulty, or pain; speaking up for what is right even if there is opposi-
tion; acting on convictions even if unpopular; includes physical bravery but is not limited to it
Industry/perseverance: Finishing what one starts; persisting in a course of action in spite of obstacles; “getting it out
the door”; taking pleasure in completing tasks
Authenticity: Speaking the truth but more broadly presenting oneself in a genuine way; being without pretense; taking
responsibility for one’s feelings and actions
Zest: Approaching life with excitement and energy; not doing things halfway or halfheartedly; living life as an adven-
ture; feeling alive and activated

3. Humanity—interpersonal strengths that involve “tending” and “befriending” others

Kindness: Doing favors and good deeds for others; helping them; taking care of them
Love/intimacy: Valuing close relationships with others, in particular those in which sharing and caring are recipro-
cated; being close to people
Social intelligence: Being aware of the motives and feelings of other people and the self; knowing what to do to fit in to
different social situations; knowing what makes other people tick

4. Justice—civic strengths that underlie healthy community life

Citizenship/teamwork: Working well as a member of a group or team; being loyal to the group; doing one’s share
Fairness: Treating all people the same according to notions of fairness and justice; not letting personal feelings bias deci-
sions about others; giving everyone a fair chance
Leadership: Encouraging a group of which one is a member to get things done and at the same time good relations
within the group; organizing group activities and seeing that they happen

5. Temperance—strengths that protect against excess

Forgiveness/mercy: Forgiving those who have done wrong; giving people a second chance; not being vengeful
Modesty/humility: Letting one’s accomplishments speak for themselves; not seeking the spotlight; not regarding one’s
self as more special than one is
Prudence: Being careful about one’s choices; not taking undue risks; not saying or doing things that might later be regretted
Self-control/self-regulation: Regulating what one feels and does; being disciplined; controlling one’s appetites and emotions

6. Transcendence—strengths that forge connections to the larger universe and provide meaning
Awe/appreciation of beauty and excellence: Noticing and appreciating beauty, excellence, and/or skilled performance in
all domains of life, from nature to art to mathematics to science to everyday experience
Gratitude: Being aware of and thankful for the good things that happen; taking time to express thanks
Hope: Expecting the best in the future and working to achieve it; believing that a good future is something that can be
brought about
Playfulness: Liking to laugh and tease; bringing smiles to other people; seeing the light side; making (not necessarily
telling) jokes
Spirituality: Having coherent beliefs about the higher purpose and meaning of the universe; knowing where one fits
within the larger scheme; having beliefs about the meaning of life that shape conduct and provide comfort
 20 • assessment of character strengths 97

table 3. VIA Strengths Assessment Strategies

The 240-item VIA Inventory of Strengths (VIA-IS) is intended for use by adults. It is a face-valid self-report question-
naire that uses 5-point Likert-style items to measure the degree to which respondents endorse each of the strengths of
character in the VIA Classification. It takes 30 minutes to complete. All scales have satisfactory alphas (>.70) and substan-
tial test-retest correlations (>.70). The VIA-IS has been validated against self- and other-nomination of character
strengths and correlates with measures of subjective well-being and happiness.

The 182-item VIA Inventory of Strength for Youth (VIA-Youth) is intended for use by young people (ages 10 –17). It is a
face-valid self-report questionnaire that uses 5-point Likert-style items to measure the degree to which respondents en-
dorse each of the 24 strengths of character in the VIA Classification. It takes 45 minutes to complete. All scales have satis-
factory alphas (>.70). The VIA-Youth has been validated against self- and other-nomination of character strengths and
correlates with measures of subjective well-being, happiness, and school grades.

The 9-item VIA-Rising-to-the-Occasion Iventory (VIA-RTO) is intended to measure the character strengths in the VIA
Classification that are arguably phasic (rising and falling depending on specifiable circumstances—e.g., the experience of
fear for the display of bravery; the occurrence of wrongdoing for the display of forgiveness) as opposed to tonic (showing
themselves steadily in most situations—e.g., kindness, zest, playfulness). It takes less than 10 minutes to complete and
has been used to date only with adults. Respondents are asked how frequently they have found themselves in a strength-
relevant setting and then to answer an open-ended question about how they typically respond in that setting; the question
spelled out the essence of the strength without explicitly labeling it. These responses are not analyzed but are intended to
discourage answers off the top of one’s head to the next question, which explicitly asks the respondent to use a 5-point
Likert-style scale to describe the degree to which these situated responses reflect the strength of character on focus. VIA-
RTO responses converge strongly (all rs between 40 and .60) with other-nominations of character strengths (so long as
the informant has had the opportunity to observe the individual in the strength-relevant setting).

The VIA Structured Interview (VIA-SI) adopts the logic and format of the VIA-RTO to an individual interview format. It
takes about 25 minutes to complete and has been used to date only with adults. The interviewer asks respondents how
they “usually” act in a given setting vis-à-vis the character strength on focus — in the case of phasic strengths, the set-
ting is detailed, and in the case of tonic strengths, it is presented as “everyday life.” If people describe displaying the
strength the majority of the time, follow-up questions ask: (i) how they “name” the strength; (ii) if the strength however
named is “really” who they are; and (iii) whether friends and family members would agree that the strength is “really”
who they are. To count as an individual’s signature strength, it must be displayed the majority of the time in relevant set-
tings, be named as the intended strength (or a synonym) as opposed to another strength, be “owned” by the individual,
and be recognized by others as highly characteristic of the individual. Our studies to date show that adults usually have
between two and five signature strengths.

comparing and contrasting VIA scores across written down and should provide ample grist
individuals, but we believe that these measures for the psychotherapeutic mill.
also have utility — theoretical and practical —
when scored ipsatively and used to judge an in- Note: We acknowledge the encouragement and
dividual’s strengths in relation to one another. support of the Manuel D. and Rhoda Mayerson
We have speculated that most individuals have Foundation in creating the Values in Action Insti-
“signature strengths,” the use of which at tute, a nonprofit organization dedicated to the de-
work, love, and play provide a route to the psy- velopment of a scientific knowledge base of human
chologically fulfilling life (Seligman, 2002). strengths.
The effects of naming these strengths for an
individual and encouraging their use deserve
study. References, Readings, & Internet Sites
Third, our adult inventory (the VIA-IS) is American Psychiatric Association. (1987). Diagnos-
available online at no cost to respondents; it tic and statistical manual of mental disorders
takes 30 minutes to complete and provides im- (3rd ed., rev.). Washington, DC: Author.
mediate feedback about an individual’s signa- Authentic Happiness. (n.d.). Home page (contains
ture strengths. These can be printed out or links to the VIA-IS and other positive psychol-
98 part i • assessment and diagnosis

ogy measures; requires registration). Retrieved tions for psychotherapy research. Psychother-
2004 from www.authentichappiness.org apy and Psychosomatics, 65, 14 –23.
Cawley, M. J., Martin, J. E., & Johnson, J. A. (2000). Saleebey, D. (Ed.). (1992). The strengths perspective
A virtues approach to personality. Personality in social work practice. New York: Longman.
and Individual Differences, 28, 997 –1013. Seligman, M. E. P. (2002). Authentic happiness.
Crowne, D. P., & Marlowe, D. (1964). The approval New York: Free Press.
motive: Studies in evaluative dependence. New Seligman, M. E. P., & Csikszentmihalyi, M. (2000).
York: Wiley. Positive psychology: An introduction. Ameri-
Greenberger, E., Josselson, R., Knerr, C., & Knerr, B. can Psychologist, 55, 5 –14.
(1975). The measurement and structure of psy- Seligman, M. E. P., & Peterson, C. (2003). Positive
chosocial maturity. Journal of Youth and Ado- clinical psychology. In L. G. Aspinwall & U. M.
lescence, 4, 127 –143. Staudinger (Eds.), A psychology of human
Jahoda, M. (1958). Current concepts of positive strengths: Fundamental questions and future
mental health. New York: Basic Books. directions for a positive psychology (pp. 305 –
Peterson, C., & Seligman, M. E. P. (2004). The Val- 317). Washington, DC: American Psychological
ues in Action (VIA) classification of strengths. Association.
Washington, DC: American Psychological As- Yearley, L. H. (1990). Mencius and Aquinas: Theo-
sociation. ries of virtue and conceptions of courage. Al-
Positive Psychology Center. (n.d.). Home page (con- bany, NY: State University of New York Press.
tains links to information about the VIA Clas-
sification). Retrieved 2004 from www.positive
Related Topic
psychology.org.
Ryff, C. D., & Singer, B. (1996). Psychological well- Chapter 5, “Increasing the Accuracy of Clinical Judg-
being: Meaning, measurement, and implica- ment (and Thereby Treatment Effectiveness)”
PART II
Psychological Testing
This page intentionally left blank
 50 WIDELY USED
21 PSYCHOLOGICAL TESTS

Thomas P. Hogan

Table 1 lists 50 of the most widely used psy- of the tests for five groups of psychologists as
chological tests. The table shows ranked usage reported in several different studies.

table 1. 50 Widely Used Psychological Tests With Usage Rankings for Five Groups of Psychologists
Psychologists

Test Clinical Counseling Forensic Neuro School

Aphasia Screening Test 23 — 27 17 —

Beck Depression Inventory 10 — 13 11 —
Bender Visual Motor Gestalt Test 5 8 7 25 8.5
Benton Revised Visual Retention Test 52 — 42 32 —
Boston Naming Test 42 — 18 8 —
California Verbal Learning Test 36 — 29 14 —
Category Test 31 — 8 9 —
Child Behavior Checklist 22 — — 43 10
Children’s Apperception Test 16 — — 60 —
Conners’ Parent and Teacher Rating Scales 18 — — 39 13
Development Test of Visual-Motor Integration 31 — — 49 5
FAS Word Fluency Test 37 — — 5 —
Finger Tapping Test 29 — 6a 6 —
Grooved Pegboard Test 44 — 15 15 —
Halstead-Reitan Neuropsychological Test Battery 23 — —b 7 —
Hand Dynamometer (Grip Strength) 44 — 20 20 —
Hooper Visual Organization Test 59 — 19 19 —
House-Tree-Person Projective Technique 8 11 — 31 4
(continued)
101
102 part ii • psychological testing

table 1. 50 Widely Used Psychological Tests With Usage Rankings for Five Groups of Psychologists (continued)
Psychologists

Test Clinical Counseling Forensic Neuro School

Human Figure Drawings 13 — 26 41 4.5

Kaufman Assessment Battery for Children 33 — — 53 15.5
Kinetic Family Drawing 25 — — 62 6
Luria-Nebraska Neuropsychological Battery 40 — 33 37 —
Memory Assessment Scales 44 — — 45 —
Millon Adolescent Clinical Inventory 16 — — 56 —
Millon Clinical Multiaxial Inventory 10 11 34 24 —
Minnesota Multiphasic Personality Inventory 2 1 2 1 —
Peabody Individual Achievement Test 52 — — 45 4
Peabody Picture Vocabulary Test 20 — — 28 10
Rey Complex Figure Test 25 — 21 12 —
Roberts Apperception Test for Children 25 — — 63 —
Rorschach Inkblot Test 4 12 23 18 —
Rotter Incomplete Sentences Blank 14 — — 51 —
Sentence Completion Test(s) 15 5 10 42 —
Shipley Institute of Living Test 48 — — 39 —
Sixteen Personality Factor Questionnaire 38 7 — 64 —
Stanford-Binet Intelligence Scale 29 — — 53 14
Strong Interest Inventory 38 1.5 — 72 —
Stroop Neuropsychological Screening Test 33 — 22 22 —
Symptom Checklist-90-R 44 — 44 49 —
Tactile Performance Test 78 — 11c 33 —
Test of Visual Motor Integration 25 — — 35 —
Thematic Apperception Test 6 6 39 26 11
Trail Making Test 12 — 4d 4 —
Vineland Adaptive Behavior Scales 18 — — 44 8.5
Wechsler Adult Intelligence Scale 1 3 1 2 4.5
Wechsler Intelligence Scale for Children 3 5 — 16 1
Wechsler Memory Scale 9 — 3 3 —
Wide Range Achievement Test 7 8.5 12 9 5.5
Wisconsin Card Sorting Test 33 — 9 12 —
Woodcock-Johnson Teste 21 — — 38 7

aIncludes finger oscillation.

bHalstead-Reitan was not listed in original source, but the source included several components of the Halstead-Reitan as separate entries.
cListed as Tactual Performance Test.
dTrails A and B reported separately in original source, with ranks of 4 and 5.
eIncludes Woodcock-Johnson Psychoeducational Battery as well as the more recent WJ Test of Cognitive Abilities and Test of Achievement.

Constructing a single list of widely used ological differences militating against direct
tests and rankings for psychologists is a daunt- comparisons among the surveys. For example,
ing, even risky challenge. At a surface level, the one survey may lump together all the “Wechs-
numerous surveys of test usage are highly sim- ler scales” while other surveys list the WAIS,
ilar. Most surveys present a laundry list of WISC, and WPPSI separately. Some surveys
better-known tests for the respondent to check treat the Bender-Gestalt as a projective test,
with space for write-in candidates. Most sur- while others treat it as a visual-motor test.
veys cover all major categories of tests—for ex- Some surveys list “interviews” and “observa-
ample, intelligence, objective personality, pro- tions” as tests; others do not. Some surveys
jectives, and so on. However, lurking beneath simply require checking whether a test is used,
the surface similarities are substantial method- while others request a rating of uses per month.
 21 • 50 widely used psychological tests 103

For all of these and related reasons, it is difficult highly ranked only among counseling psychol-
to construct a single list with multiple rankings. ogists but not listed in Table 1 were several ca-
Nevertheless, we have done so. We encourage reer interest surveys and objective personality
readers to consult the original sources for tests.
methodological details. For the forensic column in Table 1, we used
Sources for the rankings were limited to rel- the results of Lees-Haley, Smith, Williams, and
atively recent reports. Data for clinical psychol- Dunn (1995). They employed a methodology
ogists came from a survey by Camara, Nathan, quite different from the self-reports used in
and Puente (1998), who collected self-reports of other studies summarized here. They identified
the frequency of test usage from 933 clinical tests actually used in a sample of 100 forensic
psychologists (62% response rate) in indepen- cases in litigation for personal injury. Other
dent practice, specializing in mental health ser- tests highly ranked only for forensic usage but
vices. Data for neuropsychologists also came not listed in Table 1 were additional sensory
from Camara et al. (1998), specifically from 566 and perceptual tests.
neuropsychologists (47% response rate) who Data for school psychologists came from two
were members of the National Association of sources. First, Hutton, Dubes, and Muir (1992)
Neuropsychologists. obtained responses from a random sample of
Camara et al. (1998) served as the base for 389 (39% response rate) members of the Na-
the tests listed in Table 1 because they provided tional Association of School Psychologists. We
the most extensive list of tests. We retained took their percent usage data, thus allowing de-
in the list all tests appearing with higher ranks velopment of a single ranking across the nine
for at least three groups, and eliminated the reporting categories in their study. When con-
two lowest ranking remaining tests to bring the structing the single set of rankings for Hutton
list to exactly 50. As a result, a few tests that et al., we excluded group-administered achieve-
were highly ranked in the other sources but ment tests (e.g., Stanford Achievement Test),
were not captured in the original pool of tests three of which were among the most widely
from Camara et al. (1998) do not appear in used tests in this source. Second, Wilson and
Table 1. A few of these special cases of exclusion Reschly (1996) used a random sample of 251
are noted below in connection with specific (80% response rate) members of the National
sources for their respective subgroups. Association of School Psychologists. Like Hut-
Rankings for counseling psychologists came ton et al., they ranked tests within broad cate-
from a combination of three reports. Bubenzer, gories. We used their mean ratings of usage per
Zimpfer, and Mahrle (1990) listed the 18 most to construct a single ranking across categories.
frequent tests in responses from 743 (response We combined the rankings from the two stud-
rate 50%) members of the American Associa- ies, showing in Table 1 the average ranking re-
tion of Counseling and Development (since re- gardless of whether the rank appeared in just
named American Counseling Association). one or in both studies. Other tests highly
Frauenhofer, Ross, Gfeller, Searight, and Pi- ranked only among school psychologists but
otrowski (1998) provided ranks for 14 tests not listed in Table 1 were several behavior rat-
used by 166 professional counselors drawn ing inventories.
from licensing directories in four states. Wat- Although most studies of test usage employ a
kins, Campbell, and McGregor (1988) identi- self-report methodology, there are alternative
fied the 10 most frequently used tests for a methods for defining frequency of test usage. In
sample of 630 (63% response rate) members of Tests in Print V (TIP V), Murphy, Impara, and
the APA Division of Counseling Psychology. To Plake (1999) provided a good example of an al-
prepare the counseling column in Table 1, we ternative approach. They gave a citation count
determined the average rank for test usage for published references to tests appearing in the
from these three studies provided that a test Thirteenth Mental Measurements Yearbook.
appeared in at least two of them. Other tests Information for all of the tests in Table 1
104 part ii • psychological testing

may be obtained from the Educational Testing H. R., & Piotrowski, C. (1998). Psychological
Service (2003) Test Collection Web site. test usage among licensed mental health prac-
Finally, we should note that in terms of total titioners: A multidisciplinary survey. Journal of
test usage, the widely used group administered Psychological Practice, 4, 28 –33.
Hutton, J. B., Dubes, R., & Muir, S. (1992). Assess-
tests (achievement batteries and mental ability
ment practices of school psychologists: Ten
tests) far exceed the usage for tests in Table 1.
years later. School Psychology Review, 21,
Although psychologists frequently receive and 271–284.
interpret information from these tests, psy- Lees-Haley, P. R., Smith, H. H., Williams, C. W., &
chologists rarely, if ever, administer them di- Dunn, J. T. (1995). Forensic neuropsychological
rectly. Hence, we have not included them in the test usage: An empirical study. Archives of
table. Clinical Neuropsychology, 11, 45 – 51.
Murphy, L. L., Impara, J. C., & Plake, B. S. (1999).
Tests in Print V. Lincoln: University of Ne-
References, Readings, & Internet Sites
braska.
Bubenzer, D. L., Zimpfer, D. G., & Mahrle, C. L. Murphy, L. L., Plake, B. S., Impara, J. C., & Spies,
(1990). Standardized individual appraisal in R. A. (2002). Tests in Print VI. Lincoln: Univer-
agency and private practice: A survey. Journal sity of Nebraska.
of Mental Health Counseling, 12, 51– 66. Piotrowski, C. (1999). Assessment practices in the
Camara, W., Nathan, J., & Puente, A. (1998). Psy- era of managed care: Current status and future
chological test usage in professional psychol- directions. Journal of Clinical Psychology, 55,
ogy: Report to the APA practice and science di- 787 – 796.
rectorates. Washington, DC: American Psycho- Watkins, C. E., Campbell, V. L., & McGregor, P.
logical Association. (1988). Counseling psychologists’ uses of and
Camara, W., Nathan, J., & Puente, A. (2000). Psy- opinions about psychological tests: A contem-
chological test usage: Implications for profes- porary perspective. The Counseling Psycholo-
sional practice. Professional Psychology: Re- gist, 16, 476 – 486.
search and Practice, 31, 141–154. Wilson, M. S., & Reschly, D. J. (1996). Assessment
Cashel, M. L. (2002). Child and adolescent psycho- in school psychology training and practice.
logical assessment: Current clinical practices School Psychology Review, 25, 9 –23.
and the impact of managed care. Professional
Psychology: Research and Practice, 33, 446 –
Related Topics
453.
Educational Testing Service. (2003). Test collection. Chapter 22, “Sources of Information About Psycho-
Retrieved February 11, 2003, from http://www. logical Tests”
ets.org/testcoll/ Chapter 23, “Publishers of Psychological and Psy-
Frauenhoffer, D., Ross, M. J., Gfeller, J., Searight, choeducational Tests”
 SOURCES OF
22 INFORMATION ABOUT
PSYCHOLOGICAL TESTS

Thomas P. Hogan

Tests are essential in the work of many psy- to the ETS site. The ERIC/AE site also provides
chologists. New tests and revisions of older a Test Review Locator, identifying reviews
tests now appear at an astonishing rate. It is im- available in Test Critiques and the Mental Mea-
possible to be familiar with all of them or even surements Yearbooks (both described below).
a significant fraction of them. Hence, it is im-
portant to be competent in acquiring informa-
tion about the many tests that one may en- SYSTEMATIC REVIEWS
counter. We present here an overview of six
major sources of information about psycholog- Two published sources provide professional re-
ical and psychoeducational tests. views of tests: the Mental Measurements Year-
books and Test Critiques. Both limit themselves
to commercially available tests published in
ELECTRONIC LISTINGS English. Both are updated every few years, pro-
viding reviews of new or revised tests. These
Here are three exceptionally useful tools for two sources are the only ones that give thor-
obtaining information about tests through the ough, professional reviews of a wide variety of
World Wide Web: tests.
The Fifteenth Mental Measurements Year-
1. ETS Test Collection at www.ets.org/testcoll book (Plake, Impara, & Spies, 2003) is the most
2. Buros Institute at www.unl.edu/buros recent in the classic series of reviews sometimes
3. ERIC/AE Test Locator at www.ericae.net referred to as MMY, or “Buros,” after Oscar K.
Buros, who compiled and published the first
The Educational Testing Service (ETS) Test volume in 1938. The MMY series is now pre-
Collection contains information on over 20,000 pared by the Buros Institute of Mental Mea-
tests. The source provides descriptive informa- surements (Buros Institute of Mental Measure-
tion about a test, such as author, publisher, ments, University of Nebraska–Lincoln, 21
scores, and number of items. The database can Teachers College Hall, Lincoln, NE 68588-
be searched by test title, author, or keyword de- 0348; 402-472-6203) and published by the Uni-
scriptor (e.g., “anxiety”). The Buros site, home versity of Nebraska Press. Historically, new
for the Buros Institute of Mental Measure- editions of MMY appeared every three to five
ments, provides searches for test publishers, years, but new editions are now projected to ap-
test reviews, and several other sources of infor- pear every 18 to 20 months, thus precluding
mation. Some reviews can be downloaded di- the need for the inter-edition supplements.
rectly from the site for a fee. The ERIC/AE site Each new yearbook contains references to re-
previously provided a service similar to the ETS views in earlier yearbooks.
Test Collection site, but now simply cross-links Subsets of MMY reviews have been pub-

105
106 part ii • psychological testing

lished as separate volumes from time to time. contains entries for several thousand tests. TIP
These publications, for tests in such categories attempts to include all tests that are commer-
as intelligence, personality, and reading, contain cially available in English. Earlier editions ap-
nothing more than what is available in the main peared in 1961, 1974, 1983, and 1999. The Buros
MMY volumes and in the TIP series (see below). Institute (see above for contact information)
MMY reviews for the most recent volumes are prepares TIP.
also available on CD-ROM from SilverPlatter Tests: A Comprehensive Reference for As-
(SilverPlatter Information, 100 Ridge Drive, sessments in Psychology, Education, and Busi-
Norwood, MA 02062-5043; 718-769-2599 or ness, 5th edition (Maddox, 2003), is a continu-
800-343-0064); this source is available online in ing series, first appearing in 1983, by the same
many academic libraries. As noted earlier, indi- publisher as Test Critiques. This source pre-
vidual reviews may be downloaded (for a fee) sents, for the three areas identified in the title,
from the Buros Web site. lists of tests from 219 publishers. Each entry
The second source of systematic reviews is includes the age/grade range for the test, pur-
Test Critiques (TC; Keyser, 2004). This series is pose, format and timing, type of scoring, pub-
now available in 11 volumes, the first having lisher, cost, and a brief description of the test
been issued in 1984. Each volume of TC covers structure and content. (See Test Critiques above
about 100 tests. In comparison with MMY, TC for contact information.)
limits itself to more widely used tests and the The ETS Test Collection referenced earlier un-
reviews are somewhat longer, although cover- der Electronic Listings also provides Tests in Mi-
ing the same basic points. Like MMY, each new crofiche, a microfiche collection of unpublished
TC volume contains a systematic listing of re- instruments and Test Bibliographies on selected
views contained in earlier volumes. Test Cri- topics. For further information on all these deriv-
tiques is published by Pro-Ed (8700 Shoal atives consult www.ets.org/testcoll, e-mail Li-
Creek Boulevard, Austin, TX, 78757-6897; [email protected], or phone 609-734-5689.
800-897-3202). The Directory of Unpublished Experimental
Mental Measures (Goldman & Mitchell, 2003)
is a multivolume effort published by the Amer-
COMPREHENSIVE LISTINGS ican Psychological Association. As suggested by
the title, the work concentrates exclusively on
Several sources give comprehensive, hard-copy tests that are not available from regular pub-
listings of tests. Generally, these sources pro- lishers but appear in journal articles. The vol-
vide basic information about the tests (e.g., tar- umes include information (name, purpose,
get ages, publishers, types of scores) but refrain source, format, timing, etc.) for over 1,000 tests
from giving evaluative comments. These in a wide variety of areas.
sources are most helpful for two purposes.
First, if one needs to know what tests are avail-
able for a particular purpose, these listings will SPECIAL-PURPOSE COLLECTIONS
provide an initial pool of possibilities for more
detailed review. Second, if one knows the name Several books provide collections of tests and/or
of a test but nothing else about it, information test reviews within a relatively narrow band of
in these listings will provide a brief description interest. The following list is illustrative of the
of the test and its source. Currently, there is books in this category. Fischer and Corcoran
much overlap between these comprehensive (1994) provide a collection of simple, paper-
listings in hard copy and the electronic lists de- and-pencil measures of clinically relevant con-
scribed earlier. structs. There are two volumes, one concen-
The venerable series known as Tests in Print trating on measures for families, children, and
is now in its sixth edition: Tests in Print-VI couples; the other on measures for adults.
(Murphy, Plake, Impara, & Spies, 2002). Usu- Robinson, Shaver, and Wrightsman (1991) pro-
ally referred to as TIP-VI, the current edition vide an excellent collection of more than 100
 22 • sources of information about psychological tests 107

measures of attitudes, broadly conceived to in- helpful in identifying the tests widely used in
clude such areas as self-concept, locus of con- a particular field and the peculiarities of certain
trol, values, and life satisfaction. The work in- tests. In effect, colleagues can provide brief, in-
cludes both published and unpublished mea- formal versions of the lengthier reviews one
sures; for unpublished measures, generally the would find in the formal sources cited in this
entire test is included in the entry. Shaw and article.
Wright (1967) is another excellent, albeit dated
collection of attitudinal measures, mostly of the
unpublished variety in such areas as social in- References, Readings, & Internet Sites
stitutions, significant others, and social prac- Buros Institute of Mental Measurements. (2003).
tices. Byrne (1996) provides a collection of self- Center for Testing home page. Retrieved Janu-
concept measures organized by age level. All of ary 6, 2003, from http://www.unl.edu/buros/
these references provide basic descriptive infor- Byrne, B. M. (1996). Measuring self-concepts across
mation about the measures included, plus at the lifespan. Washington, DC: American Psy-
least some evaluative commentary on matters chological Association.
such as reliability and validity. Educational Testing Service. (2003). Test collection.
Retrieved January 6, 2003, from http://www.
Health and Psychosocial Instruments (HaPI)
ets.org/testcoll/
is a database of instruments produced by Be- ERIC Clearinghouse on Assessment and Evaluation.
havioral Measurement Database Services, PO (2003). Home page. Retrieved January 6, 2003,
Box 110287, Pittsburgh, PA 15232-0787, 412- from http://ERICAE.net/
687-6850. HaPI is available on CD-ROM. Fischer, J., & Corcoran, K. (1994). Measures for clin-
ical practice: A sourcebook (2nd ed., Vols. 1–2).
New York: Free Press.
PUBLISHERS’ CATALOGS Goldman, B. A., & Mitchell, D. F. (2003). Directory
of unpublished experimental mental measures
All the major test publishers produce catalogs (Vol. 8). Washington, DC: American Psycho-
listing their products. The publisher’s catalog is logical Association.
Keyser, D. J. (Ed.). (2004). Test critiques (Vol. 11).
the best source of information about the most
Austin, TX: Pro-Ed.
recent editions of a test, including variations Maddox, T. (2003). Tests: A comprehensive reference
such as large-print editions, foreign language for assessments in psychology, education, and
versions; costs of materials and scoring; types of business (5th ed.). Austin, TX: Pro-Ed.
scoring services; and ancillary materials. Pub- Murphy, L. L., Plake, B. S., Impara, J. C., & Spies,
lishers typically issue catalogs annually or R. A. (Eds.). (2002). Tests in Print VI. Lincoln:
semi-annually. Publishers’ representatives, ei- University of Nebraska Press.
ther in the field or in the home office, are also Plake, B. S., Impara, J. C., & Spies, R. A. (Eds.).
an important source of information, especially (2003). The fifteenth mental measurements
about new products and services. A call to a yearbook. Lincoln: University of Nebraska
publisher’s representative can often save hours Press.
Robinson, J. P., Shaver, P. R., & Wrightsman, L. S.
of searching for information about a price or
(Eds.). (1991). Measures of personality and so-
scoring service. For contact information for ma- cial psychological attitudes. San Diego, CA:
jor test publishers, see chapter 23. Contact in- Academic Press.
formation is also available in the Test Locator Shaw, M. E., & Wright, J. M. (1967). Scales for
service described above. the measurement of attitudes. New York:
McGraw-Hill.

OTHER TEST USERS

Related Topics
Finally, a valuable but often overlooked source Chapter 21, “50 Widely Used Psychological Tests”
of information about tests is other users of Chapter 23, “Publishers of Psychological and Psy-
tests. Experienced colleagues can be especially choeducational Tests”
 PUBLISHERS OF
23 PSYCHOLOGICAL AND
PSYCHOEDUCATIONAL TESTS

Thomas P. Hogan

The following is a list of major test publishers Association of State and Provincial Psychology
in the United States and some of their popular Boards (formerly American Association of
tests. For more complete lists of test publishers State Psychology Boards)
or to determine the publisher of a specific test, 7177 Halcyon Summit Drive
use one of these Web sites: Montgomery, AL 36117
Phone: 800-448-4069
• ETS Test Collection at www.ets.org/testcoll www.asppb.org
• Buros Institute at www.unl.edu/buros Publishes the Examination for Professional
• ERIC/AE Test Locator at www.ericae.net/ Practice in Psychology
testcoll.htm
The College Board
American College Testing Program (ACT) 45 Columbus Avenue
PO Box 168 New York, NY 10023-6992
2201 North Dodge Street Phone: 212-713-8000
Iowa City, IA 52243-0168 www.collegeboard.com
Phone: 800-645-1992 Publishes the Graduate Record Examination,
www.act.org SAT I and II, Test of English as a Second
Publishes the ACT Assessment, Career Plan- Language (some tests are sponsored jointly
ning Survey, EXPLORE, and PLAN with Educational Testing Service)

American Guidance Service Consulting Psychologists Press

4201 Woodland Road 3803 East Bayshore Road
Circle Pines, MN 55014-1796 Palo Alto, CA 94303
Phone: 800-328-2560 Phone: 800-624-1765
www.ags.net www.cpp-db.com
Publishes the Behavior Assessment System Publishes the Adjective Checklist, California
for Children (BASC), Kaufman Assessment Psychological Inventory (CPI), Myers-
Battery for Children (K-ABC), several other Briggs Type Indicator, Self-Directed Search,
Kaufman tests, Peabody Individual Achieve- and the Strong Interest Inventory
ment Test (PIAT), Peabody Picture Vocabu-
lary Test (PPVT), Vineland Adaptive Be- CTB/McGraw-Hill
havior Scales, and Woodcock Reading Mas- 20 Ryan Ranch Road
tery Tests Monterey, CA 93940

108
 23 • publishers of psychological and psychoeducational tests 109

Phone: 800-538-9547 Phone: 800-225-IPAT

www.ctb.com www.ipat.com
Publishes the California Achievement Test Publishes the IPAT Anxiety Scale, IPAT
(Terra Nova), Comprehensive Test of Basic Depression Scale, and 16 Personality Factor
Skills, and Test of Cognitive Skills Inventory (16PF)

Educational & Industrial Testing Service Lafayette Instrument Company

(EdITS) 3700 Sagamore Parkway North
PO Box 7234 Lafayette, IN 47903
San Diego, CA 92167 Phone: 800-428-7545
Phone: 800-416-1666 www.lafayetteinstrument.com
www.edits.net Publishes the Purdue Pegboard and a variety
Publishes the Personal Orientation Dimen- of biofeedback and physiological recording
sions (POD), Comrey Personality Scales equipment
(CPS), Eysenck Personality Inventory (EPI),
and Profile of Mood States (POMS) Mind Garden
1690 Woodside Road, Suite 202
Educational Testing Service Redwood City, CA 94061
Rosedale Road Phone: 650-261-3500
Princeton, NJ 08541 www.mindgarden.com
Phone: 609-921-9000 Publishes the Coopersmith Self-Esteem Inven-
www.ets.org tories, Moos’ Family Environment Scale,
Publishes the Advanced Placement Examina- Classroom Environment Scale, and Group
tions and College Level Examination Pro- Environment Scale, and State Trait Anxiety
gram (some tests are sponsored jointly with Inventory (STAI)
the College Board)
Multi-Health Systems (MHS)
Harcourt Educational Measurement 908 Niagara Falls Boulevard
555 Academic Court North Tonawanda, NY 14120-2060
San Antonio, TX 78204-2498 Phone: 800-456-3003
Phone: 800-211-8378 www.mhs.com
www.hemweb.com Publishes the Children’s Depression Inventory
Publishes the Metropolitan Achievement (CDI) and Conners’ Rating Scales
Tests, Naglieri Nonverbal Ability Test,
Otis-Lennon School Ability Tests, Stanford National Career Assessment Services
Achievement Tests, and the Stanford Diag- 601 Visions Parkway
nostic Tests PO Box 277
Adel, IA 50003
Harvard University Press Phone: 800-314-8972
79 Garden Street www.ncasi.com
Cambridge, MA 02138 Publishes the Kuder Occupational Interest
Phone: 800-405-1619 Survey (KOIS) and Kuder Career Planning
www.hup.harvard.edu System (KCPS)
Publishes the Thematic Apperception Test
NCS Pearson
Institute for Personality and Ability Testing 11000 Prairie Lakes Drive
(IPAT) Eden Prairie, MN 55344
PO Box 1188 Phone: 800-627-7271
Champaign, IL 61824-1188 www.ncspearson.com
110 part ii • psychological testing

Publishes the Millon Clinical Multiaxial In- Sigma Assessment Systems

ventory (MCMI) and several other Millon PO Box 610984
inventories; distributes the Minnesota Mul- Port Huron, MI 48061-0984
tiphasic Personality Inventory (MMPI) Phone: 800-265-1285
www.sigmaassessmentsystems.com
PRO-ED Publishes the Personality Research Form
8700 Shoal Creek Boulevard (PRF) and Jackson Personality
Austin, TX 78757-6897 Inventory
Phone: 800-897-3202
www.proedinc.com Slosson Educational Publications
Publishes the Detroit Tests of Learning Apti- 538 Buffalo Road
tude, Draw A Person: Screening Procedure East Aurora, NY 14052-0280
for Emotional Disturbance (DAP: SPED), Phone: 888-SLOSSON (756-7766)
Test of Visual Motor Integration (TVMI), www.slosson.com
and Test of Nonverbal Intelligence (TONI) Publishes the Slosson Intelligence Test and the
Slosson Oral Reading Test
Psychological Assessment Resources (PAR)
PO Box 998 Stoelting Company
Odessa, FL 33556 620 Wheat Lane
Phone: 800-331-8378 Wood Dale, Illinois 60191
www.parinc.com Phone: 630-860-9700
Publishes the Beery Developmental Test of www.stoeltingco.com
Visual-Motor Integration, Eating Disorder Publishes the Gray Oral Reading Tests, Kohs
Inventory (EDI), NEO Personality Inven- Block Design Test, Knox’s Cube Test, Leiter
tory (NEO PI), NEO Five Factor Inventory International Performance Scale, and a vari-
(NEO FFI), and Rogers Criminal Responsi- ety of biofeedback and physiological record-
bility Assessment Scales ing equipment

The Psychological Corporation University of Minnesota Press

555 Academic Court 111 Third Avenue South, Suite 290
San Antonio, TX 78204-2498 Minneapolis, MN 55455
Phone: 800-211-8378 Phone: 800-388-3863
www.hbtpc.com www.upress.umn.edu
Publishes the Bayley Scales of Infant Develop- Publishes the Minnesota Multiphasic Person-
ment, Beck Depression Inventory (BDI), Mc- ality Inventory (MMPI) and Minnesota
Carthy Scales of Children’s Abilities, Miller Multiphasic Personality Inventory–
Analogies Test, and the Wechsler scales (WAIS, Adolescent (MMPI-A)
WISC, WPPSI, WASI, WMS, WIAT, WTAR)
Western Psychological Services
Riverside Publishing 12031 Wilshire Boulevard
425 Spring Lake Drive Los Angeles, CA 90025-1251
Itasca, IL 60143-2079 Phone: 800-648-8857
Phone: 800-323-9540 www.wpspublish.com
www.riverpub.com Publishes the Bender Visual Motor Gestalt
Publishes the Cognitive Abilities Test, Das Test for Children, Hamilton Depression
Naglieri Cognitive Assessment System, Scale, Luria Nebraska Neuropsychological
Gates-MacGinitie Reading Tests, Iowa Tests Battery, Personality Inventory for Children
of Basic Skills, Stanford-Binet Intelligence (PIC), and Piers-Harris Children’s Self-
Scale, and the Woodcock-Johnson Tests of Concept Scale; distributes the Bender Visual
Achievement and Cognitive Abilities Motor Gestalt Test (adult version)
 24 • types of test scores and their percentile equivalents 111

Wide Range Related Topics

PO Box 3410 Chapter 21, “50 Widely Used Psychological Tests”
Wilmington, DE 19804 Chapter 22, “Sources of Information About Psycho-
Phone: 800-221-9728 logical Tests”
www.widerange.com
Publishes the Wide Range Achievement Test
(WRAT)

See accompanying Web site for

additional materials.

TYPES OF TEST SCORES AND THEIR

24 PERCENTILE EQUIVALENTS

Thomas P. Hogan

This chapter defines the converted or normed lustrated here. It should also be noted that some
scores commonly used with psychological and tests may have independently determined
educational tests and presents their percentile norms for two different score modes (e.g., in
equivalents. In addition, Figure 1 and Table 1 standard scores and in percentiles); if the norms
show the relationships among many of these are independently determined, they will not
normed scores. Figure 1 illustrates the equiva- correspond exactly with the equivalencies given
lence of the various scores that are based on the here.
normal curve. The figure has insufficient res-
olution for making conversions among the
scores for practical or clinical purposes. How- STANDARD SCORES
ever, Table 1 allows for such conversions. The
table is constructed with percentile ranks as Standard scores constitute one of the most fre-
the reference columns on the left and right. The quently used types of norms. Standard scores
body of the table shows conversions to several convert raw scores into a system with an arbi-
types of scores, each of which is defined below. trarily chosen mean and standard deviation. Al-
Slightly different values might be entered for though the standard score mean and standard
any particular percentile depending on how one deviation are “arbitrarily” chosen, they are se-
rounds the entries or reads up or down for lected to yield round numbers such as 50 and 10
points covering multiple scores. This is particu- or 500 and 100.
larly true at the extremes of the distribution. Standard scores may be either linear or non-
Figure 1 and Table 1 treat the equivalence of linear transformations of the raw scores. It will
different score modes, not the equivalence of usually not be apparent from a table of standard
different standardization groups. Scores from score norms whether they are linear or nonlin-
tests standardized on different groups cannot be ear; the test manual (or publisher) must be con-
equated simply by using the equivalencies il- sulted for this purpose. Nonlinear transforma-
112 part ii • psychological testing

figure 1. Equivalences of Several Standard Scores in the Normal Distribution (reprinted by permission of
the Psychological Corporation from Seashore, n.d.)

tions are used either to yield normal distribu- IQs: The “IQ” scores on most contemporary
tions or to approximate an equal interval scale intelligence tests are standard scores with M =
(as in Thurstone scaling). When used for this 100 and SD = either 15 or 16, based on age
latter purpose, particularly in connection with groupings in the standardization sample.
multilevel tests, the standard scores are some- T scores: T scores (sometimes called Mc-
times called scaled scores, and they usually do Call’s T scores) are standard scores with M = 50
not have a readily interpretable framework. and SD = 10. T scores are frequently used with
personality tests, such as the MMPI-2 and
NEO PI-R.
COMMON STANDARD Wechsler subtests: Wechsler subtests use
SCORE SYSTEMS standard scores with M = 10 and SD = 3.
SAT, GRE scores: The SAT I (formerly,
The following are commonly used standard Scholastic Assessment Test) Verbal and Math-
score systems. In these descriptions, M = mean ematics Tests; the Graduate Record Examina-
and SD = standard deviation. tion (GRE) Verbal, Quantitative, and Analytical
 24 • types of test scores and their percentile equivalents 113

table 1. Percentile Equivalents of Several Standard Score Systems

Percentile Stanine NCE IQ (15) IQ (16) W Sub T Score SAT Z Score Percentile
99 9 99 133 135 17 73 730 2.33 99
98 9 93 130 132 16 70 700 2.05 98
97 9 90 129 130 69 690 1.88 97
96 9 87 127 128 68 680 1.75 96
95 8 85 125 126 15 66 660 1.65 95
94 8 83 123 125 1.56 94
93 8 81 122 124 65 650 1.48 93
92 8 80 121 123 64 640 1.40 92
91 8 78 120 122 1.34 91
90 8 77 119 121 14 63 630 1.28 90
89 8 76 120 1.23 89
88 7 75 118 119 62 620 1.18 88
87 7 74 117 118 1.13 87
86 7 73 116 117 61 610 1.08 86
85 7 72 1.04 85
84 7 71 115 116 13 60 600 .99 84
83 7 70 .95 83
82 7 69 114 59 590 .92 82
81 7 68 113 114 .88 81
80 7 68 .84 80
79 7 67 112 113 58 580 .81 79
78 7 66 .77 78
77 7 66 111 112 .74 77
76 6 65 57 570 .71 76
75 6 64 110 111 12 .67 75
74 6 64 .64 74
73 6 63 109 110 56 560 .61 73
72 6 62 .58 72
71 6 62 109 .55 71
70 6 61 108 .52 70
69 6 60 108 55 550 .50 69
68 6 60 107 .47 68
67 6 59 107 .44 67
66 6 59 106 54 540 .41 66
65 6 58 106 .38 65
64 6 58 .36 64
63 6 57 105 11 .33 63
62 6 56 105 53 530 .31 62
61 6 56 104 .28 61
60 6 55 104 .25 60
59 5 55 .23 59
58 5 54 103 52 520 .20 58
57 5 54 103 .18 57
56 5 53 .15 56
55 5 53 102 102 .13 55
54 5 52 51 510 .10 54
53 5 52 101 .08 53
52 5 51 101 .05 52
51 5 50 .02 51
50 5 50 100 100 10 50 500 .00 50
49 5 50 –.02 49
48 5 49 99 –.05 48
47 5 48 99 –.08 47
46 5 48 49 490 –.10 46
45 547 98 98 –.13 45
44 5 47 –.15 44
(continued)
114 part ii • psychological testing

table 1. Percentile Equivalents of Several Standard Score Systems (continued)

Percentile Stanine NCE IQ (15) IQ (16) W Sub T Score SAT Z Score Percentile
43 5 46 97 –.18 43
42 5 46 97 48 480 –.20 42
41 5 45 –.23 41
40 5 45 96 –.25 40
39 4 44 96 –.28 39
38 4 44 95 47 470 –.31 38
37 4 43 95 9 –.33 37
36 4 42 –.36 36
35 4 42 94 –.38 35
34 4 41 94 46 460 –.41 34
33 4 41 93 –.44 33
32 4 40 93 –.47 32
31 4 40 92 45 450 –.50 31
30 4 39 92 –.52 30
29 4 38 91 –.55 29
28 4 38 –.58 28
27 4 37 91 90 44 440 –.61 27
26 4 36 –.64 26
25 4 36 90 89 8 –.67 25
24 4 35 43 430 –.71 24
23 4 34 89 88 –.74 23
22 3 34 –.77 22
21 3 33 88 87 42 420 –.81 21
20 3 32 –.84 20
19 3 32 87 86 –.88 19
18 3 31 86 41 410 –.92 18
17 3 30 85 –.95 17
16 3 29 85 84 7 40 400 –.99 16
15 3 28 –1.04 15
14 3 27 84 83 39 390 –1.08 14
13 3 26 83 82 –1.13 13
12 3 25 82 81 38 380 –1.18 12
11 3 24 80 –1.23 11
10 2 23 81 79 6 37 370 –1.28 10
9 2 22 80 78 –1.34 9
8 2 20 79 77 36 360 –1.40 8
7 2 19 78 76 35 650 –1.48 7
6 2 17 77 75 –1.56 6
5 2 15 76 74 5 34 340 –1.65 5
4 2 13 74 72 32 320 –1.75 4
3 1 10 72 70 31 310 –1.88 3
2 1 7 70 68 4 29 290 –2.05 2
1 1 1 67 65 3 27 270 –2.33 1

Note: IQ (15) is for IQ tests with M = 100 and SD = 15, such as Wechsler Verbal, Performance, and Total Scores. IQ (16) is for IQ tests with
M = 100 and SD = 16, such as Stanford-Binet (4th ed.) and Otis-Lennon School Ability Test. W Sub is for Wechsler subtests and Stanford-
Binet (5th ed.) subtests, where M = 10 and SD = 3. SAT covers any of the several tests that use M = 500 and SD = 100; these scores are usu-
ally reported to two significant digits (i.e., with the farthest right digit always 0), and that is how they are presented here.

Tests; the GRE Subject Tests; and the Graduate + Mathematics) is 1,000, but the SD is not 200;
Management Admissions Tests (GMAT) all use it is less than 200, since the two tests being
standard score systems with M = 500 and SD = added are not perfectly correlated.
100. In determining total scores for these tests Stanford-Binet, fifth edition (SB5): The fifth
(e.g., SAT Total), means are additive but SDs edition of the Stanford-Binet Intelligence Scale
are not. Hence, the mean for SAT Total (Verbal (2003) features two important changes from
 24 • types of test scores and their percentile equivalents 115

previous editions in terms of score scales. First, PERCENTILES AND PERCENTILE RANKS
the SD for IQs is 15 (M is still 100), rather than
16, thus bringing the SB IQ scale into alignment Percentiles and percentile ranks are among the
with the Wechsler scales. Second, subtest scores most commonly used normed scores for all
for SB5 use M = 10 and SD = 3, as for the Wechs- types of tests. A percentile is a point in the dis-
ler subtests, rather than the previously used M = tribution at or below which the given percent-
50 and SD = 8. It must be emphasized that this age of cases falls. A percentile rank is the posi-
convergence in numerical values between SB5 tion of a particular score in the distribution ex-
and Wechsler scales does not mean their scores pressed as a ranking in a group of 100. There is
are directly comparable, because the two tests a fine, technical distinction between percentiles
have different normative bases. and percentile ranks, but the terms are often
Other tests: The ACT (American College used interchangeably without harm.
Test) uses a score scale ranging from 1 to 36, Quartiles, quintiles, and deciles are offshoots
with M = 16 for high school students and M = of the percentile system, dividing the distribu-
19 for college-bound students and SD = 5. The tion of scores into quarters, fifths, and tenths,
LSAT (Law School Admission Test) has M = respectively. Unfortunately, there is no unifor-
150 and SD = 10. mity in designating the top and bottom portions
Stanines: Stanines (a contraction of “stan- of each of these divisions. For example, the
dard-nine”) are standard scores with M = 5 and “second” quartile may be either the second
SD = 2 (approximately), thus dividing the dis- from the bottom (25th– 49th percentiles) or the
tribution into nine intervals (1– 9), with sta- second from the top (50th– 74th percentiles).
nines 2– 8 spanning equal distances (each sta- Hence, special care is needed on this point when
nine covers 1⁄ 2 SD) on the base of the normal communicating results in any of these systems.
curve. Stanines are usually determined from
their percentile equivalents, thus normalizing
the resulting distribution. Stanines are fre- AGE/GRADE EQUIVALENTS
quently used with achievement tests and
group-administered ability tests but are not Age and grade equivalents are normed scores,
used much outside these types of tests. but they are very different in important re-
Stens: Stens (a contraction of “standard- spects from standard scores and percentiles.
ten”) are standard scores that span the normal Hence, they cannot be represented conve-
curve with 10 units and with M = 5.5 and SD niently in Figure 1 or in Table 1.
= 2; each sten covers 1⁄ 2 SD. An age equivalent score converts a raw score
Z scores: Z scores are standard scores with M into an age — usually years and months —
= 0.0 and SD = 1.0. These scores are used fre- corresponding to the typical (usually median)
quently in statistical work but virtually never raw score attained by a specified group. The
for practical reporting of test results. specified group is ordinarily defined within a
Normal curve equivalents: Normal curve fairly narrow age range (e.g., in 3-month inter-
equivalents (NCEs) are a type of standard score vals in the standardization group).
designed to match the percentile scale at points Age equivalents are used almost exclusively
1, 50, and 99. Thus an NCE of 1 equals a per- with tests of mental ability, in which case they
centile of 1, an NCE of 50 equals a percentile of are referred to as mental ages. However, they
50, and an NCE of 99 equals a percentile of 99. are also used with anthropometric measure-
The NCE scale divides the base of the normal ments (e.g., height and weight) for infants and
curve into equal units between percentiles of 1 children.
and 99. Using these criteria, NCEs work out to Grade equivalents convert raw scores into a
have M = 50 and SD = 21.06. NCEs were de- grade in school that is typical for the students at
signed for use in federally funded programs in that grade level. “Typical” is usually defined as
elementary and secondary schools and are used the median performance of students at a grade
almost exclusively in that context. level. The grade equivalent (GE) is ordinarily
116 part ii • psychological testing

given in school year and 10th of a year, in ment. The most immediate output from such a
which the 10ths correspond roughly to the test is a theta score, representing position on
months specified below. Exact definitions of the underlying trait. Theta scores usually range
10ths may vary by half months from one test from approximately – 6.00 to +6.00. For ordi-
series to another. Levels above grade 12.9 are nary use, theta is converted into one of the fa-
sometimes given a nonnumerical descriptor miliar normed scores described earlier. Rudner
such as PHS for “post–high school.” (1998) provides a useful, on-line demonstration
Sept. Oct. Nov. Dec. Jan. of theta scores operating in a computer adaptive
test.
.0 .1 .2 .3 .4

Feb. Mar. Apr. May June References, Readings, & Internet Sites

.5 .6 .7 .8 .9 Anastasi, A. & Urbina, S. (1997). Psychological test-

ing (7th ed.). Upper Saddle River, NJ: Prentice
One of the peculiarities of age and grade Hall.
equivalents is that their standard deviations are ERIC Clearinghouse. (1999). Assessment and Eval-
not equal across different age and grade levels. uation on the Internet. Retrieved January 7,
It is this feature that prevents them from being 2003, from http://ERICAE.NET/nintbrod.htm
Hogan, T. P. (2003). Psychological testing: A practi-
charted in Figure 1. Generally the standard de-
cal introduction. New York: Wiley.
viations increase with successively higher age Mitchell, B. C. (n.d.). Test Service Notebook 13: A
or grade levels. glossary of measurement terms. San Antonio,
TX: Psychological Corporation.
Rudner, L. M. (1998). An on-line, interactive, com-
OTHER SCORES puter adaptive testing tutorial. Retrieved Jan-
uary 7, 2003, from http://ERICAE.NET/scripts/
Proficiency levels: Recent trends in educational cat/catdemo.htm
assessment require the reporting of scores in Seashore, H. G. (n.d.). Test Service Notebook 148:
proficiency levels. The most common designa- Methods of expressing test scores. San Anto-
tions are advanced, proficient, basic, and below nio, TX: Psychological Corporation.
basic. Cutoffs between levels are determined
judgmentally, usually by panels of educators
and laypersons and are not comparable from one Related Topics
application (e.g., test area or state) to another. Chapter 21, “50 Widely Used Psychological Tests”
Theta: An increasing number of tests utilize Chapter 22, “Sources of Information About Psycho-
item response theory (IRT) for test develop- logical Tests”
 ASSESSING THE QUALITY
25 OF A PSYCHOLOGICAL
TESTING REPORT

Gerald P. Koocher

This summary describes key points that should ability to form rapport, concentration, man-
be addressed in conducting any psychological nerisms, medication side effects, language
assessment for which a report is prepared. The problems, cooperation, phenotype, or physi-
quality of the assessment report can be evalu- cal handicaps)?
ated by assessing the thoroughness and accu- • Were any deviations from standard testing
racy with which each of these 10 points is ad- administration or procedures necessary?
dressed.

LISTING OF INSTRUMENTS USED

REFERRAL QUESTIONS AND
CONTEXT • Is a complete list (without jargon or abbrevi-
ations) of the tests administered presented,
• Does the report explain the reason the client including the dates administered?
was referred for testing and state the assess- • Does the report explain the nature of any un-
ment questions to be addressed? usual instruments or test procedures used?
• Does the report note that the client or legal • If more than one set of norms or test forms
guardian was informed about the purpose of exists for any given instrument, does the
and agreed to the assessment? psychologist indicate which forms or norms
• Is the relevant psychological ecology of the were used?
client mentioned (e.g., recently divorced, fac-
ing criminal charges, candidate for employ-
ment)? RELIABILITY AND VALIDITY
• If the evaluation is being undertaken at the re-
quest of a third party (e.g., a court, an employer, • Does the psychologist comment specifically
or a school), does the examiner note that the on whether or not the test results in the pres-
client was informed of the limits of confiden- ent circumstances are to be regarded as rea-
tiality and whether a release was obtained? sonably accurate (e.g., the test administration
was valid and the client fully cooperative)?
• If there are mediating factors, are these dis-
CURRENT STATUS/BEHAVIORAL cussed in terms of reliability and validity im-
OBSERVATIONS plications?
• Are the tests used valid for assessing the as-
• What was the client’s behavior like during pects of the client’s abilities in question? This
the interview, especially with respect to any should be a special focus of attention if the
aspects that might relate to the referral ques- instrument used is nonstandard or is being
tions or the validity of the testing (e.g., mood, used in a nonstandard manner.

117
118 part ii • psychological testing

DATA PRESENTATION IS THE REPORT AUTHENTICATED?

• Are scores presented and explained for each • Is the report signed by the individual who
of the tests used? (If an integrated narrative conducted the evaluation?
or description is presented, does this address • Are the credentials/title of the person noted
all the aspects assessed, such as intellectual (e.g., Mary Smith, Ph.D., Staff Psychologist,
functioning, personality structure, etc.?) or John Doe, M.S., Psychology Intern)?
• Are the meanings of the test results ex- • If the examiner is unlicensed or a trainee, is
plained in terms of the referral questions the report cosigned by a qualified licensed
asked? supervisor?
• Are examples or illustrations included if rel-
evant?
• Are technical terms and jargon avoided? FEEDBACK
• Does the report note whether the pattern of
scores (e.g., variability in measuring similar • Is a copy of the report sent to the person who
attributes across instruments) is a consistent made the referral?
or heterogeneous one? • Is some mechanism operational for providing
• For IQ testing, arc subtest scatter and dis- feedback to the client, consistent with the
crepancy scores mentioned? context of testing and original agreement
• For personality testing, does the psychologist with the client?
discuss self-esteem, interpersonal relations,
emotional reactivity, defensive style, and ar- References, Readings, & Internet Sites
eas of focal concern?
American Psychological Association. (1993). Record
keeping guidelines. American Psychologist, 48,
308 –310.
SUMMARY
American Psychological Association, American Edu-
cational Research Association, & National
• If a summary is presented, does it err by sur- Council on Measurement in Education. (1998).
prising the reader with material not men- Standards for educational and psychological
tioned earlier in the report? testing. Washington, DC: American Psycholog-
• Is it overly redundant? ical Association.
American Psychological Association, American Edu-
cational Research Association, & National
RECOMMENDATIONS Council on Measurement in Education. (1999).
Standards for educational and psychological
testing. Washington, DC: American Educational
• If recommendations are made, is it evident
Research Association.
why or how these flow from the test results American Psychological Association, Testing and As-
mentioned and discussed earlier? sessment. (n.d.). Resource site. Retrieved 2004
• Do the recommendations mention all rele- from http://www.apa.org/science/testing
vant points raised as initial referral ques- Bersoff, D. N., & Hofer, P. J. (1995). Legal issues in
tions? computerized psychological testing. In D. N.
Bersoff (Ed.), Ethical conflicts in psychology
(pp. 291–294). Washington, DC: American
DIAGNOSIS Psychological Association.
Eyde, L. D., Robertson, G. J., Krug, S. E., Moreland,
• If a diagnosis is requested or if differential K. L., Robertson, A. G., Shewan, C. M., et al.
(1993). Responsible test use: Case studies for as-
diagnosis was a referral question, does the
sessing human behavior. Washington, DC:
report specifically address this point? American Psychological Association.
 26 • child behavior observations 119

Koocher, G. P, & Keith-Spiegel, P. C. (1998). Ethics in surement procedure. American Psychologist,

psychology: Professional standards and cases 50, 14 –23.
(2nd ed.). New York: Oxford University Press. University of Nebraska, Buros Center for Testing.
Koocher, G. P., & Rey-Casserly, C. M. (2002). Ethical (n.d.). Home page. Retrieved 2004 from http://
issues in psychological assessment. In J. R. Gra- www.unl.edu/buros
ham & J. A. Naglieri (Eds.), Handbook of As- Wetter, M. W., & Corrigan, S. K. (1995). Providing
sessment Psychology. New York: John Wiley. information to clients about psychological tests:
Matarazzo, J. D. (1990). Psychological assessment A survey of attorneys’ and law students’ atti-
versus psychological testing: Validation from tudes. Professional Psychology: Research and
Bitnet to the school, clinic, and courtroom. Practice, 26, 474 – 477.
American Psychologist, 45, 999 –1016.
Moreland, K. L., Eyde, L. D., Robertson, C. J., Pri-
Related Topic
moff, E. S., & Most, R. B. (1995). Assessment of
test user qualifications: A research-based mea- Chapter 129, “Prototype Mental Health Records”

26 CHILD BEHAVIOR OBSERVATIONS

Janice Ware

WHY USE DIRECT OBSERVATION? method assessment. Direct observation is par-

ticularly effective when used as a complement
Direct observation of child behavior is probably to parent and/or self-report. Factors influencing
the most accurate means of assessing behavior, the choice of an appropriate observational tech-
despite the many limitations of the available nique include (a) the stage of the evaluation
techniques. Direct observational data are mul- process, (b) the nature of the behaviors of in-
tipurpose. In addition to their most frequent terest, (c) the setting in which the behavior oc-
use for treatment planning, they also provide curs, and (d) the resources required to imple-
an important mechanism for evaluating treat- ment the observations.
ment outcomes and are used as a base for de-
veloping theoretical understanding of child-
hood problems. Methods range from brief, in- WHAT METHODOLOGICAL
formal single-session observations to highly CONCERNS EXIST?
structured techniques requiring extensive ex-
aminer training and considerable time input. The psychometric properties of specific obser-
Observations should serve not as a stand-alone vation strategies reflect a wide range of vari-
tool but as an important component of a multi- ability. Many of the most frequently used tools
120 part ii • psychological testing

offer the least stable properties, including prob- The most commonly used tool for home ob-
lems of objectivity, reliability, validity, reactiv- servation is the Home Observation for Measure-
ity, observer bias, and drift. ment of the Environment Inventory (HOME;
A vast number of semistructured and struc- Caldwell & Bradley, 1978). HOME uses stan-
tured direct observation tools are available. The dardized norms and a simple dyadic coding sys-
published tools that systematize observations tem to identify at-risk family settings. HOME
range from broad-based observations of overall is frequently criticized because of its high cor-
child functioning to quantification of specific relation with family socioeconomic status and
child behaviors in specific patient populations. its reliance on maternal report to supplement di-
Currently, there is a strong movement to develop rect observations. Despite its shortcomings,
population-specific techniques that are sensitive HOME has made important contributions by
to the developmental characteristics of children. systematically focusing the attention of the ob-
server on characteristics of the home environ-
ment that are known to be important influences
WHAT TECHNIQUES ARE AVAILABLE on developmental outcome.
FOR DIRECT OBSERVATION?

Observation sites include naturalistic settings TECHNOLOGICAL ADVANCES

and simulated settings, such as role-playing.
Frequency/rate, duration, latency, intensity, Innovative techniques ranging from the use of
topography, and locus are aspects of behavior fiber-optic televideo network systems (known
that can be systematically measured regardless as televideo or teleassessment) to the more
of the setting. Data are collected using either readily available use of audio/videotape equip-
continuous or sampling techniques. Observa- ment are increasingly incorporated as standard
tion codes that measure various aspects of child procedure in child assessment. The use of video
noncompliance and adult response to the be- and TV provides additional opportunities to col-
haviors are used extensively. lect developmental observations when it is not
The worth of these tools depends largely on the possible or desirable for an examiner to be pres-
quality of the data documenting adult antecedent ent. Comparisons of coding from live and video-
and consequent behavior to the child’s opposi- taped situations indicate that little information
tional patterns. O’Neill, Horner, Albin, Storey, is lost. Observational studies that have been
and Sprague (1990) have expanded these observa- found to be effective in minimizing psychome-
tional strategies to include codes for documenting tric concerns use behavior sampling techniques
severely maladaptive behavioral patterns of indi- such as intermittently activated tape recorders
viduals with developmental disabilities. or time-lapse video procedures.
Home visit observations offer the unique Teleassessment is now successfully incorpo-
opportunity to investigate the multiplicity of rated into many developmental and psychiatric
ecological influences contributing to a develop- assessment centers and is especially useful for
mental problem. Typical observed influences sites serving remote locations. Research reveals
include the family’s living conditions, the level high levels of patient and provider satisfaction
of parental attachment, the degree of structure with the technique. This technique has been
present in the home, the presence of appropri- particularly successful in settings where multi-
ate play materials, and the degree of family co- disciplinary assessment is desirable but prohib-
hesion. Tools for assessing these factors range itive because of the cost involved in transport-
from highly structured coding tools to the tak- ing a team of professionals to a remote location.
ing of clinical notes. Regardless of the level of Typical uses of televideo include multidiscipli-
structure involved in the home observation, the nary neurodevelopmental evaluation of high-
actual writing and note taking are best deferred risk infants and provision of child and adoles-
until after the visit in order not to detract from cent psychiatric interviews in areas under-
the spontaneity of the visit. served by specialty providers.
 26 • child behavior observations 121

Review of audio/videotape segments pro- assessment tools, such as the work of Gaens-
vides an opportunity for the therapist to help bauer and Harmon (1981) that assesses infant
the patient and the family reconcile differing social and emotional functioning in structured
perceptions of the problem behaviors. This can settings, including attachment behavior.
be a practical time- and cost-effective technique Many unstructured informal observational
because of the wide availability of portable variations of the SSP have evolved to evaluate
home video equipment. It also can minimize the young child’s attachment to a primary care-
the need for costly home and school visits. giver. These paradigms focus on observing
Parental reluctance to use videotaped material child proximity seeking to the attachment fig-
as a part of the clinical assessment may be due ure and reciprocal attachment figure–child
to unfamiliarity with the potential benefits of emotional responsivity following a separation.
the procedure. Clinical observations of attachment parame-
Parents will want to know what confiden- ters can be further enhanced by use of the noso-
tiality procedures have been put in place to logical categories of attachment disorder out-
safeguard their child. Parental concerns about lined by Lieberman and Pawl (1988). This sys-
confidentiality and potential misuse of the tapes tem can be used to describe disorders diagnosed
can be markedly diminished by identifying the in children between the ages of 1 and 4 – 5
parents at the outset of the audio/videotaping years.
discussion as the “keepers” of the tape. In-
formed consent procedures, including obtain-
Attention-Deficit Disorder
ing written permission for taping, must be
closely followed prior to the first taping session. The cost of obtaining direct observations for
Increasingly, school systems require written children with attention problems most often
parental permission from the parents of each precludes the inclusion of this valuable tech-
child present in the classroom when the video- nique into standardized assessment batteries.
taping takes place, regardless of whether or not Observations of children with attentional prob-
their child is targeted for observation. lems are used to confirm the diagnosis and
treatment plan and to evaluate stimulant med-
ication effects. The most widely published ob-
FREQUENTLY USED OBSERVATION servation system for assessing attention-deficit
TOOLS FOR COMMONLY REFERRED disorder (ADD) is that developed by Routh and
CHILDHOOD PROBLEMS his colleagues (Routh & Schroeder, 1976).
Many modifications to this system have been
Attachment Behavior
made by subsequent authors, including a clinic
No standard, widely used clinical tool exists for analogue system (Barkley, 1997).
assessing the attachment of the young child to Stimulant medications are well-known elic-
his or her primary caregiver. Although the de- itors of different effects for different domains of
scriptive categories of disordered attachment development. For example, a symptom trade-off
generated through Main and Ainsworth’s may occur, such as achieving optimal academic
Strange Situation Procedure (SSP; Ainsworth, performance at the cost of increasing impulsiv-
Blehar, Waters, & Wall, 1978) are frequently ity. Thus, observational techniques document-
applied in clinical settings (e.g., the “secure,” ing stimulant medication effects must be mul-
“avoidant,” “resistant,” or “disorganized” child), tidimensional.
the SSP is a research rather than a clinical tool Well-regarded tools for evaluating child be-
normed on children aged 12–18+ months. Cau- havior in the classroom include specifics of the
tion should be used in attempting to apply SSP target child’s behavior, as well as critical infor-
findings to situations where child behavior is mation on classroom environmental factors un-
observed under either clinical or naturalistic likely to be available through parent or teacher
conditions. Nevertheless, the SSP procedure report. These tools record behaviors such as be-
has served as a foundation for several clinical ing off task or out of seat, attentional shifts, and
122 part ii • psychological testing

amount of motor activity. The same tool used tinct parent and child contributions to the in-
for gathering baseline attentional data should be teraction can be discriminated.
readministered to monitor medication effects, The NCAST Teaching Scale observes and
including the critical variable of dosage incre- rates parent and child responses to parental ef-
ments. Observer bias can be minimized through forts to “teach” a common play task of child-
the use of crossover designs that alternate hood such as block building. The task is taught
placebo with treatment over the course of sev- under semistructured circumstances. The
eral weeks such that the observer is unaware of NCAST Feeding Scale offers a variation of this
the child’s status at the time of the observation. task and is an observation of parent-child inter-
An interesting and alternative strategy for actions during an actual child feeding situation.
assessing attentional problems in preschoolers Strengths of the NCAST system are its abil-
is the Goodman Lock Box, a play-based obser- ity to capture the contingent and reciprocal na-
vational coding system for use in clinical set- ture of the interaction using both the infant and
tings (Goodman, 1981). In addition to atten- the parent’s behavior as data. The NCAST sys-
tion, the Lock Box assesses other aspects of tem is difficult for some programs to incorpo-
preschool children’s mental organization, such rate because it requires specialized training by
as sequencing skills and perceptual-motor and a certified instructor.
visuospatial capacities.
Play Assessments
Autism and Mental Retardation Developmental aspects of childhood behavior
Autism and mental retardation are two of the such as interaction inhibition often make stan-
most frequently diagnosed developmental dis- dardized assessments nearly impossible, ren-
orders. They are particularly complex to diag- dering play observations an important medium
nose and treat because of the high degree of be- for gathering critical information. The system-
havioral inconsistencies that interfere with the atic observation of play can provide a useful,
ability to use standardized assessment tools unobtrusive means to understand and interpret
(Schopler, Reichler, & Renner, 1988). Conse- child behavior. Play observations are typically
quently, differential diagnosis relies heavily on nonthreatening to parent and child alike, often
the adequacy of the behavioral observations, offering an enjoyable means for parents to
coupled with caregiver reports of typical be- learn about their children.
havior. Comorbidity between the two condi- The majority of structured, clinical play-
tions also increases the importance of careful based assessments address representational and
observations of specific behaviors so that the di- cognitive capacities rather than the broader
agnoses can be discriminated and/or confirmed range of developmental tasks, including social
as coexisting. Similar observation strategies and emotional development. However, infer-
and tools are used for both disorders. ences based on observed affective displays, abil-
ity to socially reference others during the play
episode, general interest in social relatedness,
Parent-Child Interactions joint attention capacities, and mastery motiva-
Behavioral observations of parent-child inter- tion are often drawn from structured and un-
actions during infancy assess the parent’s ca- structured play tasks.
pacities across different situations to provide an For children with disabilities, play provides
emotional scaffolding for the child. The most a wealth of otherwise unobtainable informa-
widely used tools for assessing the parent-child tion. Populations that lend themselves to devel-
dyad are the tests embedded within the Nurs- opmental play observations include children
ing Childhood Assessment Tool (NCAST; Bar- with general cognitive delay and children with
nard, 1979). The paradigm on which the NCAST sensory and language disabilities and behavior
scales are based assumes that parent-child in- problems seen in autism, elective mutism, and
teraction is reciprocal and, therefore, that dis- conduct disorders.
 26 • child behavior observations 123

There are a tremendous number of play ob- nal of Consulting and Clinical Psychology, 49,
servation tools (Schaefer, Gitlin, & Sandgrund, 369 –378.
1991). Advantages and disadvantages of the Lieberman, A. F., & Pawl, J. H. (1988). Clinical ap-
various play observation tools should be care- plications of attachment theory. In J. Belsky
and T. Nezworski (Eds.), Clinical implications
fully considered (Cohen, Stern, & Balaban,
of attachment (pp. 88 – 93). Hillsdale, NJ: Erl-
1983).
baum.
Linder, T. W. (1996). Transdisciplinary play-based
References & Readings assessment: A functional approach to working
with young children. Baltimore: Paul H. Brooks.
Ainsworth, M. S., Blehar, M. D., Waters, E., & Wall, Mash, E. J., & Terdal, L. G. (1988). Behavioral as-
S. (1978). Patterns of attachment: A psycho- sessment of childhood disorders (2nd ed.). New
logical study of the Strange Situation. Hills- York: Guilford Press.
dale, NJ: Erlbaum. O’Neill, R. E., Horner, R. H., Albin, R. W., Storey,
Barkley, R. A. (1997). Defiant children: A clinician’s K., & Sprague, J. R. (1990). Functional analy-
manual for assessment and parent training sis of problem behavior: A practical assessment
(2nd ed.). New York: Guilford Press. guide. Sycamore, IL: Sycamore.
Barnard, K. E. (1979). Instructor’s learning resource Routh, D. K., & Schroeder, C. S. (1976). Standard-
manual. Seattle: NCAST Publications, Univer- ized playroom measures as indices of hyperac-
sity of Washington. tivity. Journal of Abnormal Child Psychology,
Caldwell, B. M., & Bradley, R. H. (1978). Manual 4, 199 –207.
for the home observation of the environment. Schaefer, C. E., Gitlin, K., & Sandgrund, A. (Eds.).
Little Rock: University of Arkansas Press. (1991). Play diagnosis and assessment. New
Cohen, D., Stern, V., & Balaban, N. (1983). Observ- York: Wiley.
ing and recording the behavior of young chil- Schopler, E., Reichler, R. J., & Renner, B. R. (1988).
dren. New York: Teachers College Press. The childhood autism rating scale. Los Ange-
Gaensbauer, T. G., & Harmon, R. J. (1981). Clinical les: Western Psychological Services.
assessment in infancy utilizing structured play-
room situations. Journal of the American
Related Topics
Academy of Child Psychiatry, 20, 264 –280.
Goodman, J. F. (1981). The Lock Box: A measure of Chapter 12, “Interviewing Parents”
psychomotor competence and organized behav- Chapter 27, “Measures of Children’s Psychological
ior in retarded and normal preschoolers. Jour- Development”
 MEASURES OF CHILDREN’S
27 PSYCHOLOGICAL
DEVELOPMENT

Sam S. Hill III

This chapter is essentially an updated entry of Brazelton Neonatal Behavioral

that submitted by Karen Levine in the first edi- Scale (NBAS)
tion (Koocher, Norcross, & Hill, 1998). It con- • Used primarily with premature infants or
tains an annotated listing of measures of chil- full-term newborns
dren’s intellectual ability and emotional devel- • Requires substantial training and experience
opment. with infants to administer
• Improvements over time correlate with later
Bayley Scales (Lester, 1984)
MEASURES OF INFANT
DEVELOPMENT
Infant assessment has moved away from in-
dividually administered standardized tests and
There are an ever increasing number of stan- toward a multidisciplinary approach. This in-
dardized tests that can be administered to in- terdisciplinary perspective is one in which each
fants. In the past, assessment of infants was domain of child development stands on its own
more an art than a science. Infant behavior and merits and offers findings that are coordinated
cooperation are extremely variable from in a practical developmental/treatment plan for
minute to minute, so results must be inter- the individual infant. The emphasis here is on
preted with great caution. Infant testing can be the practical. Each specialty coordinates and
useful in recognizing infants with developmen- contributes to the child’s development and
tal delays and to assist in the determination of progress measured in terms of the stated goals
eligibility for services. Infant assessment can of the clinician working with the family. A typ-
also lead to early detection autism and other de- ical infant/development assessment team is
velopmental disorders. Early intervention in made up of:
many cases can be significant in the long-term
effectiveness of treatment. The reader should • Medicine
know infant tests for normally developing chil- • Education
dren do not correlate with later measures of in- • Occupational therapy
telligence until 1.5 to 2 years of age (Bayley, • Physical therapy
1969). Hence, infant testing is extremely valu- • Psychology
able as a route to intervention but not as a pre- • Speech and language
dictor of later IQ. • Nutrition
• Audiology
• Social work

124
 27 • measures of children’s psychological development 125

This approach allows members of each disci- Wechsler Preschool and Primary
pline to employ the best practice in their field. Scale of Intelligence–III
• Normed for children ages 2 years 6 months
to 7 years 3 months
PRESCHOOL INTELLIGENCE TESTS
• Scale has been divided into two age bands,
2–6 to 3 –11 and 4 –0 to 7 –3
Preschool-age children are referred for psycho- • Well normed
logical testing for four reasons: kindergarten • Widely used by psychologists in educational
readiness, language delays, global developmen- systems and hospitals
tal delays, and executive control difficulties. • Highly correlated with WPPSI-R and to
Preschool instruments usually assess the child’s WISC-R
abilities across several domains including: ex- • Scores tend to be 8 points lower on the
pressive and receptive language; visual-spatial WPPSI
processing; fine motor skills; visual-motor in-
tegration; memory; general knowledge; and
preacademic skills (e.g., knowledge of letters McCarthy Scales of Children’s
and numbers). By preschool age, many children Abilities–Second Edition
are able to attend and follow directions suffi- • Normed for children 2 years 6 months to 8
ciently to obtain useful test results across a years 6 months
broad set of learning skills, while other chil- • Well normed
dren, especially children with communication, • “Fun”; good for young children and children
attentional, and developmental problems, can- who are difficult to test
not. A child’s performance and skills at this age • Children with significant speech and lan-
are also highly dependent on familial environ- guage delays score erroneously lower than
ment and history. Some preschool children on WPPSI Performance Scales (Morgan,
have had little exposure to the educational Dawson, & Kerby, 1992)
process of school. Careful psychological assess-
ment of preschool children can be helpful in de- If children are easy to test with normal lan-
termining specific types of problems, as well as guage and over age 6, the WPPSI-R is prefer-
executive functioning problems. able.

Stanford-Binet Intelligence
Kaufman Assessment Battery for
Scale–Fifth Edition
Children–II
• New norms for children 2 years of age • Normed for children 3 to 18 years
through adults 90+, scales vary substantially • “Fun”; good for young children and children
at different ages who are difficult to test
• New but wide use by psychologists is antici- • Well standardized
pated given the use of the fourth edition • Offers standard scores, age equivalent scores,
• Yields full-scale IQ and percentile ranks
• Less demand for strong attention in young • Several subtests containing unique and ap-
children than the fourth edition pealing types of tasks can be useful for as-
• Improved low-end items for better evalua- sessing abilities in difficult-to-test children
tion of young children and children with low (e.g., Face Recognition; Magic Window)
cognitive functioning
• Administration in Spanish provided The original version was criticized for an artifi-
cially high “floor” effect. The tests’ authors feel
they have answered those questions in the sec-
ond edition.
126 part ii • psychological testing

SCHOOL-AGE Bender Visual Motor Gestalt

INTELLIGENCE TESTS Test–Second Edition

Wechsler Intelligence Scale for • Brief shape-copying paper-and-pencil test

Children–IV • Useful in about the 4 to 85+ year range
• Assesses visual-spatial and visual-motor in-
• For children ages 6 to 16 years tegration skills
• The most widely used IQ test for school-age
children
• Very well normed Rey-Osterrieth Complex
• Can detect substantial but not all subtle Figures Test
learning disabilities • Complex shape-copying task
• Involves a significant amount of cultural • Useful in assessing visual-spatial, organiza-
knowledge and experience tional, and learning style
• May be more challenging for poor and di- • Often used as part of a neuropsychological
verse children due to language of adminis- battery
tration • Multiple administration and scoring systems
exist, with a great deal of research on each
Woodcock-Johnson Psycho-
Educational Battery III
Peabody Picture Vocabulary
• Well normed for ages 2 years and above Test–Revised
• Measures general intellectual ability, scho- • Normed for children aged 2 years 6 months
lastic aptitude, oral language, and academic through 90+
achievement • Test of receptive vocabulary
• The achievement test has 12 subtests in the • Requires ability to sustain attention
normal administration and an additional 10 • Can be adapted to be used with eye gaze in-
subtests in the extended version stead of pointing
• Eight new cognitive subtests, five new cogni- • Correlates with verbal IQ
tive clusters, two additional clusters when • Useful as a screening instrument
the cognitive and achievement batteries are • Does not identify language-processing or
used together language-formation problems
• Useful for identification of learning problems
and formulating individual education plans
TESTS FOR SPECIAL POPULATIONS

SCHOOL-AGE TESTS OF
Individuals from cultures different from those
SPECIFIC ABILITIES
of the norming sample should be tested with
Wide Range Assessment of caution. Whenever possible, these individuals
Memory and Learning–II should be tested by a psychologist from the
(WRAML-2) same culture as the child and using instru-
ments normed on that culture. Omitting test-
• Normed for children 5 to 17 years ing and conducting interviews and observations
• Useful supplement to any of the major tests are the best options when this sort of validity
of cognitive ability question arises. When testing is necessary for
• Includes three verbal scales, three memory the child’s best interests, test results should be
scales, and three learning scales interpreted cautiously and combined with the
• Especially useful when memory of visual observations of reliable observers.
processing problems is suspected Some individuals with developmental dis-
abilities cannot be validly assessed using stan-
 27 • measures of children’s psychological development 127

dardized measures. Specific assessment mea- Leiter International Performance

sures have been designed for some populations. Scale–Revised (Leiter-R)
These measures contain items that do not rely • Normed for children 2 years to 20 years 11
on systems that are impacted by the specific months
disability, and they also generally are normed • Assess cognitive function in children and
on people with the same disability. However, adolescents. The battery includes measures
these tests are generally normed on smaller of nonverbal intelligence, fluid reasoning,
groups and are less frequently revised. Hence, and visualization
when a more traditional test is felt to yield valid • Examines visual-spatial memory and atten-
information, it is preferable. The following are tion
some tests for special populations. • Based on increasingly complex one-to-one
matching (e.g., by shape, color, genus)
The Hiskey-Nebraska Test of • Useful for nonverbal children or children
Learning Aptitude who speak a language other than that of the
examiner
• Normed for children ages 3 to 16 years • Can also be adapted for children with little
• Separate norms for hearing impaired motor ability through use of eye gaze
• For children with hearing impairment • 1997 revision of the 1979 test
• Contains many traditional subtests in visual
form (e.g., number recall with plastic nu-
merals), easing interpretation TESTS OF ADAPTIVE
FUNCTIONING
Pictoral Test of Intelligence–
Second Edition It can often be helpful to obtain information
about a child’s level of independent functioning
• Normed for children ages 3 to 8 years in areas such as self-care, motor development,
• Useful for young children who have signifi- communication development, community
cant motor and/or language deficits, includ- functioning, and social functioning. While this
ing many children with spastic quadriplegic information is helpful in assessing any child, it
cerebral palsy can be particularly valuable when assessing
• Children respond to questions by pointing or children for whom traditional tests are not
by eye gaze valid or when mental retardation is suspected.
• Measures a variety of processing, memory,
and achievement domains
Vineland Adaptive Behavior
Scale–Third Edition
Merrill-Palmer Scale of
Mental Tests • Interview form, classroom edition, and ex-
panded edition
• Normed for children ages 2 years 6 months • Classroom edition, ages 3 years to 12 years
to 11 years and 11 months
• Uses an array of interesting and appealing vi- • A comprehensive and thorough interview
sual materials, most of which are self ex- measure of social, self-care, motor, and com-
planatory munity functioning
• Nonverbal items useful for children with lit- • Parent and teacher versions, as well as
tle language and/or children who are difficult Spanish-parent and teacher versions
to test
• Most useful as a qualitative rather than a
quantitative IQ instrument AAMD Adaptive Behavior Scale
• Developed in 1948 and never revised • Provides assessor with domain, factor, and
comparison scores
128 part ii • psychological testing

• Designed to measure a person’s independence Children’s Abilities. Psychology in the Schools,

and social skills 20, 11–17.
Sattler, J. M. (2001). Assessment of children: Cogni-
tive applications (4th ed.). San Diego, CA:
References & Readings Jerome M. Sattler.
Barkley, R. A. (1990). Attention deficit hyperactiv- Sattler, J. M. (2002). Assessment of children: Behav-
ity disorder: A handbook for diagnosis and ioral and clinical applications (4th ed.). San
treatment. New York: Guilford Press. Diego, CA: Jerome M. Sattler.
Bayley, N. (1969). Manual for the Bayley Scales of Woodrich, D. L. (1997). Children’s psychological
infant development. New York: Psychological testing: A guide for nonpsychologists (3rd ed.).
Corporation. Baltimore: Brooks.
Lester, B. M. (1984). Data analysis and prediction. In
T. B. Brazelton (Ed.), Neonatal Behavioral As- Related Topics
sessment Scale (pp. 85 – 96). Philadelphia: Lip-
pincott. Chapter 22, “Sources of Information About Psycho-
Morgan, R. L., Dawson, B., & Kerby, D. (1992). The logical Tests”
performance of preschoolers with speech/lan- Chapter 23, “Publishers of Psychological and Psy-
guage disorders on the McCarthy Scales of choeducational Tests”

ASSESSING MMPI-2
28 PROFILE VALIDITY

James N. Butcher

The most important step in the Minnesota response indices contained on the MMPI-2, a
Multiphasic Personality Inventory-2 (MMPI- strategy for evaluating the validity indices, and
2) profile interpretation is the initial one of de- key references for the information presented.
termining whether the profile contains valid,
useful, and relevant information about the
client’s personality and clinical problems. A RESPONSE INDICES
number of indices are available on the MMPI-2
Cannot Say Score
to aid the clinician in determining whether the
client’s item responses provide key personality This index is not a scale but simply the num-
information or are simply reflecting response ber of omitted items in the record and is used as
sets or deceptive motivational patterns to fend an index of cooperativeness. If the item omis-
off the assessor as to the client’s true feelings sions are at the end of the booklet (beyond item
and motivations. This brief introduction to as- 370), the validity and clinical scales may be in-
sessing MMPI-2 profile validity will provide terpreted, but the supplemental and MMPI-2
the following: a summary of each of the useful content scales should not be interpreted. The
 28 • assessing mmpi-2 profile validity 129

content of omitted items often provides inter- The S Scale or Superlative Self-
esting information about the client’s problems. Description Scale
If the individual has omitted more than 10 The S scale is an empirical measure developed
items, the MMPI-2 scales should be evaluated by contrasting individuals who took the MMPI-
to determine the percentage of omitted items 2 in an employment selection situation from
that appear on a particular scale. For example, a the normative sample. Applicants are usually
large number of items could appear on a partic- defensive when they are assessed in an employ-
ular scale, thereby reducing its value as a per- ment screening context. Even well-educated in-
sonality measure. If the person has omitted dividuals who are applying for a highly desir-
more than 30 items, the response record is able job tend to approach the MMPI-2 items
probably insufficient for interpretation, partic- with a cognitive set to convince the assessment
ularly if the omissions fall within the first 370 psychologist that they have a sound mind, high
items. responsibility, strong moral values, and great
capacity to work effectively with others. In
The L Scale their efforts to perform well on personality
evaluation, applicants tend to deny psychologi-
The L scale is a measure of cooperativeness and cal symptoms, aggressively disclaim moral
willingness to endorse faults or problems. Indi- flaws, and assert that they are responsible peo-
viduals who score high on this scale (T > 60) ple who get along extremely well with others
are presenting an overly favorable picture of and have the ability to compromise in interper-
themselves. If the L score is greater than 65, the sonal situations for the good of safety. In addi-
individual is claiming virtue not found among tion, they report being responsible and opti-
people in general. The L scale is particularly mistic about the future, and they assert that
valuable in situations like personnel screening or they have a degree of good adjustment that
forensic cases because many individuals being most normals do not. In sum, they present
assessed in these settings try to put their best themselves in a superlative manner, claiming to
foot forward and present themselves as “bet- be superior in terms of their mental health and
ter” adjusted than they really are. morality. The five subscales contained on the
S scale are described as follows: Beliefs in Hu-
The K Scale man Goodness, Serenity, Contentment with
Life, Patience/Denial of Irritability and Anger,
The K scale was developed as a measure of test and Denial of Moral Flaws.
defensiveness and as a correction for the ten-
dency to deny problems. The profiles of persons
who are defensive on the MMPI-2 are adjusted The F Scale
to offset their reluctance to endorse problems The F scale is an infrequency scale that is sensi-
by correcting for the defensiveness. Five MMPI tive to extreme or exaggerated problem en-
scales are corrected by adding a determined dorsement. The items on this scale are very
amount of the K score to the scale scores of Hs, rare or bizarre symptoms. Individuals who en-
Pd, Pt, Sc, and Ma. The K scale appeared to op- dorse a lot of these items tend to exaggerate
erate for MMPI-2 normative subjects much as symptoms on the MMPI-2. High F responding
it did for the original MMPI subjects. Conse- is frequently obtained by individuals with a set
quently, the K weights originally derived by to convince professionals that they need to have
Meehl were maintained in the MMPI-2. In the psychological services. This motivational pat-
MMPI-2, both K corrected and non-K corrected tern is also found among individuals with a
profiles can be obtained for psychologists inter- need to claim problems in order to influence the
ested in using non-K corrected scores. court in forensic cases. High-ranging F scores
can raise several possible interpretations: The
profile could be invalid because the client be-
130 part ii • psychological testing

came confused or disoriented or got mixed up health symptoms in the context of patients with
in responding. The F scale is also elevated in genuine psychological disorder. A high score on
random response records. High F scores are also F(P), for example, above a T score of 80, indicates
found among clients who are malingering or that the individual is endorsing more bizarre
producing exaggerated responding in order to item content than even inpatient psychiatric
falsely claim mental illness. cases endorse.

The F(B) Scale TRIN and VRIN

The F(B) scale, or Back F scale, was developed for Two inconsistency scales for determining pro-
the revised version of the MMPI to detect pos- file validity have been included in the MMPI-2.
sible deviant responding to items located to- These scales are based on the analysis of the in-
ward the end of the item pool. Some subjects dividual’s response to the items in a consistent
may modify their approach to the items part- or inconsistent manner. The first scale, True
way through the item pool and answer in a ran- Response Inconsistency (TRIN), is made up of
dom or unselective manner. Since the items on 20 pairs of items in which a combination of 2
the F scale occur earlier in the test, before item true or 2 false responses is semantically incon-
number 370, the F scale will not detect deviant sistent—for example, a pair of items that con-
response patterns occurring later in the booklet. tain content that cannot logically be answered
The 40-item F(B) scale was developed following in the same direction if the subject is respond-
the same method as for the original F scale, that ing consistently to the content.
is, by including items that had low endorse- TRIN can aid in the interpretation of scores
ment percentages in the normal population. on L and K, since the former is made up entirely
Suggested interpretations of the F(B) scale in- of items that are keyed false and the latter is
clude the following considerations: If the F scale made up of items all but one of which is keyed
is above T = 90, no additional interpretation of false. Thus, an individual who inconsistently
F(B) is indicated, since the clinical and validity responds “false” to MMPI-2 pairs of items that
scales are invalid by F scale criteria; if the T contain opposite content will have elevated
score of the F scale is valid, that is, below a scores on scales L and K that do not reflect in-
T = 89, and the F(B) is below T= 70, then a valid tentional misrepresentation or defensiveness.
response approach is indicated throughout the An individual whose TRIN score indicates in-
booklet and no additional interpretation is consistent “true” responding will have deflated
needed; or if the T score of the F scale is valid, scores on L and K that do not reflect a particu-
that is, below a T = 89, and the F(B) is above a larly honest response pattern or lack of ego re-
T = 90 (that is, if the original F scale is valid and sources.
the individual has dissimulated on the later part The Variable Response Inconsistency (VRIN)
of the booklet), then an interpretation of F(B) is scale may be used to help interpret a high score
needed. In this case, interpretation of the clini- on F. VRIN is made up of 49 pairs of (true-
cal and validity scales is possible; however, in- false; false-true; true-true; false-false) patterns.
terpretation of scales such as the content scales, The scale is scored by summing the number of
which require valid response to the later ap- inconsistent responses. A high F in conjunction
pearing items, needs to be deferred. with a low to moderate VRIN score rules out
the possibility that the F score reflects random
responding.
The F(P) Scale
The Psychopathology Infrequency Scale F(P) Two Obsolete Traditional
was developed by Arbisi and Ben-Porath (1995) Measures
to assess infrequent responding in psychiatric
settings. This scale is valuable in appraising the Two measures, popular with the original
tendency for some people to exaggerate mental MMPI, are not recommended for interpreting
 28 • assessing mmpi-2 profile validity 131

in MMPI-2: the F-K index (though sensitive to 2. Likely invalid MMPI-2 because of test
dissimulation) and the so-called subtle-obvious defensiveness if any of the following con-
items. First, the F-K index does not appear to ditions are present:
provide much additional information beyond • Cannot Say greater than 30
what is provided by the F scale alone. The F-K • L greater than 66
index, in which F is higher than K, tends to be • K greater than 70
superfluous and does not add any interpretive • S greater than 70
power beyond F alone. The F-K index in which
Indicators of exaggerated responding and
K is greater than F (sometimes suggested as a
malingering of symptoms
measure to assess “fake good” profiles) has not
worked out well in practice and is not recom- 1. Excessive symptom claiming
mended for clinical use because too many valid • F (infrequency) greater than 90
and interpretable protocols are rejected by this • F(B) greater than 90
index. • F(P) greater than 80
Second, the subtle-obvious items are essen- 2. Possibly exaggerated-invalid range
tially chance items. They are not related to the • F greater than 100
criteria for the scales (Weed, Ben-Porath, & • F(B) greater than 10
Butcher, 1990) and do not provide an index of • F(P) greater than 90
invalidity. The subtle scales have been elimi- 3. Likely malingering
nated from official MMPI-2 scoring services • F greater than 109, with VRIN less
and are not recommended for use in clinical de- than or equal to 79
cisions. • F(B) greater than 109, with VRIN less
than or equal to 79
• VRIN less than 79, with VRIN less
VALIDITY ASSESSMENT GUIDELINES than or equal to 79
• F(P) greater than 100, with VRIN less
The following guidelines or strategies are rec- than or equal to 79
ommended for determining the interpretability
of profiles:
References & Readings
Clues to non–content-oriented responding
Arbisi, P., & Ben-Porath, Y. S. (1995). An MMPI-2
• High Cannot Say’s ( 10) infrequency scale for use with psychopatholog-
Noncompliance ical populations: The Infrequency-Psychopa-
• Preponderance of T or F thology Scale, F(P). Psychological Assessment,
7, 424 – 431.
Careless or devious omissions
Baer, R. A., Wetter, M. W., & Berry, D. T. (1992).
• VRIN greater than 80 Detection of underreporting of psychopathol-
Inconsistency ogy on the MMPI: A meta-analysis. Clinical
• TRIN greater than 80 Psychology Review, 12, 509 – 525.
“Yea-saying” or “Nay-saying” (de- Baer, R. A., Wetter, M. W., Nichols, D., Greene, R.,
& Berry, D. T. (1995). Sensitivity of MMPI-2
pending on whether the score is TRIN
validity scales to underreporting of symptoms.
[T] or TRIN [F]) Psychological Assessment, 7, 419 – 423.
Indicants of defensive self-presentation Berry, D. T., Baer, R. A., & Harris, M. J. (1991). Detec-
1. Overly positive self-presentation, leading tion of malingering on the MMPI: A meta-analy-
to a somewhat attenuated record, if any, sis. Clinical Psychology Review, 11, 585 –591.
Berry, D. T., Wetter, M. W., Baer, R. A., Larsen, L.,
of these conditions, is present.
Clark, C., & Monroe, K. (1992). MMPI-2 ran-
• Cannot Say between 5 and 29 dom responding indices: Validation using a
• L over 60 but less than 65 self-report methodology. Psychological Assess-
• K over 60 but less than 69 ment: A Journal of Consulting and Clinical
• S over 65 Psychology, 4, 340 –345.
132 part ii • psychological testing

Berry, D. T., Wetter, M. W., Baer, R. A., Widiger, Timbrook, R. E., Graham, J. R., Keiller, S. W., &
T. A., Sumpter, J. C., Reynolds, S. K., et al. Watts, D. (1993). Comparison of the Wiener-
(1991). Detection of random responding on the Harmon subtle-obvious scales and the standard
MMPI-2: Utility of F, Back F, and VRIN scales. validity scales in detecting valid and invalid
Psychological Assessment: A Journal of Con- MMPI-2 profiles. Psychological Assessment, 5,
sulting and Clinical Psychology, 3, 418 – 53 – 61.
423. Weed, N., Ben-Porath, Y. S., & Butcher, J. N. (1990).
Berry, D. T. R., Wetter, M. W., Baer, R., Youngjohn, Failure of the Weiner-Harmon MMPI subtle
J. R., Gass, C., Lamb, D. G., et al. (1995). Overre- scales as predictors of psychopathology and as
porting of closed-head injury symptoms on the validity indicators. Psychological Assessment,
MMPI-2. Psychological Assessment, 7, 517 –523. 2, 281–283.
Butcher, J. N., & Han, K. (1995). Development of an Wetter, M. W., Baer, R. A., Berry, D. T., Robison,
MMPI-2 scale to assess the presentation of self L. H., & Sumpter, J. (1993). MMPI-2 profiles of
in a superlative manner: The S Scale. In J. N. motivated fakers given specific symptom infor-
Butcher & C. D. Spielberger (Eds.), Advances mation. Psychological Assessment, 5, 317 –323.
in personality assessment (Vol. 10, pp. 25 – 50). Wetter, W., Baer, R. A., Berry, D. T., Smith, G. T., &
Hillsdale, NJ: LEA Press. Larsen, L. (1992). Sensitivity of MMPI-2 valid-
Graham, J. R., Watts, D., & Timbrook, R. (1991). ity scales to random responding and malinger-
Detecting fake-good and fake-bad MMPI-2 ing. Psychological Assessment, 4, 369 –374.
profiles. Journal of Personality Assessment, 57,
264 –277.
Related Topics
Lim, J., & Butcher, J. N. (1996). Detection of faking
on the MMPI-2: Differentiation between faking- Chapter 29, “Clinical Scales of the MMPI-2”
bad, denial, and claiming extreme virtue. Jour- Chapter 31, “Characteristics of High and Low Scores
nal of Personality Assessment, 67, 1–26. on the MMPI-2 Clinical Scales”
Schretlen, D. (1988). The use of psychological tests Chapter 32, “Empirical Interpretation of the MMPI-2
to identify malingered symptoms of mental dis- Codetypes”
order. Clinical Psychology Review, 8, 451– 476.

CLINICAL SCALES
29 OF THE MMPI-2

John R. Graham

This chapter summarizes each Minnesota Mul- the clinical scales of the original MMPI and
tiphasic Personality Inventory-2 (MMPI-2) consideration of data concerning extra-test cor-
clinical scale in terms of the dimensions as- relates of the MMPI-2 clinical scales, which are
sessed by the scale. Descriptive material on per- basically the same as in the original MMPI. A
sons who have particularly high or low scale few items were deleted from the original test as
scores is given in chapter 28. Summary infor- outdated or because the content was deemed
mation is based on previously reported data for objectionable (e.g., content having to do with
 29 • clinical scales of the mmpi-2 133

religious beliefs or bowel and bladder function). symptoms and behaviors, including somatic
Other items were modified slightly to modern- complaints, worry or tension, denial of hos-
ize them, eliminate sexist references, or im- tile impulses, and difficulty in controlling
prove readability. one’s own thought processes.
• Scale 2 is an excellent index of people’s dis-
comfort and dissatisfaction with their life sit-
SCALE 1 (HYPOCHONDRIASIS) uations. Whereas highly elevated scores on
this scale suggest clinical depression, more
• Scale 1 originally was developed to identify moderate scores tend to be indicative of a
patients manifesting symptoms associated general attitude or lifestyle characterized by
with hypochondriasis. The syndrome is char- poor morale and lack of involvement.
acterized by preoccupation with the body and • Scale 2 scores are related to age, with elderly
concomitant fears of illness and disease. Al- persons typically scoring approximately
though such fears usually are not delusional 5 –10 T-score points higher than the mean
in nature, they tend to be quite persistent. for the total MMPI-2 normative sample.
One item was deleted because of objection- Some individuals who have recently been
able content, reducing Scale 1 from 33 items hospitalized or incarcerated tend to show
in the original MMPI to 32 items in the moderate elevations on Scale 2 that reflect
MMPI-2. dissatisfaction with current circumstances
• Scale 1 seems to be the most homogeneous rather than clinical depression.
and unidimensional in the MMPI-2. All the
items deal with somatic concerns or with
general physical competence. Factor analysis SCALE 3 (HYSTERIA)
indicates that much of the variance in Scale 1
is accounted for by a single factor, character- • This scale was developed to identify patients
ized by the denial of good health and report- who were utilizing hysterical reactions to
ing a variety of somatic symptoms. Patients stress situations. The hysterical syndrome is
with bona fide physical problems typically characterized by involuntary psychogenic
show somewhat elevated T scores on Scale 1 loss or disorder of function.
(approximately 60). Elderly individuals tend • All 60 items in the original version of Scale 3
to produce Scale 1 scores that are slightly were retained in MMPI-2. Some of the items
more elevated than those of adults in general, deal with a general denial of physical health
probably reflecting the declining health typ- and a variety of rather specific somatic com-
ically associated with aging. plaints, including heart or chest pain, nausea
and vomiting, fitful sleep, and headaches.
Another group of items involves a general
SCALE 2 (DEPRESSION) denial of psychological or emotional prob-
lems and of discomfort in social situations.
• Scale 2 originally was developed to assess Although these two clusters of items are rea-
symptomatic depression. The primary char- sonably independent in normal people, those
acteristics of depression are poor morale, lack utilizing hysterical defenses seem to score
of hope in the future, and a general dissatis- high on both clusters.
faction with one’s life situation. Of the 60 • Scale 3 scores are related to intellectual abil-
items originally in Scale 2, a total of 57 were ity, with brighter persons scoring higher. In
retained in the MMPI-2. Many of the items addition, high raw scores are much more
in the scale deal with aspects of depression common among women than among men in
such as denial of happiness and personal both normal and psychiatric populations.
worth, psychomotor retardation, withdrawal, • It is important to take into account the level
and lack of interest in one’s surroundings. of scores on Scale 3. Whereas marked eleva-
Other items in the scale cover a variety of tions (T > 80) suggest a pathological condi-
134 part ii • psychological testing

tion characterized by classical hysterical SCALE 5 (MASCULINITY-FEMININITY)

symptoms, moderate levels are associated
with characteristics that are consistent with • Scale 5 originally was developed by Hath-
hysterical disorders but do not include the away and McKinley to identify homosexual
classical hysterical symptoms. As with Scale invert males. The test authors identified only
1, patients with bona fide medical problems a very small number of items that differenti-
for whom there is no indication of psycho- ated homosexual from heterosexual men.
logical components to the conditions tend to Thus, items were added to the scale if they
obtain T scores of about 60 on this scale. differentiated between men and women in
the standardization sample. Items from an
earlier interest test were also added to the
SCALE 4 (PSYCHOPATHIC DEVIATE) scale. Although Hathaway and McKinley
considered this scale preliminary, it has come
• Scale 4 was developed to identify patients di- to be used routinely in its original form.
agnosed as having a psychopathic personality, • The test authors attempted, without suc-
asocial or amoral type. Whereas persons in the cess, to develop a corresponding scale for
original criterion group were characterized in identifying “sexual inversion” in women.
their everyday behavior by such delinquent As a result, Scale 5 has been used for both
acts as lying, stealing, sexual promiscuity, ex- men and women. Fifty-two of the items are
cessive drinking, and the like, no major crim- keyed in the same direction for both gen-
inal types were included. All 50 of the items in ders, whereas 4 items, all dealing with
the original scale were maintained in MMPI- frankly sexual content, are keyed in oppo-
2. The items cover a wide array of topics, in- site directions for men and women. After
cluding absence of satisfaction in life, family obtaining raw scores, T-score conversions
problems, delinquency, sexual problems, and are reversed for the sexes so that a high raw
difficulties with authorities. Interestingly, score for men automatically is transformed
the keyed responses include both admissions by means of the profile sheet itself into a
of social maladjustment and assertions of so- high T score, whereas a high raw score for
cial poise and confidence. women is transformed into a low T score.
• Scores on Scale 4 tend to be related to age, The result is that high T scores for both
with younger people scoring slightly higher genders are indicative of deviation from
than older people. In the MMPI-2 normative one’s own gender.
samples, Whites and Asian Americans scored • In the MMPI-2, 56 of the 60 items in the
somewhat lower on Scale 4 (5 –10 T-score original Scale 5 were maintained. Although a
points) than did African Americans, Native few of the items in Scale 5 have clear sexual
Americans, and Hispanics. content, most items are not sexual in nature,
• One way of conceptualizing what Scale 4 as- instead covering a diversity of topics, includ-
sesses is to think of it as a measure of rebel- ing work and recreational interests, worries
liousness, with higher scores indicating re- and fears, excessive sensitivity, and family
bellion and lower scores indicating acceptance relationships.
of authority and the status quo. The highest • Although MMPI Scale 5 scores were
scorers on the scale rebel by acting out in an- strongly related to the individual’s amount of
tisocial and criminal ways; moderately high formal education, the relationship is much
scorers may be rebellious but may express the more modest in the MMPI-2. More highly
rebellion in more socially acceptable ways; educated men tend to obtain slightly higher
and low scorers may be overly conventional Scale 5 T scores than do less educated men.
and accepting of authority. More highly educated women tend to obtain
slightly lower Scale 5 T scores than do less
educated women. These differences probably
 29 • clinical scales of the mmpi-2 135

reflect the broader interest patterns of more sions, obsessions, and unreasonable fears.
educated men and women and are not large This symptom pattern was much more com-
enough to necessitate different Scale 5 inter- mon among outpatients than among hospi-
pretations for persons with differing levels of talized patients, so the number of cases avail-
education. able for scale construction was small.
• All 48 items in the original scale were main-
tained in the MMPI-2. They cover a variety
SCALE 6 (PARANOIA) of symptoms and behaviors. Many of the
items deal with uncontrollable or obsessive
• Scale 6 originally was developed to identify thoughts, feelings of fear and/or anxiety, and
patients who were judged to have paranoid doubts about one’s own ability. Unhappiness,
symptoms such as ideas of reference, feelings physical complaints, and difficulties in con-
of persecution, grandiose self-concepts, sus- centration also are represented in the scale.
piciousness, excessive sensitivity, and rigid
opinions and attitudes. Although the scale
was considered preliminary because of prob- SCALE 8 (SCHIZOPHRENIA)
lems in cross-validation, it was retained be-
cause it produced relatively few false posi- • Scale 8 was developed to identify patients di-
tives. Persons who score high on this scale agnosed as schizophrenic. This category in-
usually have paranoid symptoms. However, cluded a heterogeneous group of disorders
some patients with clearly paranoid symp- characterized by disturbances of thinking,
toms are able to achieve average scores on mood, and behavior. Misinterpretations of
Scale 6. reality, delusions, and hallucinations may be
• All 40 of the items in the original scale were present. Ambivalent or constricted emotional
maintained in the MMPI-2. Although some responsiveness is common. Behavior may be
of the items in the scale deal with frankly withdrawn, aggressive, or bizarre.
psychotic behaviors (e.g., excessive suspi- • All 78 of the items in the original scale were
ciousness, ideas of reference, delusions of maintained in the MMPI-2. Some of the
persecution, grandiosity), many items cover items deal with such frankly psychotic
such diverse topics as sensitivity, cynicism, symptoms as bizarre mentation, peculiarities
asocial behavior, excessive moral virtue, and of perception, delusions of persecution, and
complaints about other people. It is possible hallucinations. Other topics covered include
to obtain a T score greater than 65 on this social alienation, poor family relationships,
scale without endorsing any of the clearly sexual concerns, difficulties in impulse con-
psychotic items. trol and concentration, and fears, worries,
and dissatisfactions.
• Scores on Scale 8 are related to age and race.
SCALE 7 (PSYCHASTHENIA) College students often obtain T scores in a
range of 50 –60, perhaps reflecting the devel-
• Scale 7 originally was developed to measure opmental turmoil associated with that period
the general symptomatic pattern labeled psy- in life. In some studies, African Americans,
chasthenia. Although this diagnostic label is Native Americans, and Hispanics in the
not used commonly today, it was popular MMPI-2 normative sample have scored higher
when the scale was developed. Among cur- than whites. The elevated scores for members of
rently popular diagnostic categories, the ethnic minority groups do not necessarily sug-
obsessive-compulsive disorder probably is gest greater psychopathology. They may sim-
closest to the original meaning of the psy- ply be indicative of the feelings of alienation
chasthenia label. Such persons have thinking and social estrangement sometimes experi-
characterized by excessive doubts, compul- enced by minority group members.
136 part ii • psychological testing

• Some elevations of Scale 8 can be accounted SCALE 0 (SOCIAL INTROVERSION)

for by persons who are reporting a large
number of unusual experiences, feelings, and • Scale 0 was designed to assess a person’s ten-
perceptions related to the use of prescription dency to withdraw from social contacts and
and nonprescription drugs, especially am- responsibilities. Items were selected by con-
phetamines. Also, some persons with disor- trasting high and low scorers on the Social
ders such as epilepsy, stroke, or closed-head Introversion-Extroversion Scale of the Min-
injury endorse sensory and cognitive items, nesota T-S-E Inventory. Only women were
leading to high scores on Scale 8. used to develop the scale, but its use has been
extended to men as well.
• All but 1 of the 70 items in the original scale
SCALE 9 (HYPOMANIA) remain in the MMPI-2. The items are of two
general types: one group deals with social
• Scale 9 originally was developed to identify participation, whereas the other group deals
psychiatric patients manifesting hypomanic with general neurotic maladjustment and
symptoms. Hypomania is characterized by self-depreciation. High scores can be obtained
elevated mood, accelerated speech and motor by endorsing either kind of item or both.
activity, irritability, flight of ideas, and brief • Scores on Scale 0 are quite stable over ex-
periods of depression. tended periods.
• All 46 items in the original scale were main-
tained in the MMPI-2. Some of the items deal References & Readings
specifically with features of hypomanic dis-
Ben-Porath, Y. S., Graham, J. R., Hall, G. N., Hirsch-
turbance (e.g., activity level, excitability, irri-
man, R. D., & Zaragoza, M. S. (Eds.). (1995).
tability, grandiosity). Other items cover top- Forensic applications of the MMPI-2. Thou-
ics such as family relationships, moral values sand Oaks, CA: Sage.
and attitudes, and physical or bodily concerns. Butcher, J. N., Graham, J. R., Ben-Porath, Y. S., Tel-
No single dimension accounts for much of the legen, A., Dahlstrom, W. G., & Kaemmer, B.
variance in scores, and most of the sources of (2001). Minnesota Multiphasic Personality In-
variance represented in the scale are not du- ventory-2 (MMPI-2): Manual for administra-
plicated in other clinical scales. tion, scoring, and interpretation. Minneapolis:
• Scores on Scale 9 are related to age and race. University of Minnesota Press.
Younger people (e.g., college students) typi- Butcher, J. N., & Williams, C. L. (2000). Essentials
of MMPI-2 and MMPI-A interpretation. Min-
cally obtain scores in a T-score range of
neapolis: University of Minnesota Press.
50 –60. For elderly people, Scale 9 T scores be-
Graham, J. R. (1990). MMPI-2: Assessing personal-
low 50 are common. African Americans, Na- ity and psychopathology (3rd ed.). New York:
tive Americans, and Hispanics in the MMPI- Oxford University Press.
2 normative samples scored somewhat higher Graham, J. R., Ben-Porath, Y. S., & McNulty, J. L.
(5 –10 T-score points) than Whites. (1999). MMPI-2 correlates for outpatient com-
• Scale 9 can be viewed as a measure of psy- munity mental health settings. Minneapolis:
chological and physical energy, with high University of Minnesota Press.
scorers having excessive energy. When Scale Greene, R. (2000). The MMPI-2: An interpretive
9 scores are high, one expects that charac- manual (2nd ed.). Boston: Allyn and Bacon.
teristics suggested by other aspects of the
profile will be acted out. For example, high Related Topics
scores on Scale 4 suggest asocial or antisocial
Chapter 28, “Assessing MMPI-2 Profile Validity”
tendencies. If Scale 9 is elevated along with Chapter 31, “Characteristics of High and Low
Scale 4, these tendencies are more likely to Scores on the MMPI-2 Clinical Scales”
be expressed overtly in behavior. Chapter 32, “Empirical Interpretation of the MMPI-
2 Codetypes”
 SUPPLEMENTARY SCALES OF
30 THE MMPI-2

Roger L. Greene

This overview of the MMPI-2 supplementary GENERALIZED EMOTIONAL

scales will be organized into four groupings of DISTRESS SCALES
scales: generalized emotional distress scales
(Welsh Anxiety [A], College Maladjustment Factor-analytic studies of the MMPI-2 clinical
[Mt], and Post Traumatic Stress Disorder–Keane scales have consistently identified two factors
[PK]); control/inhibition and dyscontrol/dysin- that are variously labeled and interpreted. The
hibition scales (Welsh Repression [R], Hostility first factor is generally acknowledged to be a
[Ho], and MacAndrew Alcoholism–Revised measure of generalized emotional distress and
[MAC-R]); alcohol/drug scales (MacAndrew negative affectivity, and Welsh developed his
Alcoholism–Revised [MAC-R], Addiction Ad- Anxiety (A) scale to measure this factor. There
mission [AAS], Addiction Potential [APS], and are 10 to 20 other scales in the MMPI-2 that
Common Alcohol Logistic–Revised [CAL-R]); measure this factor of generalized emotional
and the Personality Psychopathology Five distress and negative affectivity, all of which
scales (PSY-5: Harkness, McNulty, & Ben- have high positive correlations with the A scale:
Porath, 1995) that recently were added to the the clinical Scales 7 (Pt: .95) and 8 (Sc: 90); the
National Computer Systems Extended Score content scales Work Interference (WRK: .94),
Report for the MMPI-2. Given the limited Depression (DEP: .92), Anxiety (ANX: .90),
amount of space, the less frequently used sup- Obsessions (OBS: .89), and Low Self-Esteem
plementary scales covering general personality (LSE: .87); and the supplementary scales Post
dimensions (Dominance [Do], Over-Controlled Traumatic Stress Disorder–Keane (PK: .93),
Hostility [O-H]; Social Responsibility [Re]) College Maladjustment (Mt: .93), and Marital
and gender role scales (Gender Role–Feminine Distress Scale (MDS: .79). There also are a
[GF] and Gender Role–Masculine [GM]) will number of MMPI-2 scales that have high neg-
not be discussed. Information on all of these ative correlations with the A scale and as such
supplementary scales can be found in Friedman, are simply inverted measures of generalized
Lewak, Nichols, and Webb (2001); Graham distress: Ego Strength (Es: –.83) and K (Correc-
(2000); and Greene (2000). Clinicians should tion: –.79). All of these scales can be character-
keep in mind that a general style for individu- ized as generalized measures of emotional dis-
als to maximize or minimize their reported tress with little or no specificity despite the
symptoms will have a significant impact on the name of the scale and there are little empirical
elevation, or lack thereof, for all of the MMPI- data to support any distinctions among them.
2 supplementary scales, as well as the standard
validity and clinical scales and content scales. It
will be assumed in discussing the supplemen-
tary scales below that individuals have en-
dorsed the items in an accurate manner.

137
138 part ii • psychological testing

CONTROL/INHIBITION AND other scale is unusually low, clinicians should

DYSCONTROL/DYSINHIBITION give serious consideration to the hypothesis
SCALES that the individual is maximizing (A > 75; R <
45) or minimizing (A < 45; R > 60) his or her
The second factor identified in these factor- report of psychopathology. It is particularly
analytic studies of the MMPI-2 clinical scales is pathognomonic when both the A and R scales
a measure of control and inhibition, and Welsh are low (T < 50), a pattern that is seen in
developed his Repression (R) scale to measure chronic, ego syntonic psychopathology.
this factor. The major content area of the R scale
is the denial, suppression, constriction, and in-
hibition of all kinds of interests either positive ALCOHOL AND DRUG SCALES
or negative — that is, these individuals like to
keep their behavior within very narrow limits. The alcohol and drug scales on the MMPI-2 can
There are 5 to 10 other scales in the MMPI-2 be easily subdivided into rationally derived, or
that measure this factor of control and inhibi- direct, measures (Addiction Admission [AAS]
tion, but the pattern of correlations with the R and Common Alcohol Logistic–Revised
scale is much more variable and smaller than [CAL-R]) and empirically derived, or indirect
found with the A scale: the clinical Scale 9 (Ma: measures (MacAndrew Alcoholism–Revised
.45), the content scale Antisocial Practices (ASP: [MAC-R] and Addiction Potential [APS]).
.36), the supplementary scales MacAndrew Al- These four alcohol and drug scales contain 111
coholism–Revised (MAC-R: .52) and Social Re- different items, 96 of which are found on only
sponsibility (Re: .38), and the PSY-5 scales Ag- one of the four scales. These different method-
gression (AGGR: .53) and Disconstraint (DISC: ologies yielded very different item groupings
.46). The specific correlates of the second factor on these four scales that can be seen in the low
will be a function of the scale that is used to de- positive intercorrelations among them: MAC-R
fine it, but it is evident that this group of with AAS .48, APS .29, and CAL-R .32; and
MMPI-2 scales is characterized by significant AAS with APS .34; CAL-R .46. Consequently,
dyscontrol or dysinhibition associated with act- the manifestations of alcohol and drug abuse
ing out or externalization of psychopathology. will differ in specific individuals depending
Conjoint interpretations of the first two fac- upon which scale is elevated.The MAC-R scale
tors of the MMPI-2 (generalized emotional dis- is best conceptualized as a general personality
tress and control/inhibition) provide a succinct dimension. Individuals who produced elevated
approach for how individuals are coping with scores (raw scores > 24 to 26) on the MAC-R
the behaviors and symptoms that led them to scale are described as being impulsive, risk-
treatment (see Greene, 2000, Table 6.5, p. 225). taking, and sensation-seeking, and they fre-
The A scale provides a quick estimate of how quently have a propensity to abuse alcohol
much generalized emotional distress the indi- and/or stimulating drugs. They are uninhib-
vidual is experiencing, and the R scale indicates ited, sociable individuals who appear to use re-
whether the individual is trying to inhibit or pression and religion in an attempt to control
control the expression of this distress. It is par- their rebellious, delinquent impulses. They also
ticularly noteworthy in a clinical setting when are described as having a high energy level,
the A scale is not elevated (T < 50) because it having shallow interpersonal relationships, and
signifies that the individual is not experiencing being generally psychologically maladjusted.
any distress about the behaviors and symptoms Low scorers (raw scores < 18 to 20) are de-
that led, usually someone else to refer, them to scribed as being risk-avoiding, introverted, and
treatment. Similarly low scores (T < 45) on the depressive, and they abuse sedative-hypnotics
R scale suggest that the individual has no cop- and alcohol if they abuse substances. Once the
ing skills or abilities to control or inhibit the MAC-R scale is understood as a general per-
overt expression of their distress. When one of sonality dimension for risk-taking versus risk-
these two scales is elevated significantly and the avoiding, the fact that mean scores vary dras-
 30 • supplementary scales of the mmpi-2 139

tically by codetype makes sense. For example, in performs better at identifying individuals who
men, the mean raw score on the MAC-R scale are abusing substances than less direct mea-
in a 4-9/9-4 (risk-taking) codetype is 26.5 and sures such as the APS and MAC-R scales, even
in a 2-0/0-2 (risk-avoiding) codetype is 17.1 though the items are face-valid, allowing indi-
(see Greene, 2000, Appendix D), a difference of viduals not to report the substance abuse if they
over two standard deviations.There are a num- desire to do so. Weed, Butcher, and Ben-Porath
ber of issues that must be kept in mind when (1995) have provided a thorough review of all
interpreting the MAC-R scale: men score about MMPI-2 measures of substance abuse.
2 raw-score points higher than women across Davis, Offord, Colligan, and Morse devel-
most samples, which indicates that different oped the Common Alcohol Logistic (CAL) scale
cutting scores are necessary by gender; there is because of their concern that existing MMPI al-
not a single, optimal cutting score with raw cohol scales lacked adequate positive predictive
scores anywhere from 24 to 29 being used in power given the low base rate or prevalence of
different studies; clinicians need to be very cau- alcohol-related problems in general medical
tious in using the MAC-R scale in nonwhite settings. Gottesman and Prescott (1989) raised
ethnic groups, if it is used at all; classification similar concerns about the MAC-R scale in
accuracy decreases when clinicians are trying to psychiatric patients. The 33 items for the CAL
discriminate between substance abusers and scale were identified and the item weights were
nonsubstance-abusing psychiatric patients, assigned by using logistic regression in large
which is a frequent differential diagnosis; and samples of alcoholic patients, medical patients,
classification accuracy may be unacceptably low and normal individuals. Malinchoc, Offord,
in medical samples. Colligan, and Morse (1994) revised the CAL
The Addiction Potential Scale (APS) consists scale for the MMPI-2 by dropping the six items
of 39 items that differentiated among groups of on the CAL scale that were not retained on the
male and female substance-abuse patients, nor- MMPI-2. They recomputed the item weights
mal individuals, and psychiatric patients. Indi- using logistic regression on similar groups of
viduals with elevated (T > 64) scores on the patients and the resulting 27 items became the
APS scale are generally distressed and upset, as CAL-R scale that is appropriate for use with ei-
well as angry and resentful. They also are con- ther the MMPI or MMPI-2. They did not use
cerned about what others think of them, a con- the MMPI-2 item pool in this revision so it re-
cern that is not evident in individuals who ele- mains to be seen whether any of the new
vate the MAC-R scale. The APS scale appears MMPI-2 items, particularly the items asking
to be more accurate at discriminating between about alcohol and drug abuse, would have been
substance-abuse patients and psychiatric pa- selected for inclusion on the scale. The CAL-R
tients than is the MAC-R scale. The APS scale scale appears to be particularly useful to iden-
also tends to be less gender biased than the tify substance abuse in medical settings, no
MAC-R scale and to be less codetype sensitive. doubt reflecting the context in which the scale
For example, in men, the mean T score on APS was developed.
in a 4-9/9-4 codetype is 56.2 and in a 2-0/0-2 Although the focus of this section is on alco-
codetype is 49.0 (see Greene, 2000, Appendix hol and drug scales, it is important to note that
D), a difference slightly over one-half of a stan- there are a number of specific MMPI-2 items
dard deviation.The Addiction Admission Scale related to alcohol and drug use (264, 489, 511,
(AAS) consists of 13 items directly related to 544) that warrant further inquiry any time
the use of alcohol and drugs. Clinicians should they are endorsed in the deviant direction.
review the clinical history and background of Most of these items are phrased in the past
any individual who elevates the AAS scale (T > tense so the clinician cannot assume without in-
59) because of the explicit nature of the items quiry whether the alcohol and drug use is a cur-
and the fact that three or more of these items rent or past event.
have been endorsed in the deviant direction to
produce this elevation. The AAS scale typically
140 part ii • psychological testing

PERSONALITY PSYCHOPATHOLOGY tive of rather serious psychopathology. Such an

FIVE (PSY-5) SCALES interpretation of the INTR scale is particularly
likely when the NEGE scale is not elevated sig-
Harkness and McNulty created a five-factor nificantly.
model called the Personality Psychopathology The PSY-5 scales are another potential
Five (PSY-5) to aid in the description of normal source of information for the clinician in inter-
personality and to complement the diagnosis of preting the MMPI-2 profile. Research that
personality disorders. Using replicated rational demonstrates their usefulness in patients with
selection, Harkness and McNulty identified five personality disorder diagnoses is needed. Until
factors within 60 descriptors of normal and such information is available clinicians are cau-
abnormal human behavior: Aggressiveness tioned to interpret them very conservatively.
(AGGR), Psychoticism (PSYC), Disconstraint
(DISC), Negative Emotionality/Neuroticism
(NEGE), and Introversion/ Low Positive Emo- SUMMARY
tionality (INTR) (cf. Harkness, McNulty, Ben-
Porath, & Graham, 2002). The AGGR scale as- The MMPI-2 supplementary scales should be
sesses offensive aggression and possibly the en- scored and interpreted routinely as a valuable
joyment of dominating, frightening, and source of additional information that is not
controlling others, and the lack of regard for so- readily available in the standard validity and
cial rules and conventions. The PSYC scale as- clinical scales or the content scales. For example,
sesses the cognitive ability of the individual to the conjoint interpretation of the A and R scales
model the external, objective world in an accu- provides a quick insight into how individuals
rate manner. Persons who are low on the PSYC are experiencing and coping with their psy-
construct can realize that their model is not chopathology that brought them to treatment.
working and accommodate or revise the model In addition, the information on alcohol and
to fit their environment. Although the PSYC drug use can only be inferred indirectly from
scale has its largest correlations with Scales F, the MMPI-2 clinical and content scales, while
8 (Sc), and Bizarre Mentation (BIZ), it appears this information is available both directly and
to be measuring a general distress factor, much indirectly in the supplementary scales. The in-
like the NEGE scale. The DISC scale assesses a formation provided by the supplementary
dimension from rule following versus rule scales is invaluable in the treatment-planning
breaking and criminality. The DISC scale is not process.
correlated to most of the other MMPI-2 scales
and, thus, would appear to have the potential to
contribute additional information when inter- References & Readings
preting the MMPI-2. The largest correlations of Friedman, A. F., Lewak, R., Nichols, D. S., & Webb,
the DISC scale are with Scales 9 (Ma), the J. T. (2001). Psychological assessment with the
MacAndrew Alcoholism–Revised (MAC-R), MMPI-2. Mahwah, NJ: Erlbaum.
and Antisocial Practices (ASP). The NEGE scale Gottesman, I. I., & Prescott, C. A. (1989). Abuses of
assesses a broad affective disposition to experi- the MacAndrew MMPI alcoholism scale: A crit-
ence negative emotions focusing on anxiety and ical review. Clinical Psychology Review, 9,
nervousness. The NEGE scale is another of the 223 –242.
numerous markers for the first factor of general Graham, J. R. (2000). MMPI-2: Assessing personal-
ity and psychopathology (3rd ed.). New York:
distress and negative emotionality on the
Oxford University Press.
MMPI-2. The INTR construct assesses a broad Greene, R. L. (2000). The MMPI-2: An interpretive
disposition to experience negative affects and to manual (2nd ed.). Boston: Allyn & Bacon.
avoid social experiences. Although the INTR Harness, A. R., McNulty, J. L., Ben-Porath, Y. S., &
scale generally has its largest correlations with Graham, J. R. (2002). MMPI-2 Personality Psy-
MMPI-2 markers for the first factor, the INTR chopathology Five (PSY-5) scales: Gaining an
scale is a measure of anhedonia that is sugges- overview for case conceptualization and treat-
 31 • characteristics of high and low scores on the mmpi-2 scales 141

ment planning. Minneapolis: University of vances in personality assessment (Vol. 10, pp.
Minnesota Press. 121–145). Hillsdale, NJ: Erlbaum.
Malinchoc, M., Offord, K. P., Colligan, R. C., &
Morse, R. M. (1994). The Common Alcohol
Related Topics
Logistic–Revised scale (CAL-R): A revised alco-
holism scale for the MMPI and MMPI-2. Jour- Chapter 29, “Clinical Scales of the MMPI-2”
nal of Clinical Psychology, 50, 436 – 445. Chapter 31, “Characteristics of High and Low Scores
Weed, N. C., Butcher, J. N., & Ben-Porath, Y. S. on the MMPI-2 Clinical Scales”
(1995). MMPI-2 measures of substance abuse. Chapter 32, “Empirical Interpretation of the MMPI-
In J. N. Butcher & C. D. Spielberger (Eds.), Ad- 2 Codetypes”

CHARACTERISTICS OF HIGH
31 AND LOW SCORES ON THE
MMPI-2 CLINICAL SCALES

John R. Graham

These descriptions of high and low scores on • Low scores also have been defined in differ-
each clinical scale of the Minnesota Multipha- ent ways, sometimes as T scores below 40
sic Personality Inventory-2 (MMPI-2) are and other times as scores in the lowest quar-
based on examination of previously reported tile of a distribution. This latter approach has
data for the original MMPI and data concerning led to scores well above the mean being con-
the MMPI-2. sidered as low scores. In contrast with high
scores, limited information is available in the
literature concerning the meaning of low
DEFINITIONS scores. The most usual practice is to consider
T scores below 40 as low scores.
• The definition of a high score on a clinical
scale has varied considerably in the literature
and from one scale to another. Some consider GENERAL PRINCIPLES
MMPI-2 T scores above 65 as “high.” Oth-
ers have defined high scores as the upper • Some data support the notion that low scores
quartile in a distribution or have described on a particular scale indicate the absence of
several T-score levels on each scale. Another problems and symptoms characteristic of
approach identifies the highest scale in the high scorers on that scale. Other data have
profile (high point) as significant irrespective suggested that low scores on some scales are
of its T-score value. The most usual practice associated with general problems and nega-
is to consider T scores above 65 as high tive characteristics. Still other data have been
scores. interpreted as indicating that both high and
142 part ii • psychological testing

low scores on some scales indicate similar bizarre somatic concerns should be suspected.
problems and negative characteristics. If Scale 3 also is elevated, the possibility of a
• It is clear that low scores on some MMPI-2 conversion disorder should be considered. If
scales may convey important information but Scale 8 is very elevated along with Scale 1,
not as important as high scores. In nonclini- somatic delusions may be present.
cal settings, low scores are associated with • Persons with more moderate elevations on
fewer than average symptoms and problems Scale 1 (T = 60 – 80) tend to have generally
and above-average adjustment. There is little vague, nonspecific complaints. When specific
basis for interpreting low scores on the clini- symptoms are elicited, they tend to be epi-
cal scales as indicating problems and negative gastric in nature. Chronic weakness, lack of
characteristics in nonclinical samples. energy, and sleep disturbance also tend to be
• Based on the empirical data concerning the characteristic of high scorers. Medical pa-
meaning of low scores on the MMPI and tients with bona fide physical problems gen-
MMPI-2, a very conservative approach to in- erally obtain T scores of about 60 on this
terpretation of low scores on the MMPI-2 scale. When medical patients produce T
clinical scales is recommended. In nonclinical scores much above 60, one should suspect a
settings (e.g., personnel selection), low scores strong psychological component to the ill-
in a valid protocol should be interpreted as ness. Moderately high scores on Scale 1 tend
indicating more positive adjustment than to be associated with diagnoses such as so-
high or average scores. However, if the valid- matoform disorders, somatoform pain disor-
ity scales indicate that the test was completed ders, anxiety disorders, and depressive disor-
in a defensive manner, low scores should not ders. Acting-out behavior is rare among high
be interpreted at all. In clinical settings, it is Scale 1 scorers.
recommended that low scores on the clinical • High Scale 1 scorers (T > 60) in both psychi-
scales not be interpreted. The exceptions are atric and nonpsychiatric samples tend to be
Scales 5 and 0, for which some limited infer- characterized by a rather distinctive set of
ences can be made about low scorers (see be- personality attributes. They are likely to be
low). selfish, self-centered, and narcissistic. Their
• In general, T scores greater than 65 are con- outlook toward life tends to be pessimistic,
sidered high, although inferences about per- defeatist, and cynical. They are generally dis-
sons with scores at different levels are pre- satisfied and unhappy and are likely to make
sented for some scales. Note that the T-score those around them miserable. They complain
levels presented are somewhat arbitrary and a great deal and communicate in a whiny
that clinical judgment is critical in deciding manner. They are demanding of others and
which inferences should be applied to scores are very critical of what others do, although
at or near the cutoff scores described. Not they are likely to express hostility in rather
every inference presented will apply to every indirect ways. High scorers on Scale 1 often
person who has a T score at that level. are described as dull, unenthusiastic, unam-
• In general, greater confidence should be bitious, and lacking ease in oral expression.
placed in inferences based on more extreme • High scorers generally do not exhibit much
scores, with all inferences treated as hypothe- manifest anxiety, and in general they do not
ses to be considered in the context of other show signs of major incapacity. Rather, they
available information about the person. appear to be functioning at a reduced level
of efficiency. Problems are much more
likely to be long-standing than situational
INTERPRETATION OF HIGH SCORES or transient.
ON SCALE 1 • Extremely high and moderately high scorers
typically see themselves as physically ill, and
• For persons with extremely high scores on they seek medical explanations and treat-
Scale 1 (T > 80), dramatic and sometimes ment for their symptoms. They tend to lack
 31 • characteristics of high and low scores on the mmpi-2 scales 143

insight concerning the causes of their somatic logical distance from other people. They may
symptoms, and they resist psychological in- feel that others do not care about them, and
terpretations. These tendencies, coupled with their feelings are easily hurt. They often
their generally cynical outlook, suggest that have a severely restricted range of interests
these individuals are not very good candi- and may withdraw from activities in which
dates for psychotherapy or counseling. They they previously participated. They are very
tend to be highly critical of their psychother- cautious and conventional in their activities,
apists and to terminate therapy if the thera- and they are not very creative in problem
pist is perceived as suggesting psychological solving.
reasons for their symptoms or as not giving • High scorers may have great difficulty in
them enough support and attention. making even simple decisions and may feel
overwhelmed when faced with major life de-
cisions such as vocational choice or marriage.
INTERPRETATION OF HIGH SCORES They tend to be very overcontrolled and to
ON SCALE 2 deny their own impulses. They are likely to
avoid unpleasantness and tend to make con-
• High scorers on Scale 2 (particularly if the T cessions in order to avoid confrontations.
scores exceed 70) often display depressive • Because high Scale 2 scores are suggestive of
symptoms. They may report feeling de- great personal distress, they suggest a good
pressed, blue, unhappy, or dysphoric. They prognosis for psychotherapy or counseling.
tend to be quite pessimistic about the future There is some evidence, however, that high
in general and more specifically about the scorers may tend to terminate treatment pre-
likelihood of overcoming their problems and maturely when the immediate crisis passes.
making a better adjustment. They often talk
about committing suicide. Self-depreciation
and guilt feelings are common. Behavioral INTERPRETATION OF HIGH SCORES
manifestations may include lack of energy, ON SCALE 3
refusal to speak, crying, and psychomotor re-
tardation. Patients with such high scores of- • Marked elevations on Scale 3 (T > 80) sug-
ten receive depressive diagnoses. gest persons who react to stress and avoid re-
• Other symptoms of high scorers include sponsibility by developing physical symp-
physical complaints, bad dreams, weakness, toms. The symptoms usually do not fit the
fatigue or loss of energy, agitation, tension, pattern of known organic disorders, often in-
and fearfulness. They also are described as ir- cluding, in some combination, headaches,
ritable, high-strung, and prone to worry and stomach discomfort, chest pains, weakness,
fretting. They may have a sense of dread that and tachycardia. Nevertheless, such persons
something bad is about to happen to them. may be symptom free most of the time, but
• High scorers also show a marked lack of self- when they are under stress, symptoms may
confidence. They report feelings of useless- appear suddenly and are likely to disappear
ness and inability to function in a variety of just as abruptly after the stress subsides.
situations. They act helpless and give up eas- • Except for the physical symptoms, high scor-
ily when faced with stress. They see them- ers may tend to be relatively free of other
selves as having failed to achieve adequately symptoms. Although they sometimes de-
in school and at their jobs. scribe themselves as prone to worry, lacking
• High scorers tend to be described as intro- energy and feeling worn out, and having
verted, shy, retiring, timid, seclusive, and se- sleep disturbances, they are not likely to re-
cretive. A lifestyle characterized by with- port severe anxiety, tension, or depression.
drawal and lack of intimate involvement with Hallucinations, delusions, and suspiciousness
other people is common. These individuals are rare. The most frequent diagnoses for
also tend to be aloof and to maintain psycho- high Scale 3 scorers among psychiatric pa-
144 part ii • psychological testing

tients are conversion disorder and psycho- INTERPRETATION OF HIGH SCORES

genic pain disorder. ON SCALE 4
• A salient feature of the day-to-day function-
ing of high scorers is a marked lack of insight • Extremely high scores (T > 75) on Scale 4
concerning the possible underlying causes of tend to be associated with difficulty incorpo-
their symptoms. In addition, they show little rating the values and standards of society.
insight concerning their own motives and Such high scorers are likely to engage in a
feelings. variety of asocial, antisocial, and even crimi-
• High scorers are often described as extremely nal behaviors. These behaviors may include
immature psychologically and at times even lying, cheating, stealing, sexual acting out,
childish or infantile. They are self-centered, and excessive use of alcohol and/or other
narcissistic, and egocentric, and they expect a drugs.
great deal of attention and affection from oth- • High scorers on Scale 4 tend to be rebellious
ers. They often use indirect and devious toward authority figures and often are in
means to get the attention and affection they conflict with authorities. They often have
crave. When others do not respond appropri- stormy relationships with families, and fam-
ately, they may become hostile and resentful, ily members tend to blame others for their
but these feelings are likely to be denied and difficulties. Underachievement in school,
not expressed openly or directly. poor work history, and marital problems are
• High Scale 3 scorers tend to be emotionally also characteristic of high scorers.
involved, friendly, talkative, enthusiastic, • High scorers are highly impulsive persons
and alert. Although affectional and attention who strive for immediate gratification. They
needs drive them into social interactions, often do not plan their behavior, and they act
their relationships tend to be superficial and without considering the consequences. They
immature. They are involved with people are very impatient and have limited frustra-
primarily because of what they can get from tion tolerance. Their behavior may involve
them, rather than out of sincere interest. poor judgment and considerable risk taking.
• Because of their needs for acceptance and af- They tend not to profit from experiences and
fection, high scorers may initially be quite may find themselves in the same difficulties
enthusiastic about counseling and psy- repeatedly.
chotherapy. However, they may view them- • High scorers on Scale 4 are described by oth-
selves as having medical problems and want ers as immature and childish. They are nar-
to be treated medically. They are slow to gain cissistic, self-centered, selfish, and egocentric,
insight into underlying causes of their be- and their behavior often is ostentatious and
havior, and they resist psychological inter- exhibitionistic. They are insensitive to the
pretations. If therapists insist on examining needs and feelings of other people and are in-
psychological causes of symptoms, prema- terested in others in terms of how they can be
ture termination of therapy is likely. High used. Although they tend to be seen as likable
Scale 3 scorers may be willing to talk about and generally create good first impressions,
problems in their lives as long as they are not their relationships often are shallow and su-
conceptualized as causing or contributing to perficial. This may be due in part to rejection
their symptoms. These individuals often re- on the part of the people they mistreat, but it
spond well to direct advice and suggestion. also seems to reflect their inability to form
• When high Scale 3 scorers become involved warm attachments with others.
in therapy, they discuss worry about failure • High scorers often describe significant fam-
in school or work, marital unhappiness, lack ily problems. They may see their home envi-
of acceptance by their social groups, and ronments as unpleasant and family members
problems with authority figures. as unloving and unsupportive.
• In addition, high Scale 4 scorers typically are
extroverted and outgoing. They are talkative,
 31 • characteristics of high and low scores on the mmpi-2 scales 145

active, adventurous, energetic, and sponta- tivities to a greater extent than most men.
neous. They are viewed by others as intelli- • High scores on Scale 5 are uncommon among
gent and self-confident. Although they have women. When encountered, they generally
a wide range of interests and may become in- indicate rejection of traditional female roles.
volved in many activities, they lack definite Women with high Scale 5 scores are inter-
goals and clear direction. ested in sports, hobbies, and other activities
• High scorers tend to be hostile and aggres- that tend to be stereotypically more mascu-
sive. They are resentful, rebellious, antago- line than feminine, and they often are de-
nistic, and refractory. Their attitude is char- scribed as competitive and assertive.
acterized by sarcasm and cynicism. Often • Men who score low on Scale 5 are presenting
there does not appear to be any guilt associ- themselves as extremely masculine. They
ated with the aggressive behavior. Whereas have stereotypically masculine preferences
high scorers may feign guilt and remorse in work, hobbies, and other activities.
when their behaviors get them into trouble, • Women who score low on Scale 5 have many
such responses typically are short-lived, dis- stereotypically feminine interests. They are
appearing when the immediate crisis passes. likely to derive satisfaction from their roles
• Although high scorers typically are not seen as spouses and mothers. They may be tradi-
as being overwhelmed by emotional turmoil, tionally feminine or may have adopted a
at times they may admit feeling sad, fearful, more androgynous lifestyle.
or worried about the future. They may expe-
rience absence of deep emotional response,
which may produce feelings of emptiness and INTERPRETATION OF HIGH SCORES
boredom. Among psychiatric patients, high ON SCALE 6
scorers tend to receive personality disorder
diagnoses, with antisocial personality disor- • Persons whose Scale 6 T scores are above 70,
der or passive-aggressive personality disor- especially when Scale 6 also is the highest
der occurring most frequently. scale in the profile, may exhibit frankly psy-
• Because of their verbal facility, outgoing chotic behavior. Their thinking may be dis-
manner, and apparent intellectual resources, turbed, including delusions of persecution or
high scorers on Scale 4 are often perceived as grandeur. Ideas of reference also are common.
good candidates for psychotherapy or coun- These individuals may feel mistreated and
seling. Unfortunately, the prognosis for picked on; they may be angry and resentful;
change is poor. Although these individuals and they may harbor grudges. Projection is
may agree to treatment to avoid something a common defense mechanism. Among psy-
more unpleasant (e.g., jail or divorce), they chiatric patients, diagnoses of schizophrenia
generally are unable to accept responsibility or paranoid disorders are most frequent.
for their own problems and tend to terminate • When Scale 6 T scores range from 60 to 70,
treatment as soon as possible. In therapy blatant psychotic symptoms are not as com-
they often intellectualize excessively and mon. However, persons with scores within
blame others for their difficulties. this range are characterized by a variety of
traits and behaviors suggesting a paranoid
orientation. They tend to be excessively sen-
INTERPRETATION OF SCORES sitive and overly responsive to the opinions
ON SCALE 5 of others. They believe they are getting a raw
deal out of life and tend to rationalize and
• High scores (T > 60) for men on Scale 5 in- blame others for their difficulties. Also, they
dicate a lack of stereotypical masculine inter- are suspicious and guarded and commonly
ests. These individuals tend to have aesthetic exhibit hostility, resentment, and an argu-
and artistic interests and are likely to partic- mentative manner. They tend to be very
ipate in housekeeping and child-rearing ac- moralistic and rigid in their opinions and at-
146 part ii • psychological testing

titudes. Rationality is likely to be greatly act well socially. They are described as hard to
overemphasized. get to know, and they worry a great deal
• Prognosis for psychotherapy is poor because about popularity and social acceptance.
these people do not like to talk about emo- Other people see them as sentimental, peace-
tional problems and are likely to rationalize able, softhearted, trustful, sensitive, and kind.
most of the time. They have great difficulty Other adjectives used to describe them in-
in establishing rapport with therapists. In clude dependent, unassertive, and immature.
therapy, they are likely to reveal hostility • Some high scorers on Scale 7 express physi-
and resentment toward family members. cal complaints centering around the heart or
the gastrointestinal or genitourinary sys-
tem. Complaints of fatigue, exhaustion, in-
INTERPRETATION OF HIGH SCORES somnia, and bad dreams are common.
ON SCALE 7 • Although high scorers may be motivated to
seek therapy because they feel so uncomfort-
• Scale 7 is a good index of psychological tur- able and miserable, they are not very re-
moil and discomfort, with higher scorers ex- sponsive to brief psychotherapy or coun-
periencing greater turmoil. High scorers tend seling. In spite of some insight into their
to be very anxious, tense, and agitated. They problems, they tend to rationalize and intel-
worry a great deal, even over small prob- lectualize a great deal. They often are resis-
lems, and are fearful and apprehensive. They tant to interpretations and may express much
are high-strung and jumpy, report difficul- hostility toward the therapist. However, they
ties in concentrating, and often receive anxi- tend to remain in therapy longer than most
ety disorder diagnoses. patients and may show slow but steady
• High scorers tend to be highly introspective progress. Problems presented in therapy may
and sometimes report fears that they are los- include difficulties with authority figures,
ing their minds. Obsessive thinking, com- poor work or study habits, or concern about
pulsive and ritualistic behavior, and rumina- homosexual impulses.
tions, often centering around feelings of in-
security and inferiority, are common among
very high scorers. These persons lack self- INTERPRETATION OF HIGH SCORES
confidence; are self-critical, self-conscious, ON SCALE 8
and self-degrading; and are plagued by self-
doubts. They tend to be very rigid and • Although one should be cautious about as-
moralistic and to have high standards of be- signing a diagnosis of schizophrenia on the
havior and performance for themselves and basis of only the score on Scale 8, T scores in
others. They are likely to be quite perfec- a range of 75 –90 suggest the possibility of a
tionistic and conscientious, experiencing guilt psychotic disorder. Confusion, disorganiza-
feelings about not living up to their own tion, and disorientation may be present. Un-
standards or depression about falling short of usual thoughts or attitudes, perhaps even
goals. delusional in nature, hallucinations, and ex-
• In general, high scorers are neat, orderly, or- tremely poor judgment may be evident.
ganized, and meticulous. They are persistent • Extreme scores (T > 90) usually are not pro-
and reliable but lack ingenuity and original- duced by psychotic individuals; they more
ity in their approach to problems. They are likely indicate an individual in acute psycho-
seen by others as dull and formal and as hav- logical turmoil or a less disturbed person
ing great difficulty in making decisions. In who is endorsing many deviant items as a cry
addition, they are likely to distort the impor- for help. However, some recently hos-
tance of problems and to be overreactive in pitalized psychiatric patients obtain high
stressful situations. scores on Scale 8, accurately reflecting severe
• High scorers tend to be shy and do not inter- psychopathology.
 31 • characteristics of high and low scores on the mmpi-2 scales 147

• High scores on Scale 8 may suggest a longer than most patients and eventually
schizoid lifestyle. Such people tend to feel may come to trust the therapist. Medical
isolated, alienated, misunderstood, and unac- consultation to evaluate the appropriateness
cepted by their peers. They are withdrawn, of medication may be indicated.
reclusive, secretive, and inaccessible and may
avoid dealing with people and with new situ-
ations. They are described by others as shy, INTERPRETATION OF HIGH SCORES
aloof, and uninvolved. ON SCALE 9
• High scorers experience a great deal of appre-
hension and generalized anxiety, and they of- • Extreme elevations (T > 80) on Scale 9 may
ten report having bad dreams. They may feel suggest a bipolar (manic) disorder. Patients
sad or blue. They may feel very resentful, with such scores are likely to show excessive,
hostile, and aggressive, but they are unable purposeless activity and accelerated speech;
to express such feelings. A typical response they may have hallucinations and/or delu-
to stress is withdrawal into daydreams and sions of grandeur; and they are emotionally
fantasies, and some high scorers may have a labile. Some confusion may be present, and
difficult time separating reality and fantasy. flight of ideas is common.
• High scorers may be plagued by self-doubts. • Persons with more moderate elevations are
They feel inferior, incompetent, and dissatis- not likely to exhibit frank psychotic symp-
fied. They give up easily when confronted toms but have a tendency toward overactiv-
with problem situations. Sexual preoccupa- ity and unrealistic self-appraisal. They are
tion and sex role confusion are common. The energetic and talkative, and they prefer action
behavior of such persons often is character- to thought. They have a wide range of inter-
ized by others as nonconforming, unusual, ests and are likely to have many projects go-
unconventional, and eccentric. Physical com- ing at once. However, they do not use energy
plaints may be present, and these usually are wisely and often do not see projects through
vague and long-standing. to completion. They may be creative, enter-
• High scorers may at times be stubborn, prising, and ingenious, but they have little
moody, and opinionated. At other times they interest in routine or details. Such persons
are seen as generous, peaceable, and senti- become bored and restless easily and have
mental. Other adjectives used to describe low frustration tolerance. They have great
high scorers include immature, impulsive, difficulty inhibiting impulsivity, and periodic
adventurous, sharp-witted, conscientious, episodes of irritability, hostility, and aggres-
and high-strung. Although they may have a sive outbursts are common. Unrealistic and
wide range of interests and may be creative unqualified optimism is also characteristic of
and imaginative in approaching problems, high scorers. They seem to think that noth-
their goals generally are abstract and vague. ing is impossible, and they have grandiose
They seem to lack basic information required aspirations. They also have an exaggerated
for problem solving. appraisal of their own self-worth and self-
• It is important to consider the possibility that importance and are not able to see their own
high Scale-8 scores are reflecting the report- limitations. High scorers have a greater than
ing of unusual symptoms associated with average likelihood of using nonprescription
substance abuse or with medical disorders drugs and getting into trouble with the law.
such as epilepsy, stroke, or closed head in- • High scorers are very outgoing, sociable, and
jury. gregarious. They enjoy other people and gen-
• The prognosis for psychotherapy is not good erally create good first impressions. They im-
because of the long-standing nature of high press others as being friendly, pleasant, en-
scorers’ problems and their reluctance to re- thusiastic, poised, and self-confident. They
late in a meaningful way to the therapist. often try to dominate other people. Their re-
However, high scorers tend to stay in therapy lationships are usually quite superficial, and
148 part ii • psychological testing

as others get to know them better, they be- ventional, and unoriginal. They give up eas-
come aware of their manipulations, decep- ily and are somewhat rigid and inflexible in
tions, and unreliability. their attitudes and opinions. They also have
• In spite of an outward picture of confidence great difficulty in making even minor deci-
and poise, high scorers are likely to harbor sions. They seem to enjoy their work and get
feelings of dissatisfaction about what they pleasure from personal achievement.
are getting out of life. They may feel upset, • High scorers tend to worry, to be irritable,
tense, nervous, anxious, and agitated, and and to feel anxious. They are described by
they describe themselves as prone to worry. others as moody. Guilt feelings and episodes
Periodic episodes of depression may occur. of depression may occur. Such persons lack
• In psychotherapy, high scorers often report energy and do not have many interests.
negative feelings toward domineering par- • Low scorers on Scale 0 tend to be sociable and
ents, difficulties in school or at work, and a extroverted. They are outgoing, gregarious,
variety of delinquent behaviors. They resist friendly, and talkative. They have a strong
interpretations, are irregular in their atten- need to be around other people, and they mix
dance, and are likely to terminate therapy well socially. They are seen by others as ver-
prematurely. They engage in a great deal of bally fluent, expressive, active, energetic, and
intellectualization and may repeat problems vigorous. They are interested in power, sta-
in a stereotyped manner. They do not be- tus, and recognition, and they tend to seek
come dependent on the therapist, who may out competitive situations.
be a target for hostility and aggression. • Low scores on Scale 0 are indicative of per-
sons who are sociable, extroverted, outgoing,
gregarious, friendly, and talkative; who have
INTERPRETATION OF SCORES a strong need to be around other people; who
ON SCALE 0 mix well; and who are seen as expressive and
verbally fluent.
• The most salient characteristic of high scorers • Scores on Scale 0 are quite stable, even over
on Scale 0 is social introversion. These persons very long periods of time.
are very insecure and uncomfortable in social
situations, tending to be shy, reserved, timid, References & Readings
and retiring. They feel more comfortable
when alone or with a few close friends, and Butcher, J. N., Graham, J. R., Ben-Porath, Y. S., Tel-
legen, A., Dahlstrom, W. G., & Kaemmer, B.
they do not participate in many social activ-
(2001). Minnesota Multiphasic Personality
ities. They may be especially uncomfortable Inventory-2 (MMPI-2): Manual for adminis-
around members of the opposite sex. tration, scoring, and interpretation. Minneapo-
• High scorers lack self-confidence and tend to lis: University of Minnesota Press.
be self-effacing. They are hard to get to know Butcher, J. N., & Williams, C. L. (2000). Essentials
and may be described by others as cold and of MMPI-2 and MMPI-A interpretation. Min-
distant. They are sensitive to what others neapolis: University of Minnesota Press.
think of them and are likely to be troubled by Graham, J. R. (2000). MMPI-2: Assessing personal-
their lack of involvement with other people. ity and psychopathology (3rd ed.). New York:
They are overcontrolled and are unlikely to Oxford University Press.
display feelings directly. They are submis- Graham, J. R., Ben-Porath, Y. S., & McNulty, J. L.
(1997). Empirical correlates of low scores on
sive, compliant, and overly accepting of au-
MMPI-2 scales in an out-patient mental health
thority. setting. Psychological Assessment, 9, 386 –391.
• High scorers are also described as serious and Graham, J. R., Ben-Porath, Y. S., & McNulty, J. L.
having a slow personal tempo. Although (1999). MMPI-2 correlates for outpatient com-
they are reliable and dependable, their ap- munity mental health settings. Minneapolis:
proach to problems tends to be cautious, con- University of Minnesota Press.
 32 • empirical interpretation of the mmpi-2 codetypes 149

Graham J. R., & McCord, G. (1985). Interpretation Related Topics

of moderately elevated MMPI scores for nor-
Chapter 28, “Assessing MMPI-2 Profile Validity”
mal subjects. Journal of Personality Assess-
Chapter 29, “Clinical Scales of the MMPI-2”
ment, 49, 477 – 484.
Chapter 32, “Empirical Interpretation of the MMPI-
Greene, R. (2000). The MMPI-2: An interpretive
2 Codetypes”
manual (2nd ed.). Boston: Allyn and Bacon.
Keiller, S. W., & Graham, J. R. (1993). The meaning
of low scores on MMPI-2 clinical scales of nor-
mal subjects. Journal of Personality Assess-
ment, 61, 211–223.

EMPIRICAL INTERPRETATION
32 OF THE MMPI-2 CODETYPES

James N. Butcher

The Minnesota Multiphasic Personality Inven- of their predecessor (Butcher & Williams, 1992)
tory (MMPI) is the most widely researched and and have now replaced the original MMPI for
extensively used objective instrument in clinical assessment in mental health settings.
assessment (Butcher & Rouse, 1996; Lubin, Although portions of the test remained the
Larsen, & Matarazzo, 1984). Following its initial same, several changes were made during the re-
publication in 1940, the MMPI came to be em- vision, such as the omission of items with objec-
ployed across a wide variety of clinical, acade- tionable content and rewording of items that
mic, military, industrial, and forensic settings. were out of date. The traditional validity and clin-
The initial test developers, Hathaway and ical scales were retained for the revised versions
McKinley, followed an empirical scale construc- in order to maintain continuity with the original
tion strategy by finding items that separated MMPI— that is, L (Lie), F (Infrequency), K (De-
groups of individuals with known psychiatric fensiveness), 1 (Hypochondriasis), 2 (Depres-
problems, such as anxiety or depression, from sion), 3 (Hysteria), 4 (Psychopathic Deviate), 5
“normals” (Hathaway & McKinley, 1940). (Masculinity/Femininity), 6 (Paranoia), 7 (Psy-
The original MMPI underwent a substantial chasthenia), 8 (Schizophrenia), 9 (Mania), and 0
revision and redevelopment during the 1980s, (Social Introversion). In addition, a number of
and the MMPI-2 was published for use with new validity measures were developed for the re-
adults in 1989 and for adolescents (the MMPI- vised forms (i.e., True Response Inconsistency
A) in 1992. The modern versions of the instru- [TRIN] and Variable Response Inconsistency
ment were standardized on contemporary, rep- [VRIN]). In addition to the traditional clinical
resentative samples of individuals in the United scales, an important new set of scales, the MMPI-
States. The resulting instruments, with their 2 (Butcher, Graham, Williams, & Ben-Porath,
expanded range of scales, have demonstrated 1990) and MMPI-A content scales, was published
strong psychometric properties similar to those (Williams, Butcher, Ben-Porath, & Graham,
150 part ii • psychological testing

1992). These scales were derived according to a electronic computer (Butcher, 1995). Auto-
rational-empirical scale construction strategy to mated interpretation, that is, interpreting MMPI
provide several measures of specific clinical prob- profiles using actuarial tables, was initially
lems. shown by Meehl (1954) to be a more powerful
Since the MMPI-2 revision, there have been strategy than clinical interpretation. He con-
numerous studies to examine whether the ex- vincingly demonstrated that clinical predictions
tensive literature on the use of the original based on automatic combination of actuarial
MMPI can be generalized to the revised instru- data for MMPI codetypes were more accurate
ments (Archer, Griffin, & Aiduk, 1995). The than those based on “clinical” or intuitive in-
psychometric properties of the MMPI-2 and terpretation strategies.
MMPI-A scales have been found to be com- A number of empirical studies followed
parable to those of the clinical scales for the Meehl’s recommendations for developing an ac-
original MMPI. Test-retest coefficients were tuarial “cookbook” as an aid to stringent test in-
of a similar magnitude (Butcher, Dahlstrom, terpretation. The empirical research on MMPI
Graham, Tellegen, & Kaemmer, 1989). Results profile patterns that followed during the 1960s
from validity studies on the MMPI-2 and and 1970s has established a broad interpretive
MMPI-A to date have been very promising base for many of the common MMPI codetypes
(Ben-Porath, Butcher, & Graham, 1991; found in clinical settings (Gilberstadt & Duker,
Williams & Butcher, 1989a, 1989b). 1965; Marks, Seeman, & Haller, 1974). Meehl’s
The extensive objective information avail- compelling argument on the strength of the ac-
able for each of the MMPI-2 patterns makes in- tuarial method and the empirical demonstration
terpretation of the test relatively straightfor- that such mechanically generated predictions
ward. Empirical scale interpretation with the were highly accurate influenced a number of in-
MMPI-2 works as follows: An individual tak- vestigators to develop “actuarial tables” for per-
ing the MMPI-2 answers a series of true-false sonality description using MMPI scales and pro-
questions, which are scored according to objec- file codes.
tive rules. The scores are assigned T-score val- A codetype is defined by the highest elevated
ues on different scales (e.g., Scale 1 = Hypo- scale or groupings of clinical scales in the pro-
chondriasis; Scale 2 = Depression); profiles are file and their rank order in terms of elevation.
then drawn to allow for easy comparison to Most of the empirical research on MMPI code-
normals. When a new case is obtained with types has included only the basic clinical scales
profiles that resemble known patient groups, Hs, D, Hy, Pd, Pa, Pt, Sc, and Ma. Research-
that is, that match a particular prototype, the based behavioral descriptions associated with
empirical descriptors (referred to as scale corre- codetypes can be confidently applied to individ-
lates) are generated to provide an indication of uals whose profiles match the codetype. The
that individual’s psychological adjustment Single-Point Code, or “profile spike,” occurs
problems. That is, when a particular pattern is when a single clinical scale is elevated in the
obtained by an individual, the interpreter sim- critical range, that is, above a T score of 65. The
ply refers to the established behaviors and per- Two-Point Codetype, one of the most fre-
sonality factors established for it. These estab- quently researched profile codes, occurs when
lished behavior patterns can be automatically two clinical scales, such as D and Pt, are ele-
applied whenever the scores are obtained. vated above a T = 65. This codetype would be
The scale scores have been extensively re- defined as a two-point code of 2-7/7-2. The
searched, and a number of resources, known as Three-Point Code, prominent in several re-
codebooks or “cookbooks,” have accumulated search populations, occurs when three clinical
to provide a rich catalog of personality descrip- scales are elevated in the profile. For example,
tors that have been empirically shown to be as- clinical elevations on scales D, Pd, and Pt pro-
sociated with various scale patterns. This objec- duce a three-point code of 2-4-7, a profile type
tive strategy makes it possible for individual often found in drug and alcohol treatment pro-
test protocols to be effectively interpreted by grams. A few Four-Point Codes have been re-
 32 • empirical interpretation of the mmpi-2 codetypes 151

searched, for example, the 1-2-3-4 codetype in ported that the percentages of people with the
medical settings. same high-point, low-point, and two-point
Two general rules are followed to determine code showed only modest congruence on retest.
whether a particular profile pattern meets the re- They noted, however, that codetypes with more
quirements of a reliable codetype: First, the pro- extreme scores, and those that were well de-
file should be clearly defined; that is, if fined by a substantial point separation between
the profile code is at least five points greater than scale scores in the codetype from those not in-
the next scale in the profile, the codetype is likely cluded in the code, tended to be similar at retest.
to be the same on MMPI or on MMPI-2 norms The greatest codetype agreement at retest was
and likely to be a good prototypal match. In gen- obtained for profiles having a 10-point T-score
eral, Graham, Smith, and Schwartz (1986) rec- spread between the codetype. However, high
ommend exercising caution in applying tradi- congruence was obtained at retest if the code-
tional MMPI behavioral correlates for a given type was even 5 points higher than the next
codetype if the MMPI profile does not possess scale in the profile.
clear codetype definition or a clear elevation
above the next scale in the profile. Graham, Tim-
brook, Ben-Porath, and Butcher (1991) demon- ILLUSTRATION OF THE 2-7/7-2
strated that MMPI-2 codes were quite congruent PROFILE CODE
with MMPI profile codes when codetype defini-
tion was maintained. Over 90% of the profiles The 2-7/7-2 profile code is defined by having
with a five-point profile code definition will have two scales (Scale 2, or Depression, and Scale 7,
the same codetype on MMPI-2 as with the orig- or Psychasthenia) elevated above a T score of 65
inal MMPI. Second, when there has been suffi- and appearing as the highest two clinical scales
cient research on the behavioral descriptions for in the profile. The following summary would
the code (e.g., 2-7-8 codetype), there would likely likely be found to apply with the client produc-
be a sufficient empirical base to provide reliable ing the 2-7/7-2 code:
information about the client. If a codetype is an
infrequent one (with a relatively small database Symptomatic Pattern
such as with the 2-9/9-2 profile code), then a Individuals with this profile code appear anxious,
scale-by-scale interpretation strategy should be tense, nervous, and depressed. They report feeling
followed. With the MMPI-2, as with the original unhappy and sad and tend to worry to excess. They
MMPI, empirical descriptors are sparse for some feel vulnerable to real and imagined threat and typ-
codetypes. Not enough codetypes have been em- ically anticipate problems before they occur — often
pirically studied and described across a broad overreacting to minor stress as though it is a major
range of settings to classify the range of profiles catastrophe. They usually report somatic symptoms
that clinicians can obtain. such as fatigue, exhaustion, tiredness, weight loss,
How likely are MMPI-2 profile codes to re- slow personal tempo, slowed speech, and retarded
main stable over time, for example, if the client thought processes. They tend to brood and ruminate
is retested at a later date? First, as a general a great deal.
rule, MMPI scales tend to have high test-retest These persons may have high expectations for
stability. Test-retest correlations for various themselves and others and show a strong need for
groups have been reported to range from mod- achievement and recognition for accomplishments.
erate to high, depending on the population They may feel guilty when their goals are not met.
studied and the retest interval. Even test-retest These individuals typically have perfectionistic atti-
correlations over very long intervals, for exam- tudes and a conscientious life history. They may be
ple, over 30 years (Leon, Gillum, Gillum, & excessively religious or extremely moralistic.
Gouze, 1979), are quite high, with some scales
(i.e., Si) showing correlations as high as .73. Personality Characteristics
Several studies of MMPI profile stability Individuals with this pattern appear docile and
have been conducted. Graham et al. (1986) re- passive-dependent in relationships. They report prob-
152 part ii • psychological testing

lems in being assertive. They usually show a capacity Journal of Personality Assessment, 65, 391–
for forming deep, emotional ties and tend to lean on 408.
people to an excessive degree. They tend to solicit nur- Ben-Porath, Y. S., Butcher, J. N., & Graham, J. R.
turance from others. Feelings of inadequacy, insecurity, (1991). Contribution of the MMPI-2 scales to
and inferiority are long term issues. They tend to be the differential diagnosis of schizophrenia and
major depression. Psychological Assessment: A
intropunitive in dealing with feelings of aggression.
Journal of Consulting and Clinical Psychology,
3, 634 – 640.
Predictions and Dispositions
Butcher, J. N. (1995). Clinical use of computer-based
Individuals with this profile code are usually diag-
personality test reports. In J. N. Butcher (Ed.),
nosed as depressive, obsessive-compulsive, or anxi- Clinical personality assessment: Practical ap-
ety disordered. They are usually motivated for psy- proaches. New York: Oxford University Press.
chotherapy and tend to remain in therapy longer Butcher, J. N. (Ed.). (1996). International adapta-
than other patients. They tend to be somewhat pes- tions of the MMPI-2: Research and clinical ap-
simistic about overcoming problems and are indeci- plications. Minneapolis: University of Min-
sive and rigid in their thinking. This negative mind nesota Press.
set is likely to interfere with their problem-solving Butcher, J. N., Berah, E., Ellertsen, B., Miach, P.,
ability. However, they usually improve in treat- Lim, J., Nezami, E., et al. (1998). Objective per-
ment. (Butcher & Williams, 1992) sonality assessment: Computer-based MMPI-2
interpretation in international clinical settings.
The empirically based MMPI-2 correlates In C. Belar (Ed.), Comprehensive clinical psy-
chology: Sociocultural and individual differ-
have considerable robustness when applied to
ences. New York: Elsevier.
new samples—even across other languages and
Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tel-
cultural groups. The MMPI-2, if adapted care- legen, A., & Kaemmer, B. (1989). Minnesota
fully to new cultures, can provide important in- Multiphasic Personality Inventory-2 (MMPI-
formation on psychopathology about patients 2): Manual for administration and scoring.
in diverse clinical settings. The MMPI-2 ap- Minneapolis: University of Minnesota Press.
pears to work similarly in a wide variety of Butcher, J. N., Graham, J. R., Williams, C. L., &
countries. The original MMPI was widely trans- Ben-Porath, Y. S. (1990). Development and use
lated, with over 140 translations in 46 countries of the MMPI-2 content scales. Minneapolis:
(Butcher & Pancheri, 1976), and the MMPI-2 University of Minnesota Press.
has undergone a number of foreign-language Butcher, J. N., & Pancheri, P. (1976). Handbook of
translations since it was published in 1989. cross-national MMPI research. Minneapolis:
University of Minnesota Press.
Butcher (1996) conducted an extensive cross-
Butcher, J. N., & Rouse, S. V. (1996). Personality: In-
national MMPI-2 research program detailing
dividual differences and clinical assessment.
the clinical and research use of the MMPI-2 Annual Review of Psychology, 47, 87 –111.
across a large number of countries. Butcher, J. N., & Williams, C. L. (1992). Essentials
The MMPI-2 empirical descriptors apply of MMPI-2 and MMPI-A interpretation. Min-
well across international boundaries even when neapolis: University of Minnesota Press.
applied by an electronic computer. A recent Butcher, J. N., Williams, C. L., Graham, J. R.,
study by Butcher et al. (1998) found that pa- Archer, R. P., Tellegen, A., & Ben-Porath, Y.
tients from several countries were described (1992). MMPI-A (Minnesota Multiphasic Per-
with a high degree of accuracy by computer- sonality Inventory-Adolescent): Manual for
based reports generated from U.S. norms and administration, scoring, and interpretation.
descriptors derived from American based re- Minneapolis: University of Minnesota Press.
Gilberstadt, H., & Duker, J. (1965). A handbook for
search. This research provided support for the
clinical and actuarial MMPI interpretation.
generalization validity of MMPI-2 correlates in
Philadelphia: Saunders.
cross-cultural contexts. Graham, J. R., Smith, R., & Schwartz, G. (1986).
Stability of MMPI configurations for psychi-
References & Readings atric inpatients. Journal of Consulting and
Archer, R. P., Griffin, R., & Aiduk, R. (1995). Clini- Clinical Psychology, 54, 375 –380.
cal correlates for ten common code types. Graham, J. R., Timbrook, R., Ben-Porath, Y. S., &
 33 • millon clinical multiaxial inventory (mcmi-iii) 153

Butcher, J. N. (1991). Code-type congruence Williams, C. L., & Butcher, J. N. (1989a). An MMPI
between MMPI and MMPI-2: Separating fact study of adolescents: I. Empirical validity of the
from artifact. Journal of Personality Assess- standard scales. Psychological Assessment: A
ment, 57, 205 –215. Journal of Consulting and Clinical Psychology,
Hathaway, S. R., & McKinley, J. C. (1940). A multi- 1, 251–259.
phasic personality schedule (Minnesota) I: Williams, C. L., & Butcher, J. N. (1989b). An MMPI
Construction of the schedule. Journal of Psy- study of adolescents: II. Verification and limita-
chology, 10, 249 –254. tions of code type classification. Psychological
Leon, G., Gillum, B., Gillum, R., & Gouze, M. (1979). Assessment: A Journal of Consulting and Clin-
Personality stability and change over a thirty- ical Psychology, 1, 260 –265.
year period: Middle age to old age. Journal of Con- Williams, C. L., Butcher, J. N., Ben-Porath, Y. S., &
sulting and Clinical Psychology, 47, 517 – 524. Graham, J. R. (1992). MMPI-A content scales:
Lubin, B., Larsen, R. M., & Matarazzo, J. (1984). Assessing psychopathology in adolescents. Min-
Patterns of psychological test usage in the neapolis: University of Minnesota Press.
United States, 1935 –1982. American Psychol-
ogist, 39, 451– 454.
Related Topics
Marks, P. A., Seeman, W., & Haller, D. L. (1974). The
actuarial use of the MMPI with adolescents Chapter 28, “Assessing MMPI-2 Profile Validity”
and adults. Baltimore: Williams and Wilkins. Chapter 29, “Clinical Scales of the MMPI-2”
Meehl, P. E. (1954). Clinical versus statistical pre- Chapter 31, “Characteristics of High and Low
diction: A theoretical analysis and a review of Scores on the MMPI-2 Clinical Scales”
the evidence. Minneapolis: University of Min-
nesota Press.

MILLON CLINICAL MULTIAXIAL

33 INVENTORY (MCMI-III)

Theodore Millon & Seth D. Grossman

Diagnostic instruments are most useful when the MCMI-III (Millon, 1997; Millon, Millon,
developed on the basis of a comprehensive the- & Davis, 1994) shows an incremental increase
ory of psychopathology and coordinated with over that of the MCMI-II (Davis, Wenger, &
a recognized diagnostic system. Both the Mil- Guzman, 1997). Few diagnostic instruments
lon Clinical Multiaxial Inventory’s (MCMI) currently available are as fully consonant as the
Personality Disorder (Axis II) and Clinical Syn- MCMI-III with the nosological format and con-
drome (Axis I) categories meet these criteria. In ceptual terminology of the DSM-IV.
the MCMI-III, further parallelism has been
achieved by rephrasing major criteria of the
fourth-edition Diagnostic and Statistical Man- DESCRIPTION
ual of Mental Disorders (DSM-IV) constructs
and validating these items in the self-report The inventory itself consists of 24 clinical
mode. Accordingly, the diagnostic efficiency of scales (presented as a profile in Table 1) and 3
154 part ii • psychological testing

table 1. Sample Profile Illustrating the Structure and Scales of the MCMI-III

Score Profile of BR Scores

Category Raw BR 0 60 75 85 115 Diagnostic Scales

Modifying indices X 135 79 Disclosure

Y 18 84 Desirability
Z 7 56 Debasement
Clinical personality 1 7 63 Schizoid
patterns 2A 6 69 Avoidant
2B 3 55 Depressive
3 7 60 Dependent
4 22 68 Histrionic
5 27 103 Narcissistic
6A 20 88 Antisocial
6B 21 85 Aggressive (sadistic)
7 10 34 Compulsive
8A 17 80 Negativistic
8B 1 15 Masochistic
Severe personality S 2 37 Schizotypal
pathology C 11 69 Borderline
P 9 63 Paranoid
Clinical syndromes A 3 57 Anxiety disorder
H 2 57 Somatoform disorder
N 6 59 Bipolar manic disorder
D 3 57 Dysthymic disorder
B 17 99 Alcohol dependence
T 12 70 Drug dependence
R 2 27 Posttraumatic stress
Severe syndromes SS 2 27 Thought disorder
CC 1 17 Major depression
PP 3 60 Delusion disorder

“modifier” scales. The purpose of these first Development of the Millon inventories has
three indices, Disclosure, Desirability, and De- been informed by several post-MMPI psycho-
basement (X, Y, and Z), is to identify distorting metric developments. When the MCMI was
tendencies in clients’ responses. The next two initially constructed, all item selections were
sections constitute the basic personality disor- based on target diagnostic groups contrasted
der scales, reflecting Axis II of the DSM. The with representative, but undifferentiated, psy-
first section (1–8B) appraises the moderately se- chiatric patients (rather than normals), thus in-
vere personality pathologies, ranging from the creasing differential diagnostic efficiency. Item
Schizoid to the Self-Defeating (masochistic) selection and scale development for both older
scales; the second section (scales S, C, and P) and more recent forms progressed through
represents more severe personality pathologies: three sequential validation stages (Loevinger,
the Schizotypal, Borderline, and Paranoid. The 1957): theoretical-substantive, internal-struc-
following two sections cover several of the more tural, and external-criterion. Such an approach
prevalent Axis I disorders, ranging from the builds validity into the instrument from the be-
moderate clinical syndromes (scales A to T) to ginning, upholding standards of developers
those of greater severity (scales SS, CC, and PP). committed to diverse construction and valida-
The division between personality and clinical tion methods (Hase & Goldberg, 1967). The re-
disorder scales parallels the multiaxial model sulting scales are theoretically, statistically, and
and has important interpretive implications. empirically valid. Because each item must sur-
 33 • millon clinical multiaxial inventory (mcmi-iii) 155

vive each stage of refinement, the chance that the concept, it is usually intended to support the
any item will prove “rationally surprising,” continued use of T scores. However, as noted
“structurally unsound,” or “empirically indis- earlier, the base rate scores of the MCMI are in-
criminant” is greatly diminished. The final tended to remedy the global base rate assump-
MCMI-III items are weighted either 2 points or tions made in the use of T scores. Thus, while
1 point, depending on the extent to which they the prevalence rates of some disorders in partic-
fulfill this tripartite logic: centrality to their re- ular clinical settings may differ from the base
spective constructs, relation to other items on rates assumed by the MCMI and in the use of T
the same scale, and external validity. As might scores, the MCMI’s base rate scores at least do
be expected, the likelihood of instrument gen- not implicitly assume the prevalence rates of all
eralizability is greatly increased by such an ap- disorders to be equal. More frequently, the dis-
proach to instrument construction. tinction between local and global prevalence
Actuarial base rate transformations were rates is made in support of the base rate concept
used as the final measure of pathology. These by clinicians who realize its importance in im-
not only provide a basis for selecting optimal proving diagnostic efficiency, that is, positive
differential diagnostic cutting lines but also help and negative predictive power, sensitivity, and
ensure that the frequencies of MCMI- specificity. These clinicians, far from reverting
generated diagnoses and profile patterns are back to T scores, often wish to optimize the base
comparable to representative clinical prevalence rate scores for their particular setting.
rates. Although the use of base rate scores has
been one of the most widely misunderstood as-
pects of the MCMI, their utility is easily under- USES, SETTINGS, AND LIMITATIONS
stood intuitively when contrasted with the more
familiar T score. On the MMPI, for example, T The primary purpose of the MCMI is to pro-
scores of 65 and above indicate pathology, with vide information to clinicians — psychologists,
roughly equal numbers of patients scoring counselors, psychiatrists, and social workers—
above this threshold. Clinical experience, how- who must make assessments and treatment de-
ever, shows the number of depressed patients, cisions about persons with emotional and inter-
for example, to be greater than the number of personal difficulties. Because of the simplicity
patients with a thought disorder. Base rate of administration and the availability of hand-
scores are constructed to reflect these clinical re- scoring and rapid computer-scoring and inter-
alities, to yield more depressives than delusional pretive procedures, the MCMI can be used on
patients, more borderlines and antisocials than a routine basis in outpatient clinics, community
schizoids, and so on, rather than to assume their agencies, mental health centers, college coun-
numbers to be equal. In the construction of the seling programs, general and mental hospitals,
MCMI, target prevalence rates were set accord- correctional institutions (for which there is a
ing to reviews of epidemiological data, estimates special interpretive report), forensic settings,
derived from clinicians who participated in the and courts, as well as in general independent
development project, and the senior author’s practice offices. Individual scale-cutting lines
own expert judgment. Thus, if it was deemed can be used to make decisions concerning per-
that 8% of patients are most likely to resemble sonality disorders or clinical syndrome diag-
the schizoid prototype, then the lookup table for noses. Similarly, elevation levels among subsets
this personality was constructed so schizoid was of scales can furnish grounds for judgments
the highest personality elevation for 8% of the about impairment, severity, and chronicity of
patients in the normative sample. pathology. More comprehensive and dynamic
A discussion of base rate scores often leads interpretations of relationships among sympto-
to considerations of local versus global base matology, coping behavior, interpersonal style,
rates, that is, the fact that the prevalence rates and personality structure may be derived from
for different disorders vary somewhat by clin- an examination of the configural pattern of the
ical setting. When this is raised in criticism of clinical scales.
156 part ii • psychological testing

The MCMI-III, however, is not a general INTERPRETATION

personality instrument to be used for “normal”
populations. To administer the MCMI to a Clinicians interpreting the MCMI should bear
wider range of problems or class of participants, in mind that the richness and accuracy of all
such as those found in business and industry, or self-report measures are enhanced when their
to use it to identify neurological lesions or for findings are viewed in the context of other clin-
the assessment of general personality traits ical sources and data, such as demographic
among college students is to apply the instru- background, biographical history, and other
ment to settings and samples for which it is nei- clinical features. The personality and clinical
ther intended nor appropriate. features characterizing each of the separate
The MCMI is frequently used in research. scales should be reviewed before analyzing pro-
Upwards of 650 publications to date have in- file configurations. Configural interpretation is
cluded or focused primarily on the MCMI, with a deductive synthesis achieved by refining,
some 60 or so new references currently pub- blending, and integrating the separate charac-
lished annually (a list of these references can be teristics tapped by each scale. The accuracy of
obtained from National Computer Systems, at- such interpretations depends on the meaning
tention: Christine Herdes). A series of special and significance of the individual scales com-
grants for conducting research using the posing the profile. Such an interpretive pro-
MCMI-III is currently available from National cedure seeks to break the pattern of labeling
Computer Systems. Those interested should patients and fitting them into Procrustean cate-
also request Doing Publishable Research With gories. Information concerning sex, age, socioe-
the MCMI (Hsu & Maruish, 1993) for helpful conomic class, mental status observations, and
suggestions. interviews should all be used to provide a per-
spective for assessing the MCMI profile.
A basic separation should be made in the ini-
ADMINISTRATION AND SCORING tial phase of interpretation between those scales
pertaining to the basic clinical personality pat-
A principal goal in constructing the MCMI was tern (1– 8B), those pointing to the presence of
to keep the total number of items small enough severe Axis II personality pathology (S, C, and
to encourage use in diverse diagnostic and P), those signifying moderate Axis I clinical
treatment settings yet large enough to permit syndromes (A–R), and those indicating a severe
the assessment of a wide range of clinically rel- clinical state (SS, CC, and PP). Each section of
evant behaviors. At 175 items, the final form is the profile reflects different and important di-
much shorter than comparable instruments. mensions of the clinical picture. Therefore, the
Potentially objectionable items have been clinician should begin by dividing the profile
screened out, with terminology geared to an into a series of subsections, focusing first on the
eighth-grade reading level. Most clients can significance of scale elevations and profile pat-
complete the MCMI in 20 –30 minutes, thereby terns within each section. Once this is com-
minimizing client resistance and fatigue. pleted, the clinician can proceed with the step of
Administration follows a procedure similar integrating each subsection.
to that of most self-report inventories. Test di- The theoretical framework and clinical char-
rections, a patient information chart, an iden- acterizations associated with each personality
tification grid, and special coding sections for style are available in Modern Psychopathology
clinicians are printed on the front page. No spe- (Millon, 1969/1983), Toward a New Personol-
cial conditions or instructions are required to ogy: An Evolutionary Model (Millon, 1990),
achieve reliable results beyond those printed on and Disorders of Personality: DSM-IV and Be-
the test booklet itself. Answer choices (true and yond (Millon & Davis, 1996). Several synopses
false) are printed next to each of the 175 item of the various personality styles that serve as
statements. This increases the accuracy of pa- useful aids to interpretation are included in
tient markings and allows the clinician to scan these works. In each of these, the characteristics
individual item responses. of personality have been usefully organized in
 33 • millon clinical multiaxial inventory (mcmi-iii) 157

table 2. Domain Descriptors for the Narcissistic Personality

Behavioral Level
(F) Expressively Haughty (e.g., acts in an arrogant, supercilious, pompous, and disdainful manner, flouting conven-
tional rules of shared social living, viewing them as naive or inapplicable to self; reveals a careless disregard for
personal integrity and a self-important indifference to the rights of others)
(F) Interpersonally Exploitive (e.g., feels entitled, is unempathic, and expects special favors without assuming recipro-
cal responsibilities; shamelessly takes others for granted and uses them to enhance self and indulge desires)

Phenomenological Level
(F) Cognitively Expansive (e.g., has an undisciplined imagination and exhibits a preoccupation with immature and
self-glorifying fantasies of success, beauty, or love; is minimally constrained by objective reality, takes liberties
with facts, and often lies to redeem self-illusions)
(S) Admirable Self-Image (e.g., believes self to be meritorious, special, if not unique, deserving of great admiration,
and acting in a grandiose or self-assured manner, often without commensurate achievements; has a sense of high
self-worth, despite being seen by others as egotistic, inconsiderate, and arrogant)
(S) Contrived Objects (e.g., internalized representations are composed far more than usual of illusory and changing
memories of past relationships; unacceptable drives and conflicts are readily refashioned as the need arises, as are
others often stimulated and pretentious)

Intrapsychic Level
(F) Rationalization Mechanism (e.g., is self-deceptive and facile in devising plausible reasons to justify self-centered
and socially inconsiderate behaviors; offers alibis to place oneself in the best possible light, despite evident short-
comings or failures)
(S) Spurious Organization (e.g., morphologic structures underlying coping and defensive strategies tend to be flimsy
and transparent, appear more substantial and dynamically orchestrated than they are in fact, regulating impulses
only marginally, channeling needs with minimal restraint, and creating an inner world in which conflicts are dis-
missed; failures are quickly redeemed and self-pride is effortlessly reasserted)

Biophysical Level
(S) Insouciant Mood (e.g., manifests a general air of nonchalance, imperturbability, and feigned tranquility; appears
coolly unimpressionable or buoyantly optimistic, except when narcissistic confidence is shaken, at which time ei-
ther rage, shame, or emptiness is briefly displayed)

a manner similar to distinctions drawn in the Table 2 presents domain descriptors for the
biological realm, that is, by dividing them into Narcissistic personality. A more complete set of
structural and functional attributes. Functional descriptors is available in the above sources and
characteristics represent dynamic processes in the MCMI-III manual. A series of content
that transpire within the intrapsychic world scales has recently been derived on the basis of
and between the individual’s self and psy- theoretical and factional studies (Grossman,
chosocial environment. They represent “ex- 2003). For example, the Schizoid scale turns out
pressive modes of regulatory action.” Struc- to be composed of three broad factors, namely
tural attributes represent a deeply embedded “social isolation,” “cognitive vagueness,” and
and relatively enduring template of imprinted “emotional flatness.” The Negativistic or
memories, attitudes, needs, fears, conflicts, and Passive-Aggressive scale also is made up of
so on, which guide experience and transform three content sub-scales namely “contradictory
the nature of perceived events. These domains feelings,” “resentful discontent,” and “prob-
are further differentiated according to their re- lematic outlook.” Another example, the Bor-
spective data level, either biophysical, intrapsy- derline scale, is composed of content scales that
chic, phenomenological, or behavioral, reflect- are described as “affective instability,” “iden-
ing the four historical approaches that charac- tity difficulties,” and “desperate impulsivity.”
terize the study of psychopathology, namely, Similarly, the three content scales comprising
the biological, the psychoanalytic, the cogni- the Schizotypal personality are labeled “social
tive, and the behavioral. awkwardness,” “paranoid-like ideation,” and
158 part ii • psychological testing

“dysfunctional cognition.” All MCMI person- is, to those displaying psychic disturbances in
ality scales are included in these recent clinical the midranges of severity rather than those
and factional studies; they will be included as whose difficulties are either close to “normal”
facets in future Interpretive Reports. In addi- (e.g., workers’ compensation litigants, spouses
tion, Disorders of Personality presents new of patients) or of marked clinical severity (e.g.,
adult subtypes for each of the various personal- acute psychotics, chronic schizophrenics). Ac-
ity disorders. These descriptions form more cordingly, narrative analyses of patients experi-
specific prototypes against which real patients encing ordinary life difficulties or minor ad-
can be compared. justment disorders will tend to be construed as
In addition to undertaking interpretation’s on more troubled than they are; conversely, analy-
one’s own, the Microtest Q program (available ses of the most serious pathologies will often be
from National Computer Systems, attention: construed as less severe than they are.
Christine Herdes) is available for generating
rapid and convenient MCMI narratives. These
integrate both the personological and sympto- CONCLUSION
matic features of the patient; the final report is
arranged in a style similar to those prepared by Within the limitations of the self-report mode
clinical psychologists. As the report is gener- and the inherent restrictions of psychometric
ated, data are drawn from both scale score ele- technology, all steps were taken to maximize
vations and profile configurations and are based the MCMI-III’s concordance with its generative
on both actuarial research findings and the theory and the official DSM classification sys-
MCMI’s theoretical schema (Millon, 1969/ tem. Pragmatic and philosophical compromises
1983, 1986a, 1986b, 1990; Millon et al., 1994; were made where valued objectives could not be
Millon & Davis, 1996), as well as the DSM-IV. simultaneously achieved— instrument brevity
Following current psychodiagnostic thinking, versus item independence, representative na-
the Interpretive Report focuses on a multiaxial tional patient norms versus local base rate
framework of assessment and summarizes find- specificity, theoretical criterion considerations
ings along its several axes: clinical syndrome, versus empirical data. As was the case with its
personality disorder, psychosocial stressors, and forebears, the MCMI-III is not cast in stone. It
therapeutic implications. The latter section has is and will remain an evolving assessment in-
been greatly expanded specifically for the strument, upgraded and refined to reflect sub-
MCMI-III. These reports prove highly accurate stantive advances in knowledge, be it from the-
in about 55 –65% of cases; are appraised as both ory, research, or clinical experience.
useful and generally valid, but with partial mis-
judgments, in about another 25 –30% of cases; References & Readings
and seem off target or appreciably in error about
Butcher, J. N. (Ed.) (1972). Objective personality as-
10 –15% of the time. These positive figures are
sessment. New York: Academic Press.
in the quantitative range of 5 – 6 times greater
Choca, J. P., Shanley, L. A., & Van Denburg, E.
than are random diagnostic assignments or (1992). Interpretive guide to the Millon Clini-
chance (Millon, 1987). Note, however, that the cal Multiaxial Inventory. Washington, DC:
report is intended to serve as a rich source of American Psychological Association.
clinical hypotheses. What is selected, rejected, Davis, R. D., & Millon, T. (1993). Putting Humpty
emphasized, or de-emphasized in the final Dumpty back together again: The MCMI in
analysis depends on the individual case and the personality assessment. In L. Beutler (Ed.), In-
user’s experience and judgment. As noted by tegrative personality assessment (pp. 240 –
Wetzler and Marlowe (1992), “The test is only 279). New York: Guilford Press.
as good as its user” (p. 428). A more basic Pro- Davis, R. D., Wenger, A., & Guzman, A. (1997). Di-
agnostic efficiency of the MCMI-III. In T. Mil-
file Report is also available.
lon (Ed.), The Millon inventories. New York:
The MCMI’s diagnostic scale cutoffs and Guilford Press.
profile interpretations are oriented to the ma- Grossman, S. D. (2003). Theoretically and factori-
jority of patients who take the inventory, that ally derived content scales for the MCMI-III.
 34 • millon adolescent clinical inventory (maci) 159

Unpublished doctoral dissertation, Carlos Al- Millon, T. (1987). Millon Clinical Multiaxial Inven-
bezo University, Miami, FL. tory-II manual. Minneapolis, MN: National
Hase, H. D., & Goldberg, L. R. (1967). Comparative Computer Systems.
validity of different strategies of constructing Millon, T. (1990). Toward a new personology: An evo-
personality inventory scales. Psychological lutionary model. New York: Wiley-Interscience.
Bulletin, 67, 231–248. Millon, T. (Ed.). (1997). The Millon inventories:
Hsu, F., & Maruish, M. (1993). Doing publishable Contemporary clinical and personality assess-
research with the MCMI. Minneapolis, MN: ment. New York: Guilford Press.
National Computer Systems. Millon, T., (with Davis, R. D.). (1996). Disorders of
Loevinger, J. (1957). Objective tests as instruments personality: DSM-IV and beyond. New York:
of psychological theory. Psychological Reports, Wiley-Interscience.
3, 635 –694. Millon, T., Millon, C., & Davis, R. D. (1994). Millon
McCann, J. T., & Dyer, F. J. (1996). Forensic assess- Clinical Multiaxial Inventory-III manual. Min-
ment with the Millon inventories. New York: neapolis, MN: National Computer Systems.
Guilford Press. Rosen, A. (1962). Development of the MMPI
Millon, T. (1983). Modern psychopathology: A scales based on a reference group of psychi-
biosocial approach to maladaptive learning atric patients. Psychological Monographs, 76,
and functioning. Prospect Heights, IL: Wave- 527.
land Press. (Original work published 1969.) Wetzler, S., & Marlowe, D. (1992). What they don’t
Millon, T. (1986a). Personality prototypes and their di- tell you in the test manual: A response to Mil-
agnostic criteria. In T. Millon & G. Klerman (Eds.), lon. Journal of Counseling and Development,
Contemporary directions in psychopathology: 70, 427 – 428.
Toward the DSM-IV. New York: Guilford Press.
Millon, T. (1986b). A theoretical derivation of
Related Topic
pathological personalities. In T. Millon & G.
Klerman (Eds.), Contemporary directions in Chapter 34, “Millon Adolescent Clinical Inventory
psychopathology: Toward the DSM-IV. New (MACI)”
York: Guilford Press.

MILLON ADOLESCENT CLINICAL

34 INVENTORY (MACI)

Theodore Millon & Seth D. Grossman

The Millon Adolescent Clinical Inventory and reports scale changes from the MAPI to the
(MACI; Millon, Millon, & Davis, 1993) is an MACI. The MACI and its forerunners were de-
expansion of the earlier Millon Adolescent Per- veloped in consultation with psychiatrists, psy-
sonality Inventory (MAPI; Millon, Green, & chologists, and other mental health profession-
Meagher, 1982). It is a 160-item, 31-scale, self- als who work with adolescents, and they reflect
report inventory designed specifically for as- issues most relevant to understanding adoles-
sessing clinically troubled adolescent personal- cents’ behavior and concerns. The MACI was
ities, their typical areas of concern, and Axis I developed primarily for use in clinical, residen-
clinical syndromes. Table 1 lists the MACI scales tial, and correctional settings. The Expressed
160 part ii • psychological testing

table 1. A Comparison of MACI and MAPI Scales

MACI MAPI

Personality Scales
1. Introversive (schizoid) 1. Introversive (schizoid)
2A. Inhibited (avoidant) 2. Inhibited (avoidant)
2B. Doleful (depressive)
3. Cooperative (dependent) 3. Cooperative (dependent)
4. Sociable (histrionic) 4. Sociable (histrionic)
5. Confident (narcissistic) 5. Confident (narcissistic)
6A. Unruly (antisocial) 6. Unruly (antisocial)
6B. Forceful (sadistic)
7. Respectful (compulsive) 7. Respectful (compulsive)
8A. Negative (negativistic)
8B. Sensitive (self-defeating) 8. Sensitive (self-defeating)
9. Borderline tendency

Expressed Concerns
A. Identify diffusion A. Self-concept
B. Self-devaluation B. Personal esteem
C. Body disapproval C. Body comfort
D. Sexual discomfort D. Sexual acceptance
E. Peer insecurity E. Peer security
F. Social insensitivity F. Social tolerance
G. Family discord G. Family rapport
H. Childhood abuse
H. Academic confidence

Clinical Indices and Behavioral Correlates

AA. Eating dysfunctions
BB. Substance abuse proneness
CC. Delinquent predisposition TT. Societal conformity
DD. Impulsive propensity SS. Impulsive control
EE. Anxious feelings
FF. Depressive affect
GG. Suicidal tendency
UU. Scholastic achievement
WW. Attendance consistency

Concerns scales of the MACI assess teenagers’ (NCS) in 1982. The MAI and the MAPI were
attitudes regarding significant developmental identical in item content but differed in their
problems, while the Personality Patterns and norms and intended purposes. The MAPI was
Clinical Syndromes scales reflect significant ar- subsequently divided into two forms. The
eas of pathological feelings, thoughts, and be- MAPI-Clinical was designed to aid mental
havior that require professional attention. health workers in assessing adolescent difficul-
ties among youngsters who were in a diagnos-
tic or treatment setting at the time of testing;
HISTORICAL DEVELOPMENT the MAPI-Guidance was designed for school
settings, primarily to help counselors better
The original Millon Adolescent Inventory understand adolescent personalities and to iden-
(MAI) was developed in 1974. The MAI served tify students who might benefit from further
as the forerunner to the MAPI, first published psychological evaluations.
and distributed by National Computer Systems The decision to develop a purely clinical refer-
 34 • millon adolescent clinical inventory (maci) 161

ence group with appropriate, comparison norms The MACI is available in two paper-and-
served as the impetus for development of the pencil formats, one for hand scoring and one for
MACI. The MAPI-C, useful as it was for diag- computer scoring. Hand-scoring materials in-
nostic assessment, was not sufficiently broad- clude a reusable test booklet and a separate an-
based to encompass the full range of clinical swer sheet. For computer scoring, there is a
populations. There was also clearly a need to combination test booklet and answer sheet and
strengthen its psychometric features, make it an on-line format. Audiocassette recordings of
more consonant with developments in its guiding the MACI are available for use with both En-
theory, and fortify its coordination with the de- glish- and Spanish-speaking clients. While
scriptive characteristics in the most recent Diag- mail-in scoring is available through NCS, on-
nostic and Statistical Manual of Mental Disor- site computer scoring is the fastest and most
ders (DSM) classifications. Like the other Millon convenient scoring option. Both options allow
inventories, the MACI’s personality and clinical the user to select either a Profile Report or an In-
scales are grounded on a comprehensive theory terpretive Report based on the examinee’s scores.
(Millon, 1969, 1981, 1986a, 1986b, 1990, 1997), Instructions for completing the MACI are
significantly increasing the instrument’s clinical printed on the test and are largely self-explana-
utility. Item selection and scale development tory. No special conditions or instructions be-
progressed through three validation stages: the- yond those printed on the test are required. Ac-
oretical-substantive, internal-structural, and ex- cordingly, administration can be readily and
ternal-criterion. This approach created an instru- routinely handled by properly trained assis-
ment that meets the standards of developers who tants in clinic settings. The brevity of the test
are committed to diverse construction and valida- and the minimal facilities required make it con-
tion methods (Hase & Goldberg, 1967). Each item venient for use in settings where time, space,
had to pass satisfactorily through all three stages and privacy are limited. However, the MACI
of development to be retained in the inventory. should not be mailed to clients or sent home
with them for completion.
The MACI, like all the Millon inventories,
ADMINISTRATION AND SCORING employs actuarial base rate or prevalence data
to establish scale cutting lines. These not only
The MACI was constructed specifically with an provide a basis for selecting optimal differential
adolescent population in mind. Questions are diagnostic cutting lines but also help ensure that
presented in language teenagers use, with con- the frequencies of MCMI-generated diagnoses
tent that deals with their concerns and experi- and profile patterns are comparable to represen-
ences. Both reading level and vocabulary were tative clinical prevalence rates. While the use of
set to allow for ready comprehension by the vast base rate scores has been one of the most widely
majority of adolescents. The final 160-item in- misunderstood aspects of the MCMI, their utility
ventory, geared to a sixth-grade reading level, is easily and intuitively understood when con-
can be completed by most adolescents in approx- trasted with the more familiar T score. On the
imately 20 minutes. The brevity and clarity of MMPI, for example, T scores of 65 and above in-
the instrument facilitate quick administration dicate pathology, with roughly equal numbers of
with a minimum of youngster resistance. Norms patients scoring above this threshold. Clinical ex-
were established employing samples of 13- to perience, however, shows the number of de-
19-year-olds in clinical settings (its use with pressed patients, for example, to be greater than
other normative age-groups is inappropriate and the number of patients with a thought disorder.
may lead to erroneous diagnostic judgments). Base rate scores are constructed to reflect these
The presence of overwhelming anxiety, a confu- clinical realities, yielding more depressives than
sional state, drug intoxication, or sedation may delusional patients, more borderlines and antiso-
also significantly alter test results. If the instru- cials than schizoids, and so on, rather than as-
ment is administered under such circumstances, suming their numbers to be equal. In the con-
the client should be retested at a later date. struction of the MACI, target prevalence rates
162 part ii • psychological testing

were set according to reviews of epidemiological tional, apathetic, listless, distant, and asocial.
data, estimates derived from clinicians who par- Affectionate needs and feelings are mini-
ticipated in the development project, and the se- mal. Not only do they not get emotionally
nior author’s own expert judgment. Thus, if it involved, they simply do not often feel
was deemed that 8% of patients are most likely strongly about things, lacking the capacity to
to resemble the introversive prototype, then the experience both joy and sadness in any
lookup table for this personality was constructed depth. They do not avoid others, but they are
so schizoid was the highest personality elevation indifferent about the presence of others and
for 8% of the patients in the normative sample. the possibilities inherent in relationships.
A discussion of base rate scores often leads to • Inhibited (Scale 2A): High scorers are quite
considerations of local versus global base rates, shy and ill at ease with others. Although they
that is, the fact that the prevalence rates for dif- would like to be close to others, they have
ferent disorders vary somewhat by clinical set- learned that it is better to keep their distance,
ting. When this is raised in criticism of the con- and they do not readily trust friendship. Al-
cept, it is usually intended to support the contin- though they often feel lonely, they avoid close
ued use of T scores. However, as noted earlier, the interpersonal contact, fearing rejection, and
base rate scores of the MACI are intended to they closet feelings that are often very strong.
remedy the global base rate assumptions made in • Doleful (Scale 2B): High scorers characteris-
the use of T scores. Thus, while the prevalence tically exhibit a dejected and gloomy mood,
rates of some disorders in particular clinical set- perhaps since childhood. Their outlook on
tings may differ from the base rates assumed by life is sad, brooding, and pessimistic. Most
the MACI and in the use of T scores, the MACI’s are prone to guilty and remorseful feelings,
base rate scores at least do not implicitly assume viewing themselves as inadequate or even
the prevalence rates of all disorders to be equal. worthless.
More frequently, the distinction between local • Submissive (Scale 3): High scorers tend to be
and global prevalence rates is made in support of softhearted, sentimental, and kindly in rela-
the base rate concept by clinicians who realize its tionships with others. They are extremely
importance in improving diagnostic efficiency: reluctant to assert themselves, however, and
positive and negative predictive power, sensitiv- avoid taking initiative or assuming a leader-
ity, and specificity. These clinicians, far from re- ship role. They are not only inclined to be
verting back to T scores, often wish to optimize quite dependent but also exhibit clinging be-
the base rate scores for their particular setting. havior and a fear of separation. They typi-
cally play down their own achievements and
underestimate their abilities.
SCALE DESCRIPTIONS • Dramatizing (Scale 4): High scorers tend to be
talkative, charming, and frequently exhibi-
The major personality patterns, expressed psy- tionistic or emotionally expressive. They tend
chosocial concerns, and clinical syndromes typ- to have intense but brief relationships with
ical of adolescents have been organized into the others. These adolescents look for interesting
following formal scales. experiences and new forms of excitement.
They often find themselves becoming bored
with routine and long-standing relationships.
Personality Patterns
• Egotistic (Scale 5): High scorers tend to be
Twelve personality patterns are included, based quite confident of their abilities and are often
on the senior author’s theoretical schema (Mil- seen by others as self-centered and narcissis-
lon, 1969, 1981, 1986a, 1986b, 1990, 1997) and tic. They rarely doubt their own self-worth,
similar material in the fourth edition of the and they act in a self-assured manner. These
DSM (DSM-IV). individuals tend to take others for granted,
are often arrogant and exploitative, and do
• Introversive (Scale 1): High scorers keep to not share or concern themselves with the
themselves, appearing rather quiet, unemo- needs of others.
 34 • millon adolescent clinical inventory (maci) 163

• Unruly (Scale 6A): High scorers tend to act • Identity diffusion (Scale A): High scorers are
out in an antisocial manner, often resisting confused about who they are, what they
efforts to make them adhere to socially ac- want from life, and what they would like to
ceptable standards of behavior. These adoles- become. Free-floating and unfocused about
cents may display a pervasively rebellious at- future goals and values, they are unclear and
titude that could bring them into conflict directionless about the course of their future
with parents and school or legal authorities. development.
• Forceful (Scale 6B): High scorers are strong- • Self-devaluation (Scale B): Although high
willed and tough-minded, tending to domi- scorers have a sense of who they are, they are
nate and abuse others. They frequently ques- very dissatisfied with that self-image. They
tion the rights of others and prefer to control speak openly about feelings of low self-es-
most situations. They are often blunt and teem, find little to admire in themselves, and
unkind, tending to be impatient with the fear that they will fall far short of what they
problems or weaknesses of others. aspire to be.
• Conforming (Scale 7): High scorers are very • Body disapproval (Scale C): High scorers are
serious-minded, efficient, respectful, and rule- discontent with what they perceive to be
conscious individuals who try to do the “right” shortcomings or deviance in their physical
and “proper” things. They tend to keep their maturation or morphology. They may also
emotions under check and to be overcontrolled express dissatisfaction with their level of
and tense. They prefer to live their lives in a physical attractiveness and social appeal.
very orderly and well-planned fashion, avoid- • Sexual discomfort (Scale D): High scorers
ing unpredictable and unexpected situations. find sexual thoughts and feelings confusing
• Oppositional (Scale 8A): High scorers tend to or disagreeable. They are troubled by their
be discontented, sullen, passive-aggressive, impulses and often fear the expression of
and unpredictable. They may be outgoing their sexuality. They may be preoccupied
and pleasant one moment but hostile and ir- with or in conflict over the roles their sexu-
ritable the next. Often they are confused and ality requires.
contrite about their moodiness but are un- • Peer insecurity (Scale E): High scorers report
able to control these swings for long. dismay and sadness concerning perceived
• Self-demeaning (Scale 8B): High scorers peer rejection. Wanting the approval of peers
tend to be their own worst enemies, acting in but unsuccessful in attaining it, many are
self-defeating ways, at times seeming con- likely to withdraw and become even more
tent to suffer. Many undermine the efforts of isolated.
others to help them. Often they deny them- • Social insensitivity (Scale F): High scorers
selves pleasure and sabotage their own ef- are cool and indifferent to the welfare of oth-
forts to achieve success. ers. Willing to override the rights of others
• Borderline tendency (Scale 9): High scorers to achieve personal ends, they lack empathy
exhibit severe personality dysfunctions, dis- and show little interest in building warm
playing more pathological variants of the pre- personal ties.
ceding personality traits and features. They • Family discord (Scale G): High scorers report
may also exhibit marked affective instabilities, that their families are tense and full of con-
erratic interpersonal relationships, behavioral flict. They note few sources of support and
capriciousness, impulsive hostility, fear of possess a general feeling of estrangement
abandonment, and self-destructive actions. from parents. Depending on the individual’s
personality, these difficulties may reflect ei-
ther parental rejection or adolescent rebellion.
Expressed Concerns
• Childhood abuse (Scale H): High scorers re-
The following eight scales focus on areas of life port shame or disgust about having been
that troubled adolescents often find problem- subjected to verbal, physical, or sexual abuse
atic. The intensity of the problem is reflected in from parents, siblings, relatives, or family
the elevation of the scale score. friends.
164 part ii • psychological testing

Clinical Syndromes fatigue, a tendency to be despairing about the

The final seven scales of the MACI involve areas future, social withdrawal, loss of confidence,
of direct clinical significance that call for inter- and diminished feelings of adequacy and at-
vention on the part of a therapist. These diag- tractiveness.
nostic categories represent difficulties that are • Suicidal tendency (Scale GG): High scorers
found in a significant proportion of adolescents admit to suicidal thoughts and plans. They
who are seen by mental health professionals. express feelings of worthlessness and pur-
poselessness and a sense that others would be
• Eating dysfunctions (Scale AA): High scor- better off without them. High scores call for
ers exhibit distinct tendencies toward anor- professional attention and alertness on the
exia nervosa or bulimia nervosa. Though al- part of family members.
ready below normal weight, they fear “get-
ting fat.” They may engage in uncontrolled
eating, followed by self-induced vomiting or CLINICAL INTERPRETATION AND
the misuse of laxatives or diuretics. COMPUTER-GENERATED REPORTS
• Substance-abuse proneness (Scale BB): High
scorers exhibit a pattern of alcohol or drug Configural interpretation of the MACI is es-
abuse that has led to significant impairment sentially similar to that of the MCMI-III (see
of performance and behavior. Some spend in- chapter 33), proceeding from single-scale to
ordinate amounts of time obtaining their configural syntheses, with appropriate integra-
substances, behave in an unacceptable social tion of auxiliary data. Considerable interpretive
manner, and continue substance use despite material related to personality disorders, and on
cognizance of its long-term harmful effect on Millon’s evolutionary theory, is presented in
their life. various writings, most notably Modern Psy-
• Delinquent predisposition (Scale CC): High chopathology (Millon, 1969), Toward a New
scorers behave in ways or involve themselves Personology: An Evolutionary Model (Millon,
in situations in which the rights of others are 1990), and Disorders of Personality: The DSM-
likely to be violated. In doing so, any number IV and Beyond (Millon & Davis, 1996).
of societal norms or rules may be broken, in- The MACI automated interpretive reports
cluding threats, use of weapons, deception and are substantially more detailed than those of
lying, stealing, and other antisocial behaviors. the MAPI. They are based on clinically derived
• Impulsive propensity (Scale DD): High scor- configurations and statistical clusters as syn-
ers have poor control over sexual and aggres- thesized by the underlying theory. MACI re-
sive impulses and are likely to act out their sults can be furnished either in profile form or
feelings with minimal provocation. Easily ex- as an automated interpretive report. The profile
cited over minor matters, these adolescents provides limited information and assumes
may discharge their urges in sudden, impetu- knowledge of the relevant clinical literature.
ous, and often foolhardy ways. The more comprehensive and detailed interpre-
• Anxious feelings (Scale EE): High scorers tive report is considered a professional-to-
have a sense of foreboding, an apprehensive- professional consultation. Its function is to
ness about all sorts of matters. Uneasy, dis- serve as one component in the evaluation of the
quieted, fretful, and nervous, they are often adolescent, and it should be viewed by the clin-
on pins and needles as they fearfully await ician as a series of probabilistic rather than de-
the coming of unknown torments or calami- finitive judgments. Although this information is
tous events. appropriate for use in developing a therapeutic
• Depressive affect (Scale FF): High scorers program, sharing the report with adolescents or
show a decreased level of activity, clearly dis- their families is discouraged. Careful rephrasing
tinct from that which has been characteris- of text interpretations may be undertaken with
tic of them in the past. They exhibit a notable appropriate clients, using sound clinical judg-
decrease in effectiveness, feelings of guilt and ment to assure a constructive outcome.
 34 • millon adolescent clinical inventory (maci) 165

An actuarial system, particularly one that is References & Readings

supplemented by a systematic clinical theory, Hase, H. D., & Goldberg, L. R. (1967). Comparative
should yield reports as good as those prepared validity of different strategies of constructing
by human interpreters. Moreover, a computer personality inventory scales. Psychological Bul-
database is far more substantial in scope and va- letin, 67, 231–248.
riety than are the disorders seen by the average McCann, J. T. (1999). Assessing adolescents with
clinician. Diagnosticians must resort to highly the MACI: Using the Millon Adolescent Clini-
tenuous speculations when they encounter cal Inventory. New York: Wiley.
novel profile configurations. In contrast, a com- Millon, T. (1969). Modern psychopathology. Phila-
puter database is well supplied with comparable delphia: Saunders.
Millon, T. (1981). Disorders of personality: DSM-
cases to be drawn upon for interpretive refer-
III, Axis II. New York: Wiley.
ence. In a few seconds, the computer can match Millon, T. (1986a). Personality prototypes and their
a profile with comparable configurations and diagnostic criteria. In T. Millon & G. Klerman
generate an appropriate narrative report. From (Eds.), Contemporary directions in psycho-
a purely practical viewpoint, automated reports pathology: Toward the DSM-IV. New York:
provide a significant savings of professional Guilford Press.
time and effort. Millon, T. (1986b). A theoretical derivation of patho-
Computer-generated MACI interpretive re- logical personalities. In T. Millon & G. Klerman
ports include (a) a cover page, a summary page (Eds.), Contemporary directions in psycho-
providing the raw and BR scores for each scale pathology: Toward the DSM-IV. New York:
and a score profile, test validity information, Guilford Press.
Millon, T. (1990). Toward a new personology: An
and the personality code; (b) an initial para-
evolutionary model. New York: Wiley-Inter-
graph noting the appropriate context, limita- science.
tions, and restrictions of the use, a demographic Millon, T. (Ed.). (1997). The Millon inventories: Con-
summary, and a judgment as to the probable temporary clinical and personality assessment.
validity and reliability of test data given the New York: Guilford Press.
adolescent’s response tendencies and biases; (c) Millon, T., & Davis, R. D. (1996). Disorders of per-
a series of paragraphs describing the major fea- sonality: The DSM-IV and beyond. New York:
tures of the teenager’s personality patterns, the Wiley-Interscience.
manner in which difficulties are manifested, Millon, T., Green, C. J., & Meagher, R. B., Jr. (1982).
and the probable course of relationships with Millon Adolescent Personality Inventory man-
therapists; (d) a series of descriptive statements ual. Minneapolis, MN: National Computer
Systems.
characterizing the primary areas of concern as
Millon, T., Millon, C., and Davis, R. D. (1993). Millon
expressed by the youngster; (e) an interpretive Adolescent Clinical Inventory manual. Min-
summary of the nature and character of the neapolis, MN: National Computer Systems.
highest Clinical Syndromes scales in order of
their magnitude; (f) a section called “Notewor- Related Topics
thy Responses,” which indicates problem areas
that call for closer inspection and further eval- Chapter 9, “Child and Adolescent Diagnosis With
uation; (g) a summary section of “Diagnostic DSM-IV”
Hypotheses” related to the DSM-IV, arranged Chapter 33, “Millon Clinical Multiaxial Inventory
(MCMI-III)”
in a multiaxial format; and (h) a series of para-
graphs pointing out the treatment implications
of the preceding information.
 THUMBNAIL GUIDE
35 TO THE RORSCHACH
METHOD

Barry A. Ritzler

MATERIALS lish, 1961): Prior to the development of the

Comprehensive System, this was one of the
The Rorschach Method stimulus materials con- two most frequently used systems.
sist of 10 drawings based on inkblots designed • The Klopfer System (Klopfer & Kelley, 1942):
by Hermann Rorschach when he developed the This was the other most frequently used sys-
method in the early 1920s (Rorschach, 1921). tem before the Comprehensive System.
All 10 cards should be administered in numer- • The Rapaport System (Rapaport, Gill, &
ical order (I–X). A notepad is necessary for ver- Schafer, 1946): Though less frequently used
batim note taking, with two sections on the than the Beck and Klopfer Systems, the Ra-
same page for First Viewing responses and In- paport System tends to be favored by psy-
quiry (see “Administration Procedures”). A choanalytically oriented psychologists be-
scoring summary sheet and a location chart (a cause of its conceptual ties to the theory.
page with miniature copies of the 10 cards) also
should be used. The Rorschach is used throughout the world,
and numerous systems exist in other countries
but have not been introduced in the United
FREQUENTLY USED SYSTEMS States. The International Rorschach Society
(Weiner, 1994) is an organization that brings to-
Four somewhat different systems are used with gether Rorschach psychologists from many dif-
noticeable frequency by psychologists in the ferent countries for the exchange of views on dif-
United States: ferent approaches to the Rorschach Method.

• The Rorschach Comprehensive System

(Exner, 2003): First published in 1974, this ADMINISTRATION PROCEDURES
system was derived from empirical analysis
of the Rorschach to establish acceptable lev- Although administration procedures differ
els of reliability and validity. The Compre- somewhat between the frequently used sys-
hensive System incorporates coding vari- tems, some basic principles apply to all systems.
ables from several other systems and has be- For instance, the key to administration is to
come the most frequently used Rorschach minimize the influence of the examiner. The
system in the United States (Piotrowski & Method should be introduced with a minimum
Keller, 1992). of explanation. It usually is sufficient to indicate
• The Beck System (Beck, Beck, Levitt, & Mo- that the Method is a common procedure used

166
 35 • thumbnail guide to rorschach method 167

by psychologists to assess personality. No more tion and systematic methods of interpretation

specific information about the Method should that exist for the Method. Rorschach interpre-
be conveyed before administration. tation without coding risks an overly subjective
The initial instructions are very simple. For assessment biased by the psychologist’s idiosyn-
example, the Comprehensive System (Exner, cratic associations to the form and content of the
2003) simply asks the initial question “What subject’s responses. Most Rorschach experts con-
might this be?” as the subject is handed the first sider interpretation without coding to be a mis-
card. use of the Method (Allison, Blatt, & Zimet,
For most systems, all 10 cards are presented 1968; Exner, 2003).
consecutively for a First Viewing, which af-
fords the subject an opportunity to respond to
each card with little intervention by the exam- INTERPRETATION
iner, who primarily is occupied taking verbatim
notes. After the initial responses to all 10 cards Interpretation of personality functioning using
are recorded, the blots are presented again for the Rorschach Method is based on tallies and
an Inquiry period in which the examiner at- variables calculated from the coding of all re-
tempts to gain more information about the re- sponses and the content of the responses. For all
sponses by making concise, nonleading in- frequently used systems, the calculated vari-
quiries. The subject’s responses to these in- ables yield interpretive hypotheses supported
quiries also are recorded verbatim. The only by empirical research. Content analysis com-
exception to this procedure is the Rapaport Sys- plements and broadens the understanding of
tem (Rapaport et al., 1946), which administers the subject’s personality, but it should not be
the Inquiry immediately after the First View- done without integration with interpretive hy-
ing response is obtained for each card and be- potheses obtained from the Method’s quantita-
fore the next card is presented. It was Rapa- tive variables.
port’s intention to obtain Inquiry information Although the Rorschach Method yields
while the process of the First Viewing response much useful information, it should seldom, if
was fresh in the subject’s mind. The other sys- ever, be used by itself for personality assess-
tems are concerned that immediate Inquiry will ment. Integration must be made with other
bias the subject’s responses on subsequent valid personality information from testing, be-
cards. havioral observations, facts of the subject’s life
The purpose of the Inquiry is to determine history and current living situation, and objec-
where each response is located on the card and tively reported symptoms.
what stimulus qualities of the card influenced
(or determined) the subject’s responses (e.g.,
shape, color, or shading). The Inquiry also is TRAINING
used to clarify ambiguities in the subject’s com-
munication of the response. The Society for Personality Assessment’s Stan-
Detailed administration manuals exist for dards for Training (Society for Personality As-
each system and should be consulted for more sessment, 1995) sets the minimum standard for
specific instruction in proper administration. training in the Rorschach and other assessment
methods at two semesters of graduate school
coursework followed by practicum, internship,
CODING (SCORING) and postdoctoral training in the methods. Sur-
veys indicate that most American Psychological
The Rorschach Method should not be used with- Association (APA–approved graduate programs
out the application of one of the accepted coding in applied psychology teach the Rorschach
systems. Without coding, the psychologist cannot Method (e.g., Ritzler & Alter, 1986) but that the
take advantage of the substantial empirical valida- majority of such programs offer only one semes-
168 part ii • psychological testing

ter of instruction, so that the student must often • Journal for Personality Assessment ( journal
seek supplementary training. However, since the published by the Society for Personality As-
Rorschach is a frequently used clinical method sessment)
(Piotrowski & Keller, 1992), it is not difficult to • Psychological Assessment ( journal published
find internships that offer training in the by the American Psychological Association)
Method. Also, opportunities exist for postdoc- • Assessment ( journal published by Psycho-
toral training in the Method through postdoc- logical Assessment Resources)
toral fellowships and/or widely advertised work- • Rorschachiana (yearbook published by the
shops presented by qualified instructors. Such International Rorschach Society)
training beyond the graduate school level is es-
sential for development of expertise in the
References & Readings
Rorschach Method.
Allison, J., Blatt, S., & Zimet, C. (1968). The inter-
pretation of psychological tests. New York:
APPLICATIONS Harper and Row.
Beck, S., Beck, A., Levitt, E., & Molish, B. (1961).
Rorschach’s test I: Basic processes (3rd ed.).
The Rorschach Method has proved useful in
New York: Grune and Stratton.
the following settings and situations, among Exner, J. (2003). The Rorschach: A comprehensive
others: system. New York: Wiley.
Exner, J. (Ed.). (1995). Issues and methods in
• Treatment planning for inpatients and out- Rorschach research. Mahwah, NJ: Erlbaum.
patients in public and private settings Klopfer, B., & Kelley, D. (1942). The Rorschach tech-
• School assessments, particularly for class- nique. Yonkers, NY: World Book.
room behavioral and learning problems Piotrowski, C., & Keller, J. (1992). Psychological
• Forensic applications such as the assessment testing in applied settings: A literature review
of competence and criminal insanity, parole from 1982–1992. Journal of Training and
evaluations, custody determinations, assess- Practice in Professional Psychology, 6, 74 – 82.
Rapaport, D., Gill, M., & Schafer, R. (1946). Diag-
ment of psychological trauma and injury,
nostic psychological testing (Vols. 1 & 2).
and sentencing consultation Chicago: Yearbook Publishers.
• Research methodology (see especially Exner, Ritzler, B., & Alter, B. (1986). Rorschach teaching in
1995) APA approved clinical graduate programs: A
• Assessment of the personality consequences ten-year update. Journal of Personality Assess-
of brain dysfunction (in conjunction with ment, 50, 44 – 49.
neuropsychological assessment) Rorschach, H. (1921). Psychodiagnostik. Bern:
• Vocational assessment for such purposes as Bircher; trans., Bern: Hans Huber Verlag, 1942.
employee selection and placement, evaluation Society for Personality Assessment (1995). Mem-
of individual vocational problems, and con- bership directory. Mahwah, NJ: Erlbaum.
sultation for workplace relationship prob- Weiner, I. (1994). Speaking Rorschach: Building
bridges of understanding. Rorschachiana, 19,
lems
1– 6.

SOURCES OF INFORMATION REGARDING

Related Topics
THE RORSCHACH METHOD Chapter 36, “Rorschach Assessment: Questions and
Reservations”
Psychologists can follow current developments Chapter 37, “Rorschach Assessment: Scientific Sta-
tus and Clinical Utility”
in the Rorschach Method by consulting the fol-
lowing publications:
 RORSCHACH ASSESSMENT
36 Questions and Reservations

Howard N. Garb, James M. Wood,

& Scott O. Lilienfeld

The Rorschach has become increasingly con- protocols that were scored using some rules
troversial, in part because its use can lead psy- that are now outdated. After administering and
chologists to make judgments that are harmful. scoring the test, Exner revised his scoring sys-
Since 1999, the controversy has been reviewed tem but did not rescore the protocols using all
in numerous peer-reviewed journals (e.g., As- of the new rules (Hibbard, 2003, p. 261).
sessment, Journal of Personality Assessment, Perhaps the most serious problem with the
Psychological Assessment) and the popular Rorschach is that the use of the CS norms can
press. lead psychologists to overperceive psycho-
The goal of this chapter is to help psycholo- pathology. Because these norms are in error,
gists use the Rorschach in a scientifically and relatively normal individuals often appear to be
ethically responsible manner. We will propose psychologically disturbed. Thus, psychologists
and discuss three clinical guidelines (Garb, interpreting Rorschach results may errone-
Wood, Lilienfeld, and Nezworski, 2002): ously conclude that the individuals they have
1. Exercise caution when using the Compre- assessed have significant psychopathology. This
hensive System (CS) norms. Their use is re- can have harmful consequences. For instance,
lated to the overperception of psychopathol- individuals in clinical settings may be falsely
ogy. In many instances, it may be best not to identified as being psychologically disturbed.
use them. Results on the adequacy of the CS norms
The most popular system for administering, have been hotly contested. Here we summarize
scoring, and interpreting the Rorschach is the results from (a) two recent studies con-
Exner’s (2001) Comprehensive System (CS). ducted in the United States (Hamel, Shaffer, &
Exner administered the Rorschach to children Erdberg, 2000; Shaffer, Erdberg, & Haroian,
and adults in the community, then tabulated 1999); (b) a comprehensive review of the liter-
sets of norms to summarize the results. When ature (Wood, Nezworski, Garb, & Lilienfeld,
assessing clients, psychologists typically com- 2001b); and (c) analyses of data pooled from
pare their scores with these norms. nine international studies (Meyer, 2001; Wood,
Researchers have recently uncovered errors Nezworski, Garb, & Lilienfeld, 2001a). In addi-
in the CS normative samples. Although Exner tion, we will evaluate criticisms of this body of
had long described the 1993 adult normative research (e.g., Weiner, Spielberger, & Abeles,
sample as being composed of 700 distinct pro- 2003).
tocols, it was actually made up of 479 distinct In the first study (Shaffer et al., 1999), re-
protocols with the scores for 221 protocols mis- searchers administered the WAIS-R, MMPI-2,
takenly counted twice (Exner, 2001, p. 172). and Rorschach to 123 nonpatient adults. They
Furthermore, the 2001 sample is composed of excluded adults who had a history of psychi-

169
170 part ii • psychological testing

atric hospitalization, psychological treatment in (2001) claimed that “Exner’s 1993 nonpatient
the past two years, psychological testing in the reference sample consists of people with no his-
past year, a major medical illness in the past six tory of mental health treatment and some pos-
months, or a felony conviction. Participants ob- itive evidence of healthy functioning. . . . Al-
tained WAIS-R and MMPI-2 results that were though Wood et al. referred to their 32 samples
similar to the normative data for these instru- as ‘nonpatients,’ at least 5 explicitly included
ments, indicating that their level of psycholog- current or former psychiatric patients” (p.
ical functioning was about average. However, 390). Weiner and his associates (2003) repeated
Rorschach results were markedly different these same points: “These criticisms are un-
from the CS norms. In fact, if one used the CS founded. Contrary to the claim that no one in
norms to interpret the Rorschach results, one the CS nonpatient sample had a history of
would conclude that many of these relatively mental health treatment, 15% to 20% of the
normal adults appear to suffer from a serious respondents in this sample had been in coun-
thought disorder. seling or had received psychiatric treatment”
In a second study (Hamel et al., 2000), in- (John Exner, personal communication, February
vestigators administered the Rorschach to 100 6, 2001). Similarly, it is not true that five of the
schoolchildren. They excluded children if they Wood et al. samples included current or former
had a history of (a) being evaluated or treated psychiatric patients. In the five studies cited by
for an emotional or behavioral disorder or (b) Meyer (2001) and by Weiner et al. (2003), there
antisocial behavior or academic difficulties. The is no evidence that any of the participants had
children were healthier than average, as mea- ever had a psychiatric hospitalization. Some of
sured by the Conners Parent Rating Scale-93 the participants in four of the samples had re-
(Conners, 1989). Hamel and associates (2000, p. ceived psychotherapy, but some of the individ-
291) concluded that if one used the CS norms to uals included in the CS normative sample had
interpret the Rorschach results for these chil- similarly received counseling.
dren, one would infer that “their distortion of Results have also been reported for nine in-
reality and faulty reasoning approach psy- ternational samples that contained a total of
chosis.” A prominent Rorschach proponent, 2,125 nonclinical participants. Meyer (2001)
Gregory Meyer, speculated in the Los Angeles analyzed the results for 69 CS Rorschach scores
Times that the Rorschach was not properly ad- and found that these samples were about four-
ministered in this study, although he provided tenths of a standard deviation more impaired
no evidence for this claim (Mestel, 2003). than the CS normative sample. Using the data
Wood and colleagues (2001b) searched for from the same samples, Wood, Nezworski,
studies in which nonpatient adults had been ad- Garb, and Lilienfeld (2001a) analyzed the re-
ministered the Rorschach using the CS. In sults for the 14 CS scores examined in their lit-
these studies, the Rorschach was used to dis- erature review (Wood et al., 2001b). They
tinguish a clinical group (e.g., individuals with found that the international samples were
antisocial personality disorder) from nonpa- about seven-tenths of a standard deviation more
tient adults (e.g., undergraduate students). impaired than the CS normative sample. These
Wood et al. examined results for 14 scores that findings also indicate that the use of the CS
are critical for CS interpretation—for example, norms can lead to the overperception of psy-
EB style (purportedly a measure of inefficient chopathology.
problem solving) and WSumC (purportedly a In conclusion, researchers have discovered
measure of emotional control). The results serious problems with the CS norms. Relatively
from this literature review also indicate that normal individuals in the community will ap-
the use of the CS norms is likely to lead to the pear disturbed when their Rorschach protocols
overperception of psychopathology. are interpreted using the CS norms. Thus, psy-
The importance of the Wood et al. (2001b) chologists should exercise caution when using
findings has been minimized by some the CS norms, and in many instances it may be
Rorschach proponents. For example, Meyer appropriate not to use them at all.
 36 • rorschach assessment: questions and observations 171

2. Interpretations should be based on scores are inherently limited because they provide
that are valid for their intended purposes. diffuse information. They do not cumulatively
Scores should be validated in well-designed organize evidence for specific test scales and
studies, findings should be consistent, and pos- thus fail to provide fine-grained and clinically
itive results should be replicated by indepen- useful information about the value of a scale in
dent investigators. relation to specific criteria. This is a genuine
There is general agreement that some Ror- limitation of global meta-analyses, and it is im-
schach scores are valid for their intended pur- possible to circumvent this shortcoming.
poses. Even investigators who are critical of the In focused meta-analyses, results for a sin-
Rorschach generally agree that the Rorschach gle scale are pooled. Results have supported the
can be helpful for some tasks—for example, for validity of several scores, such as the Rorschach
detecting thought disorder and conditions char- Oral Dependency Scale” (Bornstein, 1996).
acterized by thought disorder (Lilienfeld, Wood, To evaluate the validity of Rorschach scores,
& Garb, 2000; Wood, Nezworski, & Garb, 2003). we used the following criteria: (1) studies must
There is also general agreement that many be methodologically sound, (2) significant find-
variables have not been adequately validated. ings must be replicated by independent investi-
As noted by Meyer and Archer (2001, p. 496), gators, and (3) results must be consistent across
“Yet many variables given fairly substantial in- studies (Lilienfeld et al., 2000). Rorschach
terpretive emphasis have received little or no scores have received at least provisional empir-
attention. . . . These include the Coping Deficit ical support for a number of tasks (Wood et al.,
Index, Obsessive Style Index, Hypervigilance 2003) including: (a) the assessment of psychotic
Index, active-to-passive movement ratio, D- conditions and thought disorder, (b) the estima-
score, food content, anatomy and X-ray con- tion of intelligence, (c) the prediction of treat-
tent, Intellectualization Index, and Isolation In- ment outcome, (d) the assessment of objective
dex.” The best-validated CS scale, the Schizo- behaviors related to dependency, (e) the assess-
phrenia Index, has recently been replaced by ment of anxious and hostile behaviors, and (f)
the Perceptual Thinking Index (Exner, 2001), a the differentiation of what used to be called
measure that has not yet been well validated. “organic” and “functional” brain disorders.
Some of the most persuasive evidence for However, many of the scores that have been
the Rorschach derives from meta-analyses. In supported are not part of the CS, and they lack
global meta-analyses, results for a range of CS adequate norms and involve elaborate scoring
and non-CS scores are pooled and average effect procedures that many psychologists may find
size estimates are calculated. Positive results impractical.
have been obtained, indicating that at least The overwhelming majority of Rorschach
some Rorschach indicators are empirically sup- scores do not satisfy the above three criteria.
ported. However, the results have not always Psychologists should limit their use of the
been accurately reported. For example, accord- Rorschach to the small number of indices that
ing to Weiner and Kuehnle (1998, p. 440), have been empirically supported.
“Parker et al. [Parker, Hanson, & Hunsley, 3. How one uses the Rorschach should de-
1988] used the effect sizes reported in 411 stud- pend on whether one is testifying in court as
ies to derive population estimates of convergent an expert witness, evaluating a client in clinical
validity of 0.41 for the Rorschach and 0.46 for practice, or using the test as an aid for explo-
the MMPI.” This statement is misleading be- ration in psychotherapy.
cause the convergent validity coefficient of .41 Psychologists should be extremely cautious
for the Rorschach is based on the results from when using the Rorschach, especially when tes-
only five studies (Parker et al., 1988, p. 370, tifying in court or writing test reports. Using
Table 1). Even more important, global meta- the Rorschach to generate exploratory hy-
analyses do not tell us which scores are valid potheses for psychotherapy can be more easily
for which tasks. As observed by Meyer and defended. Even here, however, clinicians must
Archer (2001, p. 491): “Global meta-analyses be cautious. Whether testifying in court, writ-
172 part ii • psychological testing

ing a test report, or exploring issues with a of Rorschach research: What do we know and
client in psychotherapy, psychologists should where do we go? Psychological Assessment, 13,
avoid interpreting Rorschach protocols “by the 486 – 502.
book” because problems exist with the CS Parker, K. C. H., Hanson, R. K., & Hunsley, J. (1988).
MMPI, Rorschach, and WAIS: A Meta-analytic
norms and because most CS scores have scant
comparison of reliability, stability, and validity.
empirical support.
Psychological Bulletin, 103, 367 –373.
Shaffer, T. W., Erdberg, P., & Haroian, J. (1999). Cur-
Note: For a history of the Rorschach and an ac- rent nonpatient data for the Rorschach, WAIS-
count of how psychologists have sought to tran- R, and MMPI-2. Journal of Personality Assess-
scend their prescientific past, see Wood, Nez- ment, 73, 305 –316.
worski, Lilienfeld, and Garb (2003). Weiner, I. B., & Kuehnle, K. (1998). Projective as-
sessment of children and adolescents. In A. S.
Bellack & M. Hersen (Series Eds.) & C. R.
References & Readings
Reynolds (Vol. Ed.), Comprehensive clinical
Bornstein, R. F. (1996). Construct validity of the psychology: Vol. 4. Assessment (pp. 431– 458).
Rorschach Oral Dependency Scale: 1967 –1995, Oxford, UK: Elsevier.
Psychological Assessment, 8, 200 –205. Weiner, I. B., Spielberger, C. D., & Abeles, N. (2003).
Conners, K. (1989). Manual for Conners’ rating Once more around the park: Correcting misin-
scales. North Tonawanda, NY: Multi-Health formation about Rorschach assessment. The
Systems. Clinical Psychologist, 56, 8 – 9.
Exner, J. E. (2001). A Rorschach workbook for the Wood, J. M., Nezworski, M. T., & Garb, H. N.
Comprehensive System (5th ed.). Asheville, (2003). What’s right with the Rorschach? Sci-
NC: Rorschach Workshops. entific Review of Mental Health Practice, 2,
Garb, H. N., Wood, J. M., Lilienfeld, S. O., & Nez- 142–146.
worski, M. T. (2002). Effective use of projective Wood, J. M., Nezworski, M. T., Garb, H. N., &
techniques in clinical practice: Let the data help Lilienfeld, S. O. (2001a). The misperception of
with selection and interpretation. Professional psychopathology: Problems with the norms of
Psychology: Research and Practice, 33, the Comprehensive System for the Rorschach.
454 – 463. Clinical Psychology: Science and Practice, 8,
Hamel, M., Shaffer, T. W., & Erdberg, P. (2000). A 350 –373.
study of nonpatient preadolescent Rorschach Wood, J. M., Nezworski, M. T., Garb, H. N., &
protocols. Journal of Personality Assessment, Lilienfeld, S. O. (2001b). Problems with the
75, 280 –294. norms of the Comprehensive System for the
Hibbard, S. (2003). A critique of Lilienfeld et al.’s Rorschach: Methodological and conceptual con-
(2000) “The Scientific Status of Projective Tech- siderations. Clinical Psychology: Science and
niques.” Journal of Personality Assessment, 80, Practice, 8, 397 – 402.
260 –271. Wood, J. M., Nezworski, M. T., Lilienfeld, S. O., &
Lilienfeld, S. O., Wood, J. M., & Garb, H. N. (2000). Garb, H. N. (2003). What’s wrong with the
The scientific status of projective techniques. Rorschach? Science confronts the controversial
Psychological Science in the Public Interest, 1, inkblot test. San Francisco: Jossey-Bass.
27 –66.
Mestel, R. (2003, May 19). Rorschach tested. Blot
Related Topics
out the famous method? Los Angeles Times,
F-1. Chapter 35, “Thumbnail Guide to the Rorschach
Meyer, G. J. (2001). Evidence to correct mispercep- Method”
tions about Rorschach norms. Clinical Psychol- Chapter 37, “Rorschach Assessment: Scientific Sta-
ogy: Science and Practice, 8, 389 –396. tus and Clinical Utility”
Meyer, G. J., & Archer, R. P. (2001). The hard science
 RORSCHACH ASSESSMENT
37
Scientific Status and Clinical Utility

Irving B. Weiner

The Rorschach Inkblot Method is a psychomet- far the most widely applied and studied Ror-
rically sound, performance-based instrument schach system.
for measuring personality functioning. Ror-
schach assessment provides dependable infor-
Intercoder Agreement
mation about the manner in which people focus
their attention, perceive people and events, Intercoder agreement for CS Rorschach vari-
think about their experience, express feelings, ables has consistently proved good in numerous
manage stress, view themselves, and relate studies, whether measured by percentage
to other people. Rorschach responses also pro- agreement or by kappa and intraclass correla-
vide clues to underlying needs, attitudes, con- tion coefficients (ICC) that take account of
flicts, and concerns that are likely to influence chance agreement. Two recent studies exem-
a person’s behavior, sometimes without the per- plify these findings. Meyer and colleagues
son’s conscious awareness (Weiner, 2003). In- (2002), examining four different samples and
formation about personality characteristics 219 protocols containing 4,761 responses, found
identified by the RIM often facilitates decision a median ICC of .93 for intercoder agreement
making in clinical, forensic, and organizational across 138 regularly occurring Rorschach vari-
settings. ables, with 134 of these variables falling in the
The purposes of this brief chapter are to re- excellent range for chance-corrected agreement.
view empirical evidence demonstrating the Viglione and Taylor (2003), examining coder
psychometric soundness of the Rorschach and concurrence for 84 protocols with 1,732 re-
to describe the utility of the instrument in clin- sponses, found a median ICC of .92 for 68 vari-
ical practice. ables considered to be of central interpretive
significance in the CS.
Some critics of the Rorschach have neverthe-
SCIENTIFIC STATUS less noted that codes were originally included in
the CS solely on the basis of the percentage of
Contemporary research demonstrates that intercoder agreement (80% or more) and that
Rorschach assessment is a scientifically sound there is no “field” study of intercoder agree-
procedure with good intercoder agreement, ment (i.e., whether individuals in practice code
substantial retest reliability, adequate validity reliably) (Lilienfeld, Wood, & Garb, 2000). The
when used properly for its intended purposes, contemporary kappa and ICC findings render
and a broad and useful normative reference the first of these arguments moot. The second
base. These research findings are based primar- argument is specious because (1) field studies of
ily on Exner’s (2003) Comprehensive System coder agreement are not ordinarily considered
(CS), which is a standardized procedure for necessary to demonstrate the psychometric ad-
Rorschach coding and administration and is by equacy of an assessment instrument (what is

173
174 part ii • psychological testing

known, for example, about field agreement in others, and, as just noted, the critical interpre-
scoring 0, 1, or 2 points on Wechsler Compre- tive variables in the CS tend to show particu-
hension items?), and (2) if people in the field are larly high retest correlations. Viglione and
coding Rorschach responses inaccurately and Hilsenroth (2001) have published an extensive
thus unreliably, the fault lies with them, for not summary of the Rorschach retest data that en-
being adequately informed or careful, not with compasses, either individually or within some
the instrument. Rorschach critics have not pub- combination, virtually all of the CS structural
lished or adduced any original research showing variables.
poor intercoder agreement for CS variables. The retest correlations for all regularly oc-
curring Rorschach variables having interpre-
tive significance for trait dimensions of person-
Reliability
ality compare favorably with the reliability
Retest studies with both children and adults data for other frequently used and highly re-
over intervals ranging from 7 days to 3 years garded assessment instruments, including the
have demonstrated substantial reliability for Wechsler Scales and the Minnesota Multipha-
Rorschach summary scores and indices that are sic Personality Inventory (MMPI). Rorschach
conceptualized as relating to trait characteris- critics have not published or adduced any orig-
tics, which include almost all of the CS vari- inal research showing poor reliability for these
ables. In adults, the short- and long-term sta- regularly occurring Rorschach indices of trait
bility of most CS variables exceeds .75, and 19 variables.
core variables with major interpretive signifi- The retest and reference data for children
cance have shown 1-year or 3-year retest cor- contain some compelling evidence of construct
relations of .85 or higher. validity for Rorschach variables. The increasing
The only Rorschach summary scores that 2-year stability of Rorschach findings as chil-
show low retest correlations are based on a dren age is one case in point. The Egocentricity
small number of variables and combinations of Index, conceptualized as a measure of self-
these variables that are conceptualized as mea- focusing or self-centeredness in the Piagetian
suring situational state characteristics. Chil- sense, shows an almost perfect linear decrease
dren show stability coefficients similar to those in young people from age 5 to 16, which is con-
of adults when retested over brief intervals. sistent with theory and data in developmental
Over a 2-year retest interval, young people ini- psychology. Similarly, the ratio of Form-Color
tially fluctuate considerably in their Rorschach to Color-Form responses, conceptualized as re-
scores but then show steadily increasing long- lating respectively to relatively reserved (ma-
term consistency as they grow older, which is ture) and relatively intense (immature) affec-
consistent with the gradual consolidation of tive expression, shifts gradually from a Color-
personality characteristics during the develop- Form to a Form-Color preference during the
mental years (Exner, 2003, chap. 11). childhood and adolescent years, which is con-
Rorschach critics have argued that the reli- sistent with what is known about emotional
ability of the Rorschach is yet to be demon- maturation in young people (Exner, 2003, chap.
strated because only a portion of the CS vari- 12).
ables have been included in reports of retest
studies (Lilienfeld et al., 2000). This argument
Validity
is specious on two accounts. First, most of the
retest correlations identified as “missing” per- In the most thorough study of Rorschach va-
tain either to composite variables for which re- lidity available in the literature, Hiller, Rosen-
liable data are available for their component thal, Bornstein, Berry, and Brunell-Neuleib
parts or to variables that do not occur with suf- (1999) conducted a meta-analysis based on a
ficient frequency to allow for meaningful sta- random sample of Rorschach and MMPI re-
tistical treatment. Second, some variables are search studies published from 1977 to 1997 in
more critical to the interpretive process than which there was at lest one external (nontest)
 37 • rorschach assessment: scientific status and clinical utility 175

variable and in which some reasonable basis had The mean X-% ranges from .07 in nonpatients
been posited for expecting associations between to .16 in outpatients, .20 in depressed inpatients,
variables. Their analysis of 2,276 Rorschach and .37 in schizophrenic inpatients. The mean
protocols and 5,007 MMPI protocols produced WSum6 for these four groups, respectively, are
the following results: 4.48, 9.36, 18.36, and 42.17 (Exner, 2003, chap.
12). Viglione and Hilsenroth (2001) and Weiner
1. The average effect sizes in these studies in- (2001) provide overviews of a vast body of spe-
dicated almost identical validity for the cific research studies demonstrating the validity
Rorschach and the MMPI. The unweighted of Rorschach assessment.
mean validity coefficients were .29 for Rorschach critics have nevertheless argued
Rorschach variables and .30 for MMPI vari- that validity data for the Rorschach are not suf-
ables. ficient to warrant its use. In view of the Hiller
2. According to Hiller et al. (1999), the validity et al. (1999) findings, this argument would im-
for both the Rorschach and the MMPI “is ply that practicing psychologists should not use
about as good as can be expected for person- the MMPI either, or most other currently avail-
ality tests” (p. 291), and the average effect able personality assessment instruments, for
sizes warrant examiner confidence in using that matter. The critics have contended that the
both measures for their intended purposes. Hiller et al. meta-analysis is flawed, which
3. The MMPI correlated more highly than the seems unlikely given the care with which it was
Rorschach with psychiatric diagnosis and conducted and the methodological sophistica-
self-reports (average effect sizes of .37 and tion of those who conducted it (see Rosenthal,
.18, respectively). On the other hand, Ror- Hiller, Bornstein, Berry, & Brunell-Neulieb,
schach variables showed higher effect sizes 2001). Critics have pointed out that the
than MMPI variables in predicting behavioral Rorschach does not correlate well with the
outcomes, such as whether patients continue MMPI, while ignoring not only method differ-
in or drop out of treatment (mean validity co- ences between the instruments, but also re-
efficients of .37 and .20, respectively). These search showing that RIM and MMPI correlate
differences found by Hiller et al. probably re- quite well when people respond to both instru-
flect method variance between these two in- ments in either an open or guarded manner, as
struments, with the self-report format of the opposed to being forthcoming on one and de-
MMPI resembling the basis on which psy- fensive on either or both (Meyer, 1997) They
chiatric diagnoses are made, and the perfor- have noted that the Rorschach does not corre-
mance-based Rorschach being more sensitive late well with psychiatric diagnosis, while not
to persistent behavioral dispositions. acknowledging that it is neither designed nor
intended to do.
In addition to providing theoretically consis-
tent information about developmental progres-
Normative Reference Base
sion in nonpatient children age 5 to 16, the CS
reference include 600 nonpatient adults and As already indicated, the Rorschach Compre-
adult samples of 535 psychiatric outpatients, 279 hensive System includes normative reference
patients hospitalized with major depressive dis- data on nonpatient adults (n = 600), children
order, and 328 patients hospitalized with a first age 5 to 16 (1,390), and several patient groups.
admission for schizophrenia. These four groups Because the adult nonpatient data were col-
can be expected, on average, to constitute a con- lected mainly between 1974 and 1986, there has
tinuum of increasingly severe psychological dis- been concern that they may be outdated and in
turbance. Consistent with expectation, posited need of revision. Exner (2003, chap. 12) has ac-
Rorschach indices of impaired reality testing cordingly undertaken a new normative study in
(X-%) and disordered thinking (WSum6) in- which, as in his original work, well-functioning
crease in linear fashion across these groups, thus nonpatient adults are being examined in differ-
supporting them as measures of disturbance. ent parts of the country by experienced exam-
176 part ii • psychological testing

iners. As of this writing, data have been tabu- less than zero in just 17% and less than –1 in
lated for 350 persons in the new normative just 5%.
sample. With some minor exceptions having
minimal interpretive significance, the new ref-
erence data are strikingly similar to the older CLINICAL UTILITY
data and have thus far not called for any note-
worthy modifications in interpretive strategy. Rorschach assessment facilitates decision mak-
Rorschach critics have alleged that the CS ing in clinical practice by identifying personal-
overpathologizes by identifying people as psy- ity characteristics that have implications for
chologically disturbed when they are not differential diagnosis and treatment planning.
(Wood, Nezworski, Garb, & Lilienfeld, 2001). Although the Rorschach is not a diagnostic test
This allegation is based in part on a normative and should not be used as the sole basis for di-
study conducted in northern California that agnosing psychological disorder, Rorschach
showed some differences from the CS reference variables can reveal aspects of maladaptive
data in frequency of pathological indicators. functioning that are associated with particular
However, the critics have ignored methodolog- conditions. As cases in point, Rorschach indices
ical shortcomings of this study that have been of disordered thinking (elevated WSum6) and
pointed out in the literature, including a small impaired reality testing (poor form quality)
(n = 123) and demographically unrepresenta- assist in identifying schizophrenia; indices of
tive sample and the use of inexperienced exam- dysphoric mood (achromatic color and color-
iners to collect the data (Meyer, 2001). shading blends) and pessimistic thinking (mor-
The allegation of overpathologizing is addi- bid contents) assist in identifying depression;
tionally based on control sample data, collected and indices of subjectively felt distress (D and
from 32 diverse studies, that also differ from AdjD scores) assist in identifying anxiety dis-
CS nonpatient data. However, the samples in orders.
these studies do not qualify as representative Along with helping to clarify the diagnostic
samples of nonpatient adults. The critics fail to status of persons seen clinically, Rorschach
mention that 16 of these 32 samples constituted findings contribute to treatment planning by
college students or elderly persons, who com- identifying personality characteristics that have
monly produce atypical test responses when implications for the types of intervention that
serving as volunteer participants in research are likely to prove effective, the kinds of prob-
studies. Five of the samples included current or lems or concerns that should be treatment tar-
former psychiatric patients, and 11 others were gets, and the nature of possible obstacles to
recruited without any mental health screening. progress in therapy that can be anticipated
Finally of note, participants in some of these (Weiner, 1999).
samples were given the Rorschach under un- In forensic settings, Rorschach indications of
usual conditions, such as being instructed to re- psychosis, depression, and anxiety disorders of-
main motionless during the testing (Meyer, ten have a bearing on legal determinations re-
2001). lating to a person’s competence to proceed, san-
As for the new CS normative study in ity at the time of an alleged offense, and the ex-
process, the existence of which has yet to be ac- tent of psychic trauma in personal injury cases.
knowledged by Rorschach critics, the 350 non- In family-law cases involving questions of cus-
patient adults examined so far have shown no tody and visitation rights, Rorschach informa-
indication of overpathologizing. With reference tion concerning the personality strengths and
to four key CS indices of psychological disorder, limitations of parents and the special needs of
the Perceptual Thinking Index is elevated (PTI their children frequently assist judges in arriv-
> 3) in just 1 (0%) of these 350 nonpatients; the ing at their decisions.
Depression Index is elevated (DEPI > 4) in just Some Rorschach critics have alleged that the
38 (11%); the Coping Deficit Index is elevated RIM does not meet current standards for ad-
(CDI > 3) in just 25 (7%); and the D-Score is mission into evidence in the courtroom (Grove
 37 • rorschach assessment: scientific status and clinical utility 177

& Barden, 1999). Logical reasoning and empir- J. E., Jr., Fowler, J. C., Pers, C. C., et al. (2002).
ical fact, as summarized by Ritzler, Erard, and An examination of interrater reliability for
Pettigrew (2002), prove them mistaken in this scoring the Rorschach in eight data sets. Journal
regard. of Personality Assessment, 78, 219 –274.
Ritzler, B., Erard, R., & Pettigrew, G. (2002). Pro-
Finally with respect to organizational set-
tecting the integrity of Rorschach expert wit-
tings, the RIM can be used with good effect in
nesses: A reply to Grove and Barden (1999) re:
the selection and evaluation of personnel. Per- The admissibility of testimony under Daubert/
sonnel decisions are typically based in part on Kumho analysis. Psychology, Public Policy, and
personality characteristics considered relevant the Law, 8, 201–215.
to whether a person should be hired to fill a par- Rosenthal, R., Hiller, J. B., Bornstien, R. F., Berry
ticular job, promoted to a position of responsi- D. T. R., & Brunell-Neuleib, S. (2001). Meta-
bility, or considered fit to return to a previously analytic methods, the Rorschach, and the MMPI.
held position. Rorschach findings concerning Psychological Assessment, 13, 449 – 451.
these characteristics accordingly facilitate these Society for Personality Assessment. (n.d.). Home
decisions. page. Retrieved 2004 from http://www.person
ality.org
Viglione, D. J., & Hilsenroth, M. J. (2001). The
References, Readings, & Internet Sites Rorschach: Facts, fictions, and future. Psycho-
Exner, J. E., Jr. (2003). The Rorschach: A comprehen- logical Assessment, 13, 452– 471.
sive system. Vol. 1. Basic foundations and prin- Viglione, D. J., & Taylor, N. (2003). Empirical support
ciples of interpretation (4th ed.). Hoboken, NJ: for interrater reliability of Rorschach Compre-
Wiley. hensive System coding. Journal of Clinical Psy-
Grove, W. M., & Barden, R. C. (1999). Protecting the chology, 59, 111–121.
integrity of the legal system: The admissibility Weiner, I. B. (1999). Rorschach Inkblot Method. In
of testimony from mental health experts under M. Maruish (Ed.), The use of psychological
Daubert/Kumho analysis. Psychology, Public testing in treatment planning and outcome
Policy, and the Law, 5, 224 –242. evaluation (2nd ed., pp. 1123 –1156). Mahwah,
Hiller, J. B., Rosenthal, R., Bornstein, R. F., Berry, D. NJ: Erlbaum.
T. R., & Brunell-Neuleib, S. (1999). A compar- Weiner, I. B. (2001). Advancing the science of psy-
ative meta-analysis of Rorschach and MMPI va- chological assessment: The Rorschach Inkblot
lidity. Psychological Assessment, 11, 278 –296. Method as exemplar. Psychological Assessment,
International Rorschach Society. (n.d.). Home page. 13, 423 – 432.
Retrieved 2004 from http://www.rorschach.com Weiner, I. B. (2003). Principles of Rorschach inter-
Lilienfeld, S. O., Wood, J. M., & Garb, H., N. (2000). pretation (2nd ed.). Mahwah, NJ: Erlbaum.
The scientific status of projective techniques. Wood, J. M., Nezworski, M. T., Garb, H. N., &
Psychological Science in the Public Interest, 1, Lilienfeld, S. O. (2001). The misperception of
27 –66. psychopathology: Problems with the norms of
Meyer, G. J. (1997). On the integration of personal- the Comprehensive System of the Rorschach.
ity assessment methods: The Rorschach and Clinical Psychology, 8, 350 –373.
MMPI. Journal of Personality Assessment, 68,
Related Topics
297 –330.
Meyer, G. J. (2001). Evidence to correct mispercep- Chapter 35, “Thumbnail Guide to the Rorschach
tions about Rorschach norms. Clinical Psychol- Method”
ogy: Science and Practice, 8, 389 –396. Chapter 36, “Rorschach Assessment: Questions and
Meyer, G. J., Hilsenroth, M. J., Baxter, D., Exner, Reservations”
This page intentionally left blank
PART III
Individual Psychotherapy
and Treatment
This page intentionally left blank
 PATIENTS’ RIGHTS IN
38 PSYCHOTHERAPY

Dorothy W. Cantor

Patients who enter psychotherapy have rights tion in confidence with the same rigor and
that psychologists are responsible for honoring subject to the same violation as the direct
and rights for which third-party payers and provider of care.
other entities are responsible. It is the obliga- • Information technology should be used
tion of treating psychologists to respect the for transmission, storage, or data manage-
rights of patients and, to the limits of their abil- ment only with methodologies that re-
ity, to assist patients to press third-party payers move individual identifying information
and other entities to do likewise. and assure the protection of the patients’
1. Confidentiality: Confidentiality is the cor- privacy. Information should not be trans-
nerstone of the psychotherapy process. There- ferred, sold, or otherwise utilized.
fore, patients have the right to be guaranteed
the protection of the confidentiality of their re- 2. Respectful treatment: Patients have the
lationship with a psychologist, except when right to courtesy, respect, dignity, responsive-
laws or ethics dictate otherwise. ness, and timely attention to their needs.
3. Respect for boundaries: Patients have
• Patients should not be required to disclose the right to expect their therapists to honor
confidential information, other than diag- the boundaries between them and not to in-
nosis, prognosis, type of treatment, time trude in areas that go beyond the therapeutic
and length of treatment, and cost. relationship.
• Patients should make only time-limited
disclosure with full written informed con- • Psychologists do not engage in sexual in-
sent. timacies with current patients or with for-
• Any entity receiving information about a mer patients for at least 2 years after
patient should maintain clinical informa- treatment has ended.

181
182 part iii • individual psychotherapy and treatment

• Psychologists do not accept persons with becomes reasonably clear that the patient
whom they have engaged in sexual inti- no longer needs the service, is not benefit-
macies as therapy patients. ing, or is being harmed by continued ser-
• Psychologists do not exploit patients. vice.
They refrain from entering into or prom- • Patients can expect that prior to termina-
ising another relationship— personal, sci- tion, whatever the reason, there will be a
entific, professional, financial, or other- discussion of their needs and views and
wise— with a patient. suggestions for alternative services and
that reasonable steps will be taken to fa-
4. Respect for individual differences: Pa-
cilitate transfer to another therapist, if ap-
tients have the right to quality treatment,
propriate.
without regard to race, color, religion, national
origin, gender, age, sexual orientation, or dis- 9. Parity: Patients have the right to receive
abilities. benefits for mental health and substance abuse
treatment on the same basis as for any other ill-
• Patients have the right to expect their
nesses, with the same provisions, copayments,
therapists to have competency in dealing
lifetime benefits, and catastrophic coverage in
with their individual differences.
both insurance and self-funded/self-insured
• Patients can expect their therapists to re-
health plans.
spect their values, attitudes, and opinions,
10. Right to know: Patients have the right
even when they differ from their own.
to full disclosure regarding terms of their
5. Knowledge of the psychologist’s profes- health insurance coverage.
sional expertise: Patients have the right to re-
• Benefits: Patients have the right to be pro-
ceive full information about the psychologist’s
vided information from the purchasing
knowledge, skills, preparation, experience, and
entity (such as employer, union, or pub-
credentials. They also have the right to be in-
lic purchaser) and the insurance/third-
formed about their options for treatment inter-
party payer describing the nature and ex-
ventions.
tent of their mental health and substance
6. Choice: Patients have the right to choose
abuse treatment benefits. This informa-
their therapists, according to their own prefer-
tion should include details on procedures
ences and without pressure from third-party
to obtain access to services, on utilization
payers to select from a limited panel.
management procedures, and on appeal
7. Informed consent to therapy: Patients
rights. The information should be pre-
have the right to informed consent. The lan-
sented clearly in writing with language
guage of that consent must be comprehensible.
that the individual can understand.
The patient should be informed of significant
• Contractual limitations: Patients have the
information concerning the treatment or as-
right to be informed by the psychologist of
sessment being entered into.
any arrangements, restrictions, and/or
8. Determination of treatment: Patients
covenants established between the third-
have the right to have recommendations about
party payer and the psychologist that
their treatment made by the treating psycholo-
could interfere with or influence treat-
gist in conjunction with them or their family, as
ment recommendations. Patients have the
appropriate. Treatment decisions should not be
right to be informed of the nature of in-
made by third-party payers. The patient has the
formation that may be disclosed for the
right to make final decisions regarding treat-
purposes of paying benefits.
ment.
• Appeals and grievances: Patients have the
• Patients have the right to continuity of care right to receive information about the
and to not be abandoned by their therapist. methods they can use to submit com-
• Patients can expect a psychologist to ter- plaints or grievances regarding provision
minate a professional relationship when it of care by the psychologist to the licensing
 39 • compendium of empirically supported therapies 183

board and to the professional association. • Payers and other third parties may be held
Patients also have the right to be provided accountable and liable to patients for any
information about the procedures they injury caused by gross incompetence or
can use to appeal benefit utilization deci- negligence or by their clinically unjusti-
sions to the third-party payer system, to fied decisions.
the employer or purchasing entity, and to
13. Benefit usage: Patients are entitled to
external regulatory entities.
the entire scope of the benefits within the ben-
11. Treatment review: To assure that treat- efit plan that will address their clinical needs.
ment review processes are fair and valid, pa- 14. Nondiscrimination: Patients who use
tients have the right to be guaranteed that any their mental health and substance abuse bene-
review of their mental health and substance fits shall not be penalized when seeking other
abuse treatment shall involve a professional health insurance or disability, life, or any other
having the training, credentials, and licensure insurance benefits.
required to provide the treatment in the juris-
diction in which it will be provided. The re- References & Readings
viewer should have no financial interest in the
decision and is subject to the section on confi- American Psychological Association. (1992). Ethical
principles of psychologists and code of conduct.
dentiality.
American Psychologist, 47, 1597 –1611.
12. Accountability: Patients have the right Mental Health Bill of Rights Project. (1997). Princi-
to have both the psychologist treating them and ples for the provision of mental health and sub-
the third-party payer be accountable to them. stance abuse treatment services. Independent
• Psychologists may be held accountable Practitioner, 17(2), 57 – 58.
and liable to individuals for any injury
caused by gross incompetence or negli- Related Topics
gence on the part of the professional. The Chapter 125, “Sample Psychotherapist-Patient Con-
psychologist has the obligation to advo- tract”
cate for and document necessity of care Chapter 127, “Basic Elements of Consent”
and to advise the patient of options if pay- Chapter 131, “Contracting With Managed Care Or-
ment authorization is denied. ganizations”

COMPENDIUM OF
39 EMPIRICALLY SUPPORTED
THERAPIES

Dianne L. Chambless

Beginning in 1993, the Division (now Society) chological Association has sponsored an en-
of Clinical Psychology of the American Psy- deavor to identify empirically supported psy-
184 part iii • individual psychotherapy and treatment

chological interventions and to publicize their essarily incomplete: Not all treatments have
existence to clinical psychologists, training pro- yet been reviewed, and new evidence for treat-
grams, and consumers (Task Force, 1995). The ments emerges monthly.
goals are to serve the public and the profession A number of factors need to be taken into ac-
by (1) helping psychologists and training pro- count in using these lists. First, the task forces
grams readily identify promising treatments have concentrated on specific treatments for
upon which their training efforts might, in specific psychological problems. That psycho-
part, be focused; (2) aiding psychologists in therapy in general is beneficial for the average
practice by providing data to support their adult psychotherapy client is well known. The
choice of psychological interventions and the lists of ESTs represent an attempt to provide
efficacy of their treatment in order to make their more focused information. Second, the task
services available and to obtain reimbursement forces have followed a number of decision rules
for them; and, more recently, (3) providing in- in determining what is sufficient evidence for
formation for the public about evidence-based listing a treatment. Decisions are largely based
psychotherapies. This effort is akin to move- upon randomized controlled studies that passed
ments within American psychiatry and medi- muster for methodological soundness, and the
cine in Britain (Sackett, Richardson, Rosenberg, preponderance of the data across studies must
& Haynes, 1997) to foster evidence-based prac- have been positive (Chambless & Hollon, 1998).
tice by educating clinicians about the research Third, broad generic labels (e.g., cognitive-
base for practice. Within clinical psychology, behavior therapy) may be misleading. Readers
this work may be seen as a logical extension of should check the original sources to determine
the Boulder model of scientist-practitioner the precise treatment procedures used in studies
training. providing efficacy evidence. Finally, the absence
A succession of task forces appointed by of a treatment from the tables does not mean it
presidents of the Division of Clinical Psychol- is ineffective. It may or may not be. No listing
ogy have constructed and elaborated lists of may simply reflect a dearth of data.
empirically supported treatments (ESTs, also In their 2001 review, Chambless and Ollen-
called empirically validated therapies) for dick compiled the work of eight major efforts to
adults and children. Other professional groups identify ESTs conducted in the United States or
have joined in this effort. These lists are nec- Great Britain. In Tables 1 and 2, the groups are

table 1. Empirically Supported Therapies for Adults: Summary Across Work Groups
Probably Efficacious/
Well-Established/ Efficacious or Experimental/
Efficacious and Specific Possibly Efficacious Promising
Category I Category II Category III

Anxiety and Stress

Agoraphobia/Panic Disorder with Agoraphobia

CBT A, E? F E?
Couples communication training A, D
as adjunct to exposure
Exposure A, D, E? F E?
Partner-assisted CBT D, F
Blood Injury Phobia
Applied tension F E
Exposure E
Generalized Anxiety Disorder
Applied relaxation F A, D, E
CBT A, D, E? F E?
 39 • compendium of empirically supported therapies 185

table 1. (continued)
Probably Efficacious/
Well-Established/ Efficacious or Experimental/
Efficacious and Specific Possibly Efficacious Promising
Category I Category II Category III

Geriatric Anxiety
CBT F
Relaxation F
Obsessive-Compulsive Disorder
Exposure and response prevention A, D, E?, F E?
Cognitive therapy A, D E
RET and exposure E
Family-assisted ERP and relaxation D
Relapse prevention A
Panic Disorder
Applied relaxation F A, D, E
CBT A, D, E? F E?
Emotion-focused therapy F
Exposure E? D, E?
Post-Traumatic Stress Disorder
EMDR A (civilian only), D
Exposure F A, D
Stress inoculation F A, D
Stress inoculation combined with CT and
exposure E? E? F
Structured psycho-dynamic treatment E
Public Speaking Anxiety
Systematic desensitization A
Social Anxiety/Phobia
CBT E? F A, D, E?
Exposure E? A, D, E? F
Systematic desensitization A
Specific Phobia
Exposure A, E? F E?
Systematic desensitization A
Stress
Stress inoculation A

Chemical Abuse and Dependence

Alcohol Abuse and Dependence

Community reinforcement E? F? A, D, E? F?
Cue exposure A, D
Cue exposure therapy and urge coping skills D
Motivational interviewing E? E?
BMT and disulfiram E? F? A, D, E? F?
Social skills training with inpatient treatment E? F? A, D, E? F?
Benzodiazepine Withdrawal for Panic Disorder
CBT A
Cocaine Abuse
Behavior therapy A
CBT relapse prevention A, D
Opiate Dependence
Behavior therapy (reinforcement) D
Brief dynamic therapy A, D
Cognitive therapy A, D

(continued)
186 part iii • individual psychotherapy and treatment

table 1. Empirically Supported Therapies for Adults: Summary Across Work Groups (continued)
Probably Efficacious/
Well-Established/ Efficacious or Experimental/
Efficacious and Specific Possibly Efficacious Promising
Category I Category II Category III

Depression

Bipolar Disorder
CBT for medication adherence F
Family therapy F
Psychoeducation F
Geriatric Depression
Behavior therapy E? F E? G
Brief dynamic therapy E? F E? G
CBT E? F A, E? G
Interpersonal therapy F
Problem-solving therapy F, G
Psychoeducation F
Reminiscence therapy F (mild-moderate) A, G
Major Depression
Behavior therapy A, F D
BMT (for MDD conjoint with marital
distress) F D
Brief dynamic therapy A E
CBT A, D, E? F E?
Interpersonal therapy A, E? F D, E?
Self-control therapy A, F
Social problem solving A, D

Health Problems

Anorexia
Behavioral family systems therapy F
Behavior therapy E? E?
Cognitive therapy E? E?
Family therapy F Patients < 19 years old
Binge-Eating Disorder
Comprehensive behavioral weight loss program F
CBT F A
Interpersonal therapy A, F
Bulimia
CBT A, E? F D, E?
Interpersonal therapy E? A, D, E? F
Chemotherapy Side Effects (for Cancer Patients)
Progressive muscle relaxation with or without
guided imagery D
Chronic Pain (Heterogeneous)
CBT with physical therapy A, D, H
EMG biofeedback A
Operant behavior therapy A, D
Chronic Pain (Back)
CBT H A, D
Operant behavior therapy D
Headache
Behavior therapy A
Idiopathic Pain
CBT H
 39 • compendium of empirically supported therapies 187

table 1. (continued)
Probably Efficacious/
Well-Established/ Efficacious or Experimental/
Efficacious and Specific Possibly Efficacious Promising
Category I Category II Category III

Irritable Bowel Syndrome

Cognitive therapy A, D
Hypnotherapy D
Multicomponent CBT A, D
Migraine
EMG biofeedback and relaxation D
Thermal biofeedback and relaxation training A, D
Obesity
Hypnosis with CBT A
Raynaud’s
Thermal biofeedback A
Rheumatic Disease Pain
Multicomponent CBT A, D, H
Sickle Cell Disease Pain
Multicomponent cognitive therapy A
Smoking Cessation
Group CBT D
Multicomponent CBT with relapse prevention A, D
Scheduled reduced smoking with multicomponent
behavior therapy A, D
Somatoform Pain Disorders
CBT F

Marital Discord

BMT A, D
CBT D
Cognitive therapy D
Emotion-focused couples therapy A (no more than moderately
distressed), D
Insight-oriented marital therapy A, D
Systematic therapy D

Sexual Dysfunctiona

Erectile Dysfunction
Behavior therapy aimed at reducing sexual anxiety and
improving communication E? E?
CBT aimed at reducing sexual anxiety and improving
communication E? E?
Female Hypoactive Sexual Desire
Hurlbert’s combined therapy A, D
Zimmer’s combined sex and marital therapy A, D
Female Orgasmic Disorder/Dysfunction
BMT with Masters and Johnson’s therapy D
Masters and Johnson’s sex therapy A, D
Sexual skills training D
Premature Ejaculation
Behavior therapy E
Vaginismus
Exposure-based behavior therapy E? E?

(continued)
188 part iii • individual psychotherapy and treatment

table 1. Empirically Supported Therapies for Adults: Summary Across Work Groups (continued)
Probably Efficacious/
Well-Established/ Efficacious or Experimental/
Efficacious and Specific Possibly Efficacious Promising
Category I Category II Category III

Other

Avoidant Personality Disorder

Exposure F
Social skills training E? E? F
Borderline Personality Disorder
Dialectical behavior therapy E? A, E? F
Body Dysmorphic Disorder
CBT F
Dementia
Behavioral interventions applied at environmental level
for behavior problems G
Memory and cognitive training for slowing cognitive
decline G
Reality orientation G E
Geriatric Caregivers
Psychoeducation G
Psychosocial interventions E? E?
Hypochondriasis
CBT F
Paraphilias/Sex Offenders
Behavior therapy A
CBT F
Schizophrenia
Assertive case management F
Behavior therapy and social learning/token economy
programs F
Clinical case management F
Cognitive therapy (for delusions) E, F
Behavorial family therapy D, E? F A, E?
Family systems therapy D
Social learning programs F
Social skills training F A, D
Supportive group therapy F
Supportive long-term family therapy D
Training in Community Living program F
Severely Mentally Ill
Supported employment A, F
Sleep Disorders
Behavior therapy F
CBT (for geriatric sleep disorders) G
Unwanted Habits
Habit reversal and control techniques A

Source: From “Empirically Supported Psychological Interventions: Controversies and Evidence,” Chambless and Ollendick, 2001. Reprinted,
with permission, from the Annual Review of Psychology, Volume 52, © 2001 by Annual Reviews (www.annualreviews.org).
? = unclear from authors’ description whether the treatment belongs in Category I or II; CBT = cognitive behavior therapy; BMT = behav-
ioral marital therapy; ERP = exposure plus ritual prevention; CT = cognitive therapy; EMG = electromyographic; EMDR = eye movement de-
sensitization and reprocessing.
aGroup F’s review of sexual dysfunction did not describe the treatments clearly enough to categorize them here.

Workgroups: A = Task Force, Chambless et al., 1998; B = Special Section of Journal of Pediatric Psychology (Spirito, 1999); C = Special Sec-
tion of Journal of Clinical Child Psychology (Lonigan & Elbert, 1998); D = Special Section of Journal of Consulting and Clinical Psycology
(Kendall & Chambless, 1998); E = What Works for Whom? (Roth & Fonagy, 1996); F = A Guide to Treatments That Work (Nathan & Gor-
man, 1998); G = Gatz et al., 1998; H = Wilson & Gil, 1996.
 39 • compendium of empirically supported therapies 189

table 2. Empirically Supported Therapies for Children and Adolescents: Summary Across Work Groups
Probably Efficacious/
Well-Established/ Efficacious or Experimental/
Efficacious and Specific Possibly Efficacious Promising
Category I Category II Category III

ADHD
Behavioral parent training C
Behavior modification in classroom C F
Long-term multimodal therapy E
Anxiety Disorders (Separation Anxiety, Avoidant
Disorder, Overanxious Disorder)
CBT A, C E
CBT and family AMT A, C
Pyschodynamic psychotherapy E
Chronic Pain (Musculoskeletal Disorders)
CBT B
Conduct Disorder and Oppositional Defiant Disorder
Anger control training with stress inoculation (adolescents) C
Anger coping therapy (children) C
Assertiveness training C
CBT E? E?
Cognitive problem-solving skills F
Delinquency prevention program C
Functional family therapy F
Multisystemic therapy F
Parent-child interaction therapy C
Living with Children (children) C
Parent training based on Living with Children (children) A, E? F C, E?
Parent training based on Living with Children
(adolescents) C, F
Problem-solving skills training C
Rational emotive therapy C
Time-out plus signal seat treatment C
Videotape-modeling parent training C
Depression
Coping with Depression course with skills training (adolescents) C
CBT (children) C
Disruptive Disorders
Structural family therapies E
Distress Due to Medical Procedures (mainly for cancer)
CBT B
Encopresis
Behavior modification E? A, E?
Enuresis
Behavior modification A, E? E?
Obesity
Behavior therapy A
Obsessive-Compulsive Disorder
Exposure and response prevention E
Phobias
CBT C
Filmed modeling C
Imaginal desensitization C
In vivo desensitization C
Live modeling C
Participant modeling C
Rapid exposure (school phobia) E? E?
Reinforced practice C A
(continued)
190 part iii • individual psychotherapy and treatment

table 2. Empirically Supported Therapies for Children and Adolescents: Summary Across Work Groups
(continued)

Probably Efficacious/
Well-Established/ Efficacious or Experimental/
Efficacious and Specific Possibly Efficacious Promising
Category I Category II Category III

Psychophysiological Disorder
Family therapy E? E?
Psychodynamic psychotherapy E
Pervasive Developmental Disorders, Undesirable Behavior In
Contingency management E? E?
Recurrent Abdominal Pain
CBT D, F
Recurrent Headache
Biofeedback with self-hypnosis B
Relaxation/self-hypnosis B
Thermal biofeedback B

Source: From “Empirically Supported Psychological Interventions: Controversies and Evidence,” Chambless and Ollendick, 2001. Reprinted,
with permission, from the Annual Review of Psychology, Volume 52, © 2001, by Annual Reviews (www.annualreviews.org).
ATM = anxiety management training. See footnote in Table 1 for definition of other abbreviatons.

identified by letters: A for the original Division groups in the evidence base required for various
12 task force (Chambless et al., 1998); B for a EST classifications, and because Nathan and
special section of Journal of Pediatric Psychol- Gorman did not establish categories. In addi-
ogy (Spirito, 1999); C for a special issue of Jour- tion, because Roth and Fonagy did not distin-
nal of Clinical Child Psychology (Lonigan & El- guish between Category I and II treatments,
bert, 1998); D for a special section of Journal of their ESTs are listed in the tables under both
Consulting and Clinical Psychology (Kendall & these categories with a question mark. Finally,
Chambless, 1998); E for Roth and Fonagy’s not all work groups listed promising (Category
(1996) review for the British National Health III) treatments; those doing so were groups B,
Service; F for a separate Division 12 effort, E, and F.
Nathan and Gorman’s (1998) A Guide to Treat- Table 1 lists ESTs for adults, including geri-
ments That Work; G for Gatz et al.’s (1998) re- atric clients, and Table 2 lists ESTs for children.
view of treatments for the elderly; and H for Some treatments were reviewed by only one
Wilson and Gil’s (1996) review of treatments for (or some subset) of the work groups. However,
pain. when more than one group evaluated a given
For purposes of comparison, treatments are treatment, the agreement across groups was re-
grouped into three rough categories indicating markable, given the differences among review-
level of support, with Category I being the ers in theoretical orientation and work-group
highest. These take into account the number of membership. Thus, it appears that psychologi-
studies available and their experimental rigor. cal interventions can be reliably evaluated, but
Category I refers to well established or effica- this does not speak to the question of whether
cious and specific treatments; Category II to treatments should be so evaluated.
probably efficacious, efficacious, or possibly ef- The EST projects have been lauded and con-
ficacious treatments; and Category III to treat- demned (Chambless & Ollendick, 2001). Those
ments that show promise pending further in- who favor it appear to be those who believe that
vestigation (see Chambless & Ollendick, 2001, training in specific psychological interventions
for additional details). These categories do not is meaningful — that is, that there are impor-
map precisely on those used by the different tant differences among approaches to psycho-
work groups because of differences among the therapy and among approaches for different dis-
 39 • compendium of empirically supported therapies 191

orders. Those who believe that individual dif- pirically supported therapies is now specified in
ference variables (e.g., characteristics of the the Guidelines and Principles for Accreditation
client, the therapist, or the particular therapeu- of Programs in Professional Psychology (Amer-
tic relationship) are of the utmost importance in ican Psychological Association, 1996) for both
treatment outcome find EST lists less useful, as internships and doctoral training programs.
do those who believe that psychologists are not Thus, future generations of students should
yet able to define clients’ problems or even our have exposure to one or more evidence-based
interventions in terms meaningful enough to treatments. Training for those in practice is
allow fruitful matching of treatments to target likely to be more difficult, in that the various
problems. Indeed, there is still debate about the EST task forces have concluded that practition-
relative importance of symptom relief (the ma- ers wishing to learn a new EST sharply differ-
jor, although not the sole, focus of EST evi- ent from treatments in their current repertory
dence) versus less well specified goals like per- need supervised clinical work to acquire suf-
sonal growth, and whether the most important ficient skill for ethical practice. Better vehicles
changes clients make in experiential and psy- for continuing education than the current
chodynamic therapies can be reliably and validly 3-hour to 3-day workshops need to be devel-
assessed. oped.
Reactions to the EST lists also probably dif-
fer as a function of viewing the identification of References, Readings, & Internet Sites
evidence-based treatments as a support or a
threat to clinical practice. A review of Tables 1 American Psychological Association. (1996). Guide-
lines and principles for accreditation of pro-
and 2 will readily demonstrate that most, al-
grams in professional psychology. Washington,
though not all, of the treatments identified to DC: Author.
date are behavioral or cognitive-behavioral in Chambless, D. L., Baker, M., Baucom, D. H., Beut-
nature, reflecting the greater research activity ler, L. E., Calhoun, K. S., Crits-Christoph, P., et
of psychotherapy outcome researchers of that al. (1998). Update on empirically validated ther-
orientation. Some practitioners of other orien- apies, II. The Clinical Psychologist, 51(1), 3 –16.
tations have expressed fear that their access to http://pantheon.yale.edu/~tat22/empirically_
third-party payments will be reduced because supported_treatments.htm
they do not practice treatments on the list. Chambless, D. L., & Hollon, S. D. (1998). Defining
Other clinicians have found that they can draw empirically supported therapies. Journal of
on the list to promote the efficacy and desir- Consulting and Clinical Psychology, 66, 7 –18.
Chambless, D. L., & Ollendick, T. H. (2001). Empir-
ability of their treatment plans. To some de-
ically supported psychological interventions:
gree, this particular controversy also centers on Controversies and evidence. In S. T. Fiske, D. L.
the best ways to react to the escalating demands Schacter, & C. Zahn-Waxler (Eds.), Annual Re-
for more efficient use of health care dollars. view of Psychology (Vol. 52, pp. 685 –716). Palo
Finally, the EST movement seems to dis- Alto, CA: Annual Reviews.
please psychologists to the degree that they see Dissemination Subcommittee of the Committee on
identifying manualized efficacious treatments Science and Practice. (n.d.). A guide to beneficial
as threats to their autonomy and creativity. To psychotherapy. Retrieved May 30, 2003, from
the degree that one believes psychotherapy is Division 12, American Psychological Associa-
based upon artistry rather than science, an em- tion’s Web site: http://www.apa.org/divisions/
phasis on ESTs may be viewed as a restriction. div12/rev_est/index.html
EST Document Archive. (n.d.). Task force on psy-
Other psychologists see no reason that manual-
chological interventions document repository.
based treatments cannot be combined and al- Retrieved May 21, 2003, from Society for a Sci-
tered into a configuration best for a particular ence of Clinical Psychology’s Web site: http://
client. pantheon.yale.edu/~tat22/empirically_supported_
However controversial, the EST movement treatments.htm. Also available as Empirically
has gained sufficient credence that some didac- supported treatment documents. Retrieved May
tic instruction and clinical supervision in em- 30, 2003 from Division 12, American Psycho-
192 part iii • individual psychotherapy and treatment

logical Association’s Web site: http://www.apa. Haynes, R. B. (1997). Evidence-based medicine.

org/divisions/div12/journals.html New York: Churchill Livingstone.
Gatz, M., Fiske, A., Fox, L. S., Kaskie, B., Kasl-Godley, Spirito, A. (Ed.). (1999). Empirically supported treat-
J. E., McCallum, T. J., et al. (1998). Empirically ments in pediatric psychology. Journal of Pedi-
validated psychological treatments for older atric Psychology, 24, 87 –174.
adults. Journal of Mental Health and Aging, 4, Task Force on Promotion and Dissemination of Psy-
9 – 46. chological Procedures. (1995). Training in and
Kendall, P. C., & Chambless, D. L. (1998). Empiri- dissemination of empirically-validated psycho-
cally supported psychological therapies. Journal logical treatments: Report and recommenda-
of Consulting and Clinical Psychology, 66, tions. The Clinical Psychologist, 48(1), 3 –23.
3 –167. Wilson, J. J., & Gil, K. M. (1996). The efficacy of psy-
Lonigan, C. J., & Elbert, J. C. (1998). Special issue: chological and pharmacological interventions
Empirically supported psychosocial interven- for the treatment of chronic disease-related and
tions for children. Journal of Clinical Child non-disease-related pain. Clinical Psychology
Psychology, 27, 138 –226. Review, 16, 573 – 597.
Nathan, P. E., & Gorman, J. M. (Eds.). (1998). A
guide to treatments that work. New York: Ox-
Related Topics
ford University Press.
Roth, A. D., & Fonagy, P. (1996). What works for Chapter 40, “Compendium of Psychotherapy Treat-
whom? A critical review of psychotherapy re- ment Manuals”
search. New York: Guilford Press. Chapter 41, “Compendium of Empirically Supported
Sackett, D. L., Richardson, W. S., Rosenberg, W., & Therapy Relationships”

COMPENDIUM OF
40 PSYCHOTHERAPY
TREATMENT MANUALS

Michael J. Lambert, Taige Bybee, Ryan Houston,

Matthew Bishop, A. Danielle Sanders,
Ron Wilkinson, & Sara Rice

The earliest treatment manuals were developed ent treatments under investigation (Crits-
in the 1960s. Manuals were originally created Christoph et al., 1991; Luborsky & Barber,
to provide specific definitions of treatment pa- 1993). Manuals have also been used to train and
rameters for psychotherapy research (Strupp, guide novice therapists (Moras, 1993) and have
1992). By utilizing manuals in clinical trials, now become a means of delivering empirically
researchers can reduce variability among ther- supported treatments (Addis, 1997).
apists by assuring their adherence to the differ- In clinical practice, the manuals have several
 40 • compendium of psychotherapy treatment manuals 193

advantages. Manuals provide a succinct theoret- nonspecific and relationship factors (Norcross,
ical framework for treatment, concrete descrip- 2002), and the inadequacy of manuals for inte-
tions of therapeutic techniques, and case exam- grative approaches (Goldfried, 1993).
ples of appropriate applications (Addis, 1997). It is in light of the possible advantages af-
The increased precision in detailing treatment forded by treatment manuals and with consid-
techniques has generated much enthusiasm eration of concerns regarding them that we pre-
among professionals and third-party providers sent the following inventory of current treat-
(Strupp & Anderson, 1997). ment manuals. Substantial reviews have taken
However, others have expressed concerns place emphasizing empirically supported treat-
over the use of treatment manuals in clinical ments (ESTs; Chambless & Ollendick, 2001)
practice. Among these concerns are questions for particular disorders or problems. Not all of
regarding treatment efficacy and therapist ad- the treatment manuals listed here have received
herence in clinical practice as opposed to con- extensive empirical support, but they have been
trolled research settings (Addis, 1997), the en- included for breadth of coverage and clinical in-
genderment of therapist rigidity and inflexibil- terest.
ity (Lambert & Ogles, 1988), the neglect of The manuals shown in Table 1 are grouped

table 1. Treatment Manuals

Theoretical Patient Therapy
Author/Year Title Orientation Population Modality Strengths

Anxiety Disorders
Barlow & Cerny Psychological Treatment of Panic CBT Panic disorder Individual 1, 2, 3, 4
(1988)
Beck, Emery, & Anxiety Disorders and Phobias: Cognitive Phobias Individual 1, 2, 3
Greenberg (1985) A Cognitive Perspective
Bouman & Emmel- “Panic Disorder and Agoraphobia” CBT Agoraphobia Individual 1, 2, 3
kamp (1996)a
Brown, O’Leary, & “Generalized Anxiety Disorder” Cognitive GAD Individual 1, 2, 3, 4
Barlow (2001)b
Clark & Salkovskis Treatment Manual for Focused Cognitive Panic disorder Individual 1, 2, 4
(1996) Cognitive Therapy for Panic
Disorder
Craske & Barlow “Panic Disorder and Agoraphobia” CBT Panic disorder and Individual, 1, 2, 3, 4,
(2001)b agoraphobia group 6
Dugas (2002)c “Generalized Anxiety Disorder” Behavioral GAD Individual 3, 4
Falsetti & Resnick Posttraumatic Stress Disorder Cognitive PTSD Individual 1, 4
(2001)
Foa & Franklin “Obsessive-Compulsive Disorder” CBT OCD Individual 1, 2, 3, 4
(2001)b
Gaston (1995) Dynamic Therapy for Posttraumatic Dynamic Trauma Individual 1, 2, 3
Disorder
Harris (1998) Trauma Recovery and Empowerment: Dynamic Trauma recovery, Group 1, 2, 3, 4,
A Clinician’s Guide for Working PTSD (mostly 6
with Women in Groups women)
Kozak & Foa “Obsessive-Compulsive Disorder” Behavioral OCD Individual 1, 2, 3
(1996)a
Resick & Calhoun “Posttraumatic Stress Disorder” CBT Rape victims Individual 1, 2, 3, 4
(2001)b w/ PTSD
Scholing, Emmel- “Cognitive-Behavioral Treatment of CBT Social phobia Individual 1, 2, 3, 4
kamp, & Van Social Phobia”
Oppen (1996)a

(continued)
194 part iii • individual psychotherapy and treatment

table 1. Treatment Manuals (continued)

Theoretical Patient Therapy
Author/Year Title Orientation Population Modality Strengths

Smucker & Dancu “Cognitive-Behavioral Treatment for CBT PTSD, adult Individual 1, 2, 3, 4
(1999) Adult Survivors of Childhood Trauma: survivors of
Imagery, Rescripting, and Reprocessing” trauma
Turk, Heimberg, “Social Anxiety Disorder” CBT Avoidant person- Group 1, 2, 3, 4
& Hope (2001)b ality disorder,
social anxiety
Turner & Beidel Treating Obsessive-Compulsive Behavioral OCD Individual 1, 2, ,3, 4
(1988) Disorder
White (2000) Treating Anxiety and Stress: A Group CBT Anxiety Group 1, 2, 3, 4
Psycho-Educational Approach disorders
Using Brief CBT

Affective Disorders
Beck, Rush, Shaw, Cognitive Therapy of Depression Cognitive Depression Individual, 1, 2, 3, 4,
& Emery (1979) 5
Becker, Heimberg, & Social Skills Training Treatment for Behavioral Depression Individual, 1, 2, 3
Bellack (1987) Depression group
Dick, Gallagher- Cognitive-Behavioral Therapy CBT Depressed older Individual, 4
Thompson, & adults
Thompson (1996)
Eells (1995)d “Relational Therapy for Grief Disorders” Dynamic Adjustment Individual 1, 2, 3, 4
difficulties
Freeman & Reinecke Cognitive Therapy of Suicidal Behavior: Cognitive Suicide Individual 1, 2, 3, 6
(1993) A Manual for Treatment
Gillies (2001)b “Interpersonal Psychotherapy for Interpersonal Depression: Individual 1, 2, 4
Depression and Other Disorders” postpartum,
adolescents,
HIV-seropositive,
late-life
Klerman, Weissman, Interpersonal Psychotherapy of Interpersonal Depression Individual 1, 2, 3, 4,
Rounsaville, & Depression 5
Chevron (1984)
Lewinsohn, The Coping With Depression Course: Behavioral Depression Group 1, 2, 3, 4
Antonuccio, A Psychoeducational Intervention
Steinmetz, & for Unipolar Depression
Teri (1984)
Luborsky, Mark, “Supportive-Expressive Dynamic Dynamic Depression Individual 1, 2, 3
Hole, Popp, Psychotherapy of Depression: A
Goldsmith, & Time-Limited Version”
Cacciola (1995)d
Miklowitz (2001)b “Bipolar Disorder” Family focused Bipolar disorder, Individual, 1, 2, 3, 4
treatment families of those family,
with bipolar couple
disorder
Otto & Reilly- “Cognitive-Behavioral Therapy for the CBT Bipolar disorder Individual 2, 4
Harrington Management of Bipolar Disorder”
(2002)e
Rosselló & Bernal Adapting Cognitive-Behavioral and CBT, Depressed Puerto Individual 1, 2, 4, 6
(1996) Interpersonal Treatments for De- interpersonal Rican adoles-
pressed Puerto Rican Adolescents cents
Swartz, Markowitz, “Interpersonal Psychotherapy for Interpersonal Bipolar disorder, Individual 1, 2, 4
& Frank (2002)e Unipolar and Bipolar Disorders” depression
Thase (1996)a “Cognitive Behavior Therapy Manual CBT Depressed Individual 1, 2, 3, 4
for Treatment of Depressed Inpatients” inpatients
 40 • compendium of psychotherapy treatment manuals 195

table 1. (continued)
Theoretical Patient Therapy
Author/Year Title Orientation Population Modality Strengths

Yost, Beutler, Group Cognitive Therapy: A Treat- Cognitive Depression Group 1, 2, 3, 4

Corbishley, & ment Approach for Depressed
Allender (1986) Older Adults
Young, Weinberger, “Cognitive Therapy for Depression” Cognitive Depression Individual 1, 2, 3, 4
& Beck (2001)b

Childhood Adolescent Disorders

Anastopoulos (1998)f “A Training Program for Parents of Parent Childhood Parent(s) 1, 2, 3, 4
Children with Attention-Deficit/ training ADHD
Hyperactivity Disorder”
Barkley (1998) Attention-Deficit Hyperactivity CBT ADHD Individual, 1, 2, 3, 4
Disorder: A Handbook of Diagnosis family
and Treatment
Bratton (1998)f “Training Parents to Facilitate Their Parent Adjustment Parent(s) 1, 2, 3, 4
Child’s Adjustment to Divorce Using training disorders,
Filial/Family Play Therapy Approach” children of
divorce
Camino (2000) Treating Sexually Abused Boys Empowerment Sexually abused Group, 2, 3, 4
boys individual
Eisen, Engler, & “Parent Training for Separation Parent Separation Parent(s) 1, 2, 3, 4
Geyer (1998)f Anxiety Disorder” training anxiety
disorder
Everett & Everett Family Therapy for ADHD: Treating Family ADHD Family 3, 4
(1999) Children, Adolescents, and Adults systems
Fouse & Wheeler A Treasure Chest of Behavioral Behavioral, Autistic Individual, 1, 2, 3, 4
(1997) Strategies for Individuals with systems children group
Autism
Franklin, Rynn, “Obsessive-Compulsive Disorder” Behavioral OCD Individual/ 1, 2, 3
March, & Foa systems
(2002)c
Landreth (1991) Play Therapy: The Art of the Dynamic Children Individual, 1, 2, 3, 4
Relationship group
March & Mulle “Banishing OCD: Cognitive-Behavioral CBT OCD Individual 1, 3, 4
(1996)g Psychotherapy for Obsessive-
Compulsive Disorders”
O’Connor (2000) The Play Therapy Primer Ecosystemic Children Individual, 1, 2, 3, 4
group
Reynolds (2002)c “Childhood Depression” Behavioral Depression Individual 3, 4
Roach & Gross “Conduct Disorder” Behavioral Conduct Individual 3, 4
(2002)c disorder
Rotherman-Borus, “Treatment of Suicidality: A Family CBT Outpatient Family 3, 4
Goldstein, & Intervention for Adolescent Suicide families of
Elkavich (2002)e Attempters” suicidal
adolescents
Sells (1998) Treating the Tough Adolescent: A Family Conduct disorder, Family 1, 2, 3, 4
Family-Based, Step-by-Step Guide systems oppositional
defiant disorder
Weiss & Wolchik “New Beginnings: An Empirically- Group parent Adjustment Group 1, 2, 3, 4
(1998)f Based Intervention Program for training disorders,
Divorced Mothers to Help Their children of
Children Adjust to Divorce” divorce
Wolfson (1998)f “Working with Parents on Developing Parent Infant/childhood Parent(s) 1, 2, 3, 4
Efficacious Sleep/Wake Habits for training sleep disorders
Infants and Young Children”
(continued)
196 part iii • individual psychotherapy and treatment

table 1. Treatment Manuals (continued)

Theoretical Patient Therapy
Author/Year Title Orientation Population Modality Strengths

Dissociative Identity Disorders

Kluft (1995)d “Psychodynamic Psychotherapy of Dynamic Dissociative Individual 1, 2, 3
Multiple Personality Disorder and disorder
Allied Forms of Dissociative Disorder
Not Otherwise Specified”

Eating Disorders and Weight Management Treatments

Cash & Grant “Cognitive-Behavioral Treatment of CBT Eating disorders, Individual 1, 2, 3, 4
(1996)a Body-Image Disturbances” body dysmorphic
disorder
Sansone & Johnson “Treating the Eating Disorder Patient Dynamic Eating/borderline Individual 1, 2, 3
(1995)d with Borderline Personality Disorder:
Theory and Technique”
Williamson, “Lifestyle Change: A Program for Behavioral Obesity Group 2, 3, 4
Champagne, Long-Term Weight Management” (closed)
Jackman, &
Varnado (1996)a
Wilson & Pike “Eating Disorders” CBT Bulimia Individual 2, 3, 4
(2001)b nervosa, ano-
rexia nervosa

Forensic
Bricklin (1995) The Custody Evaluation Handbook: Assessment Divorce Psychological 2, 3
Research-Based Solutions & testing
Applications
Ellis (2000) Rationale and Goals of the Custody Assessment Divorce Psychological 1, 2, 4
Evaluation testing
Ferguson & Mitten- “Cognitive-Behavioral Treatments of CBT Brain trauma Individual 1, 2, 3, 4
berg (1996)a Postconcussion Syndrome: A
Therapist’s Manual”
Marshall & Eccles “Cognitive-Behavioral Treatments of CBT Sex offenders Group 1, 2, 3
(1996)a Sex Offenders”
Ward, Hudson, & The Assessment and Treatment of CBT Sex offenders/ Group 2, 3, 4
Keenan (2001) Sexual Offenders Against Children pedophiles &
ebephiles

Impulse Control Disorders

Ciarrocchi (2002) Counseling Problem Gamblers: A Self- Eclectic/ Adult patho- Individual, 1, 2, 3, 4
Regulation Manual for Individual pragmatic logical group,
and Family Therapy gamblers family,
couple
Larkin & Zayfert “Anger Management Training with Behavioral Anger Group 1, 2, 3,4
(1996)a Essential Hypertensive Patients” management
Stanley & Mouton “Trichotillomania Treatment Manual” Behavioral Trichotillomania Individual 1, 2, 3, 4
(1996)a

Outpatient Treatments
Chethik & Morton Techniques for Child Therapy: Dynamic Outpatient Individual 1, 2, 3, 4
(2000) Psychodynamic Strategies children
Daldrup, Beutler, Focused Expressive Psychotherapy Experiential Outpatient Individual 1, 2, 3, 4
Engle, & Green-
berg (1988)
De Domenico (2000) Sand Tray World Play: A Compre- Dynamic, Outpatient Individual, 1, 2, 3, 4
hensive Guide to the Use of the Sand experiential children, adol- group,
Tray in Psychotherapeutic and escents, & family
Transformational Settings adults
 40 • compendium of psychotherapy treatment manuals 197

table 1. (continued)
Theoretical Patient Therapy
Author/Year Title Orientation Population Modality Strengths

Gumaer (1984) Counseling and Therapy for Children Various Outpatient Individual, 1, 2, 3, 4
children group,
family
Hayes, Strosahl, & Acceptance and Commitment Therapy: Behavioral, Outpatient Individual 1, 2, 3, 4
Wilson (1999) An Experiential Approach to experiential
Behavior Change
Hersen (2002)c “Clinical Behavior Therapy: Adults & Behavioral Outpatient Individual 1, 2, 3, 4
Children”
Hibbs & Jensen “Psychosocial Treatments for Child & Various Outpatient Individual 1, 2, 3, 4
(1996)g Adolescent Disorders: Empirically (child &
Based Strategies for Clinical Practice” adolescent)
Padesky & Green- Clinician’s Guide to Mind Over Mood Cognitive Outpatient Individual 1, 2, 4, 6
berger (1995)
Strupp & Binder Psychotherapy in a New Key Dynamic Outpatient Individual 1, 2, 3, 4
(1984)
Wright & Wright Clinical Practice of Hypnotherapy Hypnotherapy Outpatient Individual 1, 2
(1987)

Partner Relational Problems

Epstein & Baucom Enhanced Cognitive-Behavorial CBT Distressed Couples 1, 2, 3
(2002) Therapy for Couples: A Contextual couples
Approach
Greenberg & Emotionally Focused Therapy for Experiential Distressed Couples 1, 2, 3, 4
Johnson (1988) Couples couples
Jacobson & Gurman Clinical Handbook of Couple Therapy Various Distressed Couples 1, 2, 3, 4
(Ed.) (1995) couples
Wheeler, Christen- “Couple Distress” Integrative, Distressed Couples 1, 2, 3, 4
sen, & Jacobson behavioral couples
(2001)b
Young & Long (1998) Counseling and Therapy for Couples Integrative Infidelity, Couples 1, 4, 6
divorce

Personality Disorders
Beck & Freeman Cognitive Therapy of Personality Cognitive Personality Individual 1, 2, 3
(1990) disorders
Benjamin (2002) Interpersonal Diagnosis and Treatment Interpersonal Personality Individual 1, 2, 3, 4
of Personality Disorders disorders
Linehan, Cochran, & “Dialectical Behavior Therapy for CBT, dia- Borderline Individual 1, 2, 3, 4
Kehrer (2001)b Borderline Personality Disorder” lectical be- personality
havior disorder (in-
therapy cluding those in
substance abuse
treatment settings)
Piper, Rosie, Joyce, Time-Limited Day Treatment for Eclectic Personality Group 1, 2, 3, 4
& Azim (1996) Personality Disorders: Integration of disorders
Research and Practice in a Group
Program
Sperry (1999) Cognitive Behavior Therapy of DSM-IV CBT Avoidant, Individual 1, 2, 3, 4
Personality Disorders: Highly borderline,
Effective Interventions for the Most dependent, nar-
Common Personality Disorders cissisic, OCPD,
histrionic
Whitehurst, Ridolfi, “Multiple Family Group Treatment Psycho- Borderlines Family, 1, 2, 3, 4
& Gunderson for Borderline Personality Disorder” educational educational
(2002)e groups
(continued)
198 part iii • individual psychotherapy and treatment

table 1. Treatment Manuals (continued)

Theoretical Patient Therapy
Author/Year Title Orientation Population Modality Strengths

Schizophrenia
Herz, Marvin, Schizophrenia: Comprehensive Treat- Medical model Schizophrenia Individual, 1, 2, 3, 4
Marder, & ment and Management family
Stephen (2002) Personal Therapy for Schizophrenia Systems Schizophrenia Individual, 1, 2, 3, 4
Hogarty (2002) and Related Disorders: A Guide to group
Individualized Treatment
McFarlane (2002) Multifamily Groups in Treatment of Systems Schizophrenia Group 1, 2, 3, 4
Severe Psychiatric Disorders
Pratt & Mueser “Social Skills Training for Social skills Schizophrenia Group 1, 2, 3, 4
(2002)e Schizophrenia” training (inpatient & (template
outpatient) for
Group)
Wong & Liberman “Biobehavioral Treatment and Biobehavioral Schizophrenia Individual, 1, 2, 3
(1996)a Rehabilitation for Persons with group
Schizophrenia”

Sexual Disorders
Bach, Wincze, & “Sexual Dysfunction” CBT/systems Desire disorders, Couple, 1, 2, 3, 4
Barlow (2001)b arousal dis- individual
orders, orgasmic
disorders, pain
disorders
Jehu (1979) Sexual Dysfunction: A Behavioral Behavioral Sexual Individual, 1, 2, 3
Approach to Causation, Assessment, dysfunction couple
and Treatment
McConaghy “Treatment of Sexual Dysfunctions” CBT Sexual Individual, 1, 2, 3
(1996)a dysfunction couple

Sleep Disorders
Van Brunt, Riedel, “Insomnia” Behavioral, Sleep Individual 1, 2, 3
& Lichstein pharmaco- disturbance
(1996)a therapy

Somatic Disorders
Martin (1993) Psychological Management of Chronic CBT Headaches Individual 1, 2, 3, 4
Headaches
Warwick & Cognitive-Behavioral Treatment of CBT Hypochondriasis Individual 1, 2, 3, 4
Salkovskis (2001) Hypochondriasis

Substance Abuse Disorders

Budney & Higgens A Community Reinforcement Approach: Behavioral, Cocaine Individual 1, 2, 3, 4
(1998) Treating Cocaine Addiction relational dependence
Carroll (1998) A Cognitive-Behavioral Approach: CBT Cocaine Individual 1, 2, 3, 4
Treating Cocaine Addiction
Daley, Mercer, & Drug Counseling for Cocaine Behavioral Inpatient/ Group 1, 2, 3, 4
Carpenter (1997) Addiction: The Collaborative Cocaine outpatient
Treatment Study Model cocaine addict
Handmaker & “Motivational Interviewing for Client- Inpatient/ Individual 1, 2, 3
Walters (2002)e Initiating Change in Problem centered outpatient
Drinking and Drug Use”
Higgins, Budney, & “Cocaine Dependence” Community Cocaine addict Individual 1, 2, 3
Sigmon (2001)b
Luborsky, Woody, “Supportive-Expressive Dynamic Dynamic Opiate Individual 1, 2, 3, 4
Hole, & Velleco Psychotherapy for Treatment of dependence
(1995)d Opiate Drug Dependence”
 40 • compendium of psychotherapy treatment manuals 199

table 1. (continued)
Theoretical Patient Therapy
Author/Year Title Orientation Population Modality Strengths

McCrady (2001)b “Alcohol Disorders” Relapse Alcoholics and Individual, 1, 2, 3, 4

prevention spouses couple
Mercer & Woody An Individual Drug Counseling Behavioral Outpatient Individual 1, 2, 3, 4
(1998) Approach to Treat Cocaine Addiction: cocaine
The Collaborative Cocaine Treatment addict
Study Model
Meyers, Dominguez, “Community Reinforcement Training Behavioral Families of Individual/ 1, 2, 3, 4
& Smith (1996)a with Concerned Others” alcoholics family
Paolantonio (1990) Relapse Prevention Training Manual CBT Drug and Group 1, 2, 4
alcohol relapse
Stasiewicz & “Alcohol Abuse” Behavioral Alcohol Individual 3, 4
Bradizza (2002)c disorders
Wakefield, Williams, Alcohol Disorders CBT Alcoholics and Couple 1, 2, 3, 4
Yost, & Patterson spouses
(1996)

aContained in Sourcebook of Psychological Treatment Manuals for Adult Disorders.

bContained in Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual.
cContained in Clinical Behavior Therapy: Adults and Children.
dContained in Dynamic Therapies for Psychiatric Disorders (Axis I).
eContained in Treating Chronic and Severe Mental Disorders: A Handbook of Empirically Supported Interventions.
fContained in Handbook of Parent Training: Parents as Co-Therapists for Children’s Behavior Problems.
gContained in Psychosocial Treatments for Child and Adolescent Disorders: Empirically Based Strategies for Clinical Practice.

into patient problem or diagnostic category and amples of each technique, and include means of
listed in alphabetical order by author. The the- evaluating therapist adherence. Two other crite-
oretical orientation, patient population, and ria are a specific description of the treatment
therapy modality are given for each manual. program and a description of etiology or assess-
We rated the contents of each manual in the ment approaches. We also evaluated the manu-
“Strengths” column according to six criteria: als on the basis of cultural sensitivity/appropri-
ateness for various populations. In general, there
1. A presentation of the main principles behind is a paucity of manuals that provide information
the techniques of the form of psychotherapy on session-by-session therapist activities. The
2. Concrete examples of each technical princi- Barlow (2001) text provides the best model for
ple/treatment intervention presenting and formatting manuals and is there-
3. Description of etiology and/or assessment fore recommended for emulation.
approaches The interested clinician can obtain manuals
4. Specifically delineated description of treat- by visiting the publishers’ Internet sites, sev-
ment program (e.g., session-by-session, eral of which include: John Wiley & Sons,
step-by-step, phases) www.wiley.com; Guilford Press, www.guilford.
5. Scales to guide independent judges in eval- com; Basic Books, www.basicbooks.com; Amer-
uating samples of sessions to determine the ican Psychological Association, www.apa.org/
degree of conformity to the manual books/; and Oxford University Press, www.oup.
6. Gives attention to cultural concerns that com. Unpublished manuals will need to be re-
otherwise might interfere with treatment. quested from the manual’s author. New manu-
als appear at a rapid rate, and it is likely that
Three of these criteria were adapted from the this list fails to include a number of important
work of Luborsky and Barber (1993), who stated manual-based treatments. We invite interested
that a true manual must present the main prin- readers to inform us of published manuals that
ciples behind techniques, provide concrete ex- have come to their attention.
200 part iii • individual psychotherapy and treatment

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Related Topics
against children. In C. R. Hollin (Ed.), Hand-
book of offender assessment and treatment (pp. Chapter 39, “Compendium of Empirically Supported
349 –361). New York: Wiley. Therapies”
Warwick, H. M. C., & Salkovskis, P. M. (2001). Cog- Chapter 41, “Compendium of Empirically Supported
nitive-behavioral treatment of hypochondriasis. Therapy Relationships”

COMPENDIUM OF
41 EMPIRICALLY SUPPORTED
THERAPY RELATIONSHIPS

John C. Norcross & Clara E. Hill

Recent years have witnessed the controversial training programs. A succession of APA Divi-
promulgation of practice guidelines and evi- sion 12 Task Forces (now a standing committee)
dence-based treatments in mental health. Fore- constructed and elaborated a list of empirically
most among these initiatives in psychology was supported, manualized psychological interven-
the APA Society of Clinical Psychology’s Task tions for specific disorders based on randomized
Force efforts to identify empirically supported controlled studies (Chambless, chap. 39, this
treatments (ESTs) for adults and to publicize volume; Chambless & Hollon, 1998; Task Force
these treatments to fellow psychologists and on Promotion and Dissemination of Psycholog-
 41 • compendium of empirically supported therapy relationships 203

ical Procedures, 1995). Subsequently, ESTs supportive studies, the consistency of the re-
were applied to both older adults and children search results, the magnitude of the positive re-
(e.g., Gatz et al., 1998; Lonigan, Elbert, & John- lationship between the element and outcome,
son, 1998). the directness of the link between the element
In Great Britain, a Guidelines Development and outcome, the experimental rigor of the
Committee of the British Psychological Society studies, and the external validity of the re-
authored a Department of Health (2001) docu- search base.
ment titled Treatment Choice in Psychological The research reviews and clinical practices
Therapies and Counselling: Evidence-Based were compiled in Psychotherapy Relationships
Practice Guidelines. In psychiatry, the Ameri- That Work (Norcross, 2002) and summarized
can Psychiatric Association has published at in a special issue of Psychotherapy (Norcross,
least 10 practice guidelines on disorders ranging 2001). The following synopses are drawn from
from schizophrenia to anorexia to nicotine de- those documents.
pendence.
These and other efforts to promulgate evi-
dence-based psychotherapies have been noble GENERAL ELEMENTS OF THE
in intent and timely in distribution. At the THERAPY RELATIONSHIP
same time, they neglect the therapy relation-
ship, an interpersonal quality that makes sub- As noted, the first aim of the Task Force was to
stantial and consistent contributions to the psy- identify those relationship elements or behav-
chotherapy outcome independent of the specific iors, primarily provided by the psychothera-
type of treatment. The therapy relationship ac- pist, that are effective in general. For each of
counts for as much of the treatment outcome as these relationship elements we provide a brief
does the specific treatment method (Lambert, definition, a summary of the research linking
2003; Wampold, 2001). Efforts to promulgate the element to therapy effectiveness, and a few
practice guidelines or evidence-based lists of ef- clinical implications.
fective psychotherapy without including the
therapy relationship are thus seriously incom-
Demonstrably Effective
plete and potentially misleading.
Within this context, an APA Division of • Therapeutic alliance. The “alliance” refers to
Psychotherapy Task Force was established to the quality and strength of the collaborative
identify, operationalize, and disseminate infor- relationship between client and therapist, typ-
mation on empirically supported therapy rela- ically measured as agreement on the thera-
tionships. We aimed to identify empirically peutic goals, consensus on treatment tasks,
supported (therapy) relationships rather than and a relationship bond. Across 89 studies, the
empirically supported treatments–or ESRs effect size (ES) of the relation between the
rather than ESTs. Specifically, the dual aims of therapeutic alliance and therapy outcome was
the Division 29 Task Force were (1) to identify .21, a modest but very robust association. The
elements of effective therapy relationships, and alliance is harder to establish with clients who
(2) to identify effective methods of tailoring are more disturbed, delinquent, homeless,
therapy to the individual patient on the basis of drug abusing, fearful, anxious, dismissive, and
his/her (nondiagnostic) characteristics. preoccupied. On the therapist side, a stronger
The Task Force generated a list of empiri- alliance is fostered by communication skills,
cally supported relationship elements and a list empathy, openness, and a paucity of hostile
of means for customizing therapy to the indi- interactions.
vidual client. For each list, we judged whether • Cohesion in group therapy. “Cohesion” refers
the element was demonstrably effective, promis- to the forces that cause members to remain in
ing and probably effective, or insufficient re- the group, a sticking-togetherness. Approxi-
search to judge. The evidentiary criteria for mately 80% of the studies support positive re-
making these judgments were the number of lationships between cohesion (mostly mem-
204 part iii • individual psychotherapy and treatment

ber-to-member) and therapy outcome. Meth- of the association between positive regard and
ods to increase cohesion include pre-group therapy outcome, with 80% of the studies in
preparation, addressing early discomfort using the positive direction. More recent and rigor-
structure, encouraging member-to-member ous reviews report 49% to 56% of the find-
interaction, and actively modeling and setting ings in the positive direction, with no nega-
norms (but not being overly directive). In ad- tive associations between positive regard and
dition, both feedback and establishing a good outcome. When treatment outcome and ther-
emotional climate contribute to cohesion. apist positive regard were both rated by
• Empathy. Carl Rogers’s definition, which has clients, the percentage of positive findings
guided most of the research, is that empathy jumped to 88%. Clinically, results indicate
is the therapist’s sensitive ability and will- that therapists cannot be content with feeling
ingness to understand the client’s thoughts, good about their patients, but instead should
feelings, and struggles from the client’s point ensure that their positive feelings are com-
of view — in other words, entering the pri- municated to them.
vate, perceptual world of the other. A meta- • Congruence/genuineness. The two facets
analysis of 47 studies (encompassing 190 here are the therapist’s personal integration
tests of the empathy-outcome association) in the relationship (freely and deeply him/
revealed an ES of .32. Furthermore, a causal herself) and the therapist’s capacity to com-
link between empathy and outcome has been municate his or her personhood to the client
demonstrated, with suggestions that empa- as appropriate. Across 20 studies (and 77 sep-
thy is linked to outcome because it serves a arate results), 34% found a positive relation
positive relationship function, is a corrective between therapist congruence and treatment
emotional experience, promotes exploration outcome, and 66% found nonsignificant as-
and meaning creation, and supports clients’ sociations. The percentage of positive studies
active self-healing efforts. increased to 68% when congruence was
• Goal consensus and collaboration. The for- tested in concert with empathy and positive
mer term refers to therapist-patient agree- regard, supporting the notion that the facili-
ment on treatment goals and expectation; the tative conditions work together and cannot be
latter is the mutual involvement of the par- easily separated. Therapist congruence can be
ticipants in the helping relationship. 68% of improved with self-confidence, good mood,
the studies found a positive association be- increased involvement or activity, respon-
tween goal consensus and outcome, and 88% siveness, smoothness of speaking exchanges,
of the studies reported the same for collabo- and high levels of client self-exploration/ex-
ration and outcome. It is not concretely clear periencing.
from the research how to build goal consen- • Feedback. “Feedback” is defined as descrip-
sus or collaboration, but clinical experience tive and evaluative information provided to
suggests that clinicians should begin to de- clients from therapists about the client’s be-
velop consensus at intake, verbally attend to havior or the effects of that behavior. Across
patient problems, address topics of impor- 11 studies empirically investigating the feed-
tance to patients, resonate to patient attribu- back-outcome connection, 73% were positive
tions of blame regarding their problems, and and 27% were nonsignificant. To enhance
frequently discuss or reevaluate goals. the effects of feedback, therapists can increase
their credibility (which makes acceptance of
feedback more positive), give positive feed-
Promising and Probably Effective
back (especially early to establish the rela-
• Positive regard. This therapist quality is char- tionship), and precede or sandwich negative
acterized as warm acceptance of the client’s feedback with positive comments.
experience without conditions, a prizing, an • Repair of alliance ruptures. A rupture in the
affirmation, a deep nonpossessive caring. The therapeutic alliance is a tension or break-
early research reviews were very supportive down in the collaborative relationship. The
 41 • compendium of empirically supported therapy relationships 205

small body of research indicates that the fre- in the patient’s behavior. The research corre-
quency and severity of ruptures are increased lating frequency of interpretations and out-
by strong adherence to a treatment manual come has yielded mixed findings; however, it
and an excessive number of transference in- appears that high rates of transference inter-
terpretations. By contrast, the research sug- pretations lead to poorer outcomes, especially
gests that repairs of ruptures can be facili- for clients with low quality-of-object rela-
tated by the therapist responding nondefen- tions. By contrast, other research has high-
sively, attending directly to the alliance, and lighted the importance of the quality of in-
adjusting his or her behavior. terpretations: better outcomes are achieved
• Self-disclosure. Therapist “self-disclosure” is when the therapist addresses central aspects
defined as therapist statements that reveal of client interpersonal dynamics. The clinical
something personal about the therapist. Ana- implications are to avoid high levels of trans-
logue research suggests that nonclients gen- ference interpretations, particularly for in-
erally have positive perceptions of therapist terpersonally challenged clients, and to focus
self-disclosure. In actual therapy, disclosures interpretations on the central interpersonal
were perceived as helpful in terms of imme- themes for each patient.
diate outcomes, although the effect on the ul-
timate outcome of therapy is unclear. The re-
search suggests that therapists should dis- CUSTOMIZING THE THERAPY
close infrequently and, when they disclose, RELATIONSHIP TO INDIVIDUAL
do so to validate reality, normalize experi- PATIENTS
ences, strengthen the alliance, or offer alter-
native ways to think or act. By contrast, ther- Emerging research indicates that adapting the
apists should generally avoid self-disclosures therapy relationship to specific patient needs
that are for their own needs, remove the fo- and characteristics (in addition to diagnosis) en-
cus from the client, or blur the treatment hances the effectiveness of treatment. Accord-
boundaries. ingly, the second aim of the Task Force was to
• Management of countertransference. Al- identify those patient behaviors or qualities
though defined in various ways, “counter- that served as reliable markers for customizing
transference” refers to reactions in which the the therapy relationship.
unresolved conflicts of the psychotherapist,
usually but not always unconscious, are im-
Demonstrably Effective as a
plicated. The limited research supports the
Means of Customizing Therapy
interrelated conclusions that therapist acting
out countertransference hinders psychother- • Resistance. “Resistance” refers to being easily
apy, whereas effectively managing counter- provoked by external demands. Research con-
transference aids the process and probably firms that high patient resistance is consis-
the outcome of therapy. In terms of manag- tently associated with poorer therapy out-
ing countertransference, five central therapist comes (in 82% of studies). But matching ther-
skills have been implicated: self-insight, self- apist directiveness to client level of resistance
integration, anxiety management, empathy, improves therapy efficiency and outcome
and conceptualizing ability. (80% of studies). Specifically, clients present-
• Quality of relational interpretations. In the ing with high resistance benefited more from
clinical literature, “interpretations” are in- self-control methods, minimal therapist direc-
terventions that bring material to conscious- tiveness, and paradoxical interventions. By
ness that was previously out of awareness; in contrast, clients with low resistance benefited
the research literature, interpretations are more from therapist directiveness and explicit
behaviorally coded as making connections, guidance. The clinical implication is to match
going beyond what the client has overtly rec- the therapist’s level of directiveness to the pa-
ognized, and pointing out themes or patterns tient’s level of resistance.
206 part iii • individual psychotherapy and treatment

• Functional impairment. This complex di- tion and contemplation stages, and behav-
mension reflects the severity of the patient’s ioral processes are used most frequently by
subjective distress, as well as areas of reduced those in the action and maintenance stages.
behavioral functioning. Most of the available The therapist’s optimal stance also varies de-
studies (76%) found a significant inverse re- pending on the patient’s stage of change: a
lation between level of impairment and treat- nurturing parent with patients in the pre-
ment outcome. These results indicate that contemplation stage; a Socratic teacher with
patients who manifest impairment in two or patients in the contemplation stage; an expe-
more areas of functioning (family, social, in- rienced coach with patients in the action
timate, occupational) are more likely to ben- stage; and a consultant during the mainte-
efit from treatment that is lengthier, that is nance stage. The clinical implications are to
more intense, and that includes psychoactive assess the patient’s stage of change, match
medication. Furthermore, patients who have the therapeutic relationship and the treat-
little support from other people will more ment method to that stage, and systemati-
likely benefit from a lengthier psychother- cally adjust tactics as the patient moves
apy that explicitly targets the creation of so- through the stages.
cial support in the natural environment. • Anaclitic/sociotropic and introjective/au-
tonomous styles. In the psychoanalytic tra-
dition, there are two broad personality con-
Promising and Probably
figurations: a relatedness or anaclitic style
Effective as a Means of
that involves the capacity for satisfying in-
Customizing Therapy
terpersonal relationships, and a self-defini-
• Coping style. Although defined differently tional or introjective style that involves the
across theoretical orientations, “coping development of an integrated identity. Simi-
style” broadly refers to habitual and endur- lar distinctions are made in cognitive therapy
ing patterns of behavior that characterize the between sociotropic and autonomous styles.
individual when confronting new or prob- A small but growing body of research indi-
lematic situations. In the research, attention cates that these two personality styles are
has been devoted primarily to the externaliz- differentially related to psychotherapy out-
ing (impulsive, action or task-oriented, stim- come. Specifically, anaclitic/sociotropic pa-
ulation seeking, extroverted) and internalizing tients benefit more from therapies that offer
coping styles (self-critical, reticent, inhibited, more personal interaction and closer related-
introverted). 79% of the studies investigat- ness, whereas introjective/autonomous pa-
ing this dimension demonstrated differential tients tend to do better in therapies empha-
effects of the type of treatment as a function sizing separation and autonomy. The identifi-
of patient coping style. Hence, interpersonal cation of the patient’s personality organization
and insight-oriented therapies are more ef- may enable therapists to adapt the degree of
fective among internalizing patients, whereas interpersonal closeness to the individual pa-
symptom-focused and skill-building thera- tient.
pies are more effective among externalizing • Expectations. “Expectancy” refers to client
patients. expectations of therapeutic gain as well as of
• Stages of change. People progress through a psychotherapy procedures, the therapist’s
series of stages— precontemplation, contem- role, and the length of treatment. Of 24 stud-
plation, preparation, action, and mainte- ies on clients’ outcome expectations, 12 found
nance — in both psychotherapy and self- a positive relation between expectations and
change. A meta-analysis of 47 studies found outcome, 7 found mixed results, and 7 found
ESs of .70 and .80 for the use of different no relationship. Of 37 studies on clients’ role
change processes in the stages; specifically, expectation, 21 found positive relationships
cognitive-affective processes are used most with outcome, 12 found mixed support, and
frequently by clients in the precontempla- 8 found no association with outcome. The re-
 41 • compendium of empirically supported therapy relationships 207

search literature encourages therapists to ex- represent initial steps in aggregating and codi-
plicitly assess and discuss client expectations, fying available research. Here, we conclude
address overt skepticism, arouse positive ex- with the practice recommendations.
pectations, and activate the client’s belief that
he or she is being helped. 1. Practitioners are encouraged to make the
• Assimilation of problematic experiences. creation and cultivation of a therapy rela-
The assimilation model suggests that, in suc- tionship characterized by the elements
cessful psychotherapy, clients follow a regu- found to be demonstrably and probably ef-
lar developmental sequence of working fective in this report a primary aim in the
through problematic experiences. The se- treatment of patients.
quence is summarized in eight stages, from 2. Practitioners are encouraged to adapt the
the patient being warded off/dissociated therapy relationship to specific patient char-
from the problem at the one end, to integra- acteristics in the ways shown in the report to
tion/mastery of the problem at the other end. enhance therapeutic outcome.
A series of intensive case studies and two hy- 3. Practitioners are encouraged to routinely
pothesis-testing studies indicated that clients monitor patients’ responses to the therapy
in the mid- to late stages of assimilation relationship and ongoing treatment. Such
prosper more from directive, cognitive-be- monitoring leads to increased opportunities
havioral therapy. Furthermore, the research to repair alliance ruptures, to improve the
suggests that as the client changes, the ther- relationship, to modify technical strategies,
apist should change responsively, reflecting and to avoid premature termination. Con-
the evolving feelings, goals, and behaviors current use of empirically supported rela-
that represent therapeutic progress. tionships and empirically supported treat-
ments tailored to the patient’s disorder and
characteristics is likely to generate the best
Insufficient Research
outcomes.
The state of the current research was insuffi-
cient for the Task Force to make a clear judg- References, Readings, & Internet Sites
ment on whether customizing the therapy rela-
tionship to the following patient characteristics APA Division of Psychotherapy. (n.d.). Home page
improves treatment outcomes: (includes a link to the Task Force on Empirically
Supported Psychotherapy Relationships). Re-
trieved 2004 from http://www.cwru.edu/affil/
• Attachment style
div29/div29.htm
• Gender Chambless, D. L., & Hollon, S. D. (1998). Defining
• Ethnicity empirically supported therapies. Journal of Con-
• Religion and spirituality sulting and Clinical Psychology, 64, 497 – 504.
• Preferences Department of Health. (2001). Treatment choice in
• Personality disorders psychological therapies and counselling. Lon-
don: Department of Health Publications.
Gatz, M., Fiske, A., Fox, L. S., Kaskie, B., Kaasl-
PRACTICE RECOMMENDATIONS Godley, J. E., McCallum, T. J., et al. (1998). Em-
pirically validated psychological treatments for
The Task Force reports (Norcross, 2001, 2002) older adults. Journal of Mental Health and Ag-
ing, 4, 9 – 46.
close with a series of recommendations, divided
Gelso, C. J., & Hayes, J. A. (1998). The psychother-
into general, practice, training, research, and apy research: Theory, research, and practice.
policy recommendations. The general recom- New York: Wiley.
mendations encourage readers to interpret the Hill, C. E., & O’Brien, K. M. (1999). Helping skills:
findings in the context of the limitations of the Facilitating exploration, insight, and action.
Task Force’s work (as explicated in the reports) Washington, DC: American Psychological As-
and remind readers that the current conclusions sociation.
208 part iii • individual psychotherapy and treatment

Lambert, M. (1993). The effectiveness of psy- Handbook of psychotherapy and behavior

chotherapy. In M. J. Lambert (Ed.), Handbook change (4th ed., pp. 245 –267). New York: Wi-
of psychotherapy and behavior change (5th ed., ley.
pp. 27 – 46). New York: Wiley. Stiles, W. B., Honos-Webb, L., & Surko, M. (1998).
Lonigan, C. J., Elbert, J. C., & Johnson, S. B. (1998). Responsiveness in psychotherapy. Clinical Psy-
Empirically supported psychosocial interven- chology: Science and Practice, 5, 439 – 458.
tions for children: An overview. Journal of Task Force on Promotion and Dissemination of Psy-
Clinical Child Psychology, 27, 138 –142. chological Procedures. (1995). Training in and
Nathan, P. E., & Gorman, J. M. (Eds.). (2002). A dissemination of empirically validated psycho-
guide to treatments that work (2nd ed.). New logical treatments: Report and recommenda-
York: Oxford University Press. tions. The Clinical Psychologist, 48(1), 3 –23.
Norcross, J. C. (Ed.). (2001). Empirically supported Wampold, B. E. (2001). The great psychotherapy de-
therapy relationships: Summary Report of the bate: Models, methods, and findings. Mahwah,
Division 29 Task Force. Psychotherapy, 38(4). NJ: Erlbaum.
Norcross, J. C. (Ed.). (2002). Psychotherapy rela-
tionships that work: Therapist contributions
Related Topics
and responsiveness to patient needs. New York:
Oxford University Press. Chapter 39, “Compendium of Empirically Supported
Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Therapies”
Process to outcome in psychotherapy — noch Chapter 40, “Compendium of Psychotherapy Treat-
einmal. In A. E. Bergin & S. L. Garfield (Eds.), ment Manuals”

42 ENHANCING ADHERENCE

M. Robin DiMatteo

Adherence (also called compliance) refers to the they do not believe it is worth the trouble. Or,
success of a patient in implementing the rec- they may be quite committed to trying the reg-
ommendations of a health care professional for imen, but find it too difficult and beyond their
the prevention or management of health condi- resources.
tions. More simply, adherence refers to “coop- Research on adherence began in 1948 with a
eration with therapy.” Health professionals are study by psychologist Mary Crumpton Hardy,
often frustrated by noncompliance, such as who followed Chicago-area children whose
when clients fail to take their medication as pre- parents were given recommendations for their
scribed, or test their blood glucose levels spo- health care. This work was published in the
radically, or make misguided health care choices Journal of the American Medical Association,
based on the recommendations of friends or and since then there have been nearly 12,000
television commercials instead of the advice of citations on adherence and compliance in the
their providers. Consumers may forget or mis- medical and psychological literatures. About
understand the regimen, fail to put in the nec- 1,000 of these are empirical studies, which con-
essary effort, or ignore it altogether because stitute a sizable research literature. Adherence
 42 • enhancing adherence 209

to treatment has been studied primarily in ence difficulties. Researchers and clinicians of-
medical treatment (e.g., following regimens for ten use other means as well — counting re-
the care of diabetes, cancer), psychiatric care maining pills, weighing the contents of canis-
(e.g., taking medication for schizophrenia), and ters such as inhalers, and asking family mem-
psychological care (e.g., cognitive behavior bers—but direct communication with patients
therapy for anxiety). There are important com- about their adherence challenges remains the
monalities in these literatures — factors that best way to determine what patients are doing.
are important regardless of the treatment regi- 3. Do not equate adherence with outcome. It
men — and the clinical implications of these is critically important not to confuse health
findings are delineated below. outcomes with adherence. If the clinical picture
This literature demonstrates quite clearly is confusing and the patient is not having a pre-
that adherence to treatment significantly im- dicted response, it is certainly possible that
proves treatment outcomes. Failure to follow nonadherence is the reason, but it is also possi-
the treatments recommended by health profes- ble that the treatment is not working. It must
sionals can result in reductions in patients’ be remembered that adherence is a behavior to
quality of life, confusion in the clinical picture, be assessed. The success of the treatment de-
misleading information for subsequent care de- pends on correct diagnosis and on the appropri-
cisions, professional and patient frustration, and ateness and efficacy of the treatment regimen.
erosion of the therapeutic relationship. 4. Understand the prevalence. The preva-
lence of nonadherence depends on the patient’s
disorder and on the complexity of the treatment
PRACTICE GUIDELINES regimen. Across hundreds of studies, adherence
rates on average range from 20% to 40%, with
1. Assess adherence. The first step in en- the highest level of adherence occurring when
hancing adherence involves assessing it cor- the disease is considered very serious and ad-
rectly, an endeavor that can be surprisingly herence is essential to survival (e.g., HIV dis-
challenging. For example, determining whether ease, cancer), and when the intervention has
a patient has been using cognitive therapy tech- immediate and obvious effects (e.g., reduction
niques or has taken the antidepressant medica- in pain/distress in arthritis and gastrointestinal
tion prescribed requires trust and open com- disorders). Adherence tends to be considerably
munication about the challenges of behavior lower for the treatment of such conditions as
change. Clients may be reluctant to admit that diabetes, where care can be complex and limit-
they have failed to do what was recommended. ing and patients do not necessarily feel better
2. Adopt an open and collaborative rela- when they adhere. In pharmacotherapy for
tionship. A therapeutic relationship that fosters psychiatric disorders, adherence to medication
adherence is built with a patient through active tends to be lower in the context of difficult side
listening, nonjudgment, and empathy. These effects or the absence of obvious benefits, and
are typically conveyed through supportive ver- higher when medications make people feel bet-
bal messages and nonverbal cues of facial ex- ter.
pressions, body orientation and attention, and 5. Address patients’ views of effectiveness.
vocal tone. A therapeutic relationship that al- It is not the case that objectively more effective
lows both honest discussion about adherence treatments yield better patient adherence; it is
difficulties and a commitment to working to- the patient’s subjective assessment of the effec-
gether to overcome them has the greatest tiveness of treatment that influences his or her
chance of success. Although patients are usu- adherence. Sometimes the more effective treat-
ally not eager to tell their health professionals ments are more difficult, and health profession-
they have not followed a treatment directive, in als may be remiss in communicating the ex-
the context of a supportive and trusting rela- pected treatment efficacy to patients. Nonad-
tionship, and in response to straightforward herence may not make sense to the health
questions, patients will usually admit adher- professional, but it often makes sense to the
210 part iii • individual psychotherapy and treatment

health care consumer. Sometimes noncompli- munication, checking what patients understand,
ance is viewed by the patient as a perfectly ra- and reinforcement of the care message are es-
tional choice because he or she remains uncon- sential. Written instructions can be useful, but
vinced that the regimen is worthy of the time only if they have been explained carefully and
and trouble it demands. Patients will usually patient understanding has been ascertained.
follow only treatments they believe in. 8. Encourage patient involvement. Encour-
6. Understand the practical reasons for non- aging patients to be actively involved in their
adherence. Health care delivery may be a small care, to voice concerns, and to state preferences
part of a patient’s real life. What makes sense to for their care outcomes enhances their sense of
“commit to” in the office may be quite difficult control and meaning in the face of illness, con-
to implement at home, where competing de- veys respect, and fosters healing. For example,
mands of work and family jeopardize adher- a client who is encouraged to use meditation for
ence. stress must have the opportunity to discuss
with the therapist various options for its imple-
• Resources may be limited and patients usu- mentation and to chart a plan for evaluating its
ally allocate them as best they can. The reg- effects.
imen that is tailored as much as possible to fit 9. Incorporate cultural beliefs. Many pa-
into the patient’s life has the best chance of tients have their own personally or culturally
being followed. based explanations for their illness, which, if
• Sometimes the client has no idea what the understood by the health professional, can be
health professional is talking about (but nods used to help the patient follow the treatment
his or her head in agreement anyway). Pa- regimen. Adherence depends upon patients’ be-
tients can do only what they understand. liefs in their susceptibility to a serious health
Sometimes, unfortunately, television adver- threat and their belief that a treatment is effec-
tisements and neighbors’ opinions make tive and offers enough benefits given its costs in
more sense to the client than those of the time, money, and difficulty.
provider. Providers must convey their exper- 10. Build in social support. Many studies
tise and competence in the context of a sup- show that there is a profound impact of practi-
portive and trusting relationship; patients are cal and emotional support on helping patients to
likely to follow recommendations only from adhere. Marital status and living with another
providers they trust, and who are viewed as are not nearly as important as having available
credible. supportive and helpful others. Family cohesive-
• Patients will only follow regimens for which ness strongly supports adherence whereas fam-
they have the necessary resources. There are ily conflict can seriously jeopardize it. Deter-
many practical challenges to patient adher- mine what practical and emotional support is
ence that need to be addressed and overcome available to the patient, and screen for any fam-
in all health care visits, whether they involve ily conflict that can derail the patient’s attempts
complex self-care routines for serious med- to adhere to the treatment regimen.
ical conditions, the control of thoughts and 11. Screen for depression. Depression in pa-
behaviors using psychological modalities, tients is strongly linked to nonadherence to
the management of psychiatric conditions medical treatments. The risk of nonadherence is
with medication, or the achievement of vigor 27% higher in depressed than in nondepressed
and longevity through healthy lifestyle patients. Screening for depression in medical
choices. patients is essential so that something can be
done to help activate their inner healing re-
7. Use clear and written communication. sources. Depressed patients are at increased risk
Misunderstanding and forgetting are common of nonadherence because of the hopelessness,
in the office visit. As many as 50% of patients interference in constructive thinking and plan-
cannot accurately report what their health pro- ning, and withdrawal from social support that
fessionals have told them. Therefore, clear com- can accompany depression. Patients receiving
 42 • enhancing adherence 211

psychological or pharmacological treatment for tions for research and clinical practice. In D.
depression may need particular attention and Drotar (Ed.), Promoting adherence to medical
supportive care to adhere. treatment in childhood chronic illness: Con-
12. Attend to risk factors for nonadherence. cepts, methods, and interventions (pp. 237 –
258). Mahwah, NJ: Erlbaum.
In addition to depression, certain patient factors
DiMatteo, M. R., Giordani, P. J., Lepper, H. S., &
predispose patients toward nonadherence.
Croghan, T. W. (2002). Patient adherence and
Compared with the positive role of family sup- medical treatment outcomes: A meta-analysis.
port and the negative effects of mood disorders, Medical Care, 40, 794 – 811.
demographic factors are not strong predictors DiMatteo, M. R., Lepper, H. S., & Croghan, T. W.
of adherence. Some demographic factors do (2000). Depression is a risk factor for noncom-
have a moderate effect on adherence, however, pliance with medical treatment: A meta-analy-
and should be noted by clinicians. There is a sis of the effects of anxiety and depression on
trend for adolescents to be less adherent than patient adherence. Archives of Internal Medi-
younger pediatric patients, and a trend for cine, 160, 2101–2107.
lower adherence among individuals in middle Dunbar-Jacob, J., & Schlenk, E. (2001). Patient ad-
herence to treatment regimen. In A. Baum,
age (probably because of competing demands)
T. A. Revenson, & J. E. Singler (Eds.), Handbook
and advanced older age (probably because of
of health psychology (pp. 571– 580). Mahwah,
cognitive deficits). The relationship between NJ: Erlbaum.
education and adherence is stronger in the care DiMatteo, M. R. (1999). The role of communication
of chronic illness than acute illness, likely due and physician-patient collaboration: Enhancing
to the necessity for complex self-care for adherence with psychiatric medication. In J.
chronic illness. Guimon, W. Fischer, & N. Sartorius (Eds.), The
image of madness (pp. 222–230). Basel: Karger.
In summary, adherence is unlikely to be fos- Epstein, L. (1984). The direct effects of compliance on
tered by trying to convince patients that they health outcome. Health Psychology, 3, 385 –
have a serious condition, that treatment is good 393.
Epstein, L. H., & Cluss, P. A. (1982). A behavioral
for them, or that the health professional knows
medicine perspective on adherence to long-term
best and should be obeyed. Rather, building
medical regimens. Journal of Consulting and
partnerships with patients, learning and re- Clinical Psychology, 50, 950 – 971.
specting their perspectives on the illness, un- Hardy, M. C. (1948). Follow-up of medical recom-
derstanding their expectations for health care mendations. Journal of the American Medical
outcomes, and relating to them in an empathic Association, 136, 20 –27.
and compassionate manner enhance patient ad- International Association of Physicians in AIDS
herence. Relationships with patients are a crit- Care. (n.d.). Information on Adherence in HIV/
ical component of professional job satisfaction, AIDS care. Retrieved 2004 from http://www.
an important factor in preventing job stress, thebody.com/iapac/adherence.html
and a critical predictor of patient adherence to Norman, P., Abraham, C., & Conner, M. (Eds.).
(2000). Understanding and changing health
treatment.
behaviour: From health beliefs to self-regula-
tion (pp. 126 –138). Amsterdam: Harwood.
References, Readings, & Internet Sites
RAND Organization. (n.d.). Medical outcome stud-
Bowen, D. J., Helmes, A., & Lease, E. (2001). Pre- ies site. Retrieved 2004 from http://www.rand.
dicting compliance: How are we doing? In L. E. org/health.surveys/core
Burke & I. S. Ockene (Eds.), Compliance in Rosenthal, R., & DiMatteo, M. R. (2001). Meta-
healthcare and research (pp. 25 – 41). Armonk, analysis: Recent developments in quantitative
NY: Futura. methods for literature reviews. Annual Review
Brownell, K. D., & Cohen, L. R. (1995). Adherence to of Psychology, 52, 59 – 82.
dietary regimens: 1. An overview of research. Uchino, B, N., Cacioppo, J. T., & Kiecolt-Glaser, J. K.
Behavioral Medicine, 20, 149 –154. (1996). The relationship between social support
DiMatteo, M. R. (2000). Practitioner-family-patient and physiological processes: A review with em-
communication in pediatric adherence: Implica- phasis on underlying mechanisms and implica-
212 part iii • individual psychotherapy and treatment

tions for health. Psychological Bulletin, 119, D. (2002). Interventions to improve medication
488 –531. adherence in schizophrenia. American Journal
Ziegelstein, R. C., Fauerbach, J. A., Stevens, S. S., of Psychiatry, 159, 1653 –1664.
Romanelli, J., Richter, D. P., & Bush, D. E.
(2000). Patients with depression are less likely
Related Topics
to follow recommendations to reduce cardiac
risk during recovery from a myocardial infarc- Chapter 43, “Methods to Reduce and Counter Resis-
tion. Archives of Internal Medicine, 160, 1818 – tance in Psychotherapy”
1823. Chapter 44, “Repairing Ruptures in the Therapeutic
Zygmunt, A., Olfson, M., Boyer, C. A., & Mechanic, Alliance”

METHODS TO REDUCE AND

43 COUNTER RESISTANCE IN
PSYCHOTHERAPY

Albert Ellis

Resistant clients, like nonresistant ones, are 2001b; Walen, DiGiuseppe, & Dryden, 1992).
unique individuals in their own right. But you, Because of their low frustration tolerance and
too, as a struggling psychotherapist, may have their feelings of inadequacy, patients often do
many different ways in which you interpret not complete the required therapeutic work;
your clients’ resistance. I basically follow ratio- and their therapists, as well, are frequently lax
nal emotive behavior therapy (REBT), a pio- in this respect. Of the many methods of REBT,
neering form of cognitive behavior therapy CBT, and other therapies that you can use to
(CBT), that I created when I found that many of help your resistant clients to uncharacteristi-
my clients resisted other forms of treatment cally work at resisting their resisting, here are
that mainly used cognitive or emotional or be- 16 that I have found to be the best.
havioral methods. I went out of my way to 1. Investigate the real possibility that your
stress cognitive techniques in REBT, but I also clients’ resisting may be mainly your own prob-
heavily emphasized a number of emotive- lem: your carelessness or insecurity. Do you like
evocative and behavioral methods. I still do a client too much or too little, thereby creating
so — especially with my stubbornly resistant transference problems? Are you cavalierly tak-
clients. But I use them flexibly and include ing things too easily and failing to see and work
some general methods that I describe below. at overcoming resistances? Are you too needy of
REBT and CBT easily show patients how your clients’ approval and afraid to be assertive
they are choosing to upset themselves, but giv- and firm enough with them? Look intently at
ing them this kind of insight has to be accom- these and other likely lapses, not to damn your-
panied by their working very hard and persis- self if you find them but to try to correct them.
tently to get better and stay better (Ellis, 2001a, Give yourself unconditional self-acceptance
 43 • methods to reduce and counter resistance in psychotherapy 213

(USA) in spite of your failings while—as I shall 5. Experiment with different methods than
show later—giving your clients unconditional the ones you steadily use (Ellis, 2002). Prefer-
other-acceptance (UOA) in spite of their self- ably have a good many methods in your own
defeating resistances and other failings (Ellis, therapeutic system, and do not rigidly swear by
2002). them. I find that if I authoritatively push my
2. If you think that your clients are mainly favorite techniques with clients, they often
responsible for their own resistance, look for gain confidence in me and in these methods.
possible reasons for their sabotaging their But I watch for overselling my techniques be-
therapy. Do they have low frustration tolerance cause, when the oversold methods do not work,
and think that you should magically change my clients lose confidence in me as a therapist.
them? Do their feelings of worthlessness make So, I often show clients the value of experi-
them convinced that they are not able to menting because what works for one may be
change? Do their favorable or unfavorable feel- ineffective for another. When I see that clients
ings toward you — transference feelings — in- put themselves down for failing to successfully
terfere with their hearing your views objec- use one of my favorite methods, I explain that
tively and using your teachings to change no matter how good it may be for many people
themselves? Are they angry with their rela- it may not be for them, so they’d better exper-
tives who demand that they change, and are iment with it and see for themselves. Experi-
they therefore sabotaging their own efforts to mentation leads to good science; and it also
do so? Since your clients are seeing you upset leads to good therapy (Hanna, 2001).
about their performances and their relation- 6. Encourage your client’s special therapeu-
ships, are they also disturbed about their ther- tic inventiveness (McMullin, 2000). While
apy? Hypothesize and explore (Hanna, 2001). If showing my own resistant (and nonresistant)
you find them blocking themselves, tactfully clients how to try the techniques I suggest, I
but firmly reveal the blocks and see if you can also recommend that they add their own special
get clients to unblock themselves. variations on these methods and creatively dis-
3. REBT, along with Acceptance and Com- cover uniquely good methods for themselves.
mitment Therapy (ACT) and several other They can try my suggestion partially or com-
therapies, holds that even highly cooperative pletely, strongly or lightly, tentatively or per-
clients have to be strongly committed to ther- manently. They can also add to or subtract from
apy and work hard at change (Ellis, 2001a, them. I show them that when I do therapy, I
2001b, 2002; Hayes, Strosahl, & Wilson, 1999). learn from my own experiences — and also
Did you clearly explain the importance of com- from theirs. So by being innovative, they may
mitment to your clients when they started ther- help me to become a better therapist!
apy? Did they agree with this goal? If not, raise 7. Consider using self-help materials that fit
this issue with your resistant clients now. Keep in with your form of therapy (Ellis, 2002; Mc-
raising it! Also: are you really committed to Mullin, 2000). In my own case, I helped my-
doing the hard work of therapy, too? self, long before I became a therapist, by using
4. Clarify your and your clients’ main ther- self-help materials to work on my anxieties.
apeutic goals (Cowan & Presbury, 2000; Walen Because these worked so well for me, I natu-
et al., 1992). You may both differ somewhat in rally favor them for my clients. Resistant clients,
what you are seeking to do in therapy. But too I find, can often find self-help procedures help-
much? See if the differences lead to resistances. ful because, if they scan a number of methods,
If so, consider changing some of your own goals they can selectively choose to follow a few that
and no longer foist them on your unwilling work nicely in their own cases. Since they usu-
clients; and consider persuading your clients to ally pick methods that they like to perform and
change some of their goals. If neither of these that they believe will be effective for them,
plans work, think about recommending another they have little resistance in carrying them out
therapist to your clients who is more sympa- and often find some that really work. So don’t
thetic with their goals and values. just prescribe some of your favorite self-help
214 part iii • individual psychotherapy and treatment

methods, but give your clients leeway to pick a teaching (McMullin, 2000). I have found that
few of them out of many that they may try. when clients want to improve but actually do
8. Resistant clients are often more threat- not work to get better, they usually have two
ened than other clients and defensively ward important irrational beliefs. The first is “I’d bet-
off discussing “dangerous” topics, such as sex, ter change; but it’s too difficult for me to change
anger, and defensiveness itself. But you can and I’m a total failure for not being able to do
also be afraid of what will happen if you force so.” And second, “It’s quite hard for me to
clients to discuss “dangerous” issues (Hanna, change and it should not, must not be that
2001; Navajits, 2001). You, for example, may hard! It’s too hard and my therapist must make
fear that raising uncomfortable topics will an- it much easier!” Clients will frequently agree
tagonize, your clients and — horror of hor- that they have these self-destructive beliefs,
rors!— lose them. I do my best to watch for but they still tightly hold on to them and don’t
signs of my own queasiness, for if I am anxious, work to give them up. Therefore, as their ther-
I may help my clients to skirt what they think apist, you have to not only help them see these
are dangerous issues. I also show myself that beliefs but also induce them to strongly and
making my clients uncomfortable has its ad- emotionally fight them. This means that you
vantages as well as disadvantages. So I give my- often have to convince yourself that clients
self little time to avoid discussing ticklish prob- strongly hold such beliefs and that you had bet-
lems. This doesn’t always work, and I do lose ter vigorously work at getting them to surren-
some clients by jumping into risky areas. But der them. Both of you had better use force and
I make myself take the lesser evil of losing persistence!
a client than the greater evil of unhelpfully 11. You can encourage clients to record and
drawing out our sessions and never discovering listen to their therapy sessions. Some of them
if my “dangerous” confrontation will work. For will then regularly do so and give themselves
the clients, the danger of my not bringing up the opportunity to hear what you are teaching
topics often results in letting them inter- uninterruptedly, and perhaps to see how they
minably go comfortably on with their resisting. are wasting their time by avoiding important
9. Bite the bullet and openly discuss the issues. They may also see that expressing
clients’ resistance with them. A good many themselves volubly may be indeed enjoyable
therapists recommend openly discussing such but may have little to do with their changing
resistance with these clients: (a) their unaware- themselves.
ness that they are resisting; (b) their hypothe- 12. Integrate your psychotherapy with
ses about why they are doing so; (c) your own other kinds of treatments. You may be quite
feelings about their resisting; and (d) what both convinced that your kind of therapy is by far
of you think had better be done to alleviate the best for any clients. Maybe! But when it
their (and your) resisting. Again, this kind of isn’t working, at least try some parts of other
open discussion, which you will have to initiate, procedures that you think might work with a
may — or may not — work like a charm. If it particular resistant client. If they work, you
does, great! If it doesn’t, you may still discover will learn something; and if they don’t work,
that your client has a severe personality disor- you will have more evidence that your methods
der that practically no kind of therapy will ef- are really as good as you think they are.
fectively resolve; that you and the client are se- 13. Clients often have emotional problems
riously mismatched; that your kind of therapy, about their emotional problems: secondary
though effective with most of your clients, symptoms. They blame themselves so much
won’t work with this one; and that other im- for being anxious or depressed that they create
portant reasons exist for the client’s resistance. additional anxiety or depression. Or they “aw-
Good knowledge — and you well might never fulize” so much about their original symptoms
come up with it without your forcing an un- that they refuse to face them and are defensive
comfortable discussion on the client. about them. Assume that some of your resis-
10. You can try forceful and emotional tant clients may have secondary disturbances,
 43 • methods to reduce and counter resistance in psychotherapy 215

question them to see how they react to their acceptance (UOA): to think critically of other
primary disturbances, then especially show people’s thoughts, feelings, and actions but re-
them how to stop denigrating themselves for frain from damning other people, no matter
having and awfulizing about having their orig- how badly they behave; (c) unconditional life-
inal disturbances. Once you help them uncon- acceptance (ULA): to dislike and even hate
ditionally accept while distinctly disliking their world conditions, but when you can’t change
primary problems (such as panic) the problem them, accept life and the world in spite of these
itself may significantly decrease. conditions and enjoy yourself as much as you
14. When direct homework assignments do can. I do my best to show my resistant clients
not work, consider using paradoxical assign- that if I can convince them to work at achieving
ments. For example, clients with social anxiety these three basic self-helping philosophies, this
may not risk in vivo desensization of approach- strategy will not be a cure-all for their prob-
ing other people because rejection is seen as lems but will help them be considerably less
“demeaning” or “horrible.” If, paradoxically, disturbed in the face of life’s ubiquitous hassles
they accept the assignment of, say, making sure and problems.
that they are rejected by several people, they
view their “risks” differently and if they get re- References, Readings, & Internet Sites
jected, may not view rejection as self-demeaning
and horrible. Albert Ellis Institute. (n.d.). Home page. Retrieved
2004 from http://www.rebt.org/
15. You can use metaphors, poetry, and dra-
Cowan, E. W., & Presbury, J. H. (2000). Meeting
matic presentations when direct therapeutic client resistance with reverence. Journal of
teaching does not work (Leahy, 2001). Al- Counseling and Development, 78, 411– 419.
though most clients probably listen better to Ellis, A. (2001a). Feeling better, getting better, stay-
your simple and direct communication, resis- ing better. Atascadero, CA: Impact Publishers.
tors may not do so. Therefore, you can some- Ellis, A. (2001b). Overcoming destructive beliefs,
times reach them better with dramatic or hu- feelings, and behaviors. Amherst, NY: Pro-
morous stores, poems, plays, metaphors, and metheus Books.
other indirect ways of presentation. I would not Ellis, A. (2002). Overcoming resistance: A rational
advise that you give up using direct methods of emotive behavior therapy integrated approach.
arguing with clients’ irrational beliefs and only New York: Springer.
Hanna, F. J. (2001). Therapy with difficult clients.
use metaphorics. But if you add them to your
Washington, DC: American Psychological As-
direct communication, they may get the atten- sociation.
tion of some of your resistant clients. Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999).
16. Resistant clients, more than others, often Acceptance and commitment therapy. New
have extreme self-destructive philosophies and York: Guilford Press.
cling to them rigidly. They have uncoping dog- Leahy, R. L. (2001). Overcoming resistance in cog-
mas rather than coping self-statements. I have nitive therapy. New York: Guilford Press.
found that if I strongly and persistently show McMullin, R. E. (2000). The new handbook of cog-
them the advantages of their using powerful nitive therapy. New York: Norton.
coping statements, they may finally reduce Navajits, L. M. (2001). Helping “difficult” patients.
their profound negativism and see themselves, Psychotherapy Research, 11, 131–152.
Walen, S., DiGiuseppe, R., & Dryden, W. (1992). A
other people, and the world in a much less pes-
practitioner’s guide to rational-emotive ther-
simistic light. I do my best to teach them three apy. New York: Oxford University Press.
basic constructive philosophies that largely
overcome their negativism: (a) unconditional
self-acceptance (USA): to honestly evaluate Related Topics
their behaviors as “good” when they work and Chapter 42, “Enhancing Adherence”
as “bad” when they don’t work— but never to Chapter 44, “Repairing Ruptures in the Therapeutic
overgeneralize and evaluate themselves as Alliance”
“good” or as “bad”; (b) unconditional other-
 REPAIRING RUPTURES
44 IN THE THERAPEUTIC
ALLIANCE

Jeremy D. Safran

Although promising psychotherapies have been depressed patients who completed treatment
identified for a range of psychological disorders, remained improved at follow-up intervals of 12
substantial numbers of patients fail to benefit to 18 months. For panic disorder patients, the
from these treatments. To begin with, dropout percentage remaining improved was 54% (Wes-
rates are relatively high. The NIMH Treatment tin & Morrison, 2001).
of Depression Collaborative Research Program Given the large body of evidence that a con-
(TDCRP) had attrition rates of 33% for cogni- siderable proportion of patients fail to remain in
tive therapy and 23% for interpersonal therapy or benefit from psychotherapy, it is critical to
(Elkin, 1994). Estimates of patient attrition rates identify those who are at risk for treatment
average about 47% and range as high as 67% dropout or poor outcome and to develop ways of
(Sledge, Moras, Hartley, & Levine, 1990; Wierz- improving the likelihood that they will com-
bicki & Pekarik, 1993). plete the treatment and benefit from it.
The evidence also indicates that there is still A strong or improving therapeutic alliance
considerable room for improvement outcomes. contributes to a positive treatment outcome, re-
In a meta-analysis of well-designed studies in- gardless of treatment modality (Martin, Garske,
vestigating treatments for major depression, & Davis, 2000). Similarly, there is ample evi-
generalized anxiety disorder, and panic disorder, dence that weakened alliances are correlated with
only 63% of panic disorder patients, 52% of unilateral termination (Samstag, Batchelder,
generalized anxiety disorder patients, and 54% Muran, & Winston, 1998). Another related find-
of the depressed patients who completed treat- ing is that poor outcome cases show greater neg-
ment were considered improved at termination ative interpersonal process (e.g., hostile and com-
(Westin & Morrison, 2001). In a study of 2,405 plex interactions) than good outcome cases (e.g.,
community mental health center patients, 66% Henry, Schacht, & Strupp, 1986). These findings
of treated patients could be considered im- suggest that the process of recognizing and ad-
proved, 26% unchanged, and 8% worse (Asay, dressing alliance ruptures, and negative thera-
Lambert, Christensen, and Beutler, 1984). peutic process can be important for many pa-
It is also important to remember that these tients who are at risk for treatment failure.
studies used relatively lenient criteria for im-
provement, and they failed to assess mainte-
nance at follow-up. The TDCRP found that at CLINICAL PRINCIPLES
an 18-month follow-up interval, using rela-
tively stringent (but clinically meaningful) cri- Research evidence suggests common principles
teria for recovery, only 30% of patients receiv- in resolving alliance ruptures (Foreman & Mar-
ing cognitive therapy and 26% of patients re- mar, 1985; Rhodes, Hill, Thompson, & Elliot,
ceiving interpersonal therapy were considered 1994; Safran & Muran, 2000; Safran, Muran,
improved. In a recent meta-analysis, 38% of Samstag, & Stevens, 2002). These are as follows:

216
 44 • repairing ruptures in the therapeutic alliance 217

1. Therapists should be aware that patients of- cautiousness about inferring generalized rela-
ten have negative feelings about the therapy tional patterns), (d) the relational meaning of
or the therapeutic relationship, which they interventions (i.e., the idiosyncratic way in
are reluctant to broach for fear of the thera- which each patient construes the therapist’s in-
pist’s reactions. It is thus important for ther- tervention) is as important as the content of the
apists to be attuned to subtle indications of intervention, and (e) intensive use is made of
ruptures in the alliance and to take the ini- therapist self-disclosure and collaborative ex-
tiative in exploring what is transpiring in ploration of what is taking place in the thera-
the relationship when they suspect that a peutic relationship for purposes of coming to
rupture has occurred. understand and unhook from the cycle.
2. Patients profit from expressing negative The therapist’s task when engaging in this
feelings about the therapy to the therapist type of exploration is to identify his or her own
should they emerge or to assert their per- feelings and use them as a point of departure
spective on what is going on when it differs for collaborative exploration. Different forms of
from the therapist’s. exploration are possible. The therapist may pro-
3. When this take place, it is important for vide patients with feedback about their impact
therapists to attempt to respond in an open on him or her. For example, “I feel cautious
and nondefensive fashion, and to accept re- with you . . . as if I’m walking on eggshells” or
sponsibility for their contribution to the in- “I feel like it’s difficult to really make contact
teraction. with you. On one hand, the things you’re talk-
4. There is some evidence to suggest that the ing about really seem important. But on the
process of exploring patient fears and expec- other, there’s a subtle level at which it’s difficult
tations that make it difficult for them to as- for me to really feel you,” or “I feel judged by
sert their negative feelings about treatment you.” Such feedback can help the patient begin
may contribute to the process of resolving to see his or her own contribution to the rup-
the alliance rupture. ture. It can also pave the way for the explo-
ration of the patient’s inner experience. For ex-
ample, the therapist can add, “Does this feed-
THERAPEUTIC back make any sense to you? Do you have any
META-COMMUNICATION awareness of judging me?” This can help the
patient begin to articulate a critical attitude that
In addition to these principles, the literature he or she has not been fully aware of, thus al-
suggests the value of skillful therapeutic meta- lowing the therapist to begin working through
communication as a tool for resolving alliance the alliance rupture with the patient. It is often
ruptures (see Safran & Muran, 2000). Alliance useful for therapists to pinpoint specific in-
ruptures take place when both patient and ther- stances of patients’ eliciting actions. For exam-
apist unwittingly contribute to a maladaptive ple, “I feel dismissed or closed out by you, and
interpersonal cycle that is being enacted by the I think it may be related to the way in which
two of them. Meta-communication consists of you tend not to pause and reflect in a way that
treating this cycle as the focus of collaborative suggests you’re really considering what I’m
exploration. saying.”
Some of the key features of meta-communi- Below are described specific principles for
cation in this context are that (a) there is an in- enhancing the skillful use of therapeutic meta-
tensive focus on the here and now of the thera- communication:
peutic relationship, (b) there is an ongoing col- 1. Explore with skillful tentativeness and
laborative exploration of both patients’ and emphasize one’s own subjectivity. Therapists
therapists’ contributions to the interaction, (c) should communicate observations in a tentative
there is an emphasis on the in-depth explo- and exploratory fashion. The message at both
ration of the nuances of patients’ experience in explicit and implicit levels should be one of
context of the therapeutic relationship (and a inviting patients to engage in a collaborative at-
218 part iii • individual psychotherapy and treatment

tempt to understand what is taking place, rather not be true the next, and what was true one
than conveying information with objective sta- moment may change the next. Two therapists
tus. It is also important for therapists to em- will react differently to the same patient, and
phasize the subjectivity of their perceptions each therapist must begin by making use of his
since this encourages patients to use therapists’ or her own unique experience. For example,
observations as a stimulus for self-exploration while a third-party observer may be able to
rather than to react to them either positively or adopt an empathic response toward an aggres-
negatively as authoritative statements. sive patient, the therapist who is embedded in
2. Do not assume a parallel with other rela- the interaction with that patient may have dif-
tionships. Therapists should be wary of prema- ficulty doing so. Therapists cannot conceptually
turely attempting to establish a link between manipulate themselves into an empathic stance
the configuration enacted in the therapeutic re- they don’t feel. They must begin by fully ac-
lationship and other relationships in the pa- cepting and working with their own feelings
tient’s life. Attempts to make links of this type and subjective reactions.
(while useful in some contexts) can be experi- 5. Focus on the concrete, specific, and here
enced by patients as blaming and can also serve and now of the therapeutic relationship. When-
a defensive function for therapists. Instead the ever possible, questions, observations, and com-
focus should be on exploring patients’ internal ments should focus on concrete instances in the
experience and actions in a nuanced fashion, as here and now rather than on generalizations.
they emerge in the here and now. This promotes experiential awareness rather
3. Ground all formulations in awareness of than abstract, intellectualized speculation. For
one’s own feelings and accept responsibility for example, “I experience you as pulling away from
one’s own contributions. All observations should me right now. Do you have any awareness of
attempt to take into account what the therapist doing this?”
is feeling. Failure to do so increases the risk of a 6. Track patients’ responsiveness to all in-
distorted understanding that is influenced by terventions. Therapists should carefully moni-
factors that are out of awareness. It is critical tor the impact of their interventions. Do they
for therapists to take responsibility for their seem to facilitate the process or perpetuate the
own contributions to the interaction. We are al- rupture? If therapists sense that an intervention
ways contributing to the interaction in ways has not been facilitative, they should explore
that are not fully in awareness, and an impor- the way it has been experienced by the patient.
tant task consists of clarifying the nature of this For example, “How did it feel when I said that
contribution in an ongoing fashion. to you?” or “I’m not sure know what’s going
In some situations, the process of explicitly on for you right now. I’m wondering if you
acknowledging responsibility for one’s contri- might have felt criticized by what I said?” Ex-
butions to patients can be a particularly potent ploring the patient’s construal of an interven-
intervention. First, this process can help pa- tion that has failed can play a critical role in re-
tients become aware of unconscious or semi- fining therapists’ understanding of both the
conscious feelings that they have difficulty ar- configuration that is being enacted and the pa-
ticulating. For example, acknowledging that one tient’s inner world. This helps therapists to re-
has been critical can help patients to articulate fine their interventions in a way that ultimately
their feelings of hurt and resentment. Second, will lead to the resolution of the alliance rup-
by validating the patient’s perceptions of the ture.
therapist’s actions, the therapist can reduce his 7. Collaborative exploration of the thera-
or her need for defensiveness. peutic relationship and unhooking take place
4. Start where you are. Collaborative explo- at the same time. It is not necessary for thera-
ration of the therapeutic relationship should pists to have a clear formulation prior to meta-
take into account feelings, intuitions, and ob- communicating. In fact, the process of thinking
servations that are emerging for the therapist at out loud about the interaction often helps ther-
the moment. What was true one session may apists to remove from the configuration that is
 44 • repairing ruptures in the therapeutic alliance 219

being enacted by putting into words subtle per- Lambert, M. J., & Bergin, A. E. (1994). The effec-
ceptions that might otherwise remain implicit. tiveness of psychotherapy. In A. E. Bergin &
Moreover, the process of telling patients about S. L. Garfield (Eds.), Handbook of psychother-
an aspect of one’s experience that one is in con- apy and behavior change (4th ed., pp. 143 –
189). New York: Wiley.
flict over can free therapists to see the situation
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Re-
more clearly.
lation of the therapeutic alliance with outcome
8. Remember that attempts to explore what and other variables: A meta-analytic review.
is taking place in the relationship can function Journal of Consulting and Clinical Psychology,
as new cycles of an ongoing enactment. For ex- 68, 438 – 450.
ample, the therapist articulates a growing intu- Rhodes, R. H., Hill, C. E., Thompson, B. J., & Elliot,
ition that the patient is withdrawing and says, R. (1994). Client retrospective recall of resolved
“It feels to me like I’m trying to pull teeth.” In and unresolved misunderstanding events. Jour-
response the patient withdraws further and an nal of Counseling Psychology, 41, 473 – 483.
intensification of an existing vicious cycle en- Safran, J. D., & Muran, J. C. (2000). Negotiating the
sues in which the therapist escalates his at- therapeutic alliance: A relational treatment
guide. New York: Guilford Press.
tempts to break through and the patient be-
Safran, J. D., Muran, J. C., Samstag, L. W., &
comes more defensive. It is critical to track the
Stevens, C. (2002). Repairing the alliance rup-
quality of patients’ responsiveness to all inter- tures. In J. C. Norcross (Ed.), Psychotherapy re-
ventions and to explore their experience of in- lationships that work (pp. 235 –254). New
terventions that have not been facilitative. Does York: Oxford University Press.
the intervention deepen the patient’s self-explo- Samstag, L. W., Batchelder, S. T., Muran, J. C., &
ration or lead to defensiveness or compliance? Winston, A. (1998). Early identification of
The process of exploring the ways in which pa- treatment failures in short-term psychother-
tients experience interventions that are not fa- apy: An assessment of therapeutic alliance and
cilitative helps to refine the understanding of interpersonal behavior. Journal of Psychother-
the cycle that is being enacted. apy Practice and Research, 7, 126 –143.
Seligman, M. E. P. (1995). The effectiveness of psy-
chotherapy —The Consumer Reports study.
References & Readings American Psychologist, 50, 965 – 974.
Asay, T. P., Lambert, M. J., Christensen, E. R., & Sledge, W. H., Moras, K., Hartley, D., & Levine, M.
Beutler, L. E. (1984). A meta-analysis of men- (1990). Effect of time-limited psychotherapy on
tal health treatment outcome. Unpublished patient drop-out rates. American Journal of
manuscript, Brigham Young University, De- Psychiatry, 147, 1341–1347.
partment of Psychology. Westin, D., & Morrison, K. (2001). A multidimen-
Elkin, I. (1994). The NIMH treatment of depression sional meta-analysis of treatments for depres-
collaborative research program: Where we be- sion, panic, and generalized anxiety disorder:
gan and where we are. In A. E. Bergin & S. L. An empirical examination of the status of em-
Garfield (Eds.), Handbook of psychotherapy pirically supported therapies. Journal of Con-
and behavior change (4th ed., pp. 114 –139). sulting and Clinical Psychology, 69, 875 – 899.
New York: Wiley. Wierzbicki, M., & Pekaric, G. (1993). A meta-analyis
Foreman, S. A., & Marmar, C. R. (1985). Therapist of psychotherapy dropout. Professional Psy-
actions that address initially poor therapeutic chology: Research and Practice, 24, 190 –195.
alliances in psychotherapy. American Journal of
Psychiatry, 142, 922– 926. Related Topics
Henry, W. P., Schact, T. E., & Strupp, H. H. (1986).
Structural analysis of social behavior: Applica- Chapter 42, “Enhancing Adherence”
tion to a study of interpersonal process in dif- Chapter 43, “Methods to Reduce and Counter Resis-
ferential psychotherapeutic outcome. Journal of tance in Psychotherapy”
Consulting and Clinical Psychology, 54, 27 –31.
 SYSTEMATIC ASSESSMENT
45 AND TREATMENT MATCHING

Oliver B. Williams, Larry E. Beutler,

& Kathryn Yanick

This synopsis of Systematic Treatment Selec- tape of the intake session (e.g., Beutler et al.,
tion (STS; Beutler, Clarkin, & Bongar, 2000) 2000). The items presented here to assess these
presents two major components: (1) question- dimensions do not constitute comprehensive
naire responses that identify patient predictors and psychometrically pure scales. They are rep-
and indicators, and (2) the translation of these resentative and clear items that can estimate pa-
variables to making treatment decisions. The tient characteristics that can be used for treat-
first section presents items used to assess five ment selection; they should be seen as guides to
basic domains of patient functioning. Once help the clinician, rather than as standardized
these domains have been assessed, treatment tests.
selection decisions can be addressed logically These assessment dimensions, and the treat-
and algorithmically. The second section is di- ment decisions that they portend, are derived
vided into two parts: assigning the level of pa- from 18 research-informed principles on evi-
tient care and determination of optimal treatment dence-based treatment matching (Beutler &
approaches. Level-of-care decisions are based on Clarkin, 1990). The interested clinician can ob-
a determination of patient functionality, safety, tain a demonstration of a more complete pro-
treatment setting, and the potential for medical cess of relating patient characteristics to treat-
consultation (mode). In contrast, the selection ment decisions at the Web site www.systematic
of optimal treatment approaches relies on a com- treatmentselection.com. A more detailed dis-
bination of indicators based on patient person- cussion of the STS model and the internet-
ality and interpersonal styles, all of which facil- deployed system, respectively, is in Beutler and
itate matching the patient to treatment. Harwood (2000) and Harwood and Williams
(2003). And information about stand-alone or
network versions of the computer program
SYSTEMATIC ASSESSMENT Systematic Treatment Selection for Windows
may be obtained from New Standards (1080
There are five basic domains, each representing Montreal Avenue, Suite 300, St. Paul, MN
a general patient characteristic that can be 55116; 800-755-6299).
rapidly assessed to match treatments. These five
domains are the patient’s (1) severity and func-
Severity/Functionality
tionality; (2) personal and problem complexity;
(3) distress; (4) level of resistance (sometimes The safety of the patient and of those around
called “reactance”); and (5) coping style. Find- her/him are central to determining the optimal
ings from a large body of research show that level of care. Additionally, the patient’s ability
these patient characteristics can be measured re- to conduct tasks necessary to physical and social
liably by a clinician during the course of an in- living determine functionality, which is also
take session, or by a clinician viewing a video- central to level of care. The factors of severity

220
 45 • systematic assessment and treatment matching 221

and functionality prescribe the treatment set- C4. Can the patient also be diagnosed with an
ting and environment, or the amount of re- Axis II disorder?
striction imposed upon the patient necessary to
maintain his or her safety and/or the safety of Add items C1–C4. This score is Complexity.
others.
Answer the following questions, assigning a
Distress
score of 1 (yes) or 0 (no):
We conceptualize distress as three contributing
S1. Has the patient just recently suffered se- factors: the comfort level as the patient reports
vere loss due to prolonged use of alcohol it; how the clinician perceives the patient’s dis-
and/or other drugs? tress level; and the patient’s self-esteem, where
S2. Is the patient disoriented in time, place, or low self-esteem is indicative of psychological
person? distress. These distress factors are independent
S3. Within the past year, has this patient ever of diagnoses and are manifested as “psycholog-
been explosive, charged with criminal con- ical pain.” Relief of such pain can motivate the
duct, threatened harm to another, or de- patient to become involved in treatment and to
stroyed property in a fit of anger or retri- initiate change. Answer the following ques-
bution? tions to guide your estimate of patient distress.
S4. Does the patient currently demonstrate ex- The patient . . .
tremely violent behavior?
S5. Is the patient grossly disabled, or unable to D1. Would probably frequently report, “I of-
care for herself/himself? ten feel nervous, anxious, or restless even
when things are going OK”
Add items S1–S5. Call this score Severity. D2. Overreacts to disappointments and dis-
couragement
D3. Feels guilty, unworthy, or self-disliked
Patient/Problem Complexity
most of the time
The depth, history, and thematic nature of the D4. Is very uncertain about the future
patient’s profile provide important predictors of D5. Feels unhappy or sad
the prognosis and probable length of treatment. D6. Has many symptoms of emotional distress
Situational problems suggest a more acute (e.g., agitation, dysphoria, confusion, guilt)
symptom architecture where brief and targeted
psychotherapeutic procedures are indicated. Total the number of yes responses. Call this
More complex profiles are reflected in long- sum Distress.
standing and thematic complaints that recur in
almost all facets of the patient’s life. A yes re-
Level of Resistance
sponse to each of the following questions sug-
gests greater complexity and chronicity. The to- Resistance— or what may be, in extreme form,
tal number of yes responses roughly identifies oppositional behavior — connotes an individ-
the level of problem complexity. ual’s relative sluggishness or alacrity to accept
the therapist’s direction. Resistance can be con-
C1. Has there been more than one similar ceptualized as a kind of “psychological inertia.”
episode of the presenting problem, or of Analogously, the more inertia a patient has, the
major depression? more effort is required to move him or her to
C2. Does this patient merit more than one change course and direction. Consider the fol-
Axis I diagnosis? lowing questions about the patient.
C3. Does the patient have recurrent and dis- The patient . . .
tressful thoughts and feelings about his/
her nuclear family (mother, father, close R1. Is not likely to accept and follow the direc-
relatives)? tions of those in authority
222 part iii • individual psychotherapy and treatment

R2. Has trouble being a follower I5. Is timid

R3. Is prone to criticize others I6. Likes to be alone
R4. Is controlling in relationships
R5. Is distrustful and suspicious of others’ mo-
tives TREATMENT MATCHING
R6. Often breaks “the rules”
R7. Is passive-aggressive Treatment decisions are complex and, accord-
ingly, are developed from weighing and inte-
Add the number of yes responses, and call grating a number of patient and treatment di-
the total Resistance. mensions. Balancing multiple factors in clinical
practice usually is done through an idiosyn-
cratic process that relies heavily on one’s per-
Coping Style
sonal and clinical experience. Even expert clin-
The patient’s coping style is defined as the usual icians are limited in the number of patient and
manner in which she or he manages anxiety environmental dimensions they can conceptu-
and stress. Anxiety can be exhibited through ally manage and effectively integrate in treat-
outward expression into one’s physical and so- ment planning.
cial environment, called externalization. It can This section presents a suggested method of
also be focused inwardly by containment of weighing variables identified in the assessment
feelings and thoughts, called internalization. and a systematic means of combining them to
Individuals are not uniformly at one pole or the make decisions about the level of care and treat-
other, but rather are best defined as having both ment approach for a particular patient. More
internalizing (self-reflective) and externalizing specific recommendations than those presented
(impulsive) qualities, of which one dominates. here are possible, but they require more psy-
chometrically rigorous assessments and more
Externalizing Answer the following questions complex weightings. A computer-based version
and call the total number of yes responses Ex- of this process produces complex algorithms in
ternalization. order to select appropriate therapists, identify
The patient . . . particular treatments that fit the patient, and
select specific techniques that are likely to be
E1. Is socially gregarious and outgoing effective.
E2. Has used alcohol/drugs excessively at one
time
Level of Care
E3. Gets frustrated easily
E4. Often gets into trouble because of his/her Severity = 0: Intensive or more than supportive
behavior treatment does not appear warranted for this
E5. Gets bored easily patient at this time. Optional treatment set-
E6. Has an inflated sense of importance tings could include the site of difficulty, office
treatment, the home, or any combination of
Internalizing Answer the following questions these environments during of treatment. The
and call the total number of yes responses clinician may want to consider how the present
Internalization. environment optimally affects and facilitates
The patient . . . treatment outcome.
S1 is Yes or S2 is Yes or S3 is Yes and S5 is
I1. Is more likely to feel hurt than angry No: Treatment is indicated for this patient. The
I2. Worries or ruminates a lot level of problem severity suggests that the pa-
I3. Feels more than passing guilt, remorse, or tient will be manageable as an outpatient.
shame about minor things S1 and S5 are Yes: The patient may require
I4. Is more interested in ideas than taking ac- protective controls against harming himself/
tion herself. Acute hospitalization should be consid-
 45 • systematic assessment and treatment matching 223

ered while the patient becomes stabilized on a dominant interpersonal needs or desires that
treatment regimen. motivate the initiation of interpersonal rela-
Total Severity *3: Serious consideration tionships, (2) the avoided and feared responses
must be given to providing a protective envi- that are expected to come from others as the pa-
ronment along with medical management and tient tries to meet these needs or achieve these
consultation. wants, and (3) the acts of the patient to attempt
Severity = 1 and Axis I Count < 4 And a compromise between personal desires and
Complexity = 1: The patient presents problems feared consequences.
of mild to moderate severity. Most of the symp- Distress *3 and Complexity = 0: Indicators
tomatic presentations probably can be expected suggest focus and outcome objectives should be
to be resolved within six months of regular on symptom removal. There is little indication
treatment. If the problems prove to be compli- of a persistent and continuing problem beyond
cated by personality disorder or multiple prob- situational disturbance. Since this patient’s pre-
lems, a reconsideration of this projection will be senting problems are relatively situational, this
indicated. should not pose a major difficulty for the treat-
Severity > 1 and C3 = Yes and Complexity ment. Good and even lasting outcomes have
2: This patient presents with chronic and diffi- been noted with procedures that are designed to
cult problems. These difficulties are likely to be induce rapid symptom change. Indeed, insight-
resolved slowly. While one may expect some oriented treatments are often more time-con-
increased optimism and some dissipation of suming than warranted by the problems pre-
some symptoms within a period of less than six sented by patients such as this.
months, substantial change may require both It may be possible to restrict the goals of
long-term care and periods in which the fre- treatment to symptom removal. If so, treat-
quency of visits and varieties of care are in- ment can be expected to produce some diminu-
creased. tion of the major symptoms of depression and
S2 is Yes and S5 is Yes: The patient is prone anxiety within 20 to 30 sessions or weeks. If
to aggressive acts and these may involve risk to there are more focal symptoms being pre-
other people. Protections against these acts are sented, such as sleep, sexual, or impulse-
indicated. At least short-term hospitalization or control problems, they may require a some-
legal management may be indicated. what longer period of time. Treatment should
be addressed to symptom removal, to the re-
duction of subjective distress, and to the in-
Treatment Approaches
crease in objective life adjustment. Cognitive
(Complexity = 1 or 2) and Distress *3: Both control strategies, contingency programs for
chronicity and acuteness are indicated, where symptomatic control, and response prevention
acuteness has exacerbated long-standing prob- interventions should be considered.
lems. The first goal should be narrow focus and Complexity *2 and Distress > 3: Com-
symptom removal; the second goal should be plexity suggests chronic and long-standing
long-term behavioral management. symptoms. Treatment objectives should be on
There are indications that this patient’s long-term behavioral management. Thus, the
problems reflect persistent and long-term con- long-term goals of treatment should not be
flicts. Thus, the long-term goals of treatment constrained to symptom removal.
should not be limited to symptom removal. This patient is likely to have conflicts and re-
This patient is likely to have conflicts and re- current dysfunctional behaviors in interper-
current dysfunctional behaviors in interper- sonal relationships that prevent the long-term
sonal relationships that prevent the long-term resolution of symptoms. An understanding of
resolution of symptoms. An understanding of the patient’s intrapersonal dynamics and inter-
the patient’s intrapersonal dynamics and inter- personal problems is necessary in addressing
personal problems is necessary in addressing these problems. It often helps to define (1) the
these problems. It often helps to define (1) the dominant interpersonal needs or desires that
224 part iii • individual psychotherapy and treatment

motivate the initiation of interpersonal rela- the assumption of personal responsibility for
tionships, (2) the avoided and feared responses initiating change.
that are expected to come from others as the pa- Externalization > 3 and Reactance > 3: Be-
tient tries to meet these needs or achieve these haviorally focused and cognitive change thera-
wants, and (3) the acts of the patient to attempt pies may be particularly helpful for this patient.
a compromise between personal desires and However, because the patient tends to be more
feared consequences. resistant to direction than usual, modifications
Distress < 3 and Complexity < 2: Given the of the treatments may be necessary. Such mod-
low level of personal distress, a question must ifications may employ self-help manuals and ef-
be raised as to why this person is seeking treat- forts to make homework assignments more
ment at this time. Careful consideration must flexible than usual.
be given to the need and advisability of treat- Severity = 1 and Distress > 2 and Internal-
ment, external (environmental and situational) ization > Externalization: Treatment is indi-
factors that may be motivating it, and especially cated for this patient, and the level of problem
to the possible gains that may determine a re- severity suggests that the patient will be man-
ferral for treatment at the present time. ageable as an outpatient. Moreover, the patient
C3 = Yes and Complexity > 1: Family ther- appears to be in sufficient distress to provide
apy appears to be indicated. This therapy motivation for ongoing psychotherapy. Such
should focus on conflicts in the patient’s current individuals tend to work quite well in psy-
family. The role of other symptoms and prob- chotherapy relationships, especially if they
lems may either be ancillary or primary in the have a history of being able to form social at-
family problems, but the significance of family tachments. Their motivation for treatment is
disruption nonetheless warrants direct atten- typically to reduce stress, however, and rapid
tion. change of symptoms may reduce their motiva-
Externalization > 3 and Reactance > 3 and tion.
S2 is Yes: The patient exhibits possible explo- Severity = 0 and Distress *3 and External-
sive outbursts. Thus, caution is advised and ization > Internalization: While the patient has
treatment should include behavioral protec- little impairment functionally, the level of in-
tions such as the initiation of nonviolence con- ternal distress indicates the desirability of
tracts, monitoring of impulsivity, and ongoing treatment. This distress level is sufficient to
assessment of escalating emotional intensity. provide motivation for treatment and indicates
Training in emotional recognition, identifica- that engagement in an outpatient treatment is
tion of risk environments, and cognitive man- possible. Engaging such patients in the process
agement skills are indicated. of therapy is difficult because they often have
(Severity > 0 and Severity < 3) and Distress difficulty assessing their role in causing or
> 3 and Externalization > Internalization: The maintaining their problems. A focus on prob-
patient appears to be in sufficient distress to lematic behaviors and cognitions with short-
provide motivation for ongoing psychotherapy. term, measurable objectives is more likely to be
Nonetheless, treatment progress is often slow effective than insight oriented treatments.
with such individuals. They tend to work in- Severity = 0 and Distress *3 and Internal-
consistently in treatment, even withdrawing ization > Externalization: While the patient
from treatment prematurely when their dis- has little functional impairment, the level of in-
tress lessens. They have difficulty seeing their ternal distress indicates the desirability of
own contribution to their problems, they tend treatment. This distress level is sufficient to
to blame others and to attribute their difficul- provide motivation for treatment and indicates
ties to forces that are outside of their personal that engagement in an outpatient treatment is
control. Treatment would do well to reinforce possible. The patient is self-reflective, suggest-
assumptions of personal responsibility. Some- ing that insight is possible and even desirable as
times, group therapies have been useful in pro- a treatment goal. Insight into unwanted feel-
viding a level of confrontation that encourages ings may prove to be advantageous.
 45 • systematic assessment and treatment matching 225

Severity = 0 and Distress < 3 and External- References, Readings, & Internet Sites
ization > Internalization: This patient appar- Beutler, L. E. (1979). Toward specific psychological
ently has minimal impairment of functioning. therapies for specific conditions. Journal of Con-
Coupled with the low level of personal distress, sulting and Clinical Psychology, 47, 882– 897.
this raises a question as to why this person is Beutler, L. E. (2001). Comparisons among quality as-
seeking treatment at this time. Careful consid- surance systems: From outcome assessment to
eration must be given to the need and advis- clinical utility. Journal of Consulting and Clin-
ability of treatment, and especially to the moti- ical Psychology, 69, 197 –204.
vations that are determining a referral for Beutler, L. E., & Clarkin, J. (1990). Systematic treat-
treatment at the present time. Engaging such ment selection: Toward targeted therapeutic in-
terventions. New York: Brunner/Mazel.
patients in the process of therapy is difficult be-
Beutler, L. E., Clarkin, J. F., & Bongar, B. (2000). Sys-
cause they often have difficulty assessing their tematic guidelines for treating the depressed
role in causing or maintaining their problems. patient. New York: Oxford University Press.
A focus on problematic behaviors and cogni- Beutler, L. E. & Harwood, T. M. (2000). Prescriptive
tions with short-term, measurable objectives is psychotherapy: A practical guide to Systematic
more likely to be effective than insight oriented Treatment Selection. New York: Oxford Uni-
treatments. versity Press.
Severity = 0 and Distress < 3 and Internal- Beutler, L. E., & Williams, O. B. (1995). Computer
ization > Externalization: This patient also ap- applications for the selection of optimal psy-
parently has minimal impairment of function- chosocial therapeutic interventions. Behavioral
ing. Coupled with the low level of personal dis- Healthcare Tomorrow, 4, 66 – 68.
Beutler, L. E., & Williams, O. B. (2002). www.syste
tress, this raises a question as to why this
matictreatmentselection.com [Internet-deployed
person is seeking treatment at this time. Care- interactive system]. Oxnard, CA: Center for
ful consideration must be given to the need and Behavioral HealthCare Technologies.
advisability of treatment, and especially of the Harwood, T. M., & Williams, O. B. (2003). Identify-
motivations that are determining a referral for ing treatment relevant assessment: The STS. In
treatment at the present time. However, the pa- L. E. Beutler & G. Groth-Marnat (Eds.), Inte-
tient is self-reflective, suggesting that insight is grative assessment of adult personality (2nd
possible and even desirable as a treatment goal. rev. ed., pp. 65 –81). New York: Guilford Press.
Insight into both hidden motives and into un-
wanted feelings may prove to be advantageous. Related Topics
Severity > 2: This patient may require a
Chapter 39, “Compendium of Empirically Supported
very structured and concrete approach to treat-
Therapies”
ment including pretreatment preparation, Chapter 40, “Compendium of Psychotherapy Treat-
clearly established goals, and an outline of in- ment Manuals”
treatment and outside of treatment expecta- Chapter 46, “Stages of Change: Prescriptive Guide-
tions. lines”
 STAGES OF CHANGE
46
Prescriptive Guidelines

James O. Prochaska, John C. Norcross,

& Carlo C. DiClemente

Over the past 25 years our research has focused There are multiple ways to measure the
on the structure of change that underlies both stages of change. In our studies employing the
self-mediated and treatment-facilitated modifi- discrete categorization measurement of stages
cation of problem behavior (for summaries, see of change, we ask if the individual is seriously
DiClemente, 2003a; DiClemente, 2003b; Pro- intending to change the problem behavior in
chaska, DiClemente, & Norcross, 1992; Pro- the near future, typically within the next six
chaska, Norcross, & DiClemente, 1995). From months. If not, he or she is classified as a pre-
an integrative or transtheoretical perspective, contemplator. Even precontemplators can wish
this chapter summarizes prescriptive and pro- to change, but this is quite different from in-
scriptive guidelines for psychosocial interven- tending or seriously considering change. Items
tions based on the client’s stage of change. that are used to identify precontemplation on
the continuous stage of change measure in-
clude: “As far as I’m concerned, I don’t have any
DEFINITIONS OF STAGES problems that need changing” and “I guess I
have faults, but there’s nothing that I really
The following are brief descriptions of each of need to change.” Resistance to recognizing or
the five stages. Each stage represents a period of modifying a problem is the hallmark of precon-
time, as well as a set of tasks needed for move- templation.
ment to the next stage. Although the time an 2. Contemplation is the stage in which peo-
individual spends in each stage may vary, the ple are aware that a problem exists and are se-
tasks to be accomplished are assumed to be in- riously thinking about overcoming it, but they
variant. have not yet made a commitment to take action.
1. Precontemplation is the stage at which People can remain stuck in the contemplation
there is no intention to change behavior in the stage for long periods. In one study of self-
foreseeable future. Most individuals in this changers we followed a group of 200 smokers in
stage are unaware or underaware of their prob- the contemplation stage for two years. The
lems. Families, friends, neighbors, or employ- modal response of this group was to remain in
ees, however, are often well aware that the pre- the contemplation stage for the entire two years
contemplators have problems. When precon- of the project without ever moving to signifi-
templators present for psychotherapy, they cant action (Prochaska & DiClemente, 1983).
often do so because of pressure from others. Contemplators struggle with their positive
Usually they feel coerced into changing by evaluations of their dysfunctional behavior and
spouses who threaten to leave, employers who the amount of effort, energy, and loss it will
threaten to dismiss them, parents who threaten cost to overcome it. On discrete measures, indi-
to disown them, or courts who threaten to pun- viduals who state that they are seriously con-
ish them. sidering changing their behavior in the next six

226
 46 • stages of change 227

months are classified as contemplators. On the behaviors, maintenance can be considered to last
continuous measure, these individuals endorse a lifetime. Being able to remain free of the ad-
such items as “I have a problem and I really dictive behavior and to consistently engage in a
think I should work on it” and “I’ve been new incompatible behavior for more than six
thinking that I might want to change some- months are the criteria for the maintenance
thing about myself.” Serious consideration of stage. On the continuous measure, representa-
problem resolution is the central element of tive maintenance items are “I may need a boost
contemplation. right now to help me maintain the changes I’ve
3. Preparation is a stage that combines in- already made” and “I’m here to prevent myself
tention and behavioral criteria. Individuals in from having a relapse of my problem.” Stabiliz-
this stage are intending to take action in the ing behavior change and avoiding relapse are the
next month and have unsuccessfully taken ac- hallmarks of maintenance.
tion in the past year. As a group, individuals As is now well known, most people taking
who are prepared for action report small be- action to modify dysfunctional behavior do not
havioral changes, such as smoking five fewer successfully maintain their gains on their first
cigarettes or delaying their first cigarette of the attempt. With New Year’s resolutions, for ex-
day for 30 minutes longer than precontempla- ample, the successful self-changers typically
tors or contemplators. Although they have re- report three to five years of consecutive pledges
duced their problem behaviors, individuals in before maintaining the behavioral goal for at
the preparation stage have not yet reached a cri- least six months (Norcross, Mrykalo, & Blagys,
terion for effective action, such as abstinence 2002). Relapse is the rule rather than the ex-
from smoking or alcohol abuse. They are in- ception across virtually all behavioral disorders.
tending, however, to take such action in the Accordingly, change is not a linear progres-
very near future. On the continuous measure, sion through the stages; rather, most clients
they score high on both the contemplation and move through the stages of change in a spiral
action scales. pattern. People progress from contemplation to
4. Action is the stage in which individuals preparation to action to maintenance, but most
modify their behavior, experiences, and/or en- individuals will relapse. During relapse, indi-
vironment in order to overcome their problems. viduals regress to an earlier stage. Some relapsers
Action involves the most overt behavioral feel like failures—embarrassed, ashamed, and
changes and requires considerable commitment guilty. These individuals become demoralized
of time and energy. Behavioral changes in the and resist thinking about behavior change. As a
action stage tend to be most visible and exter- result, they return to the precontemplation
nally recognized. Individuals are classified in stage and can remain there for various periods
the action stage if they have successfully al- of time. Approximately 15% of relapsers in our
tered the dysfunctional behavior for a period self-change research regress to the precontem-
from one day to six months. On the continuous plation stage. Fortunately, most—85% or so—
measure, individuals in the action stage endorse move back to the contemplation stage and even-
statements like “I am really working hard to tually back into preparation and action.
change” and “Anyone can talk about changing;
I am actually doing something about it.” They
score high on the action scale and lower on the PRESCRIPTIVE GUIDELINES
other scales. Modification of the target behavior
to an acceptable criterion and concerted overt ef- 1. Assess the client’s stage of change: Prob-
forts to change are the hallmarks of action. ably the most obvious and direct implication is
5. Maintenance is the stage in which people the need to assess the stage of a client’s readi-
work to prevent relapse and consolidate the gains ness for change and to tailor interventions ac-
attained during action. For addictive behaviors, cordingly. Stages of change can be ascertained
this stage extends from six months to an inde- by multiple means, of which three self-report
terminate period past the initial action. For some methods will be described here.
228 part iii • individual psychotherapy and treatment

A first and most efficient method is to ask may be able to double the chances of partici-
the patient a simple series of questions to iden- pants taking action on their own in the near fu-
tify his or her stage — for example, “Do you ture.
think behavior X is a problem for you now?” (if 4. Recognize that clients in the action stage
yes, then contemplation, preparation, or action are far more likely to achieve better and
stage; if no, then maintenance or precontem- quicker outcomes: The amount of progress
plation stage) and “When do you intend to clients make during treatment tends to be a
change behavior X?” (if some day or not soon, function of their pretreatment stage of change.
then contemplation stage; if in the next month, For example, an intensive action- and mainte-
then preparation; if now, then the action stage). nance-oriented smoking cessation program for
A second method is to assess the stage from a cardiac patients achieved success for 22% of
series of mutually exclusive questions, and a precontemplators, 43% of contemplators, and
third is a continuous measure that yields sepa- 76% of those in action or prepared for action at
rate scales for precontemplation, contempla- the start of the study were not smoking six
tion, action, and maintenance (McConnaughy, months later (Ockene, Ockene, & Kristellar,
DiClemente, Prochaska, & Velicer, 1989; Mc- 1988). This repeated finding has direct implica-
Connaughy, Prochaska, & Velicer, l983). tions for selecting and prioritizing treatment
2. Beware treating all patients as though goals.
they are in action: Professionals frequently de- 5. Facilitate the insight-action crossover: Pa-
sign excellent action-oriented treatment and tients in successful treatment evidence steady
self-help programs, but then are disappointed progression on the stages of change. Patients
when only a small percentage of people regis- entering therapy are typically in the contem-
ter or when large numbers drop out of the pro- plation or preparation stage. In the midst of
gram after registering. The vast majority of treatment, patients typically cross over from
people are not in the action stage. Aggregating contemplation into action. Patients who remain
across studies and populations, we estimate that in treatment progress from being prepared for
10% to 15% are prepared for action, approxi- action to taking action over time. That is, they
mately 30% to 40% are in the contemplation shift from thinking about their problems to do-
stage, and 50% to 60% in the precontemplation ing things to overcome them. Lowered precon-
stage. Thus, professionals approaching patients templation scores also indicate that, as engage-
and settings only with action-oriented pro- ment in therapy increases, patients reduce their
grams are likely to underserve or misserve the defensiveness and resistance. The progression
majority of their target population. from contemplation to action is postulated to be
3. Assist clients in moving one stage at a essential for beneficial outcome regardless of
time: If clients progress from one stage to the whether the treatment is action-oriented or
next during the first month of treatment, they insight-oriented.
can double their chances of taking action in the 6. Anticipate recycling: Most self-changers
next six months. Among smokers, for example, and psychotherapy patients will recycle several
of the precontemplators who were still in pre- times through the stages before achieving long-
contemplation at one-month follow-up, only term maintenance. Accordingly, intervention
3% took action by six months. For the precon- programs and personnel expecting people to
templators who progressed to contemplation at progress linearly through the stages are likely
one month, 7% took action by six months. to gather disappointing results. Be prepared to
Similarly, of the contemplators who remained include relapse prevention in treatment, antic-
in contemplation at one month, only 20% took ipate the probability of recycling patients, and
action by six months. At one month, 41% of try to minimize therapist guilt and patient
the contemplators who progressed to the prepa- shame over recycling.
ration stage attempted to quit by six months. 7. Conceptualize change mechanisms as
These data indicate that treatments designed to processes, not as specific techniques: Literally
help people progress just one stage in a month hundreds of specific psychotherapeutic tech-
 46 • stages of change 229

niques have been advanced; however, a small right time (stages): Twenty-five years of re-
and finite set of change processes or strategies search in behavioral medicine, self-change, and
underlie these multitudinous techniques. psychotherapy converge in showing that dif-
Change processes are covert and overt activ- ferent processes of change are differentially ef-
ities that individuals engage in when they at- fective in certain stages of change; a meta-
tempt to modify problem behaviors. Each analysis of 47 studies (Rosen, 2000) found ef-
process is a broad category encompassing mul- fect sizes of .70 and .80 for the use of different
tiple techniques, methods, and interventions change processes in the stages. In general
traditionally associated with disparate theoret- terms, change processes traditionally associated
ical orientations. These change processes can be with the experiential, cognitive, and psychoan-
used within therapy sessions, between therapy alytic persuasions are most useful during the
sessions, or without therapy sessions. earlier precontemplation and contemplation
The processes of change represent an in- stages. Change processes traditionally associ-
termediate level of abstraction between meta- ated with the existential and behavioral tradi-
theoretical assumptions and specific techniques tions, by contrast, are most useful during action
spawned by those theories. While there are and maintenance.
400-plus ostensibly different psychotherapies, In the transtheoretical model, particular
we have been able to identify only 12 different change processes will be optimally applied at
processes of change based on principal compo- each stage of change. During the precontem-
nents analysis. plation stage, individuals use the change
Table 1 presents the eight processes receiv- processes significantly less than people in any
ing the most theoretical and empirical support of the other stages. Precontemplators process
in our work, along with their definitions and less information about their problems, devote
representative examples of specific interven- less time and energy to reevaluating them-
tions. A common and finite set of change selves, and experience fewer emotional reac-
processes has been repeatedly identified across tions to the negative aspects of their problems.
diverse disorders. In therapy, these are the most resistant or the
8. Do the right things (processes) at the least active clients.

table 1. Titles, Definitions, and Representative Interventions of Eight Processes of Change

Process Definition: Interventions

1. Consciousness raising Increasing information about self and problem: observations;

confrontations; interpretations; bibliotherapy
2. Self-reevaluation Assessing how one feels and thinks about oneself with respect to a
problem: value clarification; imagery; corrective emotional experience
3. Emotional arousal (or dramatic relief) Experiencing and expressing feelings about one’s problems and solutions:
psychodrama; grieving losses; role playing
4. Social liberation Increasing alternatives for nonproblem behaviors available in society:
advocating for rights of repressed; empowering; policy interventions
5. Self-liberation Choosing and committing to act or belief in ability to change:
decision-making therapy; New Year’s resolutions; logotherapy
techniques; commitment-enchancing technques
6. Counterconditioning Substituting alternatives for anxiety related behaviors: relaxation;
desensitization; assertion; cognitive restructuring
7. Stimulus control Avoiding or countering stimuli that elicit problem behaviors:
restructuring one’s environment (e.g., removing alcohol or fattening
foods); avoiding high-risk cues; fading techniques
8. Contingency management Rewarding oneself or being rewarded by others for making changes:
contingency contracts; overt and covert reinforcement; self-reward

Source: Adapted from Prochaska, DiClemente, & Norcross, 1992.

230 part iii • individual psychotherapy and treatment

Individuals in the contemplation stage are techniques, is how clinicians determine thera-
most open to consciousness-raising techniques, peutic “relationships of choice” in terms of in-
such as observations, confrontations, and inter- terpersonal stances (Norcross, 2002).
pretations, and are much more likely to use bib- The research and clinical consensus on the
liotherapy and other educational techniques. therapist’s stance at different stages can be char-
Contemplators also profitably employ emo- acterized as follows (Prochaska & Norcross,
tional arousal, which raises emotions and leads 2002). With precontemplators often the role is
to a lowering of negative affect when the person like that of a nurturing parent joining with the
changes. As individuals became more conscious resistant youngster who is both drawn to and
of themselves and the nature of their problems, repelled by the prospects of becoming more in-
they are more likely to reevaluate their values, dependent. With contemplators, the therapist
problems, and themselves both affectively and role is akin to a Socratic teacher who encour-
cognitively. ages clients to achieve their own insights and
Both movement from precontemplation to ideas into their condition. With clients who are
contemplation and movement through the con- in the preparation stage, the stance is more like
templation stage entail increased use of cog- that of an experienced coach who has been
nitive, affective, and evaluative processes of through many crucial matches and can provide
change. Some of these changes continue during a fine game plan or can review the person’s own
the preparation stage. In addition, individuals action plan. With clients who are progressing
in preparation begin to take small steps toward into action and maintenance, the psychothera-
action. pist becomes more of a consultant who is avail-
During the action stage, people use higher able to provide expert advice and support when
levels of self-liberation or willpower. They in- action is not progressing as smoothly as ex-
creasingly believe that they have the autonomy pected.
to change their lives in key ways. Successful ac- 10. Avoid mismatching stages and pro-
tion also entails effective use of behavioral cesses: A person’s stage of change provides pro-
processes, such as counterconditioning and scriptive as well as prescriptive information on
stimulus control, in order to modify the condi- treatments of choice. Action-oriented therapies
tional stimuli that frequently prompt relapse. may be quite effective with individuals who are
Contingency management also comes into fre- in the preparation or action stages. These same
quent use here. programs may be ineffective or detrimental,
Successful maintenance builds on each of the however, with individuals in the precontempla-
processes that came before. Specific preparation tion or contemplation stages.
for maintenance entails an assessment of the We have observed two frequent mismatches.
conditions under which a person would be First, some therapists and self-changers rely
likely to relapse and development of alternative primarily on change processes most indicated
responses for coping with such conditions for the contemplation stage — consciousness
without resorting to self-defeating defenses and raising, self-reevaluation— while they are mov-
pathological responses. Continuing to apply ing into the action stage. They try to modify
counterconditioning, stimulus control, and behaviors by becoming more aware, a common
contingency management is most effective criticism of classical psychoanalysis: insight
when based on the conviction that maintaining alone does not necessarily bring about behavior
change supports a sense of self that is highly change. Second, other therapists and self-
valued by oneself and significant others. changers rely primarily on change processes
9. Prescribe stage-matched “relationships of most indicated for the action stage — contin-
choice” as well as “treatments of choice”: Psy- gency management, stimulus control, counter-
chotherapists seek to customize or tailor their conditioning — without the requisite aware-
interpersonal stance to different patients. One ness, decision making, and readiness provided
way to conceptualize the matter, paralleling the in the contemplation and preparation stages.
notion of “treatments of choice” in terms of They try to modify behavior without aware-
 46 • stages of change 231

ness, a common criticism of radical behavior- tionships that work: Therapist contributions
ism: overt action without insight is likely to and responsiveness to patient needs. New York:
lead to temporary change. Oxford University Press.
11. Think complementarily: Competing sys- Norcross, J. C., Mrykalo, M. S., & Blagys, M. D.
(2002). Auld lang syne: Success predictors,
tems of psychotherapy have promulgated pur-
change processes, and self-reported outcomes of
portedly rival processes of change. However,
New Year’s resolvers and nonresolvers. Journal
ostensibly contradictory processes become of Clinical Psychology, 58, 397 – 405.
complementary when embedded in the stages Ockene, J., Ockene, I., & Kristellar, J. (1988). The
of change. While some psychotherapists insist coronary artery smoking intervention study.
that such theoretical integration is philosophi- Worcester: National Heart Lung Blood Insti-
cally impossible, our research has consistently tute.
documented that ordinary people in their nat- Prochaska, J. O., & DiClemente, C. C. (1983). Stages
ural environments and psychotherapists in and processes of self-change in smoking: To-
their consultation rooms can be remarkably ward an integrative model of change. Journal of
effective in synthesizing powerful change Consulting and Clinical Psychology, 5, 390 –
395.
processes across the stages of change.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C.
(1992). In search of how people change: Appli-
References, Readings, & Internet Sites cations to addictive behaviors. American Psy-
chologist, 47, 1102–1114.
Cancer Prevention Research Center (home of the
Prochaska, J. O., & Norcross, J. C. (2002). Systems of
transtheoretical model). (n.d.). Home page. Re-
psychotherapy: A transtheoretical analysis
trieved 2004 from http://www.uri.edu/research/
(5th ed.). Pacific Grove, CA: Brooks/Cole.
cprc/
Prochaska, J. O., Norcross, J. C., & DiClemente, C. C.
DiClemente, C. C. (2003a). Addiction and change.
(1995). Changing for good. New York: Avon.
New York: Guilford Press.
Prochaska, J. O., Velicer, W. F., Fava, J. L., Ruggiero,
DiClemente, C. C. (2003b). Motivational interview-
L., Laforge, R. G., Rossi, J. S., et al. (2001).
ing and the stages of change. In W. R. Miller &
Counselor and stimulus control enhancements
S. Rollnick (Eds.), Motivational interviewing
of a stage-matched expert system intervention
(2nd ed.). New York: Guilford Press.
for smokers in a managed care setting. Preven-
DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K.,
tive Medicine, 32, 23 –32.
Velicer, W. F., Velasquez, M. M., & Rossi, J. S.
Rosen, C. S. (2000). Is the sequencing of change
(1991). The process of smoking cessation: An
processes by stage consistent across health
analysis of precontemplation, contemplation
problems? A meta-analysis. Health Psychology,
and preparation stages of change. Journal of
19, 593 – 604.
Consulting and Clinical Psychology, 59, 295 –
Valasquez, M. M., Maurer, G., Crouch, C., & Di-
304.
Clemente, C. C. (2001). Group treatment for
McConnaughy, E. A., DiClemente, C. C., Prochaska,
substance abuse: A stages-of-change therapy
J. O., & Velicer, W. F. (1989). Stages of change in
manual. New York: Guilford Press.
psychotherapy: A follow-up report. Psy-
chotherapy, 26, 494 – 503.
McConnaughy, E. A., Prochaska, J. O., & Velicer, Related Topic
W. F. (l983). Stages of change in psychotherapy:
Chapter 45, “Systematic Assessment and Treatment
Measurement and sample profiles. Psychother-
Matching”
apy, 20, 368 –375.
Norcross, J. C. (Ed.). (2002). Psychotherapy rela-
 PSYCHOTHERAPY TREATMENT
47 PLAN WRITING

Arthur E. Jongsma, Jr.

HISTORICAL BACKGROUND aged care organizations’ emphasis on early

treatment planning is to move the patient to fo-
Over the past 30 years, formalized treatment cus on progressing toward change as soon as
planning has gradually become a vital aspect of possible. Treatment plans must be specific as to
the entire health care delivery system, whether the problems and interventions, individualized
it is treatment related to physical health, mental to meet the patient’s needs and goals, and mea-
health, child welfare, or substance abuse. What surable in terms of setting milestones that can
started in the medical sector in the 1960s spread be used to chart the patient’s progress. Pressure
into the mental health sector in the 1970s as from third-party payers, accrediting agencies,
clinics, psychiatric hospitals, agencies, and oth- and other outside parties has therefore in-
ers began to seek accreditation from bodies such creased the need for clinicians to produce effec-
as the Joint Commission on Accreditation of tive, high-quality treatment plans in a short
Healthcare Organizations (JCAHO) to qualify time frame. However, the pressure on clinicians
for third-party reimbursements. To achieve ac- from these outside sources to produce individ-
creditation, most treatment providers had to ualized treatment plans has brought with it
develop or strengthen their documentation several concomitant rewards.
skills in the area of treatment planning. Previ-
ously, most mental health and substance abuse
treatment providers had, at best, a rudimentary TREATMENT PLAN UTILITY
plan that looked similar for most of the indi-
viduals they treated. As a result, patients often Detailed, written treatment plans can benefit
were uncertain as to what they were trying to not only the patient, therapist, treatment team,
attain in psychiatric treatment. Goals were insurance community, and treatment agency
vague, objectives were nonexistent, and inter- but also the overall psychotherapy profession.
ventions were applied equally to all patients. The patient is served by a written plan because
Outcome criteria were not measurable, and nei- it stipulates the issues that are the focus of the
ther the patient nor the treatment provider treatment process. It is very easy for both
knew exactly when treatment was completed. provider and patient to lose sight of what the is-
Treatment planning has gained even greater sues were that brought the patient into therapy.
importance since the coming of managed care in The treatment plan is a guide that structures
the 1980s. Managed care systems insist that what the therapeutic contract is meant to focus
clinicians move rapidly from assessment of the on. Although issues can change as therapy pro-
problem to the formulation and implementa- gresses, the treatment plan must be viewed as a
tion of the treatment plan. The purpose of man- dynamic document that can and must be up-

232
 47 • psychotherapy treatment plan writing 233

dated to reflect any major change of problem, tient treatment used to be the only communi-
definition, goal, objective, or intervention. cation approach, and often therapeutic conclu-
Patients and therapists benefit as a result of sions or assignments were not recorded. Now a
the treatment plan forcing both to think about thorough treatment plan stipulates in writing
therapy outcomes. Behaviorally stated, mea- the details of objectives and the varied inter-
surable objectives clearly focus the treatment ventions (pharmacological, milieu, group ther-
endeavor. Patients no longer have to wonder apy, didactic, recreational, individual therapy,
what therapy is trying to accomplish. Clear ob- etc.) and who will implement them.
jectives also allow the patient to channel effort Every treatment agency or institution is con-
into specific changes that will lead to the long- stantly looking for ways to increase the quality
term goal of problem resolution. Therapy is no and uniformity of the documentation in the
longer a vague contract to just talk honestly and clinical record. A standardized, written treat-
openly about emotions and thoughts until the ment plan with problem definitions, goals, ob-
patient feels better. Both patient and therapist jectives, and interventions in every patient’s file
are concentrating on specifically stated objec- enhances that uniformity of documentation.
tives using specific interventions. This uniformity eases the task of record re-
Providers are aided by treatment plans be- viewers inside and outside the agency. Outside
cause they force them to think analytically and reviewers, such as the JCAHO, insist on docu-
critically about therapeutic interventions that mentation that clearly outlines assessment,
are best suited for objective attainment for spe- treatment, progress, and discharge status.
cific patients. Therapists were traditionally The demand for accountability from third-
trained to “follow the patient,” but now a for- party payers and HMOs is partly satisfied by a
malized plan is the guide to the treatment pro- written treatment plan and complete progress
cess. The therapist must give advance attention notes. More and more managed care systems
to the technique, approach, assignment, or ca- are demanding a structured therapeutic con-
thartic target that will form the basis for inter- tract that has measurable objectives and explicit
ventions. interventions. Clinicians cannot avoid this move
Clinicians benefit from clear documentation toward being accountable to those outside the
of treatment that becomes a part of the perma- treatment process.
nent record because it provides added protec- The psychotherapy profession stands to ben-
tion against a disgruntled patient’s litigation. efit from the use of more precise, measurable
Malpractice suits are increasing in frequency, objectives to evaluate success in mental health
and insurance premiums are soaring. The first treatment. Outcome data can be more easily
line of defense against allegations is a complete collected regarding interventions that are effec-
clinical record that includes detail regarding the tive in achieving specific objectives. Compar-
treatment process. A written, individualized, isons between different treatment strategies in-
formal treatment plan that is the guideline for volving various objectives and interventions will
the therapeutic process, has been reviewed and be possible by clinicians and researchers. Treat-
signed by the patient, and is coupled with problem- ment planning computer software has been
oriented progress notes is a powerful defense published that assists in creating a treatment
against exaggerated or false claims. plan but also tracks patients’ progress, analyz-
A well-crafted, problem-focused treatment ing and graphing outcome data (Jongsma, Pe-
plan that clearly stipulates intervention strate- terson, & McInnis, 1997).
gies facilitates and guides the treatment process
that must be carried out by all team members
in an inpatient, residential, or intensive out- HOW TO DEVELOP A TREATMENT PLAN
patient setting. Good communication between
team members is critical about what approach is The process of developing a treatment plan in-
being implemented and who is responsible for volves a logical series of steps that build on each
each intervention. Team meetings to discuss pa- other much as one would construct a house.
234 part iii • individual psychotherapy and treatment

The foundation of any effective treatment plan what on the degree to which treatment ad-
is the data gathered in a thorough biopsychoso- dresses his or her greatest needs.
cial assessment. When the patient presents for
treatment, the clinician must sensitively listen
Step Two: Problem Definition
to and understand the patient’s struggles in
terms of family of origin issues, current stres- The problem definition is similar to the speci-
sors, emotional status, social network, physical fications of what the structural beams are made
health, coping skills, interpersonal conflicts, of. Each individual patient presents with unique
self-esteem, and so on. Assessment data may be behavioral manifestations of the problem.
gathered from a social history, physical exam, Therefore, each problem that is selected for
clinical interview, psychological testing, behav- treatment focus requires a specific definition of
ioral observations, or contact with a patient’s how it is evidenced in this particular patient.
significant others. The integration of all this in- The symptom pattern should be associated with
formation by the clinician or members of the diagnostic criteria and codes such as those
multidisciplinary treatment team is a critical found in DSM-IV or the ICD-9.
first step in arriving at an understanding of the
patient and the focus of the patient’s struggle.
From this clinical formulation should evolve a Step Three: Goal Development
list of problems that form the structure around
The goals represent the rendering of what the
which a treatment plan is created. An accurate
finished house will look like. Setting broad
and complete assessment of the nature of the
goals for the resolution of the target problem is
patient’s problems will provide focus in devel-
the next step in the treatment plan development
oping a specific treatment plan (Scholing, Em-
process. These statements need not be crafted
melkamp, & Van Oppen, 1996). The develop-
in measurable terms but can be global, long-
ment of the treatment plan from the integrated
term goals that indicate a desired positive out-
biopsychosocial assessment data is a six-step
come to the treatment procedures. One goal
process.
statement for each problem is all that is re-
quired in a treatment plan.
Step One: Problem Selection
The problem list is like the structural beams
Step Four: Objective Construction
that support the framework of a house under
construction. Although the patient may discuss The objectives are like the building materials
a variety of issues during the assessment, the (the bricks, mortar, studs, and drywall) of the
clinician must ferret out the most significant house under construction — the elements nec-
problems on which to focus the treatment pro- essary to achieve the final product. In contrast
cess. Usually a primary problem will surface, to long-term goals, objectives must be stated in
and additional secondary problems will also be behaviorally measurable language. It must be
evident. Some other problems may have to be clear when the patient has achieved the estab-
set aside as not urgent enough to require treat- lished objectives; therefore, vague, subjective
ment at this time. An effective treatment plan objectives are not acceptable. Review agencies
can deal with only a few selected problems or (e.g., JCAHO), HMOs, and managed care orga-
treatment will lose its direction. nizations insist that psychological treatment
As the problems to be selected become clear outcome be more measurable, so objectives must
to the clinician or the treatment team, it is im- be crafted to meet this demand for accountabil-
portant to include opinions from the patient ity. The clinician must exercise professional
about his or her prioritization of issues for judgment regarding which objectives are most
which he or she seeks help. A patient’s motiva- appropriate for a given patient.
tion to participate in and cooperate with an Each objective should be developed as a step
eventual treatment process will depend some- toward attaining the broad treatment goal. In
 47 • psychotherapy treatment plan writing 235

essence, objectives can be thought of as a series also available (e.g., Gabbard, 1995). The ther-
of steps that, when completed, will result in the apeutic approach of the clinician will influence
achievement of the long-term goal. There should what type of intervention statements are writ-
be at least two objectives for each problem, but ten.
the therapist should construct as many as nec- Assigning interventions to a specific pro-
essary for goal achievement. New objectives vider is most relevant if the patient is being
should be added to the plan as the individual’s treated by a team in an inpatient, residential,
treatment progresses. When all the necessary or intensive outpatient setting. Within these
objectives have been achieved, the patient should settings, personnel other than the primary
have resolved the target problem successfully clinician may be responsible for implement-
and achieved the treatment goal. Additional ac- ing a specific intervention. Review agencies
countability is required as reviewers demand require that stipulation of the provider’s name
that target attainment dates be assigned to each be attached to every intervention if the pa-
objective. This is an attempt to shorten and focus tient is being treated by a multidisciplinary
the counseling process because the emphasis is team.
on brief symptom resolution rather than per-
sonality change or personal growth.
Step Six: Diagnosis Determination
The determination of an appropriate diagnosis
Step Five: Intervention Creation is based on an evaluation of the patient’s com-
Interventions represent the creative skills of plete clinical presentation. The clinician must
the architect — the tools of the trade — that compare the behavioral, cognitive, emotional,
guide the building process. Interventions are and interpersonal symptoms that the patient
the actions of the clinician to help the patient presents to the criteria for diagnosis of a men-
complete the objectives. The clinician may tal illness condition as described in the DSM-
choose from cognitive, dynamic, behavioral, IV. The issue of differential diagnosis is admit-
pharmacological, family treatment, or solution- tedly a difficult one that research has shown to
focused brief therapeutic interventions. There have rather low interrater reliability. Psychol-
should be at least one intervention for every ogists have also been trained to think more in
objective. New interventions should be added terms of maladaptive behavior than in terms of
as the original interventions have been imple- disease labels. In spite of these factors, diag-
mented but the patient has not yet accom- nosis is a reality that exists in the world of
plished the objective. Addition of new inter- mental health care, and it is a necessity for
ventions and objectives to promote treatment third-party reimbursement. (However, recently,
success is especially appropriate given the re- managed care agencies have become more in-
cent trend toward a patient’s progression terested in behavioral indices that are exhib-
through various levels of a continuum of care ited by the patient than in the actual diagno-
in mental health and substance abuse pro- sis.) It is the clinician’s thorough knowledge of
grams. The clinical skills of the provider are DSM-IV criteria and a complete understanding
tested as therapeutic intervention strategies of the patient assessment data that contribute
must be created to assist the patient in achiev- to the most reliable, valid diagnosis. An accu-
ing the objectives. Treatment planning books rate assessment of behavioral indicators will
are available that provide a menu of concise also contribute to more effective treatment
suggestions for behavioral definitions of prob- planning.
lems, long-term goals, short-term objectives,
as well as therapeutic interventions (Jongsma One final but important aspect of an effective
& Peterson, 1995; Jongsma, Peterson, & Mc- treatment plan is that it must be designed to
Innis, 1996). Treatment plan resources that deal with each individual patient specifically.
are more general and theoretically based are Treatment plans, like quality homes, are not to
236 part iii • individual psychotherapy and treatment

be mass-produced with the same plan applied to Gabbard, G. O. (1995). Treatment of psychiatric dis-
all patients, even if they have similar problems. orders (2nd ed., Vols. 1 & 2). Washington, DC:
The individual’s strengths and weaknesses, American Psychiatric Press.
unique stressors, social network, family circum- Jongsma, A. E., Jr., & Peterson, L. M. (1995). The
complete psychotherapy treatment planner.
stances, and symptom pattern must be consid-
New York: Wiley.
ered in developing a treatment strategy (Axel-
Jongsma, A. E., Jr., Peterson, L. M., & McInnis, W. P.
rod, Spreat, Berry, & Moyer, 1993). A treatment (1996). The child and adolescent psychother-
plan that takes into account the uniqueness of apy treatment planner. New York: Wiley.
the patient’s dynamics, traits, and circum- Jongsma, A. E., Jr., Peterson, L. M., & McInnis, W. P.
stances will stand a greater chance of producing (1997). TheraScribe 3.0: The computerized as-
a satisfactory, measurable outcome in a shorter sistant to psychotherapy treatment planning
time frame. (Version 3.0) [Computer software]. New York:
Wiley.
Scholing, A., Emmelkamp, P. M., & Van Oppen, P.
Note: This chapter was adapted from Introduction, (1996). Cognitive-behavioral treatment of so-
in A. E. Jongsma & L. M. Peterson, The Complete cial phobia. In V. B. Van Hasselt & M. Hersen
Psychotherapy Treatment Planner (New York: (Eds.), Sourcebook of psychological treatment
Wiley, 1995), pp. 1–7. Reprinted with permission. manuals for adult disorders (pp. 123 –177).
New York: Plenum Press.

References & Readings

Related Topics
Axelrod, S., Spreat, S., Berry, B., & Moyer, L.
(1993). A decision-making model for selecting Chapter 46, “Stages of Change: Prescriptive Guide-
the optimal treatment procedure. In R. Van lines
Houten and S. Axelrod (Eds.), Behavior analy- Chapter 76, “Choice of Treatment Format”
sis and treatment: Applied clinical psychology Chapter 130, “Utilization Review Checklist”
(pp. 183 –202). New York: Plenum Press.

KEY PRINCIPLES IN
48 THE ASSESSMENT OF
PSYCHOTHERAPY OUTCOME

Michael J. Lambert, Bruce W. Jasper, & Joanne White

Psychotherapists have a scientific and ethical maining unchanged, or recovering and can im-
responsibility to learn whether they are pro- prove the effectiveness of treatment. Although
viding helpful services to their clients. Effective more and more therapists are employing out-
outcome assessment can let clinicians know come measures in their practices, most clini-
whether individual clients are deteriorating, re- cians do not yet objectively assess psychother-
 48 • key principles in the assessment of psychotherapy outcome 237

apy outcome in routine practice (Hatfield & and are therefore highly recommended. Lit-
Ogles, in press). erally hundreds of measures are available
The recent movement toward measuring the for use. We recommend the Brief Symptom
effects of therapy on individual clients (so- Inventory (available at http://assessments/
called patient-focused research) provides a tests/bsi.htm), a shortened version of the
strategy for clinicians who want to enhance Symptom Checklist-90-R that focuses on a
client outcomes. This strategy involves using wide variety of symptoms. The Short Form-
session-by-session outcome to inform individ- 36 Health Survey (http://www.sf-36.com) is
ual therapy in real time. When outcome assess- also a promising measure for adults. The
ment is used in real time it can enhance the Outcome Questionnaire-45 (http://www.
treatment of the persons who complete the out- oqfamily.com) is growing in popularity. It
come measure. measures symptoms, interpersonal func-
This chapter summarizes the key principles tioning, social role performance, and quality
involved in (1) selecting potentially useful of life, and has been shown to be sensitive to
measures and (2) using outcome data to en- treatment effects. For children, the Ohio
hance routine practice. Youth Problems, Functioning, and Satisfac-
tion Scales (http://oak.cats.ohiou.edu/ogles)
or the Youth Outcome Questionnaire (http://
SELECTING POTENTIALLY www.oqfamily.com/) appear to be especially
USEFUL MEASURES promising because they are relatively short,
sensitive to change, and available in parent-,
The following principles of selecting measures self-, and other-report formats.
attempt to strike a balance between what is 2. Use caution if you tailor the change crite-
practical for the everyday clinician and what is ria to the individual in therapy: Tailoring
scientifically necessary in order to obtain use- change criteria with individualized goals for
ful outcome data. a particular patient has been advocated be-
cause it is likely to provide evidence for ef-
1. Select a brief measure (5-10 minutes) that ficacy. The use of individualized change
can be easily administered and scored by measures enables the therapist to assess
clerical staff or computer: Practical concerns change from an idiographic and multifaceted
in routine practice demand that outcome as- perspective, which is consistent with the
sessment be painless and resource effective wide range of problems presented by an in-
(e.g., money, time, and energy). Most clini- dividual (e.g., Persons, 1991). However, such
cians who are assessing client outcome are change criteria are often poorly defined,
using brief self-report measures. Outcome subjective in nature, and have little credibil-
measures have been developed that can be ity. The amount of change reflected by such
completed by the client, a parent/guardian/ measures is often overly dependent on the
spouse, the therapist, or an independent therapist’s judgments. On the other hand, in
judge. However, because it is usually feasi- difficult-to-treat individuals, idiographic
ble to obtain only one perspective, in the change criteria may be a necessary addition
case of an adult, a self-report measure is to standardized outcome measures. Such in-
ideal and in the case of a child/adolescent a dividuals abound in residential, geriatric, se-
parent-report measure is recommended. Ad- verely mentally ill, or neuropsychologically
ditionally, it should be kept in mind that in- impaired populations that may be atypically
struments and methods useful for diagnos- responsive or appear to be nonresponsive on
tic purposes and treatment planning are standard measures.
unsuitable for the purpose of measuring pa- 3. Make sure the measure covers broad, yet
tient change (Vermeersch, Lambert, & crucial, content areas: The three broad areas
Burlingame, 2000). Symptom-focused mea- to be assessed are the subjective state of the
sures are most likely to reflect improvement client (intrapersonal functioning, including
238 part iii • individual psychotherapy and treatment

behavior, affect, and cognition), the state of you select will have several “critical” items that
the client’s intimate relationships (interper- you may want to routinely examine (e.g., “I
sonal functioning), and the state of the indi- have thoughts of ending my life”; “I have peo-
vidual’s participation in the community (so- ple around me that I can turn to for support”).
cial role performance). Both symptomatic The most important aspect of tracking
change and functioning are important, if not change after the initial assessment is assessing
essential, targets for outcome assessment. A whether client scores tend to increase, stay the
compendium of suitable measures has been same, or decrease in relation to the intake score.
edited by Maruish (2004). Research demonstrates that early positive re-
4. Select measures that can detect clinically sponse to treatment foretells final success,
meaningful change: Methods have been de- while negative change foretells final failure
veloped to set standards for clinically mean- (Haas, Hill, Lambert, & Morrell, 2002). In any
ingful client change (Jacobson & Truax, case, until the client’s functioning is within the
1991). The clinical significance methodology normal range, some kind of treatment is needed.
provides for the calculation of two specific Many clinicians find it helpful to graphically
statistical indexes: a cutoff point between display client data across time or sessions in or-
normal and dysfunctional samples and an der to better visualize score changes and gen-
evaluation of the reliability of the change eral trends. If a client’s scores worsen after be-
score. These indexes provide specific cut ginning treatment, then the clinician can con-
scores for interpreting the importance of ob- sider the causes and possibly modify treatment
served scores and some existing measures (e.g., more frequent sessions, medication refer-
provide such guidelines. When they are not ral, change in treatment focus). On the other
available, however, the clinician can consult hand, if the client’s scores indicate improve-
the work of Jacobson for the formulas for es- ment and a return to normal functioning, the
tablishing a cutoff score, as well as a reliable focus of treatment could shift to preparing
change index. the client for termination and maintenance. The
specific details of what to do in the individual
cases vary and are up to the treating clinician
USING OUTCOME DATA TO and the client.
ENHANCE ROUTINE PRACTICE One might ask how much a client’s score
needs to change in order to be considered mean-
Once an outcome measure is selected, it is best ingful. Although clinicians can try to rely on
to have it completed prior to treatment (even an personal methods of detecting significant
intake interview can provide relief to the client change, standardized methods are available to
and such relief is important to record). It is also better serve clinicians and clients. As already
important to gather data on a session-by- noted, these methods operationalize meaning-
session basis; this ensures that there will be at ful change so clinicians can know how much a
least one measure of change, provided that the client’s score must change in order to be con-
client has a second appointment. Since many sidered clinically significant. If a client’s score
patients improve rapidly, and most attend few changes by at least the amount of the Reliable
sessions, delaying the second assessment is Change Index (RCI; individually calculated for
likely to result in underestimating treatment the particular instrument being used), then the
benefits or failing to gather any outcome data. client is considered to have reliably changed,
The initial assessment can be used to (1) de- becoming symptomatically worse or better.
termine the client’s incoming symptom sever- However, reliable change by itself cannot be
ity and forming an opinion about expected equated with recovery. For example, a client’s
length of treatment, (2) highlight possible tar- score may change in the amount of the RCI and
get symptoms seen at the individual item level, still be in the dysfunctional range. If, however,
and (3) identify particular strengths that might a client’s score (1) moves from the dysfunc-
be capitalized on. For example, the measure(s) tional range to the functional range and (2) the
 48 • key principles in the assessment of psychotherapy outcome 239

amount of change is equal to or greater than the maintain treatment gains? Journal of Clinical
RCI, then the client is considered to have made Psychology, 58, 1157 –1172.
clinically significant improvement, sometimes Hatfield, D. R., & Ogles, B. M. (in press). The cur-
labeled recovery. Ogles, Lambert, and Fields rent climate of outcome measures used by psy-
chologists in clinical practice. Professional Psy-
(2002) have listed cutoff scores and Reliable
chology: Research and Practice.
Change Indices (RCIs) for some of the most
Jacobson, N. S., & Truax, P. (1991). Clinical signifi-
commonly used measures, such as the SCL- cance: A statistical approach to defining mean-
90R, BDI, and CBCL. ingful change in psychotherapy research. Jour-
Another way to use session-by-session data nal of Consulting & Clinical Psychology, 59,
to enhance treatment outcome is to compare a 12–19.
client’s treatment response to a typical or ex- Lambert, M. J., Whipple, J. L., Bishop, M. J., Ver-
pected treatment response. By comparing a meersch, D. A., Gray, G. V., & Finch, A. E.
client’s symptom course to the average symp- (2002). Comparison of empirically-derived
tom course among others that have the same methods for identifying patients at risk for
initial assessment score, you can know if they treatment failure. Clinical Psychology and Psy-
chotherapy, 9, 149 –164.
are progressing as “expected.” Although this
Lambert, M. J., Whipple, J. L., Hawkins, E. L., Ver-
technique is more specific than relying on RCIs
meersch, D. A., Nielsen, S. L., & Smart, D. W.
and cutoff scores, it is not yet readily available (2003). Is it time for clinicians to routinely track
for most outcome measures. Nevertheless, such patient outcome?: A meta-analysis. Clinical
data help to inform clinicians if the client is re- Psychology: Science and Practice, 10, 288 –301.
sponding faster or slower than similar clients. Maruish, M. E. (2004). The use of psychological test-
Psychotherapy research investigating this ing for treatment planning and outcomes as-
method is promising and will probably become sessment (3rd ed.). Mahwah, NJ: Erlbaum.
widely available for use in routine practice. The Ogles, B. M., Lambert, M. J., & Fields, S. A. (2002).
interested reader can consult other sources Essentials of outcome assessment. New York:
(Lambert et al., 2002; Ogles et al., 2002; Whip- Wiley.
Persons, J. B. (1991). Psychotherapy outcome studies
ple et al., 2003). This research demonstrates
do not accurately represent current models of
that feedback to therapists about potential treat-
psychotherapy: A proposed remedy. American
ment failure (based on client deviations from Psychologist, 46, 99 –106.
expected treatment response) improves out- Vermeersch, D. A., Lambert, M. J., & Burlingame,
comes and reduces deterioration for the 20% of G. M. (2000). Outcome questionnaire: Item
clients who are at risk for treatment failure sensitivity to change. Journal of Personality
(Lambert et al., 2003). It is our hope that clini- Assessment, 74, 242–261.
cians will continue to improve the quality of Whipple, J. L., Lambert, M. J., Vermeersch, D. A.,
their work through systematic assessment of Smart, D. W., Nielsen, S. L., & Hawkins, E. J.
outcomes. (2003). Improving the effects of psychotherapy:
The use of early identification of treatment fail-
ure and problem-solving strategies in routine
References, Readings, & Internet Sites practice. Journal of Counseling Psychology, 50,
59 – 68.
Albert Einstein College of Medicine. (n.d.). Testing
resources. Retrieved 2004 from http://library.
Related Topics
aecom.yu.edu/resources/psychtest
American Psychological Association. (n.d.). Science Chapter 39, “Compendium of Empirically Supported
directorate Web site. Retrieved 2004 from http:// Therapies”
www.apa.org/science/faq-findtest.html Chapter 40, “Compendium of Psychotherapy Treat-
Haas, E., Hill, R., Lambert, M. J., & Morrell, B. ment Manuals”
(2002). Do early responders to psychotherapy
 TREATMENT AND
49 MANAGEMENT OF THE
SUICIDAL PATIENT

Bruce Bongar & Glenn R. Sullivan

Suicide is the most frequently encountered of legally, ethically, and professionally responsible
all mental health emergencies (Beutler, Clarkin, for determining appropriate patient care. Clin-
& Bongar, 2000; Schein, 1976), with a typical icians must override managed-care decisions
practicing psychologist treating an average of that inappropriately restrict patient services if
five suicidal patients per month (Greaney, it is necessary to prevent suicide.
1995). Psychologists have a better than a one in
five chance of losing a patient to suicide, and
student therapists have a one in three chance of GENERAL PRINCIPLES
experiencing a patient suicide or suicide attempt
during their training years (Stolberg, Glass- The mental health professional’s assessment
mire, & Bongar, 1999). Psychotherapists con- and treatment efforts represent an opportunity
sistently rank work with suicidal patients as the to translate knowledge (albeit incomplete) of el-
most stressful of all clinical endeavors (Deutsch, evated risk factors into a plan of action (Bongar,
1984). 2002). The management plan for patients who
Patient suicide must be considered a real oc- are at an elevated risk for suicide should ame-
cupational hazard for those clinicians involved liorate those risk factors that are most foresee-
in direct patient care (Bongar, Peruzzi, & Grea- ably likely to result in suicide or self-harm
ney, 1997). This hazard entails not only the (Brent, Kupfer, Bromet, & Dew, 1988). Several
threat of malpractice action but also an intense general principles that apply across broad diag-
emotional toll on both the patient’s family and nostic categories should guide the treatment of
the patient’s psychologist. Psychologists re- patients at elevated risk for suicide:
spond to the loss of a patient to suicide as they
do to the death of a family member (Chemtob, • The most basic principle is that, because most
Hamada, Bauer, Torigoe, & Kinney, 1988). suicide victims take their own lives or harm
A growing body of evidence suggests that themselves in the midst of a psychiatric
the shift from fee-for-service to managed care episode, it is critical to understand that a
has resulted in an erosion of standards of care proper diagnosis and careful management/
for the management of suicidal patients. In treatment plan of the acute psychiatric dis-
some instances, this shift has resulted in ad- order could dramatically alter the risk for
verse consequences for patients (Hall, Platt, & suicide (Brent et al., 1988). The data on adult
Hall, 1999). Hall et al. (1999) found that the suicides indicate that more than 90% of
criteria used by several managed-care organi- these suicide victims were mentally ill before
zations for approving the hospitalization of their deaths.
acutely suicidal patients were unrealistic and • Special precautions must be taken when as-
not based on accepted scientific standards. It is sessing and treating patients who present
imperative that clinicians realize that they are with chronic suicidal ideation and behavior

240
 49 • treatment and management of the suicidal patient 241

(i.e., where the clinician takes repeated calcu- • Routinely involve other mental health pro-
lated risks in not hospitalizing). The clinician fessionals in evaluation and treatment plan-
must weigh the short-term solution of hos- ning; obtain a “biopsy of the standard of
pitalization against the long-term solution of care” through consultation with a senior
treating the chronic condition in an outpa- clinician (Appelbaum & Gutheil, 1991, p.
tient environment. 201).
• Involve the patient’s family and support net-
work to maximize adherence to the treat- All of our assessment and management ac-
ment plan. tivities also should include a specific evaluation
• Diagnose and treat any comorbid medical of the patient’s competency to participate in
and psychiatric condition(s). management and treatment decisions, espe-
• Focus on the provision of hope, particularly cially the patient’s ability to form a therapeutic
to new-onset patients. alliance (Bongar, 2002). An essential element in
• Because the availability of firearms, espe- strengthening this alliance is the use of in-
cially handguns, plays such a prominent role formed consent — that is, patients have the
as the “method of choice” for many com- right to participate actively in making decisions
pleted suicides, the psychologist should as- about their psychological/psychiatric care.
siduously assess the presence of, access to, Clinicians need to directly and continuously
and knowledge the patient has about this evaluate the quality of this special relation-
highly lethal means. This also necessitates ship — to understand that the quality of this
carefully thinking through the patient’s en- collaborative alliance is inextricably part of any
tire life environment and how the patient successful treatment/management plan (Bon-
spends each day, so as to determine proac- gar, Peterson, Harris, & Aissis, 1989).
tively the presence of any potentially lethal
means (e.g., the hoarding of pills; access to
poisons; or whether the patient has a means RISK ASSESSMENT AND
in mind, such as hanging, jumping from a MANAGEMENT
particular building, or driving the car off the
road). Furthermore, it is worth mentioning There are common themes in complaints
again that the psychologist must not hesitate lodged against outpatient therapists, reflecting
to contact others in the life of the patient and possible breaches in the duty of care and the
enlist their support in the treatment plan. practitioner’s failure to act in a reasonable and
• Continuously monitor indications for psy- prudent manner. Attention to these “failures”
chiatric hospitalization. may therefore represent an opportunity to de-
• Clinicians must assess their own technical velop appropriate treatment and risk manage-
proficiencies, as well as their emotional toler- ment strategies. The list below, adapted from
ance levels for the intense demands required Bongar, Maris, Berman, and Litman (1992), de-
in treating suicidal patients. The mental tails the most common failure scenarios in out-
health professional who is called upon to treat patient care.
the suicidal patient needs to have already eval-
uated the strengths and limitations of his or 1. Failure to properly evaluate the need for
her own training, education, and experience in psychopharmacological intervention, or un-
the treatment of specific patient populations in suitable pharmacotherapy.
specific clinical settings. Welch (1989) noted 2. Failure to specify criteria for and to imple-
that “the greatest threat to ‘quality of care’ ment hospitalization.
comes not from those with limited training 3. Failure to maintain appropriate clinician-
but from those with a limited recognition of patient relationships (e.g., dual relationships
the limitations of their own training” (p. 28). and sexual improprieties).
• Meticulously document every aspect of the 4. Failures in supervision and consultation.
patient’s care. 5. Failure to evaluate for suicide risk at intake.
242 part iii • individual psychotherapy and treatment

6. Failure to evaluate suicide risk at manage- amination, history, information from signif-
ment transitions. icant others, the results of any psychological
7. Failure to secure records of prior treatment tests and data from risk estimators, suicide
or inadequate history taking. lethality scales, and so on; also, a review of
8. Failure to conduct a mental status exam. the psychologist’s formulation of the pa-
9. Failure to diagnose. tient’s DSM-IV diagnosis, together with any
10. Failure to establish a formal treatment other specific psychotherapeutic formula-
plan. tions, clinical assessments, and evaluation of
11. Failure to safeguard the outpatient envi- any special treatment and management is-
ronment. sues (e.g., comorbidity of alcohol/substance
12. Failure to adequately document clinical abuse, physical illness).
judgments, rationales, and observations. 2. Issues of managing the patient with chroni-
cally suicidal behavior, violent behavior, pa-
The consultation model operationalized by tient dependency, patient hostility and ma-
Bongar (2002) seeks to optimize clinical, legal, nipulation, toxic interpersonal matrices, lack
and ethical standards of care for suicidal pa- of psychosocial supports, and the patient’s
tients. The model first emphasizes the impor- competency to participate in treatment deci-
tance of developing a strong therapeutic alliance, sions, along with an assessment of the qual-
facilitated via informed consent procedures at ity of the therapeutic alliance and the pa-
treatment initiation. The informed consent pro- tient’s particular response to the psycholo-
cedure should begin an ongoing process of in- gist and to the course of treatment (e.g.,
formation-giving and collaboration with the intense negative or positive transference).
client. By involving patients and their families, 3. The psychologist’s own feelings about the
when appropriate, as “collaborative risk man- progress of treatment and feelings toward
agement partners” (Bongar, 2002, p. 232), coop- the patient (e.g., the psychologist’s own feel-
eration with treatment is improved, the protec- ings of fear, incompetency, anxiety, helpless-
tive net is widened, responses to treatment are ness, or even anger) and any therapeutic re-
more closely monitored, and the quality and actions such as negative countertransference
quantity of available data are improved. or therapist burnout.
Second, the model emphasizes the impor- 4. The advisability of using medication or need
tance of routinely seeking professional consul- for additional medical evaluation (e.g., any
tations from colleagues, particularly ones who uncertainties as to organicity or neurologi-
are senior clinicians and/or have forensic ex- cal complications); also, a request for a re-
pertise. These consultants should be retained evaluation of any current medications that
professionally and given sufficient information the patient is taking (e.g., effectiveness,
to provide reasonable advice, and their advice compliance in taking medication, side ef-
should be carefully recorded in the psycholo- fects, polypharmacy).
gist’s records. This written record is necessary 5. The indications and contraindications for
in order for the consultation to be legally rec- hospitalization; a review of available com-
ognized and unquestioned (Bongar, 2002). munity crisis intervention resources for the
Although the following list of discussion patient with few psychosocial supports; day
points is not exhaustive, it does suggest the sort treatment options; emergency and backup
of specific questions that could be discussed arrangements and resources; and, planning
with a consultant when treating the suicidal pa- for the psychologist’s absences.
tient. These include reviewing: 6. Indications and contraindications for family
and group treatment; indications and con-
1. The overall management of the case, specific traindications for other types of psychother-
treatment issues, uncertainties in the assess- apy and somatic interventions; questions on
ment of elevated risk or in diagnosis. This the status of and progress in the integration
can include a review of the mental status ex- of multiple therapeutic techniques.
 49 • treatment and management of the suicidal patient 243

7. The psychologist’s assessment criteria for the simplistic principle that “if it isn’t writ-
evaluating dangerousness and imminence ten down, it didn’t happen” (no matter what
(e.g., does the consultant agree with the the subsequent testimony or elaboration of
clinician’s assessment of the level of pertur- the defendant maintains). Defensive clinical
bation and lethality?); review of specifics of notes, written after the fact, may help some-
patient’s feelings of despair, depression, what in damage control, but there is no sub-
hopelessness, impulsivity, cognitive con- stitute for a timely, thoughtful, and com-
striction, and impulses toward cessation. plete chart record that demonstrates (through
8. The issues of informed consent and confi- clear and well-written assessment, review,
dentiality, and the adequacy of all current and treatment notes) a knowledge of the epi-
documentation on the case (e.g., intake demiology, risk factors, and treatment liter-
notes, progress notes, utilization reviews, ature for the suicidal patient. Such a case
family meetings, supervisor notes, tele- record should also include (where possible) a
phone contacts). formal informed consent for treatment, for-
9. Whether the consultant agrees with the psy- mal assessment of competence, and a docu-
chologist’s current risk-benefit analysis and mentation of confidentiality considerations
management plan in particular. Does the (e.g., that limits were explained at the start
consultant agree that the dual issues of fore- of any treatment).
seeability and the need to take affirmative 3. Information on previous treatment. Clini-
precautions have been adequately addressed? cians must obtain, whenever possible, all
(Bongar, 2002, pp. 239 –240). previous treatment records, and consult
with past psychotherapists. When appropri-
ate, they should involve the family and sig-
SUMMARY GUIDELINES nificant others in the management or dispo-
sition plan.
We believe that the following steps constitute a 4. Consultation on present clinical circum-
set of standards that will ensure the highest stances. Clinicians should routinely obtain
level of professional treatment for the benefit of consultation and/or supervision (or make re-
the patients under our care, suicidal patients in ferrals) on all cases where suicide risk is de-
particular. termined to be even moderate and after a pa-
tient suicide or serious suicide attempt. They
1. Evaluation and assessment. For each patient also should obtain consultation and/or su-
seen as part of a clinician’s professional prac- pervision on (or refer) cases that are outside
tice activities, there must be an initial evalu- their documented training, education, or ex-
ation and assessment, regular ongoing clin- perience, as well as when they are unsure of
ical evaluations and case reviews, consulta- the best avenue for initiating or continuing
tion reports and supervision reports (where treatment. The principle that two perspec-
indicated), and a formal treatment plan. All tives are better than one should guide the
of these activities need to demonstrate clinician in moments of clinical uncertainty.
specifically a solid understanding of the sig- 5. Sensitivity to medical issues. Clinicians should
nificant factors used to assess elevated risk of be knowledgeable about the effects of psy-
suicide and how to manage such risk— with chotropic medication and make appropriate
a documented understanding of the progno- referrals for a medication evaluation. If the
sis for the success (or possible paths to fail- clinician decides that medication is not in-
ure) of subsequent outpatient (or inpatient) dicated in the present instance, he or she
treatment or case disposition. should thoroughly document the reasoning
2. Documentation. Clinicians must be aware of for this decision in the written case record.
the vital importance of the written case Where appropriate, the patient (and, when it
record. In cases of malpractice, courts and ju- is indicated, the patient’s family or signifi-
ries often have been observed to operate on cant others) also should be included in this
244 part iii • individual psychotherapy and treatment

decision-making process. Clinicians also need Legal Standards of Care, 2nd edition (Washing-
to know the possible organic etiologies for ton, DC: American Psychological Association,
suicidality and seek immediate appropriate 2002). Reprinted with permission.
medical consultation for the patient when
they detect any signs of an organic condition.
References & Readings
6. Knowledge of community resources. Clini-
cians who see suicidal patients should have Appelbaum, P. S., & Gutheil, T. G. (1991). Clinical
access to the full armamentarium of re- handbook of psychiatry and the law (2nd ed.).
sources for voluntary and involuntary hos- Baltimore: Williams & Williams.
pital admissions, day treatment, 24-hour Beutler, L. E., Clarkin, J. F., & Bongar, B. (2000).
Guidelines for the systematic treatment of the
emergency backup, and crisis centers. This
depressed patient. New York: Oxford Univer-
access can be direct or indirect (through an sity Press.
ongoing collaborative relationship with a Bongar, B. (2002). The suicidal patient: Clinical and
psychologist or psychiatrist colleague). legal standards of care (2nd ed.). Washington,
7. Consideration of the effect on self and oth- DC: American Psychological Association.
ers. If a patient succeeds in committing sui- Bongar, B., Maris, R. W., Berman, A. L., & Litman,
cide (or makes a serious suicide attempt), R. E. (1992). Outpatient standards of care and
clinicians should be aware not only of their the suicidal patient. Suicide and Life Threaten-
legal responsibilities (e.g., they must notify ing Behaviors, 22, 453 – 478.
their insurance carrier in a timely fashion) Bongar, B., Peruzzi, N., & Greaney, S. (1997). Risk
but, more important, of the immediate clin- management with the suicidal patient. In P.
Kleespies (Ed.), Emergencies in mental health
ical necessity of attending to both the needs
practice (pp. 199 –216). New York: Guilford
of the bereaved survivors and to the clini- Press.
cian’s own emotional needs. (The clinician Bongar, B., Peterson, L. G., Harris, E. A., & Aissis, J.
must acknowledge that it is both normal and (1989). Clinical and legal considerations in the
difficult to work through feelings about a management of suicidal patients: An integrative
patient’s death or near-death and that he or overview. Journal of Integrative and Eclectic
she, having lost a patient to suicide, is also a Psychotherapy, 8, 53 – 67.
suicide survivor.) The concern should be for Brent, D. A., Kupfer, D. J., Bromet, E. J., & Dew,
the living. After consultation with a knowl- M. A. (1988). The assessment and treatment of
edgeable colleague and an attorney, immedi- patients at risk for suicide. In A. J. Frances & R.
ate clinical outreach to the survivors is not E. Hales (Eds.), American Psychiatric Press Re-
view of Psychiatry, Vol. 7 (pp. 353 –385). Wash-
only sensitive and concerned clinical care,
ington, DC: American Psychiatric Press.
but in helping the survivors to deal with the Chemtob, C. M., Hamada, R. S., Bauer, G. B., Tori-
catastrophic aftermath via an effective clin- goe, R. Y., & Kinney, B. (1988). Patient suicide:
ical postvention effort, the clinician is also Frequency and impact on psychologists. Profes-
practicing effective risk management. sional Psychology: Research and Practice, 19,
8. Preventative preparation. Most important, 416 – 420.
clinicians must be cognizant of the above Deutsch, C. J. (1984). Self-report sources of stress
standards and take affirmative steps to en- among psychotherapists. Professional Psychol-
sure that they have the requisite knowledge, ogy: Research and Practice, 15, 833 – 845.
training, experience, and clinical resources Greaney, S. (1995). Psychologists’ behavior and at-
prior to accepting high-risk patients into titudes when working with the non-hospital-
ized suicidal patient. Unpublished doctoral dis-
their professional care. This requires that all
sertation, Pacific Graduate School of Psychol-
of these mechanisms be in place before the ogy, Palo Alto, California.
onset of any suicidal crisis (Bongar, 2002, pp. Hall, R. C. W., Platt, D. E., & Hall, R. C. W. (1999).
259 –261). Suicide risk assessment: A review of risk factors
for suicide in 100 patients who made severe sui-
Note: Portions of this chapter are adapted from cide attempts: Evaluation of suicide risk in a
Bruce Bongar, The Suicidal Patient: Clinical and time of managed care. Psychosomatics, 40, 18 –27.
 50 • crisis intervention 245

Maltsberger, J. T., & Goldblatt, M. J. (Eds.). (1996). Welch, B. (1989). A collaborative model proposed.
Essential papers on suicide. New York: New American Psychological Association Monitor,
York University Press. 20, 28.
Schein, H. M. (1976). Obstacles in the education of
psychiatric residents. Omega, 7, 75 – 82.
Related Topic
Stolberg, R. R., Glassmire, D. M., & Bongar, B.
(1999). The effect of a patient suicide on stu- Chapter 14, “Assessment of Suicidal Risk”
dent therapists. Poster presented at the 107th
Convention of the American Psychological As-
sociation, Boston, August.

50 CRISIS INTERVENTION

Kenneth France

1. Clients who need crisis intervention: A 2. Clients who need emergency mental
crisis exists when a person’s usual coping meth- health intervention: An emergency is a life-
ods fail to successfully handle current pressures threatening or other potentially catastrophic
and the individual feels overwhelmed by seem- situation in which immediate action is neces-
ingly unresolvable difficulties. Finding oneself sary in order to rescue those at risk. Some-
in crisis usually results in new coping efforts times the situation involves a person who has
(Folkman, Lazarus, Dunkel-Schetter, DeLongis, struggled in crisis for so long that he or she is
& Gruen, 1986), which may include actions now withdrawing from the world either vol-
such as contacting a psychologist. A person untarily (through contemplated suicide) or in-
reaching out in this way is desperate for an end voluntarily (through personality disorganiza-
to the stress and is likely to welcome the pro- tion). For psychologists, however, it is more
fessional’s crisis intervention assistance (Hal- common to encounter a patient who has a long
pern, 1973, 1975). Together they work in a history of emotional difficulties and who is
problem-solving alliance that draws on the again showing behaviors that have been prob-
client’s knowledge and experience to forge the lematic in the past. In either of these cases, the
beginnings of an adaptive resolution. Empirical goal of an emergency mental health interven-
research has demonstrated that crisis interven- tion is to arrange an appropriate disposition,
tion can result in client benefits such as de- which may involve the imposition of a solution
creased anxiety, depression, confusion, anger, (such as involuntary hospitalization and treat-
and helplessness, as well as improved perfor- ment).
mance in career and family roles (Bunn & 3. Choosing between crisis intervention
Clarke, 1979; Capone, Westie, Chitwood, Fei- and emergency mental health intervention:
genbaum, & Good, 1979; Viney, Clarke, Bunn, Crisis intervention is appropriate if the person
& Benjamin, 1985; Koocher, Curtiss, Pollin, & is in crisis and is able to participate in logical
Patton, 2001). problem solving. Emergency mental health in-
246 part iii • individual psychotherapy and treatment

tervention is necessary when active guidance 6. The philosophy of crisis intervention:

and assertive decision making by the psycholo- The minimum goal in crisis intervention is
gist are required to decrease imminent danger. restoration of the previous level of functioning.
Making the right choice between these two op- The optimal goal is for the crisis to become a
tions is crucial. Individuals in crisis who are learning experience that leaves the person bet-
simply told what to do often fail to implement ter able to cope with future pressures. Positive
the suggestion. Consequently, emergency men- outcomes are more likely when intervention is
tal health intervention is inappropriate for most immediately available. Although the response
persons in crisis. Likewise, problem solving from the psychologist is an active one, all ef-
does not work with someone who is incapable forts recognize and use the client’s abilities. As
of rational decision making. Thus, crisis inter- a secondary prevention activity, crisis interven-
vention is doomed to failure with such individ- tion catches the difficulties in their early stages,
uals. thereby decreasing the episode’s duration and
4. Making the most of the time you have: severity. Such progress is brought about by
In a 50-minute session, you must make an engaging the individual in a problem-solving
early decision as to whether you should em- process.
ploy crisis intervention or emergency mental 7. Problem solving: The central endeavor in
health intervention. If emergency mental crisis intervention is problem solving. Al-
health intervention is your choice, then the though there are many approaches to this ac-
session’s activities may involve the following: tivity, one strategy is to think of it as involving
determining appropriate diagnoses; surveying three phases: exploring thoughts and feelings,
previous treatment; exploring issues related to considering alternatives, and developing a plan
suicidal/homicidal danger, availability of sup- (France, 2002). And while a variety of commu-
port, and level of cooperation; and securing nication styles can be effective, the use of reflec-
necessary authorizations from service gate- tion, along with a judicious number of open-
keepers. When you choose crisis intervention, ended questions, tends to be beneficial. (Open
there may be some exploration relating to dan- questions usually begin with the word what or
ger and suicide lethality, but the majority of how. Reflection involves using new words to
the time will be spent in collaborative problem summarize central ideas and emotions commu-
solving. nicated by the other person.)
5. Characteristics of crises: A crisis is pre- 8. Exploring thoughts and feelings: During
cipitated by an identifiable event that over- this phase of problem solving, the task is for the
whelms the person’s ability to cope. We all en- client and the psychologist to develop a joint
counter such distressing episodes, so crises are understanding of the issues confronting the
a normal part of being human. Because each of person and the emotions associated with those
us has our own personal values and perspec- topics. Specific events should be discussed in
tives, what causes a crisis for one person may conjunction with the related feelings, so that a
not bother another individual. There also can be shared view develops as to how the crisis came
pronounced differences among those who are in about and what has been happening. As long
crisis. Some may fall into coping characterized as new material continues to emerge, the ex-
by repression, denial, distortion, cognitive re- ploration phase should continue. It ends with
striction, drug and alcohol abuse, or physical agreement on three areas: the nature of the dis-
difficulties. Others may strive for accurate un- tressing circumstances, how the person is feel-
derstanding, acceptance, gradual progress, and ing about them, and what changes the individ-
optimism. But one way or another, most crises ual desires.
are resolved within a matter of weeks. In the 9. Considering alternatives: Once there is
minority of instances in which that is not the an understanding of the issues, the interaction
case, the person eventually may be at risk for moves to deciding what to do about them. The
suicide or personality disorganization. goal of this phase is to identify and consider
 50 • crisis intervention 247

two or three solid options. One tactic for gen- deadly; Michel, 1987); feelings of hopelessness
erating these possibilities is to explore three or depression (initial improvement during a
questions: What has the client already tried? clinical depression is an especially dangerous
What has the client thought about doing? And, time); past suicide attempts by the client (al-
right now as you are talking, what other ideas though most people who die by suicide kill
can the client generate? (Only after strongly themselves on the first attempt) and past at-
pulling for options from the client would it be tempts or completed suicide by close relatives
appropriate for the crisis intervener to make a or friends; a recent upsurge in difficulties expe-
suggestion.) When exploring in detail a prom- rienced by the client (Riskand, Long, Williams,
ising possibility, have the client consider the & White, 2000); and significant object loss as-
likely positive and negative consequences asso- sociated with the current crisis (Heikkinen,
ciated with that option. This phase ends with Aro, & Lonnqvist, 1993).
agreement on an approach, or a combination of 13. Intervening with a suicidal person: If
approaches, that can become the person’s plan. the client has attempted suicide or is currently
10. Developing a plan: The one absolute re- at risk, keep in mind the following five endeav-
quirement of an initial crisis intervention contact ors. Arrange an immediate medical evaluation
is the development of a plan that has four char- for an individual who has just engaged in self-
acteristics. The plan is collaboratively created harm. Determine the appropriate intervention
rather than dictated by the psychologist (Deci & or combination of interventions: crisis inter-
Ryan, 1987); it focuses on current issues, and vention for a person in crisis who wants help,
there are aspects of it that the client can begin ongoing treatment for an individual with long-
working on the same day or the next day; it in- standing problems, and hospitalization for a
volves specific tasks that have been thought client who is either ambivalent about wanting
through; and it is likely, not just possible, that to be alive or certain about wanting to be dead.
the individual will carry out those tasks. Once a Decrease the availability of lethal means; for
negotiated, present-focused, concrete, and real- example, develop a plan for removing firearms
istic plan has been developed, the client should from the person’s residence. Engage the indi-
review its major components. Clarify any mis- vidual in problem solving that begins to move
understandings or ambiguities that become ap- him or her toward adaptive ways of relieving
parent, and arrange a subsequent contact. the pain. For a client who remains suicidal, rec-
11. Subsequent contact: The initial activity ognize the potential for homicide. (A study by
of a subsequent contact is to review the client’s Asnis, Kaplan, van Pragg, and Sanderson, 1994,
efforts in implementing the plan. Successes focused on 403 psychiatric outpatients and
should be highlighted, and difficulties should found that of the 127 who had made a suicide
be identified. Negotiate necessary modifica- attempt, 35% also had contemplated or at-
tions in existing components of the plan, and tempted homicide.)
engage in problem solving with regard to im- 14. Deciding whether to support outpatient
portant issues that still need to be addressed. therapy or hospitalization: Bengelsdorf, Levy,
12. Suicide lethality assessment: Both in Emerson, and Barile (1984) developed the Cri-
crisis intervention and in emergency mental sis Triage Rating Scale to assist clinicians in
health intervention, it is appropriate to ask if deciding whether a person needs outpatient or
the client has been thinking about suicide. An inpatient services. The evaluator assigns scores
affirmative response to this question necessi- for dangerousness, support, and cooperation,
tates further exploration. If you believe there is then adds the numbers together. Bengelsdorf
an ongoing risk of suicide, you may want to ex- and his colleagues believe that a total score of 9
amine the following five factors that have been or lower suggests a need for hospitalization,
shown to increase the probability of suicide: the whereas a score of 10 or higher tends to indi-
existence of a plan for suicide that is specific, cate outpatient services as being appropriate.
available, and deadly (or the person believes is The scale’s scoring criteria are described below.
248 part iii • individual psychotherapy and treatment

DANGEROUSNESS Bengelsdorf, H., Levy, L. E., Emerson, R. L., & Bar-

ile, F. A. (1984). A Crisis Triage Rating Scale:
1. Threats of suicidal or homicidal behavior, a Brief dispositional assessment of patients at
recent dangerous attempt, or unpredictable risk for hospitalization. Journal of Nervous and
violence Mental Disease, 172, 424 – 430.
2. Threats of suicidal or homicidal behavior or Bunn, T. A., & Clarke, A. M. (1979). Crisis interven-
tion: An experimental study of the effects of a
a recent dangerous attempt, but sometimes
brief period of counselling on the anxiety of
views such ideas and actions as unacceptable, relatives of seriously injured or ill hospital pa-
or past violence but no current problems tients. British Journal of Medical Psychology,
3. Ambivalence associated with life-threaten- 52, 191–195.
ing thoughts, a “suicide attempt” not in- Capone, M. A., Westie, K. S., Chitwood, J. S.,
tended to end in death, or impulse control Feigenbaum, D., & Good, R. S. (1979). Crisis
that is inconsistent intervention: A functional model for hospital-
4. Some ongoing or past life-threatening be- ized cancer patients. American Journal of Or-
havior or ideas but clearly wants to control thopsychiatry, 49, 598 – 607.
such behavior and is able to do so Deci, E. L., & Ryan, R. M. (1987). The support of
5. No life-threatening ideas or actions and no autonomy and the control of behavior. Journal
of Personality and Social Psychology, 53,
history of problems with impulse control
1024 –1037.
Folkman, S., Lazarus, R. S., Dunkel-Schetter, C., De-
Longis, A., & Gruen, R. J. (1986). Dynamics of
SUPPORT a stressful encounter: Cognitive appraisal, cop-
ing, and encounter outcomes. Journal of Per-
1. Inadequate support from family members, sonality and Social Psychology, 50, 992–
friends, and community resources 1003.
2. Possible support but effect is likely to be France, K. (2002). Crisis intervention: A handbook
small of immediate person-to-person help (4th ed.).
3. Appropriate support possibly developed but Springfield, IL: Charles C Thomas.
with difficulty Halpern, H. A. (1973). Crisis theory: A definitional
study. Community Mental Health Journal, 9,
4. Appropriate support possibly developed, but
342–349.
some components may not be reliable Halpern, H. A. (1975). The Crisis Scale: A factor
5. Access to appropriate support analysis and revision. Community Mental
Health Journal, 11, 295 –300.
Heikkinen, M., Aro, H., & Lonnqvist, J. (1993). Life
COOPERATION events and social support in suicide. Suicide
and Life-Threatening Behavior, 23, 343 –358.
1. Unwilling or unable to cooperate Koocher, G. P., Curtiss, E. K., Pollin, I. S., & Patton,
2. Little appreciation or understanding of on- K. E. (2001). Medical crisis counseling in a
going intervention efforts health maintenance organization: Preventive
3. Passively accepts intervention efforts intervention. Professional Psychology: Re-
search and Practice, 32, 52– 58.
4. Ambivalence or limited motivation regard-
Michel, K. (1987). Suicide risk factors: A compari-
ing intervention efforts son of suicide attempters with suicide com-
5. Actively requests outpatient services and pleters. British Journal of Psychiatry, 150,
wants to productively participate in therapy 78 – 82.
Riskind, J. H., Long, D. G., Williams, N. L., &
References & Readings White, J. C. (2000). Desperate acts for desper-
ate times: Looming vulnerability and suicide.
Asnis, G. M., Kaplan, M. L., van Praag, H. M., & In T. Joiner & M. D. Rudd (Eds.), Suicide sci-
Sanderson, W. C. (1994). Homicidal behaviors ence: Expanding the boundaries (pp. 105 –115).
among psychiatric outpatients. Hospital and Boston: Kluwer Academic Publishers.
Community Psychiatry, 45, 127 –132.
 51 • impact of disasters 249

Viney, L. L., Clarke, A. M., Bunn, T. A., & Ben- Related Topics
jamin, Y. N. (1985). Crisis-intervention coun-
Chapter 49, “Treatment and Management of the
seling: An evaluation of long- and short-term
Suicidal Patient”
effects. Journal of Counseling Psychology, 32,
Chapter 51, “Impact of Disasters”
29 –39.
Chapter 121, “A Model for Clinical Decision Mak-
ing With Dangerous Patients”

51 IMPACT OF DISASTERS

Eric M. Vernberg & R. Enrique Varela

This chapter describes important concepts and Disaster Response Network

issues in evaluating the impact of disasters on The American Psychological Association Disas-
individuals. Items are arranged chronologically ter Response Network (DRN) was established
in relation to the disaster events: predisaster in 1991 to organize psychologists within each
planning, impact and short-term adaptation state into a disaster response network with for-
phases, and long-term adaptation phase. mal ties to the American Red Cross (ARC) and
local emergency management services. The
DRN offers short-term crisis intervention at
PREDISASTER PLANNING
disaster sites at the request of the ARC and is a
useful resource for clinicians working with dis-
Almost every community in the United States aster survivors. To obtain information about
has a local emergency management network in the DRN in your state, contact the APA Practice
place, yet the emphasis on mental health as- Directorate at 202-336-5898.
pects of disasters varies greatly. More wide- The ARC offers a 2-day training program
spread disasters require involvement of a state, for psychologists who wish to provide emer-
regional, or national emergency management gency mental health services as part of a Red
network. Participation in planning activities at Cross disaster team. Contact your local ARC
one or more of these levels is a necessity for chapter or the DRN for a schedule of training
psychologists who want to be involved in the opportunities.
crisis management aspects of disaster mental In 2002, the National Child Traumatic
health. Disasters, especially those receiving in- Stress Network established a Terrorism and
tense media coverage, often draw a tremendous Disaster Branch (TDB) to promote the well-
number of offers of help from a broad range of being of children and families by strengthening
mental health service providers. Understand- the nation’s preparedness and response to ter-
ably, emergency management personnel have rorism and disaster. This organization focuses
difficulty processing such offers in the after- on increasing public awareness of the need to
math of a disaster and prefer to rely instead on include resources and services specifically tar-
relationships developed earlier. geted for children and families after terrorism
250 part iii • individual psychotherapy and treatment

and disaster. The TDB offers consultation, in- injured or killed as a result of the disaster?”
formational support, and training on disaster • Witnessing or learning of violence to a loved
mental health issues for children and families one: “Did you see anyone get injured or
(www.NCTSNet.org). killed?”
• Exposure to toxins with long-term effects:
“Do you know of any health problems that
IMPACT AND SHORT-TERM could be caused by what happened to you in
ADAPTATION PHASES the disaster?”

The disaster impact phase refers to the period Not all elements of traumatic exposure are
when a disaster is occurring. Exposure to trau- equally likely to produce symptomatology. Ad-
matic events of an overwhelming nature is a ditional important distinctions include the du-
central characteristic of this phase, and mental ration of exposure, the cause of the disaster
health roles often involve acute crisis manage- (e.g., natural vs. human-made; accidental vs.
ment. The short-term adaptation phase in- deliberate or negligent), the proportion of the
cludes the period after the overwhelming disas- community affected, the degree of geographic
ter events end and the tasks of inventorying dislocation, and the potential impact on the
losses and developing a plan for recovery are ac- survivor’s life (e.g., permanent disability, cat-
complished. This phase generally requires 3 –9 astrophic economic loss, multiple deaths in
months to complete. Emergency services and family).
intense media activity are generally withdrawn
within this period.
Context of Evaluation and
Intervention
Elements of Traumatic Exposure
Hearing detailed descriptions of traumatic ex-
The nature of exposure to trauma is an impor- periences may be troubling for family members
tant indicator of risk for acute or chronic men- or others who were not directly exposed. De-
tal health sequelae of disasters. Indeed, most re- tailed descriptions in group contexts should be
search finds a dose-response relationship be- solicited only among individuals who shared
tween traumatic exposure and subsequent similar levels of traumatic exposure. Mixed
symptomatology. A useful typology distin- groups of survivors and rescue workers (other
guishes the following elements of traumatic ex- than mental health personnel acting as facilita-
posure (Green, 1990; selected structured ques- tors) are not appropriate. Initial evaluation and
tions are included from the DIS/DS, Robins & intervention in community settings rather than
Smith, 1993). clinical settings are preferable to minimize
stigmatization and resistance to mental health
• Threat to one’s life or bodily integrity: “At services.
any time did you think you might die?”
• Physical harm or injury to self: “Did you
Psychological First Aid
have any illness or injuries as a result of the
disaster?” Common initial reactions to overwhelming
• Receipt of intentional injury or harm: “Do traumatic exposure include confusion, disorga-
you think the disaster was just an act of God nization, and emotional numbness. Basic men-
or nature, or do you think the people who tal health roles during and shortly after the im-
were involved were in part to blame?” pact phase may be categorized as psychological
• Exposure to the grotesque: “Sometimes peo- first aid to connote the clear distinction from
ple in disasters have to see or do things they more traditional mental health interventions.
find disgusting. Did this happen to you?” Psychological first aid does not deal with
• Violent/sudden loss of a loved one: “Were chronic, long-term, or intrapsychic problems.
any of your family, friends, or companions Instead, the focus is on the here and now, en-
 51 • impact of disasters 251

hancing current functioning, and providing tional distress in the immediate aftermath of a
sufficient environmental support to prevent disaster or traumatic event. The goals are to as-
further injury. Appropriate activities include sess the extent of current mental health im-
the following: pairment in relation to pretrauma functioning,
to provide pragmatic emotional support, and to
• Providing direct, instrumental assistance give information and advice to help regain emo-
with problem solving and practical needs; tional equilibrium. Depending on the psycho-
this may include active advocacy on behalf of logical state, this may include information on
survivors the process of recovery from trauma, maladap-
• Providing factual information about the dis- tive versus adaptive coping strategies, resources
aster, typical reactions, and resources for sup- and supports, and indicators of the need for fur-
port and assistance ther mental health assistance (American Red
• Offering assistance in evaluating information Cross, 1991).
and formulating responses
• Activating social support systems, including
Guidelines for Providing More
family and community networks and access
Intensive Services
to other survivors
In the course of receiving psychological first
Specific forms of psychological first aid in- aid, individuals should be provided with more
clude the following. Debriefing and defusing extensive evaluations or treatments under the
refer to sessions in which individuals or groups following conditions (American Red Cross,
of survivors are encouraged to review the ma- 1991):
jor elements of a traumatic experience soon af-
ter exposure. The goals of these interventions • Preexisting serious mental disorder that is
include emotional release, enhancing social exacerbated by the disaster
support, reducing social isolation, translating • Extremely impaired functioning, including
iconic memories into language (to facilitate cog- thought disturbances, dissociative episodes,
nitive processing of the traumatic events), and extreme overarousal or mood lability, or in-
providing education, information, and stress- ability to care for personal needs
management strategies. Debriefing and defus- • Acute risk of harm to self or others, includ-
ing sessions also offer opportunities to screen ing suicidality, homicidal ideation, extreme
for severe impairment that may require addi- substance abuse, or inappropriate anger or
tional evaluation and treatment (American Red abuse of others
Cross, 1991). • Evidence of a life-threatening health condi-
Although formal debriefing and defusing are tion (e.g., heart problems, diabetes, high blood
widely practiced and strongly embraced by pressure) that is not currently being treated
many disaster mental health workers, evidence and appears to be causing problems
for their efficacy in general or the superiority of
one protocol over another remains sparse (Gist
& Lubin, 1998).
LONG-TERM ADAPTATION PHASE
Crisis reduction counseling is conducted
with an individual or family and focuses on as-
Mental health issues related to long-term adap-
sessing psychological states, validating and nor-
tation following disasters begin to fit more tra-
malizing thoughts and feelings, identifying and
ditional approaches to clinical assessment and
prioritizing current problems, and identifying
treatment. Still, several issues deserve special
sources of support (American Red Cross, 1991).
attention in assessing and treating disaster sur-
Discussion is limited to issues related to the dis-
vivors in the months and years after traumatic
aster recovery process.
exposure.
Crisis intervention is carried out with an in-
dividual or family to mitigate extreme emo-
252 part iii • individual psychotherapy and treatment

Common Mental Health Problems

the identified disaster event has ended. It is ex-
After Disasters
tremely important to inquire about ongoing
stressful circumstances that follow many severe
Anxiety, depression, and somatic complaints: disasters. These include economic struggles,
The most consistent mental health problems dislocation, rebuilding, employment disrup-
found in studies of disaster survivors are symp- tion, changes in household composition, and in-
toms of anxiety (including posttraumatic stress creases in “daily hassles.” When ongoing dis-
disorder), depression, and somatic symptoms. ruption is high, it is appropriate to continue the
Substance abuse: Although widely believed functions characteristic of psychological first
to be affected by disasters, increases in sub- aid long after the primary disaster event has
stance abuse problems among disaster sur- ended.
vivors have been reported less consistently Psychological resources: Several psycholog-
than the anxiety/depression/somatic complaint ical resources have been linked to resilience fol-
symptoms described above. The topic needs lowing traumatic events of varying types. Reli-
further study, as some studies have found in- gious faith and philosophical perspectives that
creases in alcohol use (and other substances, in some way enable individuals to make sense
such as tranquilizers) among disaster-exposed of disaster experiences appear to be important
populations in the United States and others resources following disasters. A second set of
have not. psychological resources includes at least aver-
Aggression and anger: Problems with anger age intelligence, good communication skills,
and aggression appear to be linked to disasters, and strong beliefs of self-efficacy.
although there is less evidence for this than for Socioeconomic status: Education and finan-
anxiety, depression, and somatic complaints. cial status may influence recovery from disas-
A number of studies have found anger and ters and even levels of exposure to traumatic ex-
irritability to be higher in disaster-exposed periences during disasters. Education may in-
populations than in nonexposed comparison fluence an individual’s ability to cope with the
groups, and there is some suggestion that these demands for documentation and careful com-
problems may be quite persistent over time. pletion of applications for disaster assistance.
There is surprisingly little research document- Education is also linked to skills in seeking in-
ing increases in actual aggression after disas- formation regarding resources. Financial status
ters. exerts multiple possible influences on postdis-
aster functioning. In terms of increased expo-
Factors Influencing Recovery
sure to traumatic experiences during disasters,
housing built of less durable materials (e.g.,
Social support: Social support is swiftly mobi- mobile homes) or in less desirable locations
lized by most disasters but often is depleted and (e.g., flood-prone land) is more likely to be
diminished long before recovery is accom- damaged by disasters in the first place. This
plished (Kaniasty & Norris, 1997). This sense places poorer individuals, on average, at greater
of declining support may contribute to distress. risk for loss of personal possessions and expo-
Assessment of access to needed support is es- sure to life-threatening circumstances. Follow-
sential in designing interventions for disaster ing disasters, individuals with few financial re-
survivors. Improving access to needed forms of sources (including personal property insurance)
social support is a major goal for mental health may find it virtually impossible to repair or re-
providers. Risk of poor access to social supports place lost belongings. Even for poorer families
following disasters is especially high for mar- with some insurance, months of waiting may
ginalized members of communities (e.g., poorer, be required before claims are settled, placing
less educated individuals; geographically iso- extreme financial pressures on those with few
lated individuals). financial reserves. Many lower-paying, lower-
Ongoing disruptions: Many disasters cause occupational-status jobs offer little in the way
serious disruptions for individuals long after of paid personal leave or scheduling flexibility.
 51 • impact of disasters 253

This may further complicate postdisaster re- symptoms than others (e.g., parents, teachers)
covery by making it difficult for individuals to report for them. Relying solely on parent or
find the time to pursue aid or repairs. teacher reports to identify postdisaster mental
health problems in school-age children is al-
most certain to underestimate these problems.
Age-Related Issues
Adolescents are more competent to help with
Age is related to disaster response in numerous recovery and are less dependent than younger
ways, and children and the elderly are typically children. At the same time, adolescents may en-
viewed as “special populations” in the disaster gage in greater risk-taking behaviors after dis-
literature. Children and some of the elderly are asters. Adolescents also may have intense feel-
similar in their greater dependence on others to ings of being cheated out of expected experi-
meet basic needs for food, clothing, and shelter. ences (e.g., athletic and social events that are
Impairment in individuals or systems that canceled or postponed) after disasters.
meet these dependency demands places both Young and middle-aged adults: There is
groups at risk for mental health disturbance, some evidence of differences in disaster-related
and possibly for physical danger. distress between young adults (18 – 40) and
Children and adolescents: Children of dif- middle-aged adults (40 – 65), with the latter
ferent ages have different types of difficulties group typically faring worse. Middle-aged
related to disasters. Infants and toddlers are of- adults are more likely than other age cohorts to
ten very sensitive to disruptions in caretaking have responsibility for children and elderly
and may show increases in feeding problems, parents during and after disasters, and this in-
irritability, and sleep problems. These behav- creased responsibility may contribute to psy-
ioral problems in turn place increased demands chological distress.
on caretakers, who may themselves be highly Older adults: Health status (including men-
distressed by a disaster. tal health) and competence to perform tasks of
Preschool children are beginning to use lan- daily living are also important aspects in deter-
guage in relatively sophisticated ways but are mining postdisaster needs of the elderly. Sen-
very limited in their understanding of disaster- sory changes accompanying aging are impor-
related events. This limited understanding of- tant to consider. Hearing and vision problems
ten leads to fears that may seem unwarranted may make it more difficult for the elderly to ob-
to older children and adults (e.g., extreme fears tain information regarding disaster relief ef-
during thunderstorms that occur after a flood forts or to provide information to others. Noisy,
or tornado). These fears may lead to dramatic crowded settings (such as disaster shelters or
reactions to relatively harmless postdisaster Disaster Assistance Centers) may be particu-
events. larly problematic because it becomes increas-
School-age children understand the physical ingly difficult with age to filter out competing
environment much better than preschoolers noises during conversations. Decreased sense of
but may be very preoccupied by the loss of pos- smell and taste tend to make the elderly prefer
sessions or pets or by memories of traumatic foods with more flavor, and elders may respond
events. Elementary school–age children also are to bland food provided through disaster relief
often able to recognize distress in their caretak- teams by adding salt (which aggravates hyper-
ers and may be quite worried about the safety tension) or reducing food intake (which may
and security of their families. Children of this result in malnutrition). The relationship be-
age can do relatively little to help actively in the tween cognitive functioning and physical
recovery process, which may increase feelings health becomes increasingly strong during late
of isolation and helplessness. Children over 8 adulthood, and declines in physical health due
years old generally are competent reporters of to poor nutrition or disruptions in medications
psychiatric symptoms (especially internalizing may contribute to significant mental health
symptoms) when given appropriate measures. problems, including confusion, disorientation,
Children typically report more postdisaster and depression. Similarly, loss of social support
254 part iii • individual psychotherapy and treatment

and disruptions in routines following disasters tervention. Dordrecht, The Netherlands: Kluwer
may produce poor health behaviors, leading to Academic Publishers.
increased dysfunction. Sudden changes in liv- La Greca, A. M., Silverman, W. K., Vernberg, E. M.,
ing arrangements are difficult for older adults, & Roberts, M. C. (Eds.). (2002). Helping chil-
dren cope with disasters and terrorism. Wash-
especially those with cognitive, physical, or
ington, DC: American Psychological Associa-
sensory impairments. Many elderly also attach
tion.
a strong stigma to the use of mental health ser- Norris, F. H., Friedman, M. J., & Watson, P. J. (2002).
vices, and substantial efforts may be required to 60,000 disaster victims speak: Part II. Sum-
make such service acceptable. Some older adults mary and implications of the disaster mental
who are aware of their diminished capabilities health research. Psychiatry: Interpersonal and
may fear that they will be placed in nursing Biological Processes, 65, 207 –239.
homes or other restrictive settings if their dif- Norris, F. H., Friedman, M. J., Watson, P. J., Byrne,
ficulties become known to relief workers. It is C. M., Diaz, E., & Kaniasty, K. (2002). 60,000
important to communicate that mental health disaster victims speak: Part 1. An empirical re-
workers are attempting to help the elderly live view of the empirical literature. Psychiatry: In-
terpersonal and Biological Processes, 65, 207 –
as independently as possible and that they may
239.
help garner the resources and support needed
Robins, L. N., & Smith, E. M. (1993). Diagnostic
for this to occur. interview schedule: Disaster supplement. St.
Louis, MO: Washington University School of
Medicine, Department of Psychiatry.
References & Readings
Saylor, C. F. (Ed.). (1993). Children and disasters.
American Red Cross. (1991). Disaster services reg- New York: Plenum Press.
ulations and procedures (ARC Document Ursano, R. J., McCaughey, B. G., & Fullerton, C. S.
3050M). Washington, DC: Author. (Eds.). (1994). Individual and community re-
Gist, R., & Lubin, B. (Eds.). (1998). Response to dis- sponses to trauma and disaster: The structure
aster: Psychosocial, community, and ecological of human chaos. Cambridge, UK: Cambridge
approaches. Bristol, PA: Taylor and Francis. University Press.
Green, B. L. (1990). Defining trauma: Terminology
and generic stressor dimensions. Journal of Ap-
plied Social Psychology, 20, 1632–1642.
Related Topic
Hobfoll, S. E., & de Vries, M. W. (Eds.) (1995). Ex-
treme stress and communities: Impact and in- Chapter 50, “Crisis Intervention”
 PRINCIPLES IN THE
52 TREATMENT OF BORDERLINE
PERSONALITY DISORDER

John F. Clarkin & Pamela A. Foelsch

Patients with borderline personality disorder fused patients primarily, or identity and
(BPD) are characterized by identity diffusion, impulsive, or affective with suicidal behav-
affective dyscontrol, impulsivity, and chaotic ior. The prominence of the three factors is
interpersonal relations. Often they exhibit most important in setting and prioritizing
repetitive self-mutilating or frank suicidal be- treatment goals.
haviors. These patients rarely present with 2. Carefully assess for comorbid Axis I and
BPD alone but manifest comorbid Diagnostic Axis II conditions. Only rarely does a pa-
and Statistical Manual of Mental Disorders tient meet criteria for BPD alone. The com-
(DSM-IV) Axis II conditions, most frequently mon comorbid Axis I conditions include af-
histrionic, narcissistic, and antisocial features fective disorder, eating disorders, and sub-
or disorders, and common DSM-IV Axis I con- stance use and abuse. Common Axis II
ditions of major depression, eating disorders, conditions include histrionic, narcissistic,
and substance abuse. This is a group of patients and antisocial personality disorders/traits.
who have serious pathology, which is frighten- 3. In the assessment, carefully explore two
ing to therapists because of the safety and legal areas of pathology: (a) the manner in which
implications, and they elicit intense counter- the patient has used or abused prior treat-
transference feelings. ments and (b) the interpersonal behaviors
Based on the growing body of research and between patient, therapist, and significant
our own extensive experience, we present 10 others, particularly surrounding self-muti-
important principles for the assessment and lating and suicidal behaviors. These prior
treatment of these patients. behaviors must be considered in structur-
ing the next treatment. For example, if the
1. Determine the specific criteria for BPD met patient has destroyed a treatment by not
by the individual patient. Since Axis II is talking during the regular session then
polythetic in nature, patients may receive telephoning the therapist on the weekend
the diagnosis of BPD by meeting any 5, 6, and insisting on crisis help, the likelihood
7, 8, or 9 DSM-IV criteria. This means that of this happening in the new therapy will
mathematically there are 256 ways of ob- be discussed, along with how the therapist
taining the diagnosis. Just on the BPD cri- will structure the therapy.
teria themselves, the patients are quite het- 4. Structure the treatment from the begin-
erogeneous. A factor analysis of the BPD ning with a clear contract delineating the
criteria (Clarkin, Hull, & Hurt, 1993) sug- patient’s treatment role and responsibilities
gests three factors: an identity diffusion and the therapist’s role and responsibili-
factor, an affect disregulation factor includ- ties. The need for a structured treatment
ing suicidal behavior, and an impulsive fac- contract is recognized in both psychody-
tor. Thus, BPD patients can be identity dif- namic and cognitive-behavioral orientations

255
256 part iii • individual psychotherapy and treatment

(Linehan, 1993; Yeomans, Selzer, & Clarkin, used group treatment alone with these pa-
1992). It is especially around destruction of tients. Because there is insufficient re-
the patient (i.e., suicidal behavior) and de- search on the question of treatment for-
struction of the therapy (e.g., coming to mat, the clinician must consider the specific
sessions intoxicated, refusing to talk during goals and practicality in deciding on the in-
sessions) that the roles and responsibilities dividual case. Group treatment is more
of patient and therapist must be delineated. economical, but this advantage must be
This verbal agreement provides both a weighed against the high dropout rate of
structure within which the therapy can these patients, who strongly prefer indi-
proceed and a treatment frame that the vidual treatment if given a choice.
therapist can refer to later should difficul- 8. Medication can be considered as an adjunct
ties arise. to a consistent therapeutic relationship
5. Focus the treatment around goals identified (Koenigsberg, 1997). Medications can be of
early in process. These goals should be deter- assistance with depressive symptoms and
mined by the nature of the patient’s pathol- possibly with impulsive behaviors. Atten-
ogy and the therapist’s orientation. Two tion must be paid to the patient’s tendency
prominent treatment orientations are the to seek medications as a “quick fix” or to
cognitive-behavioral orientation (Linehan, undermine therapy. A strong working re-
1993), which strives for reduction of ther- lationship between therapist and psy-
apy-interfering behaviors and for an increase chopharmacologist is essential.
in social skills, and the psychodynamic ori- 9. The therapist should be alert to the clinical
entation (Clarkin, Yeomans, & Kernberg, and legal standards of care when dealing
1999; Kernberg, Selzer, Koenigsberg, Carr, & with these patients, who are often suicidal.
Appelbaum, 1989), which focuses on the This includes information about legal per-
here-and-now transference with the goal of spectives, assessment of suicide risk, and
increasing identity as opposed to identity risk management, such as documentation
diffusion. One can also use a supportive of clinical decisions and consultation with
orientation, which may be of assistance in other professionals when appropriate (Bon-
achieving some equilibrium and mainte- gar, 1991).
nance of that status (Rockland, 1992). Still 10. Borderline patients, especially those who
others (Horwitz et al., 1996) suggest tailor- are suicidal with comorbid narcissistic and
ing the treatment with a balance of expres- antisocial traits are extremely difficult to
sive and supportive techniques. treat. Their behavior in sessions is compli-
6. At times of crisis, especially those involv- cated by identity diffusion and intense af-
ing serious suicidal ideation and/or threats, fect, often of a hostile and aggressive na-
hospitalization to control this behavior ture. All these factors suggest that clini-
must be considered. The advantage of hos- cians, even experienced ones, should seek
pitalization in protecting the patient briefly consultation with colleagues about certain
from suicidal potential must be weighed situations. Some therapists who treat bor-
against the possibility of rewarding sui- derline patients form a peer group with
cidal threats with the comfort of around- other professionals treating these patients.
the-clock attention, which may reinforce
future suicidal ideation. References & Readings
7. While individual treatment is often recom-
Bongar, B. (1991). The suicidal patient: Clinical and
mended for these patients, other treatment legal standards of care. Washington, DC: Amer-
formats should be considered. One cogni- ican Psychological Association.
tive-behavioral approach uses a combina- Clarkin, J. F., Hull, J. W., & Hurt, S. W. (1993). Fac-
tion of individual treatment and group tor structure of borderline personality disorder
treatment for skills enhancement (Linehan, criteria. Journal of Personality Disorders, 7,
1993). Others (Munroe-Blum, 1992) have 137 –143.
 53 • psychotherapy with reluctant and involuntary clients 257

Clarkin, J. F., & Lenzenweger, M. F. (1996). Major Meissner, W. W. (1984). The borderline spectrum:
theories of personality disorder. New York: Differential diagnosis and developmental is-
Guilford Press. sues. New York: Jason Aronson.
Clarkin, J. F., Marziali, E., & Munroe-Blum, H. (1992). Munroe-Blum, H. (1992). Group treatment of bor-
Borderline personality disorder: Clinical and derline personality disorder. In J. F. Clarkin, E.
empirical perspectives. New York: Guilford Press. Marziali, & H. Munroe-Blum (Eds.), Border-
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. line personality disorder: Clinical and empiri-
(1999). Psychodynamic treatment of borderline cal perspectives (pp. 288 –299). New York:
personality organization. New York: Wiley. Guilford Press.
Horwitz, L., Gabbard, G. O., Allen, J., Frieswyk, Rockland, L. H. (1992). Supportive therapy for bor-
S. H., Colson, D. B., Newsom, G. E., et al. (1996). derline patients: A psychodynamic approach.
Borderline personality disorder: Tailoring the New York: Guilford Press.
psychotherapy to the patient. Washington, Stone, M. H. (1990). The fate of borderline patients:
DC: American Psychiatric Press. Successful outcome and psychiatric practice.
Kernberg, O. F. (1984). Severe personality disorders: New York: Guilford Press.
Psychotherapeutic strategies. New Haven, CT: Yeomans, F. E., Selzer, M. A., & Clarkin, J. F. (1992).
Yale University Press. Treating the borderline patient: A contract-
Kernberg, O. F. (1992). Aggression in personality based approach. New York: Basic Books.
disorders and perversions. New Haven, CT:
Yale University Press.
Kernberg, O. F., Selzer, M. A., Koenigsberg, H. W., Related Topics
Carr, A. C., & Appelbaum, A. H. (1989). Psy-
Chapter 46, “Stages of Change: Prescriptive Guide-
chodynamic psychotherapy of borderline pa-
lines”
tients. New York: Basic Books.
Chapter 49, “Treatment and Management of the
Koenigsberg, H. W. (1997). Integrating psychother-
Suicidal Patient”
apy and pharmacotherapy in the treatment of
Chapter 65, “Refusal Skills Training”
borderline personality disorder. In Session: Psy-
Chapter 76, “Choice of Treatment Format”
chotherapy in Practice, 3, 39 – 56.
Linehan, M. M. (1993). Cognitive-behavioral treat-
ment of borderline personality disorder. New
York: Guilford Press.

PSYCHOTHERAPY
53 WITH RELUCTANT AND
INVOLUNTARY CLIENTS

Stanley L. Brodsky

When therapists offer counseling from the tary clients, they set up themselves and their
same frame of reference for reluctant and in- clients for considerable frustration. Some re-
voluntary clients as they do for eager, volun- luctant clients will never fully participate in
258 part iii • individual psychotherapy and treatment

counseling; for them, quick termination of the Most people are not offenders.
treatment may be the decision of choice. For Most people are not mentally ill.
other clients, the reluctance becomes trans-
Therefore most offenders are mentally ill.
formed into active participation and the treat-
ment itself becomes a productive venture. The
beginning points in approaching treatment of A fundamental rule emerges from this prin-
reluctant clients are awareness of therapist as- ciple: Do not attempt to cure antisocial behav-
sumptions and of client roles and rights. ior per se through psychotherapy. Instead,
treatment services should be offered without
institutional pressures to offenders who request
REACTIONS TO RELUCTANT CLIENTS such services (Monahan, 1980).

Therapists have a need to present themselves as

expert and trustworthy in their therapeutic THE RIGHT TO REFUSE TREATMENT
roles (Beutler, Machado, & Neufeldt, 1994). If
therapists are frustrated by clients, these needs Every client’s right to decline treatment as well
may rise to prominence, occasionally in exag- as to choose treatment knowledgeably should
gerated form. The resultant events are often be respected. The choice to refuse treatment, as
confrontational demands by the therapists for fully as to participate in therapy, should be an
clients to give up their reluctance or a facade by informed one, particularly when there are in-
clients of conformity to the patient role. stitutional, occupational, or family consequences
Therapists enter their professions in part al- of not entering therapy. Clients should know
truistically, to feel good about helping others precisely what choices they are declining. The
(Guy, 1987). Reluctant clients are unapprecia- therapist’s responsibility is to ensure that the
tive and do not provide the customary positive client understands the alternatives of what
feedback therapists want as part of their work. treatment is available, how long it lasts and how
Many therapists take this lack of appreciation well it works, the nature of the therapeutic pro-
personally and feel threatened, incapable, and cedures, and the assumption of client self-
frustrated. In order to avoid becoming impaired determination in continuing therapy. Contracts
in working with the client, they need to be able with clients and outlines of information to be
to address the threat and frustration as fore- given to clients have been gathered in Bersoff
ground personal issues. (1995, pp. 305 –334).

THE MENTAL HEALTH – CRIME FALSE REFERRAL CLARIFICATION:

SYLLOGISM WHY IS A CLIENT HERE?

Law violators are the most frequent category of Often agencies do not know exactly why they
reluctant client, often explicitly coerced to enter have referred a client. They know something is
psychotherapy as a condition of probation or wrong and that the client needs help or an in-
parole or as proof of progress toward being a tervention but little more. Thus, the therapist
desirable candidate for parole or privileges should find out why a coercive referral has been
within prison. It is incorrectly concluded by made. The specific information needed includes
many clinicians that being a serious offender is the treatment aims, the referrer’s anticipation
prima facie evidence of need for psychotherapy. of success, the time constraints, the legal or fa-
This conclusion takes the form of the following milial frames of reference, and the influences of
implicit false syllogism (Davis & Brodsky, the client’s transient situation. These actions
1992): consist of clarifying and redefining the referral.
Otherwise therapists become engaged in a
vague plan of “just doing therapy.”
 53 • psychotherapy with reluctant and involuntary clients 259

LOW TRUST– HIGH CONTROL DILEMMAS TREATING THE ABRASIVE CLIENT

With voluntary clients, the customary thera- Abrasive clients are individuals who have a spe-
peutic relationship is characterized by high trust cial knack for irritating others. They know how
and little effort to control the other’s behaviors. to get under others’ skin to annoy. They become
With confined populations and clients pressured adept at jabbing at the vulnerabilities of their
to enter therapy, mutual distrust of motives is therapists. Sometimes it is done with subtlety;
often accompanied by the therapist having con- therapists become aware of this process when
siderable control over client living conditions, they find themselves getting annoyed without
privileges, and release (Harris & Watkins, 1987). apparent good reason. According to Wepman
The subsequent therapist fear of manipulation and Donovan (1984), abrasive individuals have
produces a role conflict between helping and “su- both a high need for human intimacy and a fear
pervising.” The normal trust and rapport be- of closeness. The need for intimacy brings them
tween therapist and client become displaced by a toward therapists emotionally, whereas their
concern over being used and by excessive control fear leads them to push therapists away. Clients
measures, which themselves are antagonistic to who have criticized a therapist’s clothing, fam-
good treatment. The resolution of these dilem- ily, office decor, facial expression, tone of voice,
mas lies in explicit delineation of limits, as well ethnicity, or personal appearance succeed when
as absolute separation of therapeutic roles from they are rejected. The treatment is to try to re-
evaluative and organizational roles (Brodsky, spond to the hurt and the desire for closeness:
1973; Davis & Brodsky, 1992). “The alliance must be made with the wounded,
vulnerable aspects of the personality” (Wepman
& Donovan, 1984, p. 17).
WHO IS THE CLIENT?

Therapists may be classified as falling on a con- THERAPY AS AN AVERSIVE CONTINGENCY

tinuum from system professional to system FOR INAPPROPRIATE BEHAVIOR
challenger, depending on the extent to which
they accept the existing aims of the agency. If the treatment itself is a negative experience
Therapists need to define their stances and con- for clients, it can be used as an aversive stimu-
sider client versus agency responsibilities, coer- lus following undesirable behavior. In a discus-
cion effects, and other values implicit in treat- sion of behavioral treatment of delinquents,
ment activities. All psychotherapy has implicit Levinson, Ingram, and Azcarate (1973) de-
values. The therapist needs to be especially sen- scribed just such an effective program with
sitive to social values and imposing normative confined, severely antisocial youthful offenders.
behaviors. This dilemma is best resolved by The youths were able to earn the right to dis-
making explicit on an a priori basis the social continue mandatory group therapy by going 3
values with which one is practicing. successive months without being sent to segre-
Confidentiality is often the playing field on gation. Once this program was introduced, mis-
which these conflicts become tested. Confiden- conduct reports among group members dropped
tiality is not absolute. Explicit agreement from 43% in a 6-month period after therapy. In
the beginning on confidentiality is important, other settings, such as family therapy, anecdo-
with all parties being informed in writing and tal reports have indicated that children’s prob-
in advance about the level of confidentiality lem behaviors have diminished or disappeared
(Report of the Task Force on the Role of Psy- with the promise that attendance in therapy
chology in the Criminal Justice System, 1980). would no longer be required.
260 part iii • individual psychotherapy and treatment

ERRORS IN TECHNIQUE about suing are poor candidates for therapeutic

progress. Therapists fearful of lawsuits become
When the criterion for success is reduced recidi- legalistic, distant, overly cautious, and less effec-
vism, nondirective and traditional psychody- tive. The therapist’s role will be addressed here
namic therapies, as well as any approach with rather than that of the client. Most therapists’
low-risk offenders, have little payoff (Gendreau, fears of litigation are excessive and irrational
1996). Therapy that is vaguely targeted and not (Brodsky, 1988). The litigaphobic therapist be-
intensive in nature seems to fail. With diagnosed comes what he or she fears—a surrogate lawyer,
psychopaths, these failures become even more second-guessing every action. The alternative is
compelling. Insight-oriented therapies and to assess realistically the base rate for such
group therapies, in particular, are associated with suits — statistically low — and to get consulta-
higher rates of future crime (Hare, 1996). Ther- tion as necessary to manage such fears. A scale is
apy is best offered for specific behaviors that dis- available for assessing the extent of fear of liti-
rupt criminogenic social networks and to provide gation (Breslin, Taylor, & Brodsky, 1976).
relapse prevention training.
Therapy also fails when therapists (a) pas-
sively accept problematic aspects of the client’s OBJECTIVE SELF-AWARENESS
behavior and attitudes, such as evasiveness and
negativism; (b) fail to address deficiencies in the This phenomenon, described by Duval and
therapeutic relationship; or (c) present destruc- Wicklund (1972), has powerful implications for
tive or poorly timed interventions (Sachs, reluctant clients. When clients are encouraged
1983). Effective therapists do not sit back and to listen in at staff meetings about their cases
wait in the therapy office but instead are active. and discussions of their therapeutic progress, as
Timing, specificity of focus, and intense in- well as to read documents written about them,
volvement in therapeutic work are crucial. they become, in effect, outside observers of
themselves. As a result, they become motivated
and fascinated. This principle can be used by
UTILIZING RESISTANCE sharing with clients the videotapes and audio-
tapes of sessions, ongoing therapy records, and
When clients actively resist involvement and especially the opportunity to hear discussions
change, therapists should not be in direct oppo- of their dynamics and progress (Brodsky &
sition. Instead, they should consider aiming at Myers, 1986).
second-order change so that clients accept in an
oppositional way the view therapists would
originally have wanted. Thus, one can ask re- LIFE SKILLS ENHANCEMENT
sistant clients, “Why should you change?” or
instruct clients to “go slow.” In the same spirit, In enhancement of life skills, therapeutic efforts
one might tell a distrustful client to never trust are offered as short courses that are closed
the therapy fully. These procedures may be ended and based on a published curriculum.
conceptualized as co-opting clients’ cognitive Each unit of instruction attends to narrowly de-
space. Teyber’s (1988) interpersonal process in fined areas of functioning. The short courses
psychotherapy addresses this approach by ex- have scheduled beginnings and endings, the use
plicitly using what he calls “honoring the cli- of pass or fail criteria, and the advance identifi-
ent’s resistance.” cation of specific treatment content. In this al-
ternative to conventional open-ended therapies,
topics that are addressed include conflict man-
LITIGIOUS CLIENTS agement, human sexuality, assertiveness train-
ing, and fairness awareness (Scapinello, 1992).
Therapists and clients alike can become influ-
enced by fears of lawsuits. Clients who think
 53 • psychotherapy with reluctant and involuntary clients 261

FOUR MORE PRACTICAL APPROACHES with envy? With feelings of wasted living?
Regret? One book compellingly develops
1. Keep the client for three sessions: One third this theme: Grudin’s Time and the Art of
of therapy clients never return for a second Living (1982), which asserts that when time
appointment even after a definite time has becomes a foreground issue, it can serve to
been set. An additional 40% stop before the help with problems in living and in therapy.
sixth session. In their research using the 4. Concrete changes: Giving clients immediate
Vanderbilt Psychotherapy Process Scale, and concrete self-coping methods yields
O’Malley, Suh, and Strupp (1983) found no good motivation to continue with therapy.
relationship whatever between first-session For example, in the case of anxiety problems
events and eventual outcome. A strong re- and panic attacks, cognitive therapies and
lationship was found between third-session teaching of diaphragmatic breathing and re-
events and outcome. By that time, patients laxation techniques lead to rapid improve-
became involved, and that involvement made ment. Help with sleep problems has an es-
a difference. Thus, the therapist should set pecially strong impact, given that about
up contracts or trial therapy agreements for 40% of the general population and 80% of
three or four sessions. institutionalized persons have sleeping diffi-
2. Common foundations for therapy: When culties. Clients welcome assistance in man-
conventional approaches to building rapport aging insomnia, difficulties falling asleep,
do not work, the therapist should consider and waking easily during the night.
adapting the “group conversation method”
developed by DuBois and Li (1971). In this
method, clients are asked to take turns de- SUMMARY
scribing sensory memories (such as smells
and tastes from childhood), activities at Therapists should not automatically assume
school or home, or particular holidays. The that traditional therapies with voluntary and
questions include: How did you use to spend cooperative clients apply to reluctant and invol-
Halloween? What are your memories of untary clients. Instead, referral questions, def-
worst teachers? Best teachers? Christmas initions of client, and confidentiality should be
smells? Where you grew up? Earliest reli- examined carefully. Milieu demands for control
gious memories? Otto (1973), who has of client behavior can compromise therapeutic
called this network of positive formative relationships, as can abrasive and resistant
experiences the Minerva experience, sug- client behaviors. Therapists should consider
gests the joint recollection of such experi- utilizing client resistances, ensuring that ther-
ences is a positive bonding. apy continues through at least three sessions,
3. Time and therapy: Our experiences are cap- and adapting the length of therapy sessions to
tured by conventions of time. Therapists individual clients. With these clients, concrete
become entrained by 50-minute hours and and immediate changes are important, along
appointment books, and they believe that with promoting objective self-awareness and
“good” clients should comply as well. As a using closed-ended short-term treatments.
beginning point with difficult clients, ex-
periment with very short or long sessions. References & Readings
More broadly, however, try to understand
the meaning of time in clients’ lives. Re- Bersoff, D. N. (Ed.). (1995). Ethical conflicts in psy-
chology. Washington, DC: American Psycho-
sponsibility and personal development are
logical Association.
concepts seated in part in elements of time, Beutler, L. E., Machado, P. P. P., & Neufeldt, S. A.
such as continuity and comprehension of (1994). Therapist variables. In A. E. Bergin &
consequences (McGrath, 1988). How do the S. L. Garfield (Eds.), Handbook of psychother-
clients experience time passing? Five years apy and behavior change (4th ed., pp. 229 –
from now, will they look back at the present 269). New York: Wiley.
262 part iii • individual psychotherapy and treatment

Breslin, F. A., Taylor, K. R., & Brodsky, S. L. (1986). icine tastes bad. In J. S. Stumphauzer (Ed.), Be-
Development of a litigaphobia scale: Measure- havior therapy with delinquents (pp. 159 –
ment of excessive fear of litigation. Psychologi- 163). Springfield, IL: Thomas.
cal Reports, 58, 547 – 550. McGrath, J. E. (Ed.). (1988). The social psychology
Brodsky, S. L. (1973). Psychologists in the criminal of time. Newbury Park, CA: Sage.
justice system. Urbana: University of Illinois Monahan, J. (Ed.). (1980). Who is the client? The
Press. ethics of psychological intervention in the crim-
Brodsky, S. L. (1988). Fear of litigation in mental inal justice system. Washington, DC: American
health professionals. Criminal Justice and Be- Psychological Association.
havior, 15, 492–500. O’Malley, S. S., Suh, C. S., & Strupp, H. H. (1983).
Brodsky, S. L., & Myers, H. H. (1986). In vivo rota- The Vanderbilt Psychotherapy Process Scale: A
tion: An alternative method of psychotherapy report on the scale development and a process-
supervision. In F. W. Kaslow (Ed.), Supervision outcome study. Journal of Consulting and
and training: Models, dilemmas, and chal- Clinical Psychology, 51, 581– 586.
lenges (pp. 95 –104). New York: Haworth. Otto, H. A. (1973). Ways of growth: Approaches to
Davis, D. L., & Brodsky, S. L. (1992). Psychotherapy expanding awareness. New York: Penguin.
with the unwilling client. Residential Treat- Sachs, J. S. (1983). Negative factors in brief psycho-
ment for Children and Youth, 9(3), 15 –27. therapy: An empirical assessment. Journal of
DuBois, R. D., & Li, M.-S. (1971). Reducing social Consulting and Clinical Psychology, 51, 557 –
tension and conflict through the group conver- 564.
sation method. New York: Association Press. Scapinello, K. F. (1992). Specialized services offered
Duval, S., & Wicklund, R. A. (1972). A theory of by the Psychology Department (Programme
objective self-awareness. New York: Academic Report No. PR92-2). Brampton: Ontario Cor-
Press. rectional Institute.
Gendreau, P. (1996). Offender rehabilitation: What Teyber, E. (1988). Interpersonal process in psy-
we know and what needs to be done. Criminal chotherapy: A guide to clinical training. Boston:
Justice and Behavior, 23, 144 –161. Dorsey.
Grudin, R. (1982). Time and the art of living. New Wepman, B. J., & Donovan, M. W. (1984). Abrasive-
York: Ticknor and Fields. ness: Descriptive and dynamic issues. Psy-
Guy, J. D. (1987). The personal life of the psy- chotherapy Patient, 1, 11–20.
chotherapist. New York: Wiley.
Hare, R. D. (1996). Psychopathy: A clinical con-
struct whose time has come. Criminal Justice Related Topics
and Behavior, 23, 25 – 54.
Harris, G. A., & Watkins, D. (1987). Counseling the Chapter 38, “Patients’ Rights in Psychotherapy”
involuntary and reluctant client. College Park, Chapter 121, “A Model for Clinical Decision Mak-
MD: American Correctional Association. ing With Dangerous Patients”
Levinson, R. B., Ingram, G. L., & Azcarate, E. (1973). Chapter 125, “Sample Psychotherapist-Patient Con-
Aversive group therapy: Sometimes good med- tract”
 TREATMENT MATCHING
54 IN SUBSTANCE ABUSE

Carlo C. DiClemente

“Different strokes for different folks” certainly • Group therapy, whether dynamically ori-
characterizes the treatment of substance abuse. ented (Brown, 1995) or a skills-based/relapse-
Consider what substances of abuse encompass: prevention approach (Marlatt & Gordon,
(a) multiple classes of drugs (sedatives, stimu- 1985), has been the treatment of choice for
lants, opiates); (b) different sources of drug drug abuse in most treatment settings, usu-
availability (cocaine and crack; beer, wine, and ally along with some case management and
hard liquor; cigarettes and smokeless tobacco); a referral to Alcoholics Anonymous, Nar-
(c) varied routes of administration (oral, nasal, cotics Anonymous, Rational Recovery, or
intravenous); and (d) a broad range of abusing some other self-help support group.
individuals representing every social class, eth- • Cognitive-behavioral treatment includes a
nicity, educational level, and profession. combination of treatment strategies to change
The past few decades have witnessed sub- habitual patterns of thoughts and behaviors.
stantial improvement in treating substance Counterconditioning techniques, including re-
abusers and a more differentiated view of the laxation training and cue extinction; thought-
critical differences and similarities across the stopping and countering techniques; skills
various substances. Although interventions for training for affect management, assertive-
alcohol, nicotine, and illegal drugs have been de- ness, and interpersonal interactions; efficacy-
veloped in parallel and not with a collaborative enhancing exercises; and relapse-prevention
treatment development strategy, there is today training, including recognizing cues and
an increasing level of communication and cross- triggers, teaching drink and drug refusal
fertilization. There is also a growing realization skills, encouraging changes in the social en-
that substance abuse is a biobehavioral problem vironment, and coping with expectancies and
and that both pharmacological and psychosocial triggers that promote relapse, are all stan-
interventions are needed to adequately address dard components in the cognitive-behavioral
the problem and promote effective change. Psy- treatment of substance abuse (Montt, Rad-
chosocial treatments and treatment matching den, Rohsenow, Cooney & Abrams, 2002;
are the focus of this chapter. Rotgers, Keller, & Morgenstern, 2003).
• Cognitive therapy for substance abusers is a
recent adaptation of the cognitive therapy ap-
TREATMENT APPROACHES proaches (Beck, Wright, Newman, & Liese,
1993) specifically to treat alcohol and drug
A variety of psychosocial treatments and treat- abuse clients. These approaches typically fo-
ment modalities have been applied to substance cus on changing the beliefs, thoughts, and ex-
abuse problems (Onken & Blaine, 1990; Mc- pectations that appear to underlie both the
Crady & Epstein, 1999; Miller & Heather, use of the substances and the difficulties in
1998). Among the most popular are the follow- changing or quitting the substance abuse, in-
ing: cluding enduring withdrawal symptoms and
craving.

263
264 part iii • individual psychotherapy and treatment

• Couples, family, and social network thera- community model. Often they employ psy-
pies: Since the spouse and significant others chological principles, including counter-
play a role in abuse as either collaborators or conditioning, reinforcement management,
critics, this approach focuses on the mutual and relapse prevention.
interactions and how to change these interac- • Stage-based methods: Since most substance
tions in order to facilitate change (McCrady abusers are not ready to change their be-
& Epstein, 1999). These approaches have havior, action-oriented interventions have
brought into the treatment spouses, friends, low levels of success. Viewing treatment as
family members, colleagues, ministers, and involving movement through a series of se-
so forth in order to support the substance quential steps and attempting to increase
abuser in the process of change. motivation prior to offering action-oriented
• Behavior-focused treatments entail chang- interventions, like skills training and re-
ing the reinforcements and contingencies as- lapse prevention, is becoming a common ap-
sociated with the substance use. They have proach among treatment providers (Di-
been incorporated into what has been called Clemente, 2003; Prochaska, DiClemente, &
a community reinforcement approach, which Norcross, 1992).
attempts to increase the positive reinforcers • Court-mandated treatment: Many judges
associated with work, social networks, and and probation officials are referring many
personal functioning in order to change the clients as a condition of their probation for
environment of the drug abuser (Rotgers, offenses that involve substance abuse. Man-
Keller, & Morgenstern, 2003). Token econ- dated treatment increases the numbers of in-
omies and offering rewards or punishments dividuals who come to treatment but rarely
contingent on not engaging in the drug produces internal motivation for change.
abuse have often been used quite effectively • Relapse prevention and recycling treat-
to achieve short-term change but have had ments: Relapse, or a return to the problem-
difficulty maintaining that change after the atic behavior, is frequent with addictive be-
contingencies are removed. haviors. In fact, most clients experience mul-
• Motivational interventions: Motivational tiple relapses and quitting attempts as they
interviewing strategies developed by Miller recycle through the process of change before
and Rollnick (2002) use motivation and achieving sustained change. Most treatment
decision-making to deal with the ambiva- programs have a specific component devoted
lence and resistance often associated with to relapse prevention that usually employs
changing an addictive behavior. However, the cognitive-behavioral strategies (Marlatt
confrontation is notably absent in this moti- & Gordon, 1985).
vational approach. Instead, personal respon-
sibility for the behavior change is empha-
sized, and the clinician offers feedback and TREATMENT MATCHING
advice in the context of an empathic, listen-
ing, and reflective style. Over the past 30 years, psychologists have as-
• 12-step approaches, which are based on the sumed that the extensive heterogeneity in sub-
principles of Alcoholics Anonymous and stance abusers necessitated differentiation in
usually include attendance at AA or similar treatment. Many hypothesized that clients
meetings, are very common in most commu- with certain characteristics (e.g., antisocial per-
nity treatment programs. They have been sonality, cognitive impairment, levels of cogni-
incorporated into numerous comprehensive, tive complexity, severity of dependence) would
medically oriented treatment approaches, in- respond differently to different types of treat-
cluding detox and inpatient programs. ments either to increase or to decrease the effi-
• Residential treatment settings offer psy- cacy of that treatment approach. This matching
chosocial rehabilitation based on either a hypothesis, which assumes a client attribute by
12-step or a more confrontive therapeutic treatment interaction (ATI), has been explored
 54 • treatment matching in substance abuse 265

both in educational settings and in treatment term drinking outcomes if they received a
programs. Although a number of individual 12-step approach and attend AA.
studies have supported the matching hypothe-
sis, they are typically small-N studies that of- Project MATCH studied a more static con-
ten found matching post hoc. ceptualization of treatment matching, relying
In the largest single trial of psychosocial on the assumption that a single characteristic
treatments of its kind, the National Institute on would interact with one type of treatment to
Alcohol Abuse and Alcoholism and a large produce better outcomes. If the process of
group of senior addiction investigators exam- change is a dynamic one represented by stages
ined the question of treatment matching of change, a static model as a basis for matching
through Project MATCH (Babor & DelBoca, would not be the most appropriate model, since
2003; Project MATCH Research Group, 1993, the individual engaged in changing a behavior
1997). Do certain patient characteristics in- represents a moving target and not a static en-
teract with certain types of treatments to pro- tity (DiClemente, 2003). Some data indicate
duce differential outcomes? This randomized, that, when treatments are targeted at the stages
clinical trial yielded several important find- change in a more dynamic type of matching,
ings: these interventions can be more effective. How-
ever, this requires complex individualization of
1. Compliance of alcohol-dependent clients the treatment process. Newer technologies, in-
with all three of the individual treatments cluding computer-generated feedback, make it
(cognitive-behavioral, 12-step facilitation, possible to create more individualized interven-
and motivational enhancement) was substan- tions that can target shifting client decisional
tial, with patients receiving on average two considerations, current coping activities, levels
thirds of the prescribed treatment dose over of self-efficacy to abstain or refrain from the
a 12-week period. substance, and psychosocial risk factors. Early
2. There were dramatic changes in drinking indications suggest that this more dynamic,
from pre- to posttreatment, with few differ- process-oriented type of matching can aid the
ences in outcomes among the treatments. delivery and outcome of efforts to promote suc-
Although there was no treatment control cessful, sustained behavior change among sub-
comparison to definitively test for treatment stance abusers (DiClemente & Prochaska, 1998;
effects, the changes in drinking were sig- Prochaska, DiClemente, Velicer, & Rossi, 1993).
nificant and were well sustained throughout
the 12 months posttreatment and even ex-
tending out to 39 months posttreatment. PRACTICAL SUGGESTIONS
Three years after treatment there continued FOR TREATMENT
to be dramatic differences from the pretreat-
ment level of drinking. Although there are only minimal data for spe-
3. There was only minimal support for the pri- cific treatment matching to client characteris-
mary treatment matching hypotheses tested tics, current research does yield the following
in this study, so that individuals could be as- suggestions:
signed to any of these treatments with little
difference in outcome. 1. There is significant co-occurrence of alcohol
4. There were two interesting treatment by and drug problems with many psychiatric
characteristics interactions. Outpatients with syndromes. Screening for alcohol or drug
higher levels of anger had better drinking abuse and dependence should be included in
outcomes when treated with a motivational clinical intake procedures and both problems
enhancement approach rather than either addressed.
cognitive-behavioral or 12-step approaches. 2. Individuals currently experiencing serious
Outpatients living in environments with withdrawal symptoms or those who have
more extensive drinking had better long- had indications of delirium tremens (alcohol)
266 part iii • individual psychotherapy and treatment

or another drug-related organic brain syn- stance abuse infested environments with 12-
drome need supervised detoxification from step and self-help support systems make
alcohol or drugs prior to psychosocial treat- clinical sense and should be incorporated in
ment. treatment planning.
3. Individuals with intact marriages and a
spouse willing to attend treatment do better
References, Readings, & Internet Sites
with some behavioral marital therapy.
4. Individuals with multiple psychosocial prob- Babor, T., & DelBoca, F. (Eds.). (2003). Project MATCH:
lems, including financial, social, housing, and The book. Cambridge University Press.
occupational, do better when given access to Beck, A. T., Wright, F. D., Newman, C. F., & Liese,
multiple services or treatments addressing B. S. (1993). Cognitive therapy of substance
these problems in addition to the psychoso- abuse. New York: Guilford Press.
Brown, T. (Ed.) (1995). Treating alcoholism. San
cial treatment of the drinking or drug prob-
Francisco: Jossey-Bass.
lems. Concurrent interventions, as in the DiClemente, C. C. (2003). Addiction and change:
community reinforcement approach or social How addictions develop and addicted people
network therapy, are recommended. change. New York: Guilford Press.
5. Brief interventions consisting of 30 – 60 DiClemente, C. C., & Prochaska, J. O. (1998). To-
minutes of discussion and advice appear to ward a comprehensive, transtheoretical model
produce significant change in drinking and of change. In Miller and Heather (Eds.), Treat-
possibly drug use. At minimum, practition- ing addictive behaviors (2nd ed., pp. 3 –24).
ers should offer some brief intervention of New York: Plenum Press.
feedback and advice to everyone who screens Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Re-
positive for alcohol or drug abuse and de- lapse prevention: Maintenance strategies in
the treatment of addictive behaviors. New
pendence.
York: Guilford Press.
6. Intensity of treatment appears to have little McCrady, B. S., & Epstein, E. E. (Eds.). (1999). Ad-
relation to treatment outcome for a broad dictions: A comprehensive guidebook. New
range of individuals with alcohol problems. York: Oxford University Press.
Engagement and retention of individuals in Miller, W. R., & Heather, N. (Eds.). (1998). Treating
treatment appear to be the most important addictive behaviors (2nd ed.). New York:
dimensions. Offering choice and engaging Plenum Press.
the client in the treatment are important Miller, W. R., & Rollnick, S. (2002). Motivational
strategies with substance abusers. interviewing: Preparing people to change ad-
7. Motivation to change the substance use is an dictive behavior. New York: Guilford Press.
important dimension to consider in designing Monti, P. M., Kadden, R. M., Rohsenow, D. J.,
Cooney, N. L., & Abrams, D. B. (2002). Treat-
treatments. Clients with low motivation
ing alcohol dependence (2nd ed.). New York:
need interventions that acknowledge the Guilford Press.
client’s perspective and are proactive in keep- National Institute of Alcohol Abuse. (n.d.). Home
ing the client in treatment. Confrontation page. Retrieved 2004 from http://www.niaa.gov
appears to increase defensiveness and denial. National Institute of Drug Abuse. (n.d.). Home
8. There is a crucial role for behavioral and psy- page. Retrieved 2004 from http://www.nida.gov
chosocial interventions to be given in con- Onken, L. S., & Blaine, J. D. (Eds.). (1990). Psy-
junction with pharmacological treatments chotherapy and counseling in the treatment of
such as nicotine replacement, naltrexone or drug abuse (NIDA Research Monograph 104,
other drugs used to reduce craving for opi- DHHS Publication No. ADM 90-1172). Wash-
ates and alcohol, and disulfiram and other ington, DC: Superintendent of Documents.
Prochaska, J. O., DiClemente, C. C., & Norcross,
drugs used as antagonists for alcohol and
J. C. (1992). In search of how people change:
other drugs (Volpicelli, Pettinati, McLellan, Applications to addictive behaviors. American
& O’Brien, 2001). Psychologist, 47, 1102–1114.
9. Matching patients high in anger with moti- Project MATCH Research Group. (1993). Project
vational approaches and those living in sub- MATCH: Rationale and methods for a multi-
 55 • motivational interviewing 267

site clinical trial matching alcoholism patients O’Brien, C. P. (2001). Combining medication
to treatment. Alcoholism: Clinical and Experi- and psychosocial treatments for addictions:
mental Research, 17, 1130 –1145. The BRENDA approach. New York: Guilford
Project MATCH Research Group. (1997). Matching Press.
alcoholism treatments to client heterogeneity:
Project MATCH posttreatment drinking out-
comes. Journal of Studies on Alcohol, 58, 7 –
Related Topics
29.
Rotgers, F., Keller, D. S., & Morgenstern, J. (Eds.). Chapter 16, “Identification and Assessment of Alco-
(2003). Treating substance abuse: Theory and hol Abuse”
technique. New York: Guilford Press. Chapter 46, “Stages of Change: Prescriptive Guide-
Substance Abuse and Mental Health Services Ad- lines”
ministration. (n.d.). Home page. Retrieved Chapter 55, “Motivational Interviewing”
2004 from http://www.samshsa.gov Chapter 74, “Guidelines for Relapse Prevention”
University of Maryland, Baltimore County. (n.d.). Chapter 96, “Common Drugs of Abuse”
Habits Lab home page. Retrieved 2004 from Chapter 100, “Facilitating Client Involvement in
http://www.umbc.edu/psych/habits Self-Help Groups”
Volpicelli, J. R., Pettinati, H. M., McLellan, A. T., &

MOTIVATIONAL
55 INTERVIEWING

William R. Miller & Theresa B. Moyers

Psychotherapists are usually trained in how to Motivational interviewing (MI) was designed
work with people who want to change, but are specifically to help psychotherapists work with
less often prepared to help people want to change. clients who are less ready for change. Origi-
People who seek treatment are often ambivalent nally developed to address substance use disor-
about change: they want it, and they don’t. Ther- ders, MI is now used to enhance motivation for
apists sometimes dismiss clients who seem insuf- change in a wide array of health behaviors. It
ficiently motivated, inviting them to return when is defined as a client-centered, yet directive
they are ready for change. Particularly in ad- method for evoking intrinsic motivation to
dressing addictive behaviors or criminal offenses, change (Miller & Rollnick, 2002). Ambivalence
it has been common in the United States to use is understood as a normal stage in the process of
heavy-handed confrontational, punitive, or coer- change (Prochaska, DiClemente, & Norcross,
cive strategies in order to provide extrinsic mo- 1992), and MI seeks to resolve ambivalence in
tivation for change. Faced with such pressure to the direction of commitment to change. For
change, the typical human response is resistance, clients who perceive little or no need for
which in turn decreases the likelihood of long- change, the initial goal of MI is usually to de-
term behavior change (Brehm & Brehm, 1981; velop discrepancy (ambivalence) that is then re-
Miller, Benefield, & Tonigan, 1993). solved toward change.
268 part iii • individual psychotherapy and treatment

FOUR GUIDING PRINCIPLES upon his or her own particular strengths and
resources. The motivational interviewer is a
MI is not a technique so much as a method of consultant, offering options that clients may
psychotherapy. The underling spirit of MI is not have considered from a broad menu of
collaborative, evocative, and respectful of client change strategies, and particularly eliciting
autonomy (Miller & Rollnick, 2002). The col- clients’ own ideas.
laborative aspect involves a companionable
partnership of client and counselor, de-empha-
sizing power differentials. The therapist avoids TWO PHASES
an expert or authoritarian role, instead regard-
ing clients as experts on themselves. Informa- It is helpful to think of MI as occurring in two
tion and advice is provided when requested, but phases. The first phase focuses on evoking in-
primary emphasis is on evoking the client’s trinsic motivation by having the client give
own intrinsic motivation for change and per- voice to change talk — in essence, arguments
spectives on how to achieve it. The clients’ au- for change. Four types of change talk are distin-
tonomy and ability to choose their own life guishable, memorable by the acronym DARN:
course are emphasized.
Four principles guide the practice of MI, as • Desire. Why and in what ways does the
follows: client want to change?
• Ability. Why and how would the client be
1. Express empathy. MI is heavily rooted in a able to change, should she choose to do so?
client-centered style of counseling, as for- • Reasons. What are some reasons for change,
mulated by Carl Rogers (1980) and his asso- from the client’s perspective?
ciates. Therapeutic empathy, acceptance, and • Need. Why and in what ways is it important
respect are communicated through the use for the client to make a change?
of reflective listening to attain accurate un-
derstanding of the client’s own perspectives. Giving voice to such change talk moves the
Accurate empathy is a foundational skill, client along toward voicing commitment to
without which MI proficiency cannot be change, which is the focus of the second phase
achieved. of MI. Timing is important here. The therapist
2. Develop discrepancy. The MI therapist helps needs a sense for when the client is developing
clients to recognize the discrepancy between the intention to change, and at this point shifts
their current behavior and their important toward evoking a specific plan for implement-
goals or values. This is done primarily by ing change and commitment to carry it out. If
having the client, rather than the therapist, the therapist shifts prematurely to phase two,
give voice to the reasons for change. Clients resistance occurs and the therapist returns to
literally talk themselves into changing. phase one strategies for further evoking intrin-
3. Roll with resistance. “Resistance” is under- sic motivation.
stood simply as clients voicing the status
quo side of their ambivalence. The therapist
avoids arguing, pushing against, or con- OARS AND THE DIRECTIVE
fronting such resistance, which only tends to ASPECT
entrench it. Instead, the therapist responds
in ways that diffuse resistance and direct the Four specific skills are particularly emphasized
client back toward intrinsic motivation for for fostering client safety, acceptance, and
change. change, represented by the acronym OARS:
4. Support self-efficacy. Finally, the therapist ac-
tively conveys the message that the client is 1. Open questions. The psychotherapist asks
capable of change. The client is the expert in open-ended questions intended to evoke
solving the problem, and the therapist draws change talk (desire, ability, reasons, need).
 55 • motivational interviewing 269

Relatedly, the therapist avoids asking ques- THERAPEUTIC USES OF

tions the answer to which would be argu- MOTIVATIONAL INTERVIEWING
ments for the status quo (e.g., “Why haven’t
you . . . ?” or “What keeps you from . . .?”). There are at least three general therapeutic ap-
With a well-crafted open question, the an- plications of MI. First, it has been used early in
swer is change talk. or as a prelude to treatment in order to enhance
2. Affirmation. The therapist emphasizes and client motivation for change. Clinical trials in-
affirms the client’s strengths, efforts, abili- dicate that an initial session at the beginning of
ties, and steps in the right direction. treatment can enhance retention, adherence,
3. Reflective listening. Again, the Rogerian and motivation for treatment. In substance-
skill of accurate empathy is crucial, manifest abuse randomized trials, these effects have been
in skillful reflective listening that helps the reflected in a doubling, on average, of absti-
client to continue exploring and experienc- nence rates following treatment. When added
ing the current dilemma. to other treatment approaches, MI appears to
4. Summaries. As the client offers arguments have a synergistic effect on outcomes.
for change, the therapist provides periodic Second, MI has been used as a stand-alone
summaries in which change talk statements brief intervention. A single session of MI has
are drawn together. In essence, the therapist been found to be effective in triggering signifi-
collects each change-talk theme like a flower, cant change relative to no treatment or place-
and then offers them back to the client in ment on a waiting list. If there is a waiting list,
ever larger bouquets. clients are likely to fare much better if given a
single session of MI than if simply left to wait
These four skills are used in a consciously for treatment. MI has also been used for oppor-
directive manner to promote and reinforce tunistic interventions, where a problem is de-
change talk. The therapist first and foremost tected for which the person was not initially
evokes clients’ own motivations for change. seeking help. For example, patients seeking
Clients, of course, hear themselves voice these health care can be screened for alcohol abuse,
arguments for change. Next, they hear the and MI can be used as a brief intervention
therapist affirm and reflect their change talk, in within the context of primary health care.
essence emphasizing and reinforcing it. Then Third, MI can be integrated into other treat-
they hear their change statements yet again, ments. The overall style of MI can be used by
collected into summaries. the therapist even when the specific focus on
In essence, MI involves the selective and reducing ambivalence is no longer necessary.
strategic use of OARS with the goal that clients Maintaining the supportive-directive style of
will talk themselves into change. The therapist MI may help to minimize client resistance. Fur-
asks particular open questions, selectively re- thermore, it is not uncommon to encounter
flects change talk, affirms movement in the ambivalence and resistance later in treatment,
hoped-for direction, and selectively summa- as therapy progresses and new challenges are
rizes the clients’ own motivations for change. It encountered. In this circumstance the therapist
is here that MI evolves from Rogers’s concep- can augment the MI style with specific inter-
tion of client-centered therapy as nondirective ventions to elicit and reinforce commitment
by providing specific guidelines for strategi- language, thereby delivering the complete method
cally responding in a directive manner in order as it is needed. As ambivalence resolves and re-
to evoke the client’s own arguments for change. sistance fades, the therapist can return to the in-
An analogy for MI is that of ballroom dancing: tended therapeutic approach, dancing back and
one moves smoothly with the partner, but is forth between the elements of MI and other
also leading in a particular direction. methods. One of the best examples of combin-
ing MI with other methods is found in Motiva-
tional Enhancement Therapy (MET). Here, MI
is combined with objective and personalized
270 part iii • individual psychotherapy and treatment

feedback in a structured, four-session interven- of MI in clinical trials include increased diabetic

tion originally used in Project MATCH (Miller, glucose self-monitoring, keeping of food diaries
Zweban, DiClemente, & Rychtarik, 1992). in a weight-loss program, and decreased salt in-
take in treatment for hypertension.

EVIDENCE OF EFFICACY
Outcomes
More than 60 randomized clinical trials of MI As intended, MI has also been shown to pro-
have been published. The CD that accompanies mote positive changes in health behaviors.
this volume contains a PowerPoint file offering Evaluations of MI in the treatment of abuse
summaries of many of these studies. Space here disorders have shown significant improvement
permits only a summary of what is known on a broad range of outcome measures includ-
about the efficacy of MI to date. Recent sum- ing total abstinence, frequency, and volume of
maries of outcome research on MI (Burke, alcohol use and alcohol problems. Reductions in
Arkowitz, & Dunn, 2002; Miller, in press) sug- illicit drug use have been reported for mari-
gest that MI is useful at various points along juana, stimulants, heroin, and polydrug abuse.
the treatment continuum, although specific Studies of other health behaviors have reported
mechanisms of effectiveness have not yet been significant treatment effects of MI in dietary
identified. change, smoking cessation, use of water purifi-
cation, and decreased incidence of unprotected
sexual intercourse.
Client Motivation
First, there is evidence that MI does what it was
Amplification of Treatment Effects
intended to do: increase motivation for change.
In one study, patients in an inpatient substance- As discussed above, MI has often been shown
abuse treatment center were randomly assigned to enhance the efficacy of treatment programs
to receive or not receive one MI session at in- to which it has been added. Significantly im-
take. Ward staff unaware of group assignment proved outcomes have been reported when MI
reliably rated patients who had received a has been added to cognitive-behavior therapy,
preparatory MI session as more cooperative, disease-model treatment for alcoholism, dia-
punctual, and working harder in treatment, and betes management, cardiovascular rehabilita-
as more likely to remain sober. MI has been tion, and dietary counseling. In the treatment
shown to yield higher rates of client change talk of substance-use disorders, the magnitude of ef-
and commitment to change, and to promote fect has been found in several studies to be a
advancement through one or more stages of doubling of abstinence rates for the same treat-
change. ment program with versus without an initial
MI session.
Retention and Adherence
References, Readings, & Internet Sites
There is published evidence that MI can in-
crease retention in treatment, as well as behav- Brehm, S. S., & Brehm, J. W. (1981). Psychological
reactance: A theory of freedom and control.
ioral adherence to specific change regimens.
New York: Academic Press.
Studies have supported the effectiveness of MI
Burke, B. L., Arkowitz, H., & Dunn, C. (2002). The
in increasing attendance in outpatient sub- efficacy of motivational interviewing and its
stance-abuse treatment sessions for both ado- adaptations: What we know so far. In W. R.
lescents and mandated adult offenders. Other Miller & S. Rollnick, Motivational interview-
trials have reported increased retention in ing: Preparing people for change (2nd ed., pp.
methadone maintenance, cocaine detoxification, 217 –250). New York: Guilford Press.
treatment for dual disorders, and aftercare at- Holder, H. D., Cisler, R. A., Longabaugh, R., Stout,
tendance. Measures showing significant effects R. L., Treno, A. J., & Zweben, A. (2000). Alco-
 56 • anxiety/anger management training 271

holism treatment and medical care costs from tional Institute on Alcohol Abuse and Alco-
Project MATCH. Addiction, 95, 999 –1013. holism.
Miller, W. R. (1983). Motivational interviewing with Motivational Interviewing Network of Trainers.
problem drinkers. Behavioural Psychotherapy, (n.d.). Resources for clinicians, researchers, and
11, 147 –172. trainers. Retrieved 2004 from http://www.
Miller, W. R. (2000). Rediscovering fire: Small inter- motivationalinterview.org
ventions, large effects. Psychology of Addictive Prochaska, J. O., DiClemente, C. C., & Norcross, J. C.
Behaviors, 14, 6 –18. (1992). American Psychologist, 47, 1102–1114.
Miller, W. R. (in press). Motivational interviewing in Rogers, C. R. (1980). A way of being. Boston:
the service of health promotion. American Jour- Houghton Mifflin.
nal of Health Promotion. Rollnick, S., Mason, P., & Butler, C. (1999). Health
Miller, W. R., Benefield, R. G., & Tonigan, J. S. behavior change: A guide for practitioners.
(1993). Journal of Consulting and Clinical Psy- New York: Churchill Livingstone.
chology, 61, 445 – 461. Rollnick, S., & Miller, W. R. (1995). What is moti-
Miller, W. R., & Rollnick, S. (2002). Motivational in- vational interviewing? Behavioural and Cogni-
terviewing: Preparing people for change (2nd tive Psychotherapy, 23, 325 –334.
ed.). New York: Guilford Press.
Miller, W. R., Zweban, A., DiClemente, C. C., &
Related Topics
Rychtarik, R. (1992). Motivational enhance-
ment therapy manual: A clinical research guide Chapter 74, “Guidelines for Relapse Prevention”
for therapists treating individuals with alcohol Chapter 121, “A Model for Clinical Decision Mak-
abuse and dependence. (Project MATCH Mono- ing With Dangerous Patients”
graph Series: Volume 2). Rockville, MD: Na-

ANXIETY/ANGER
56 MANAGEMENT
TRAINING

Richard M. Suinn

Anxiety and stress present major concerns for Anger is now being recognized as another
the general population. Primary care practition- crucial problem area. Severe angry episodes are
ers report that anxiety ranks next highest as the experienced by as high as 20% of the popula-
major reason patients see their physicians. Anx- tion. Anger is the source of varied social and
iety can be at the core of various disorders: personal problems:

• Generalized anxiety disorder or phobic dis- • Child or family abuse

orders • Physical or verbal assault
• The blocking of coping behaviors, healthy • Community property damage
lifestyles, educational attainment, or success- • Disruption of work performance
ful performance • Interference with health and the immune
• Biomedical consequences system
272 part iii • individual psychotherapy and treatment

Developed in the 1970s, Anxiety Manage- HOW TO CONDUCT SESSIONS

ment Training (AMT) was designed as a brief
intervention for anxiety (Suinn, 1990, 1995). Among the basic or core characteristics of the
Since then, empirical results have proved its ap- AMT method are the following:
plication for anger. It is a six- to eight-session
structured procedure that trains patients in us- • Guided imagery for anxiety or anger arousal
ing relaxation to deactivate anxiety or angry • Relaxation for deactivating the arousal
emotional states. • Practice for self-control
• Homework for generalization

APPLICATIONS: EMPIRICAL The guided imagery involves use of anxiety or

VALIDATION anger imagery from the patient’s experience to
precipitate arousal. Anxiety or anger arousal is
Empirical results confirm the value of AMT for precipitated during the sessions in order to aid
the following: the client in the use of relaxation to reduce an
actual experience of anxiety or anger. Thus, the
• Generalized anxiety disorder (Durhan et al., client can first practice controlling his or her
1994 anxiety in the safe setting of the treatment en-
• Mathematics anxiety (Suinn & Richardson, vironment, prior to being assigned homework
1971) in real-life applications. AMT covers six to
• Essential hypertension (Jorgensen, Houston, eight sessions.
& Zurawski, 1981) Session 1 involves relaxation training using
• Diabetes (Rose, Firestone, Heick, & Faught, the standard Jacobsen tension/relaxation method
1983) (1938) or biofeedback.
• Dysmenorrhea (Quillen & Denney, 1982) Session 2 involves identification of an anxi-
• Depression (Cragan & Deffenbacher, 1984; ety (or anger scene for anger treatment), relax-
Jannoun, Oppenheimer, & Gelder, 1982) ation, and anxiety (or anger arousal) followed
• Type A characteristics (Hart, 1984; Nakano, by relaxation. The anxiety (anger) scene in-
1990) volves a real experience that has been associated
• Anger (Deffenbacher, Filetti, Lynch, Dahlen, & with a moderately high level of anxiety (anger).
Oetting, 2002; Suinn & Deffenbacher, 1988) After the client is relaxed, anxiety (anger)
• Removing anxiety blocking patient’s ability arousal is initiated through the therapist’s in-
to respond to traditional psychotherapy (Van struction to switch on this scene and use it to
Hassel, Bloom, & Gonzales, 1982) reexperience anxiety (anger). Instructions in-
clude description of both scene-setting and anx-
iety (anger)–arousal details to aid in arousal.
ADVANTAGES OF AMT After about 10 –15 seconds of exposure, the
scene is terminated and the therapist reintro-
A major advantage of AMT is the fact that it is duces the relaxation.
a brief therapy using a self-control approach Session 3 follows the steps used in session 2,
that permits generalization. Moreover, because with the addition of self-initiated relaxation and
the procedure is structured, it is possible to de- attention to the client’s personal signs asso-
termine progress at each session and to deter- ciated with anxiety (anger). This might in-
mine the need for additional or fewer sessions. volve symptoms such as heightened respira-
The step-by-step characteristics of AMT also tion, clenched fists, catastrophic thoughts, and
allow monitoring of gains from session to ses- so on. After the client obtains arousal, the ther-
sion. Such concrete information can be most apist instructs the client to pay attention to the
useful for the practitioner who wishes to care- anxiety (anger) symptoms. The following in-
fully monitor progress or for the researcher structions are given: “Pay attention to how you
who wishes to study variables involved in change experience anxiety [anger]; perhaps it is in body
from each session. signs such as your hands or neck tensing, or
 56 • anxiety/anger management training 273

your heart rate, or in some of your thoughts.” Hart, K. (1984). Stress management training for
Then relaxation is again retrieved, with the Type A individuals. Journal of Behavioral Med-
therapist taking responsibility for guiding the icine, 12, 133 –140.
relaxation. This cycle of arousal, attention to Jacobsen, E. (1938). Progressive relaxation. Chicago:
University of Chicago Press.
anxiety (anger) signs, and retrieval of relax-
Jannoun, L., Oppenheimer, C., & Gelder, M. (1982).
ation is continued to the end of the hour—a cy-
A self-help treatment program for anxiety
cle of about three to five repetitions. state patients. Behavior Therapy, 13, 103 –111.
Session 4 adds two new major components. Jorgensen, R., Houston, B., & Zurawski, R. (1981).
First, a high-intensity anxiety (or anger) scene Anxiety management training in the treatment
is identified. During this session, this scene will of essential hypertension. Behavior Research
be alternated with the moderate-level scene and Therapy, 19, 467 – 474.
used in sessions 2 and 3. Second, the session re- Nakano, K. (1990). Effects of two self-control proce-
quires the client to assume more responsibility dures on modifying Type A behavior. Journal
for regaining self-control after anxiety (anger) of Clinical Psychology, 46, 652– 657.
arousal. Instead of the therapist terminating the Pantalon, M. V., & Motta, R. W. (1998). Effectiveness
of anxiety management training in the treat-
anxiety (anger) scene and reinitiating the re-
ment of posttraumatic stress disorder: A prelim-
laxation, the client decides when to end the anx-
inary report. Journal of Behavior Therapy and
iety (anger) scene and takes responsibility for Experimental Psychiatry, 29, 21–29.
relaxation retrieval. Quillen, M. A., & Denney, D. R. (1982). Self-control
Session 5 completes the fading out of thera- of dysmenorrheic symptoms through pain man-
pist control and the completion of client self- agement training. Journal of Behavior Therapy
control. At the start of the session, the client and Experimental Psychiatry, 13, 123 –130.
self-initiates relaxation, signaling its achieve- Rose, M., Firestone, P., Heick, H., & Faught, A.
ment. Although the therapist switches on the (1983). The effects of anxiety management train-
anxiety (anger) scene, all activities from this ing on the control of juvenile diabetes mellitus.
point are client controlled. Journal of Behavioral Medicine, 27, 381–395.
Shoemaker, J. (1976). Treatment for anxiety neuro-
Sessions 6–8 repeat the session 5 format un-
sis. Unpublished doctoral dissertation, Col-
til self-control appears complete. New anxiety
orado State University, Ft. Collins.
(anger) scenes may be employed as needed to Suinn, R. (1990). Anxiety management training: A
increase generalization. behavior therapy. New York: Plenum Press.
Suinn, R. (1995). Anxiety management training. In
References & Readings K. Craig & K. Dobson (Eds.), Anxiety and de-
pression in adults and children (pp. 159 –179).
Cragan, M. K., & Deffenbacher, J. L. (1984). Anxiety Thousand Oaks, CA: Sage.
management training and relaxation as self- Suinn, R., & Deffenbacher, J. (1988). Anxiety man-
control in the treatment of generalized anxiety agement training. Counseling Psychologist,
in medical outpatients. Journal of Counseling 16, 31– 49.
Psychology, 1, 123 –131. Suinn, R., & Richardson, F. (1971). Anxiety man-
Deffenbacher, J. (1994). Anger reduction: Issues, as- agement training: A non-specific behavior
sessment, and intervention strategies. In A. therapy program for anxiety control. Behavior
Siegman & T. Smith (Eds.), Anger, hostility, Therapy, 2, 498 – 512.
and the heart (pp. 239 –269). Hilsdale, NJ: Van Hassel, J., Bloom, L. J., & Gonzales, A. C.
Lawrence Erlbaum. (1982). Anxiety management training with
Deffenbacher, J., Filetti, L., Lynch, R., & Oetting, E. schizophrenic outpatients. Journal of Clinical
(2002). Cognitive-behavioral treatment of high Psychology, 38, 280 –285.
anger drivers. Behaviour Research and Ther-
apy, 40, 895 –910.
Durhan, R., Murphy, T., Allan, T., Richard, K., Tre- Related Topics
living, L. R., & Fenton, G. W. (1994). Cognitive Chapter 79, “Treating High-Conflict Couples”
therapy, analytic psychotherapy, and anxiety Chapter 121, “A Model for Clinical Decision Mak-
management training for generalized anxiety ing With Dangerous Patients”
disorder. British Journal of Psychiatry, 165,
315 –323.
 PSYCHOLOGICAL
57 INTERVENTIONS IN ADULT
DISEASE MANAGEMENT

Carol D. Goodheart

Chronic illnesses are now the primary cause of cording to theoretical orientation, population,
disability and death in the United States, a setting, and emphasis. Among the diverse ap-
change from the acute conditions of the past. proaches, however, there are common themes
Over a 25-year span, the number of people with for the clinician (Goodheart & Lansing, 1997).
chronic conditions will increase by 35 million, 1. Obtain medical information: Clinicians
from 99 million in 1995 to 134 million in 2020 need not become medical experts, but they
(Institute for Health and Aging, 1996). The must obtain sufficient background to under-
chronic illnesses form a spectrum of diseases; stand the choices, treatments, and experiences
they may be life-threatening, progressive, of the adult with a chronic condition. Collabo-
manageable, unpredictable, or of known or un- ration with the patient’s physician can provide
known etiology. Such illnesses include cancer, information on the outcome, process, etiology,
cardiovascular disease, diabetes, asthma, arthri- and management needs of a particular disease
tis, HIV disease, Alzheimer’s disease, postviral (the acronym OPEN makes the list easy to re-
syndromes, and gastrointestinal disorders, member). Other important medical resources
among many others. are available through the Internet, medical ref-
Behavior, genetics, and the environment in- erence libraries, federal and state government
teract to produce or prevent disease. The Hu- health agencies (on-line, mail, and facsimile
man Capital Initiative (1995) reports the state transmissions), and specific disease organiza-
of the psychological research agenda on health tions such as the American Cancer Society, the
and behavior, which fosters the understanding American Diabetes Association, and the Amer-
of basic processes necessary for the prevention ican Heart Association. The Merck Manual of
and treatment of chronic illness. Once disease is Diagnosis and Therapy (Beers & Berkow, 1999)
present, symptomatology may be affected by provides a medical overview of most conditions
behavior, cognition, emotion, and interpersonal a clinician will encounter and is searchable via
dynamics. Overall, the application of psycho- the Internet (http://www.merck.com/pubs/
logical interventions to disease management re- mmanual/). Perhaps the most valuable and
sults in improvements in mental health func- comprehensive source of on-line medical infor-
tioning and reductions in medical service use mation is the National Institutes of Health
(Lechnyr, 1992; Pallak, Cummings, Dorken, & home page for health information (http://
Henke, 1994; Schlesinger, Mumford, Glass, www.health.nih.gov/). It is possible to search
Patrick, & Sharfstein, 1983). The following most health topics at this site and to gain access
summary highlights the key elements in the to MEDLINEplus, which is a health database
psychological treatment of adults with chronic maintained by NIH’s National Library of Med-
illnesses. icine, available in English and Spanish, and
There are many models of psychological in- Healthfinder, a health resource maintained by
tervention during illness, with variations ac- the Department of Health and Human Services.

274
 57 • psychological interventions in adult disease management 275

Links are provided for clinical studies, drug in- 4. Offer a menu of interventions: The se-
formation, library references, special programs, lection of interventions is based on the chang-
and other health agencies. ing needs and capacities of the chronically ill
2. Assess response to illness and psycholog- adult and the knowledge and skills of the clin-
ical status: The adult’s capacity to cope with ill- ician. Interventions may be directed toward
ness is affected by premorbid personality orga- prevention of further illness (e.g., smoking
nization, life stage roles and tasks, maturational cessation, weight control); toward screening
development, internal resources such as tem- for disease (e.g., decreasing the avoidance of
perament and intelligence, and external re- warranted HIV testing or mammograms); or
sources such as socioeconomic status, family toward management of disease. Disease man-
support, and level of access to health care. These agement interventions include the following:
factors are evaluated through clinical interview
and, in some situations, through specific stan- • Focused psychotherapy: A time-limited
dardized assessment measures/scales for de- approach to problem solving, based on
pression, anxiety, somatization, hostility, or biopsychosocial stressors and resources.
other relevant indices. • Decision making: Helping adults arrive at
3. Integrate theoretical orientation and ill- the best decisions for their personal cir-
ness: Cross-fertilization between and among cumstances from among the medical
differing schools of psychological theory often choices they are given.
occurs when clinicians work with chronically ill • Medical symptom reduction: Helping
adults. Dynamic clinicians add behavioral and adults decrease pain, lessen side effects of
educational components; cognitive clinicians add treatments (e.g., anticipatory nausea as-
inferred self- and relational components; family sociated with chemotherapy), or decrease
systems, feminist theory, humanistic, and eclec- frequency or intensity of acute episodes
tic clinicians add to the diversity. In general, (e.g., incidents of asthma exacerbation).
clinicians tend to borrow from other clinicians’ • Coping enhancement: Helping adults to
attitudes and techniques. Regardless of orienta- plan actively, elicit support, seek informa-
tion, the focus on coping with illness is en- tion, develop new habits, reduce anxiety,
hanced when clinicians understand the patient’s and facilitate mourning while preventing
global mastery-competence level and how the depression.
patient manages reality, affect, and anxiety, in- • Treatment adherence: Helping adults de-
terpersonal relationships, and cognitive func- velop motivation and overcome obstacles
tions. Examples of three treatment approaches to maintaining adherence to prescribed
with theoretically different underpinnings medical treatment regimens.
are Medical Family Therapy (McDaniel, Hep- • Stress and pain reduction: Helping adults
worth, & Doherty, 1992), a family systems ori- learn techniques of progressive relaxation,
entation; Managing Chronic Illness: A Bio- hypnosis, biofeedback, visualization, medi-
psychosocial Perspective (Nicassio & Smith, tation, or focused breathing.
1995), a cognitive-behavioral orientation; and • Interpersonal techniques: Helping adults
Treating People With Chronic Disease: A Psy- learn new or improved skills for commu-
chological Guide (Goodheart & Lansing, 1997), nication, assertion, and conflict resolution
a psychodynamic-pyschoeducational orienta- with medical personnel, family, partners,
tion. All three texts are based on a biopsychoso- employers, coworkers, friends.
cial model of understanding and intervention. • Adaptation: Helping adults make quality-
All recommend an interdisciplinary collabora- of-life adjustments to an altered reality
tive approach to health care and are appropriate due to the losses of illness, effects of med-
for community practice and medical settings. ications, aftereffects of medical treat-
Another key reference guide is Clinical Health ments, or disability.
Psychology in Medical Settings: A Practi- • Crisis management: Helping adults mo-
tioner’s Guidebook (Belar & Deardorff, 1995). bilize internal and external supportive re-
276 part iii • individual psychotherapy and treatment

sources to regain control, for use when the It is not possible within the limits of this
patient is flooded with affect and over- entry to detail the implementation of each in-
whelmed by anxiety and when the pa- tervention given. Even experienced clinicians
tient’s ability to cope on his or her own is may not be skilled in every type of interven-
compromised. tion listed above. For example, most clinicians
• Anger management: Helping adults con- are trained in graduate school to offer crisis
trol anger through the use of shame re- management, but few are trained to offer hyp-
duction, guided imagery, anger arousal nosis for pain management. For further train-
combined with relaxation, and through ing in specific modalities, clinicians may turn
improved self-efficacy in communication to appropriate postdoctoral continuing educa-
and problem solving. tion programs (e.g., the American Society for
• Nonverbal psychotherapeutic techniques: Clinical Hypnosis offers hypnosis training
Helping adults express affect and experi- throughout the United States). There is now a
ence through art therapy, sand play, or practical self-assessment model available to help
movement therapy. Rarely used alone, clinicians gauge their readiness to provide
these visual, tactile, motile techniques are chronic illness consultation and services (Belar
particularly useful in adults with learning et al., 2001). This resource provides multiple
disabilities, posttraumatic stress disorder, avenues for further study to develop and en-
or a blocked, regressed, dissociated, or hance skills.
concrete state of functioning. 5. Match the focus of intervention to the
• Family involvement: Helping the care- need: No single intervention is sufficient if used
givers, partners, and family members of exclusively. Individuals with chronic illness
adults with chronic illness by conjoint vary in their willingness or ability to make use
treatments and the development of coping of the strategies. Nevertheless, important over-
and support structures within the home lapping areas of need that represent common
care system. impediments to functioning have been identi-
• Support for self disease management: fied in chronically ill adults:
Helping adults contribute to their own
• Isolation, losses and dependency, fear of
well-being through self-selected adjunc-
death, confines of illness, lack of familiar-
tive activities (e.g., personal illness di-
ity with medical culture (Shapiro &
aries, exercise and nutrition programs
Koocher, 1996)
[within limits of medical recommenda-
• Separation, loss of key roles and auton-
tions], religious and spiritual participa-
omy and control, disruption of plans, as-
tion, humorous tapes and books).
sault on self-image and self-esteem, un-
• Referral: Helping adults decrease their
certain and unpredictable futures, dis-
isolation and increase the support network
tressing emotions (Turk & Salovey, 1995)
available to them through disease support
• Decreased self-esteem associated with
groups and community services.
body image changes, mourning associ-
• Handling uncertainty and fear of death:
ated with losses, negative affects asso-
Helping adults with the anxiety and de-
ciated with physical, psychological, and
pression that often accompany disease pro-
social discomfort (Goodheart & Lansing,
gression. The primary technique for death
1997)
anxiety is to listen fully, which may be dif-
ficult under severe and threatening circum- 6. Face the personal impact of working with
stances. To listen fully means to listen chronically ill adults: Clinicians have their own
without judgment, without withdrawal, idiosyncratic responses to the presence of dis-
without denial, and without interference to ease and to patients’ characterological reactions
the patient’s hopes. To listen fully is to be to disease. Entering into a therapeutic relation-
present, with the patient, in facing death. ship with a chronically ill adult carries special
challenges. Like everyone else, clinicians have
 57 • psychological interventions in adult disease management 277

deeply held personal attitudes toward bodily sponse to illness and psychological status, inte-
needs, functions, disfigurements, and pains and grating psychological theory and the illness, of-
toward caretaking and dependency. They have fering a varied selection of interventions, match-
personal fears about debilitation, decline, and ing the focus of intervention to the need, and
death. Working with ill patients often induces facing the personal impact of working with
countertransference reactions in clinicians, which chronically ill adults.
may be expressed as
• Anxiety (e.g., exposure to death, failure, References, Readings, & Internet Sites
vulnerability, or loss may stimulate anxi- Belar, C. D., Brown, R. A., Hersch, L. E., Hornyak,
ety) L. M., Rozensky, R. H., Sheridan, E. P., et al.
• Affect (e.g., anger may be a marker of (2001). Self-assessment in clinical health psy-
frustration with the toll of disease or with chology: A model for ethical expansion of prac-
patients who complain more than the clin- tice. Professional Psychology: Research and
ician thinks is necessary; disgust or dis- Practice, 32(2), 135 –141.
taste may be evoked by the graphic details Belar, C. D., & Deardorff, W. W. (1995). Clinical
health psychology in medical settings: A prac-
of illness)
titioner’s guidebook. Washington, DC: Ameri-
• Defensive reactions (e.g., withdrawal, de- can Psychological Association.
nial, moralizing, minimizing, or rescuing Beers, M., & Berkow, R. (Eds.) (1999). The Merck
may occur if clinicians’ anxieties or nega- manual of diagnosis and therapy. Rahway, NJ:
tive affects are aroused sufficiently) Merck. http://www.merck.com/pubs/mman-
ual/.
It is not always possible to resolve these is-
Goodheart, C., & Lansing, M. (1997). Treating peo-
sues in ideal ways, but it is realistic to identify ple with chronic disease: A psychological
and manage clinicians’ personal responses that guide. Washington, DC: American Psychologi-
interfere with clinical care. Potential signs of cal Association.
difficulty include the following: Human Capital Initiative. (1995). Do the right thing:
A research plan for healthy living. Washing-
• Preoccupation with thoughts of the pa-
ton, DC: American Psychological Association.
tient out of session Institute for Health and Aging, University of Cali-
• Persistent intense feelings about the pa- fornia, San Francisco. (1996). Chronic care in
tient America: A 21st century challenge. Princeton,
• Depressive constellation of discourage- NJ: Robert Wood Johnson Foundation.
ment, fatigue, and pessimism Lechnyr, R. (1992). Cost savings and effectiveness of
• Treatment impasse mental health services. Journal of the Oregon
• Feedback from patient, supervisor, col- Psychological Association, 38, 8 –12.
leagues, family, or friends regarding af- McDaniel, S. H., Hepworth, J., & Doherty, W. J.
fects, anxieties, or reactions to the work (1992). Medical family therapy. New York:
Basic Books.
National Institutes of Health. (2003). Health infor-
mation. Retrieved 2004 from http://www.
SUMMARY health.nih.gov/
Nicassio, P. M., & Smith, T. W. (Eds.). (1995). Man-
Psychological interventions in adult chronic ill- aging chronic illness: A biopsychosocial per-
ness are becoming increasingly important as spective. Washington, DC: American Psycho-
logical Association.
the number of people with chronic conditions
Pallak, M. S., Cummings, N., Dorken, H., & Henke,
grows. The research literature on interactions C. J. (1994). Effects of mental health treatment
among behavior, biology, and disease provides on medical cost. Mind/Body Medicine, 1, 7 –
the basis for increasingly targeted psychologi- 16.
cal intervention strategies. The overview frame- Schlesinger, H. J., Mumford, E., Glass, G. V., Patrick,
work for these strategies includes obtaining C., & Sharfstein, S. (1983). Mental health
sufficient medical information, assessing re- treatment and medical care utilization in a fee
278 part iii • individual psychotherapy and treatment

for service system: Outpatient mental health ioral treatment of illness behavior. In P. M. Ni-
treatment following the onset of a chronic dis- cassio & T. W. Smith (Eds.), Managing chronic
ease. American Journal of Mental Health, 73, illness: A biopsychosocial perspective. Washing-
422– 429. ton, DC: American Psychological Association.
Shapiro, D. E., & Koocher, G. P. (1996). Goals and
practical considerations in outpatient medical
Related Topic
crises intervention. Professional Psychology:
Research and Practice, 27, 109 –120. Chapter 84, “Psychological Interventions in Child-
Turk, D. C., & Salovey, P. (1995). Cognitive-behav- hood Chronic Illness”

ASSESSING AND TREATING

58 NORMATIVE MALE ALEXITHYMIA

Ronald F. Levant

Alexithymia literally means the inability to put sometimes even their bodily sensations. When
emotions into words. The term is composed of a men are required to give an account of their
series of Greek roots: a (“without”), lexus emotions and are unable to identify them di-
(“words”), and thymos (“emotions”)—“with- rectly, they tend to rely on their cognition to
out words for emotions.” This condition was logically deduce what they should feel under
originally described by Sifneos (1967) and the circumstances. They cannot do what is so
Krystal (1982) to characterize the severe emo- easy, and almost automatic, for most women—
tional constriction they encountered in their to simply sense inward feelings and let the ver-
(primarily male) patients who were psychoso- bal description come to mind.
matic, drug-dependent, or affected by posttrau- This widespread inability among men to
matic stress disorder (see also Sifneos, 1988). identify emotions and put them into words has
They were dealing with cases of severe alex- enormous consequences. It blocks men who
ithymia, which is at the far end of the contin- suffer from it from utilizing the most effective
uum of this disorder. Through my work on this means known for dealing with life’s stresses
topic at the Boston University Fatherhood Proj- and traumas — namely, identifying, thinking
ect (Levant & Kelly, 1989) and in my subse- about, and discussing one’s emotional responses
quent research and clinical practice (Levant & to a stressor with a friend, family member, or
Kopecky, 1995), I have found that alexithymia therapist. Consequently, it predisposes such
also occurs in mild to moderate forms and in men to deal with stress in ways that make cer-
these forms is very widespread among men. I tain forms of pathology more likely, such as
have come to call this normative male alexi- substance abuse, violent behavior, sexual com-
thymia. pulsions, stress-related illnesses, and early
Simply put, as a result of the male role so- death. It also makes it less likely that such men
cialization ordeal, boys grow up to be men who will be able to benefit from psychotherapy as
are genuinely unaware of their emotions and traditionally practiced.
 58 • assessing and treating normative male alexithymia 279

I hasten to point out that by characterizing 1. To what extent is the patient aware of dis-
men’s traditional inability to put emotions into crete emotions, as contrasted with either
words as a mild form of alexithymia I do not the neuroendocrinological and musculo-
mean to pathologize men. Rather, this aspect of skeletal components of emotions (e.g., ten-
traditional masculinity does not serve men well sion in the forehead, tightness in the gut) or
in today’s world and is therefore dysfunctional, signs of stress (e.g., feeling “overloaded” or
although it did serve a purpose in earlier his- “zapped”)? Some specific questions are, Do
torical eras. you have feelings that you can’t quite iden-
Normative alexithymia, like the more se- tify? Is it easy for you to find the right
vere forms, is a result of trauma — in this case, words for your feelings? Are you often con-
the trauma of the male role socialization fused by what emotion you are feeling? Do
process that is so normative that we do not you find yourself puzzled by sensations in
think of it as trauma at all (Levant, 1995; Le- your body? (Questions adapted from the
vant & Kopecky, 1995). In brief, the male role Taylor Alexithymia Scale or TAS-20; Bagby,
socialization ordeal, through the combined in- Taylor, & Parker, 1994.)
fluences of mothers, fathers, and peer groups, 2. What emotions does the patient become
suppresses and channels natural male emo- aware of? Is he aware of his emotions in the
tionality to such an extent that boys grow up vulnerable part of the spectrum — that
to be men who develop an action-oriented vari- is, emotions that make him feel vulnera-
ant of empathy, cannot readily sense their feel- ble, such as worry, fear, anxiety, sadness,
ings and put them into words, and tend to hurt, dejection, disappointment, rejection, or
channel or transform their vulnerable feelings abandonment? A typical question is, When
into anger and their caring feelings into sexu- you are upset, do you know if you are sad,
ality. frightened, or angry? If he is not aware of
My approach to helping men identify and his vulnerable emotions, are these emotions
process their emotions integrates cognitive- transformed into anger and expressed as
behavioral, psychoeducational, skills-training, anger, rage, or violence?
and family systems components. The program 3. Is the patient aware of his emotions in the
is an active, problem-solving approach that re- caring/connection part of the spectrum, such
lies on the use of homework assignments. I as concern, warmth, affection, appreciation,
have found that many men find such an ap- love, neediness/dependency, closeness, or at-
proach very congenial because it is congruent tachment? Is he limited in his ability to ex-
with aspects of the male code. In addition, men press caring/connection emotions? Does he
who are demoralized for one reason or another express them primarily through the channel
may find that it restores their sense of agency. of sexuality?
Helping men overcome normative alex- 4. Is the patient aware of his emotions in the
ithymia is useful at the beginning stages of anger part of the spectrum? Does he become
therapy because it enables them to develop the aware of an emotion— such as anger— only
skills of emotional self-awareness and emo- where it is very intense?
tional expressivity that will empower them to 5. At what intensities does the patient experi-
wrestle with deeper conflicts. ence his emotions? Some specific questions
are, Would “cool, calm, and collected” de-
scribe you? When you are angry, is it easy
ASSESSMENT for you to still be rational and not overreact?
Does your heart race at the anticipation of an
During the first interview, in addition to taking exciting event? Do sad movies deeply touch
a standard history, I also assess the man’s abil- you? When you do something wrong, do
ity to become aware of his emotions and put you have strong feelings of shame and guilt?
them into words. I typically use the following (Questions adapted from the Affect Inten-
format. sity Measure or AIM; Larsen & Diener, 1987.)
280 part iii • individual psychotherapy and treatment

TREATMENT Step 4: Keep an Emotional Response Log

The next step involves teaching the patient to
The treatment of alexithymia consists of five
apply emotional words to his own experience.
steps.
To do this, I ask him to keep an emotional re-
sponse log, noting when he experienced a feel-
Step 1: Psychoeducation About Normative ing that he could identify or a bodily sensation
Alexithymia or sign of stress that he became aware of and
what circumstances led up to it. The instruc-
In order for the patient to make sense of his ex-
tions for keeping an emotional response log are
perience and utilize the treatment techniques,
as follows:
he needs to know the limitations of his ability
to know and express his emotions and how
• Record the bodily sensation or sign of stress
these limitations came about. An important
(or feelings, if you notice them) that you be-
part of this step is helping the patient develop
come aware of and when you first started to
his ability to tolerate certain emotions (such as
experience it.
fear or sadness) that he may regard as unmanly
• Describe the social or relational context
and therefore shameful (Krugman, 1995).
within which the emotion was aroused: Who
was doing what to whom? How did that af-
Step 2: Develop a Vocabulary for Emotions fect you?
• Go through your emotional vocabulary list
Since men tend not to be aware of emotions,
and pick out the words that seem to best de-
they usually do not have a very good vocabu-
scribe the emotion that you were experi-
lary for emotions. This also follows from the
encing.
research literature on the gender-differentiated
development of language for emotions. The
next step, then, is to help the man develop a vo- Step 5: Practice
cabulary for the full spectrum of emotions, par-
The final step involves practice. Emotional self-
ticularly the vulnerable and caring/connection
awareness is a skill, and like any other skill, it
emotions. I ask patients to record as many
requires practice to become an automatic part of
words for emotions as they can during the
one’s functioning. In structured groups, I use
course of a week.
role plays, videotaped for immediate feedback,
to practice the skill. Men are taught to tune in
Step 3: Learn to Read the Emotions of Others to their feelings through watching and dis-
cussing immediate playbacks of role plays in
The third step involves learning to apply emo-
which feelings were engendered. By pointing
tional words to feeling states. Since it is often
out the nonverbal cues and asking such ques-
less threatening to do this with other people,
tions as, What were your feelings when you
and since men can readily build on their action-
grimaced in that last segment?, men learn how
empathy skills to learn emotional empathy, I
to access the ongoing flow of emotions within.
recommend focusing on other people at this
Although working on these matters in a
stage. I teach patients to read facial gestures,
group context with video feedback is obviously
tone of voice, and other types of “body lan-
advantageous, one can also practice this skill
guage” in other people. I encourage them to
without such arrangements. By systematically
learn to identify the emotions of other people,
keeping an emotional response log and dis-
in conversations, while observing other people
cussing the results in therapy, one can gradu-
or while watching movies. I instruct them to
ally improve the ability to recognize feelings
ask themselves questions during this process,
and to put them into words.
such as, What is that person feeling? What
does this feel like from that person’s perspec-
tive?
 58 • assessing and treating normative male alexithymia 281

Note: Portions of this article were adapted with per- Levant, R. F. (1996). The new psychology of men.
mission from Levant, R. (1998). Desperately seeking Professional Psychology, 27, 259 –265.
language: Understanding, assessing and treating Levant, R. F. (1998). Desperately seeking language:
normative male alexithymia. In W. Pollack & R. Le- Understanding, assessing, and treating norma-
vant (Eds.), New Psychotherapy for Men: A Case tive male alexithymia. In W. S. Pollack & R. F.
Approach (pp. 35 – 56). New York: Wiley. This ma- Levant (Eds.), New psychotherapy for men: A
terial is used by permission of John Wiley & Sons, case approach (pp. 35 – 56). New York: Wiley.
Inc. Levant, R. F., & Kelly, J. (1989). Between father and
child. New York: Viking.
Levant, R. F., & Kopecky, G. (1995). Masculinity re-
constructed. New York: Dutton.
References & Readings
Pleck, J. H. (1995). The gender role strain paradigm:
Bagby, R. M., Taylor, G. J., & Parker, J. D. A. (1994). An update. In R. F. Levant & W. S. Pollack
The twenty-item Toronto Alexithymia Scale: (Eds.), A new psychology of men (pp. 11–32).
II. Convergent, discriminant, and concurrent New York: Basic Books.
validity. Journal of Psychosomatic Research, Sifneos, P. E. (1967). Clinical observations on some
38, 33 – 40. patients suffering from a variety of psychoso-
Krugman, S. (1995). Male development and the matic diseases. Proceedings of the Seventh Eu-
transformation of shame. In R. F. Levant & ropean Conference on Psychosomatic Re-
W. S. Pollack (Eds.), A new psychology of men search. Basel, Switzerland: Kargel.
(pp. 91–126). New York: Basic Books. Sifneos, P. E. (1988). Alexithymia and its relation-
Krystal, H. (1979). Alexithymia and psychotherapy. ship to hemispheric specialization, affect, and
American Journal of Psychotherapy, 33, 17 – creativity. Psychiatric Clinics of North Amer-
30. ica, 11, 287 –292.
Krystal, H. (1982). Alexithymia and the effective- Taylor, G. J. (1994). The alexithymia construct:
ness of psychoanalytic treatment. Interna- Conceptualization, validation, and relationship
tional Journal of Psychoanalytic Psychother- with basic dimensions of personality. New
apy, 9, 353 –378. Trends in Experimental and Clinical Psychia-
Larsen, R. J., & Diener, E. (1987). Affect intensity as try, 10, 61– 74.
an individual difference characteristic: A re-
view. Journal of Research in Personality, 21,
Related Topics
1–39.
Levant, R. F. (1995). Toward the reconstruction of Chapter 78, “Guidelines for Conducting Couple and
masculinity. In R. F. Levant & W. S. Pollack Family Therapy”
(Eds.), A new psychology of men (pp. 229 – Chapter 79, “Treating High-Conflict Couples”
251). New York: Basic Books. Chapter 80, “Treatment of Marital Infidelity”
 ASSESSING AND TREATING MALE
59 SEXUAL DYSFUNCTION

Joseph LoPiccolo & Lynn M. Van Male

Assessing and treating sexual dysfunction in • Intrapsychic or cognitive issues, including

men is a challenging and multifaceted under- “performance anxiety,” religious orthodoxy,
taking. In this overview we will present a brief gender identity conflicts, homosexual orien-
summary of the theoretical concepts and prin- tation or conflict, anhedonic or obsessive-
ciples underlying postmodern sex therapy for compulsive personality, sexual phobias or
men, as well as summarize the major technolo- aversions, fear of loss of control over sexual
gies available for treating erectile failure, pre- urges, masked sexual deviation, fears of hav-
mature ejaculation, and male orgasmic disorder. ing children, unresolved feelings about
death or loss of a previous partner or spouse,
underlying depression, aging concerns, and
POSTMODERN SEX THERAPY: attempting sex in a context or situation that
A SUMMARY OF THEORETICAL is not psychologically comfortable for the
CONCEPTS AND PRINCIPLES patient
• Operant issues in the couple’s day-to-day
Postmodern sex therapy is conceptualized as a environment or the reinforcing consequences
blend of cognitive therapy, systems theory, and of the dysfunction that come not from the re-
behavioral psychotherapy (LoPiccolo, 2002). lationship with the partner or from the pa-
This approach identifies five basic categories of tient’s own psyche but from the external
causes of sexual dysfunction, which are applic- world
able to both men and women: • Physiological or medical issues, including
any of a number of illnesses and/or diseases
• Family of origin learning history, including that cause pain, chronic fatigue, restriction of
parental prohibitions against childhood mas- movement, reduction of blood flow to the
turbation and sex play, parental negativism pelvis, or impairment in the neurological
about adolescent dating and premarital sex- system that controls arousal and orgasm
ual experience, and unpleasant or traumatic (e.g., diabetes, heart disease, spinal-cord in-
sexual experiences in childhood and adoles- jury, multiple sclerosis, pituitary/hypothal-
cence amic tumors, and end-state renal disorder);
• Systemic issues in the couple’s relationship, commonly prescribed medications (e.g., anti-
including lack of attraction to partner, poor hypertensive, antianxiety, antidepressant,
sexual skills of the partner, general marital and antipsychotic medications); chronic sub-
unhappiness, fear of closeness or intimacy, stance use/abuse (e.g., alcohol, marijuana,
lack of basic trust, differences between the heroin, cocaine, and barbiturates); and hor-
couple in degree of “personal space” desired monal imbalances (e.g., too much or too lit-
in the relationship, passive-aggressive solu- tle prolactin, testosterone, estrogen). A com-
tions to a power imbalance, poor conflict res- prehensive listing of sexual effects of medical
olution skills, and inability to blend feelings conditions and medications with sexual side
of love and sexual desire effects may be found in LoPiccolo (1993).

282
 59 • assessing and treating male sexual dysfunction 283

Although different practitioners may empha- gies of sex therapy to be effective, positive at-
size one of these five elements more than an- titude change and acceptance of sexuality as a
other, an examination of all factors is necessary normal, healthy part of being human often
to gain a complete understanding of the origi- need to be addressed in treatment.
nal causes and current maintainers of a sexual • Elimination of performance anxiety: Quite
dysfunction. Failure to attend to the individual often patients in sex therapy experience anx-
or couple dynamic relationship needs that are iety as a result of “keeping score” and being
being served by the sexual dysfunction often goal-oriented or orgasm-focused. Since it is
creates a situation in which symptom removal precisely this goal-directedness that inter-
can be disruptive, thus leading to “resistance” feres with arousal, the effect of focusing on
to therapeutic progress. We cannot overempha- pleasure and enjoying the sexual process au-
size the importance of examining contextual tomatically has the side effect of facilitating
factors prior to utilizing the specific sex therapy the goal of normal sexual functioning.
technologies enumerated later in this overview. • Increase of effective communication: Sexu-
(For further reading on postmodern sex ther- ally dysfunctional couples tend to be unable
apy, see LoPiccolo, 2002.) to tell each other what they like and dislike
about sex. Postmodern sex therapy encour-
ages open, clear, and effective communication
MECHANISMS OF CHANGE about sexual techniques, preferences, re-
sponses, and the initiation and refusal of sex-
Currently, sex therapy consists of a complex, ual activity.
multifaceted package of procedures. However, • Change of destructive sex roles and life-
given that the postmodern view espouses con- styles: Patients may need to be encouraged to
sidering the sexual problem in its full systemic examine issues such as rigidly adhering to a
context, treatment often focuses not only on societally determined stereotypes about what
the individual but also on the couple. We con- men and women “should” want in sexual re-
ceptualize couple sex therapy as involving nine lationships, disengaging from in-laws who
major general principles: are a destructive influence on their relation-
ship, withdrawing from their adult children’s
• Mutual responsibility: Sexual dysfunctions problems, or quitting a job that requires one
are most often shared disorders. Thus, even of them to commute too far to and from
if the nondysfunctional partner is not di- work.
rectly involved in causing or maintaining • Change of disruptive marital systems and
the dysfunction, both partners will need to enhancement of the marital relationship:
change for therapy to help them in the solu- Often it is not possible to directly intervene
tion of their problems. in the sexual problem without also directly
• Information and education: In the present intervening in the marital relationship.
age of increased patient access to self-help When the couple is having significant diffi-
books, magazine articles, and videos on sex- culties over finances, child rearing, or other
uality, only rarely are people who enter sex issues, it is unrealistic to expect them to leave
therapy completely ignorant of the basic these issues outside the bedroom door when
anatomy and physiology of the human sex- they begin to have a sexual session assigned
ual response. Nonetheless, even in cases by the therapist.
where there are other complex causes and • Physical and medical interventions: As men-
maintainers of the sexual dysfunction, it is tioned earlier, several major classes of med-
always useful to include a specific informa- ical diseases and chemical agents may inter-
tional and educational component to get max- fere with sexual functioning. Thus, concur-
imally effective results. Zilbergeld (1999) pro- rent medical care is often necessary in the
vides an excellent source of such material. treatment of sexual dysfunction. In the event
• Attitude changes: For the specific technolo- physiological antecedents to sexual dysfunc-
284 part iii • individual psychotherapy and treatment

tion are not addressable, the patient’s focus of • “Stuffing” technique: When the couple is
treatment may not be on regaining full sex- ready to resume penile-vaginal intercourse,
ual functioning but rather on the appropriate the man lies on his back and the woman
adaptation to alternative erotic and intimate kneels above him and uses her fingers to
activities. push his nonerect penis into her vagina. This
• Prescription of direct changes in sexual be- procedure, known as the “stuffing tech-
havior and teaching of effective sexual tech- nique,” frees him from having to have a
nique: Although the eight types of proce- rigid penis to accomplish entry. The couple is
dures listed above are key elements in post- instructed to achieve the woman’s orgasms
modern sex therapy, the truly distinctive through manual or oral sex, again reducing
element of sex therapy, as opposed to other pressure on the male to perform.
psychotherapeutic approaches, is the prescrip- • Intercourse: When the couple has mastered
tion by the therapist of a series of specific sensate focus and “stuffing,” they are ready
sexual behaviors for the patients to perform to resume intercourse in their preferred po-
in their own home. The particular behavioral sition (e.g., female superior, male superior,
prescriptions vary with the dysfunction and side-by-side).
are summarized below.
This set of procedures seems to work well in
cases in which there is no major organic im-
Erectile Failure
pairment of erection. Physical intervention is
Treatment of erectile failure consists of reduc- often indicated, however, for men with sig-
ing performance anxiety and increasing stimu- nificant physical problems underlying or com-
lation (LoPiccolo, 2003). The following list plicating their difficulty with erection. For these
summarizes the main steps in treating erectile men, the following approaches may be sug-
failure. gested.

• Sensate focus: Initially, attempts to have in- • Penile prostheses: One type of penile pros-
tercourse — and even to have an erection — thesis consists of a semirigid rod made of
are proscribed. Instead, during sensate focus, rubber and wire, which, when surgically im-
the couple learns the “tease technique,” in planted, produces an artificial erection. It can
which, if he gets an erection in response to be bent down so that the man can wear nor-
her caressing, they stop until he loses it. This mal clothing but bent up to an erect position
exercise teaches them that erections occur when the man wants to have intercourse.
naturally in response to stimulation, as long Another type of prosthesis consists of inflat-
as the couple does not focus on performance. able hollow cylinders inserted into the penis,
More recently, increasing direct stimulation a reservoir of fluid placed under the abdomi-
of the penis has been focused on in addition nal wall, and tubing connecting the penile
to reducing performance anxiety. Many men cylinders and the reservoir to a pump in-
with erectile failure have either mild organic serted in the scrotum. When the man wants
impairment or normal aging changes in erec- to have sex, he squeezes the pump, forcing
tile responsiveness, which make direct stim- fluid from the reservoir to the penile cylin-
ulation of the penis necessary for erection to ders, which expand and produce an erection.
occur. While this may seem obvious, many These prostheses are expensive (between
cases seen in current clinical practice involve $5,000 and $15,000, depending on the type),
unwillingness of the female partner — or but over 25,000 were installed in 1988 in the
sometimes the male himself — to engage in United States. In recent years, prostheses
direct stimulation of the penis. In such cases, have become less commonly used as nonsur-
negative attitudes are explored, and the cou- gical medical interventions (i.e., the vacuum
ple is helped to engage in normal “foreplay” erection device and penile injections) have
stimulation of the penis. become available.
 59 • assessing and treating male sexual dysfunction 285

• Vacuum erection device (VED): A hollow fore stimulation is carried through to ejac-
cylinder is placed over the penis and pushed ulation, so the man ultimately experiences
against the body to create an airtight seal. much more total time of stimulation than
The cylinder is connected to a hand pump, he has ever experienced before and learns to
which pumps the air out of the cylinder and have a higher threshold for ejaculation.
leaves the penis in a partial vacuum. The re- • “Squeeze” procedure: This technique is
sultant pressure differential draws blood into much like the “stop-start” procedure, except
the penis and produces an erection. The cy- that when stimulation stops, the woman
linder is removed, and a rubber constriction firmly squeezes the penis between her
ring is placed around the base of the penis to thumb and forefinger, at the place where the
maintain the erection. The VED is less ex- head of the penis joins the shaft. This
pensive ($300 –$600), but it interferes with squeeze seems to reduce arousal further.
the spontaneity of sex, since the man must • Vaginal containment: After a few weeks of
take time to use it during lovemaking. The training involving “stop-start” and “squeeze”
vacuum device is most often used for men procedures, the necessity of pausing di-
whose erectile failure is caused by diabetes or minishes. Then the couple may progress to
neurological problems, and it seems to work putting the penis in the vagina, but without
well for these men (LoPiccolo, 1992). any thrusting movements. Again, if the man
• Chemical vasodilators: Another nonsurgical rapidly becomes highly aroused, the penis is
treatment for men with medically based withdrawn and the couple waits for arousal to
erectile failure is injection of drugs that di- drop off.
late the penile arteries. Drugs that were for- • Active thrusting: When good tolerance for
merly used for this purpose tended to cause inactive containment of the penis is achieved,
scarring in the penis over long periods of use the training procedure is repeated during ac-
and so were used more as a short-term “con- tive thrusting. Generally, 2 to 3 months of
fidence booster” for men with situational practice are sufficient to enable a man to en-
erectile failure. However, the drugs that are joy prolonged intercourse without any need
now used do not seem to have this effect. for pauses or squeezes.
• The effectiveness of the oral medication Vi- • Medical practitioners now commonly treat
agra has greatly reduced the usage of vac- premature ejaculation with SSRI antidepres-
uum devices and penile injections. Viagra sants. While this is effective, the medication
works in about 75% of cases, but sexual must be taken at full daily dosage constantly
stimulation plus the medication is needed— and does not work on an “as needed” basis.
Viagra alone does not produce erection, es- Therefore, psychotherapeutic treatment of-
pecially in older men. fers real advantages.

Premature Ejaculation
Male Orgasmic Disorder
Premature ejaculation is treated with almost a
100% success rate by direct behavioral retrain- Male orgasmic disorder is treated by reducing
ing procedures (Masters & Johnson, 1970). The performance anxiety and ensuring adequate
following summarizes the steps in this typi- stimulation. The couple is instructed that dur-
cally effective treatment. ing sex the penis is to be caressed manually
(and, if acceptable to them, orally) until the
• “Stop-start” or “pause” procedure: In this man is aroused, but that stimulation is to stop
technique, the penis is manually stimulated whenever he feels he might be close to having
until the man is fairly highly aroused. The an orgasm. This paradoxical instruction reduces
couple then pauses until the man’s arousal goal-focused anxiety about performance and al-
subsides, then the stimulation is resumed. lows the man to enjoy the sexual pleasure pro-
This sequence is repeated several times be- vided by the caressing. An electric vibrator may
286 part iii • individual psychotherapy and treatment

be used to increase the intensity of stimulation. L. J. Haas (Ed.), Handbook of psychology in

For men with neurological damage, therapy is primary care. New York: Oxford University
likely to include some physiological treatment, Press.
possibly a drug that increases arousal of the Masters, W. H., & Johnson, V. E. (1970). Human
sexual inadequacy. Boston: Little, Brown.
sympathetic nervous system or stimulation of
O’Donohue, W., & Geer, J. H. (Eds.). (1993). Hand-
the anus with a vibrator to trigger the ejacula-
book of sexual dysfunctions: Assessment and
tion reflex (LoPiccolo, 1996). treatment. Boston: Allyn and Bacon.
Wincze, J. P., & Carey, M. P. (1991). Sexual dysfunc-
tion: A guide for assessment and treatment.
References & Readings New York: Guilford Press.
LoPiccolo, J. (1992). Post-modern sex therapy for Zilbergeld, B. (1999). The new male sexuality. New
erectile failure. In R. C. Rosen & S. R. Leiblum York: Bantam Books.
(Eds.), Erectile failure: Diagnosis and treat-
ment (pp. 171–197). New York: Guilford
Press. Related Topics
LoPiccolo, J. (1996). Premature ejaculation and male
Chapter 58, “Assessing and Treating Normative
orgasmic disorder. In G. O. Gabbard & S. D.
Male Alexithymia”
Atkinson (Eds.), Synopsis of treatments of
Chapter 60, “Assessing and Treating Female Sexual
psychiatric disorders (pp. 797 – 804). Washing-
Dysfunction”
ton, DC: American Psychiatric Press.
Chapter 63, “Assessment and Treatment of Les-
LoPiccolo, J. (2002). Postmodern sex therapy. In F.
bians, Gay Men, and Bisexuals”
W. Kaslow (Ed.), Comprehensive handbook of
Chapter 78, “Guidelines for Conducting Couple and
psychotherapy (Vol. 4, pp. 41– 43). New York:
Family Therapy”
John.
LoPiccolo, J. (2003). Male sexual dysfunction. In

ASSESSING AND TREATING

60 FEMALE SEXUAL DYSFUNCTION

Joseph LoPiccolo & Lynn M. Van Male

The assessment and treatment of sexual dys- technologies available for treating female
function in women are no less challenging and arousal and orgasm dysfunctions, vaginismus,
multifaceted than the assessment and treatment dyspareunia, and low sexual desire and aversion
of sexual dysfunction in men. In addition to to sex. (A detailed discussion of theoretical con-
presenting a brief summary of the theoretical cepts and mechanisms of change is given in the
concepts and principles underlying postmodern overview of male sexual dysfunction in chapter
sex therapy, this chapter reviews the major 59.)
 60 • assessing and treating female sexual dysfunction 287

POSTMODERN SEX THERAPY: • Increase of effective communication

A SUMMARY OF THEORETICAL • Change of destructive sex roles and lifestyles
CONCEPTS AND PRINCIPLES • Change of disruptive marital systems and
enhancement of the marital relationship
Postmodern sex therapy is an amalgamation of • Physical and medical interventions
cognitive therapy, systems theory, and behav- • Prescription of direct changes in sexual behav-
ioral psychotherapy. The following five cate- ior and teaching of effective sexual technique
gories are theorized to account for the causes
and maintainers of sexual dysfunction:
A Note on Sexual Victimization
• Family of origin learning history Although sexual victimization is by no means
• Systemic issues in the couple’s relationship the only route into the manifestation of sexual
• Intrapsychic or cognitive issues dysfunction, it is not uncommon for patients
• Operant issues in the couple’s day-to-day en- who have sexual dysfunction(s) to have a his-
vironment tory of sexual trauma or childhood molestation.
• Physiological or medical issues For such cases, it is vital to stress that the ther-
apist’s first objective is to address sexual vic-
The degree to which each of these factors con- timization issues prior to treating any sexual
tributes to the development or maintenance of dysfunction(s). For example, for an inorgasmic
a sexual dysfunction varies case by case. How- survivor of sexual trauma, some of the orgasm
ever, a thorough examination of all five types of triggers mentioned below may serve as triggers
factors is necessary to gain a complete under- for flashback rather than assisting in achieving
standing of a sexual dysfunction. The sexual orgasm. Thus, for patients with both a sexual
dysfunction often serves an important role in dysfunction and a history of sexual trauma or
the individual or couple dynamic; thus attempts childhood molestation, additional therapeutic
to remove it without attending to the need(s) it procedures are indicated. These procedures are
fulfills can meet with great resistance on the described in other works, such as Courtois
part of the individual or the couple. We cannot (1988).
overemphasize the importance of examining
contextual factors prior to utilizing the specific
sex therapy technologies enumerated later in Female Arousal and Orgasm
this overview. (For further reading on post- Dysfunctions
modern sex therapy, see LoPiccolo, 1985.)
Global, Lifelong Inorgasmia Specific treatment
techniques for female arousal and orgasm dys-
MECHANISMS OF CHANGE functions include self-exploration, body aware-
ness, and directed masturbation training (Hei-
Currently, sex therapy consists of a complex, man & LoPiccolo, 1988). Masters and Johnson
multifaceted package of procedures. However, (1970) stressed the use of couple sensate-focus
given that the postmodern view espouses con- procedures for such cases, but later experience
sidering the sexual problem in its full systemic showed that it is more effective for the woman
context, treatment often focuses not only on to learn to have orgasm by herself first and then
the individual but also on the couple. It is pos- share this knowledge with her partner. The di-
sible to conceptualize couple sex therapy as in- rected masturbation program that has been
volving nine general principles: most successful in our work has nine steps and
a “pre-step”:
• Mutual responsibility
• Information and education • Exploration of beliefs about sexuality: Be-
• Attitude changes fore the woman even begins the program
• Elimination of performance anxiety steps, it is important for her to explore her
288 part iii • individual psychotherapy and treatment

beliefs and possible fears about becoming a have the opportunity to observe how their
fully sexual woman. What does she risk los- partner prefers to be erotically stimulated,
ing by becoming orgasmic? we suggest partners be the first to demon-
• Education: In step 1 the woman uses dia- strate self-stimulation to orgasm in order to
grams and reading materials simply to learn help disinhibit clients.
about her body, her genitals, and the female • Partner-assisted orgasm: In step 8 her part-
sexual response. ner rests his hand on hers as she mastur-
• Full-body exploration: In step 2 she explores bates to orgasm. Once she is comfortable
her whole body visually (with the aid of a with this, she may guide his hand to teach
mirror) and by touch. him how she likes to be touched, and then
• Finding pleasure zones: Step 3 consists of lo- the couple may move on until he is able to
cating erotically sensitive areas on her entire bring her to orgasm with manual, oral, or
body (lips, thighs, the curve of her waist, vibrator stimulation.
etc.), with a focus on her breasts and genitals, • Intercourse: In the last step, the woman and
especially her clitoris. her partner practice intercourse in positions
• Erotic self-pleasuring: Actual stimulation that permit one or the other of them to con-
(masturbation) of the areas identified in step tinue to stimulate her clitoris while the penis
3 is the focus of step 4. is in the vagina.
• Enhanced erotic self-pleasuring: Step 5 is
erotic masturbation accompanied by sexual This training program has been found to be
pictures, stories, and the woman’s own fan- very effective: over 90% of women learn to
tasies. Women are encouraged to write their have an orgasm during masturbation, about
own erotic stories, as well as reading com- 80% during caressing by their partner, and
mercially published collections of women’s about 30% during intercourse. Because it is a
sexual fantasies. structured program, it works equally well in
• Masturbation aids, enactment, and “orgasm group therapy and even as a self-treatment,
triggers”: Step 6 has three elements. First, if since the woman can go through the program
the woman has not yet experienced an or- without a therapist, using a self-help book
gasm, it is suggested that she begin to use an (Heiman & LoPiccolo, 1988) and instructional
electric vibrator to increase the intensity of videotape (LoPiccolo, 1980).
stimulation. Second, she will be instructed to
act out or role-play a very exaggerated or- Situational Orgasmic Dysfunction In contrast
gasm to overcome any fears about losing to women with global, lifelong lack of orgasm,
control or looking silly when she has a real some women are able to have an orgasm in
orgasm. Finally, she will use “orgasm trig- some way but not in a way that is satisfactory
gers,” such as tilting her head back, holding to them. Such types of situational orgasmic
her breath with diaphragm tensed as if try- dysfunction include being able to reach orgasm
ing to exhale, arching her feet and pointing only in solitary masturbation or only in some
her toes, contracting her pelvic muscles, particular sexual activity, such as oral stimula-
tensing her leg muscles, and thrusting her tion. Treatment for situational lack of orgasm
pelvis. includes a process of gradual stimulus gener-
• Sensate focus and mutual masturbation: alization. This procedure is designed to help
Step 7 integrates Masters and Johnson’s sen- the woman expand the ways in which she
sate focus procedure with the woman’s indi- reaches orgasm by the identification of numer-
vidual progress. This training in communica- ous intermediate steps that will help her ex-
tion and sexual skill teaches her to dem- pand the situations in which she is able to
onstrate for her partner how she prefers to be achieve an orgasm.
stimulated and how she can have an orgasm. For example, consider the case of a woman
Because most women find it easier to demon- who can reach orgasm only when she is alone,
strate how they like to be touched if they through masturbating by pressing her thighs
 60 • assessing and treating female sexual dysfunction 289

together, and cannot have orgasm in any way “working hard” to make quick progress in
when her partner is present. The intermediate the treatment of vaginismus is almost always
steps she and her therapist identify may include countertherapeutic.
using thigh pressure but also putting her fin- • Voluntary control of the pubococcygeal mus-
gers on her clitoris, direct stimulation of her cli- cle: Vaginismic patients practice contracting
toris with her thighs spread apart, thigh pres- and relaxing the pubococcygeal muscle, which
sure with her partner present, thigh pressure is part of the pelvic floor and surrounds the
with her partner’s fingers on her clitoris, her vagina, until they have acquired voluntary
partner’s direct stimulation of her clitoris with- control over their vaginal muscles.
out thigh pressure, and direct clitoral stimula- • Graduated dilator containment: To assist in
tion during intercourse (Zeiss, Rosen, & Zeiss, overcoming their fear of penetration, vagi-
1977). This approach is quite effective in help- nismic women are taught to use a set of grad-
ing women learn to have orgasm with a partner. ually larger dilators, which they insert in
Sex therapists do not consider lack of orgasm their own vagina at home and at their own
during intercourse to be a problem, provided pace, so that they are not frightened or trau-
the woman enjoys intercourse and can have or- matized. It is critical to emphasize that dila-
gasm when her partner caresses her. For this tor insertion is done gently, not with a vig-
reason, reassurance about their normality, not orous thrusting motion. Additionally, the
treatment, is indicated for women whose only woman should not progress to the next larger
concern is situational lack of orgasm during in- dilator until she is able to comfortably con-
tercourse. Although sex therapists agree that tain the previous, smaller one.
lack of orgasm during intercourse is not a prob- • Partner participation in dilator insertion:
lem, popular books and magazines continue to Later, when the woman can comfortably in-
suggest ways for women to achieve orgasm sert the largest dilator, she begins to guide
during intercourse. One such suggestion is the her partner as he slowly and gently inserts
“high ride” position, in which the man posi- the dilators. Again, it is important to stress
tions his body upward on his partner until the that dilator insertion is not done forcefully
top of her head is even with his shoulder area. or with repetitive thrusting motions.
This position bends the man’s penis back until it • Vaginal containment of the penis: As her
is sliding along the woman’s clitoris during in- partner lies passively on his back, the woman
tercourse. Although the “high ride” is sup- kneels above him and gradually inserts his
posed to lead to orgasm during intercourse, it penis at a pace that is comfortable to her.
does not seem to be effective and is also un- • Intercourse: Once the woman is able to com-
comfortable for many couples. fortably contain her partner’s penis, the cou-
ple may begin to add thrusting motions and
to explore various intercourse positions that
Vaginismus
are enjoyable to both of them.
Vaginismus refers to spastic contractions of the
muscles around the vagina, which make it im- The therapist stresses the need for effective
possible for the penis to enter. The treatment stimulation, so that the patient learns to associ-
for this dysfunction is shown in a video (LoPic- ate penetration with vaginal lubrication, plea-
colo, 1981) and includes the following elements. sure, and arousal instead of with fear or pain.
Some therapists use muscle-relaxing drugs or
• Deep muscle relaxation and breathing: Vagi- hypnosis during dilation, but this does not
nismic women are first taught how to relax seem to be a necessary part of the treatment.
the muscles of their bodies to promote so- Therapy for vaginismus is highly successful:
matic awareness prior to the focus of treat- over 90% of the women treated become able to
ment being directed toward their presenting have pain-free intercourse.
complaint. It is critical that the patient be al-
lowed to progress at her own pace because
290 part iii • individual psychotherapy and treatment

Dyspareunia aware of her negative emotions regarding

Dyspareunia refers to pain that a woman ex- sex. Therapy sessions during which the pa-
periences during intercourse. Most cases of tient visualizes sexual scenes help uncover
dyspareunia involve some physiological abnor- feelings of anxiety, fear, resentment, vulner-
mality, such as unrepaired damage following ability, and so forth. Many patients claim that
childbirth. However, some cases are exclusively they have overcome negative ideas about sex,
psychogenic in origin. There are no specific but such changes are likely to be superficial,
treatment procedures for psychogenic dyspare- leaving a negative affectual (emotional or
unia. Since psychogenic dyspareunia is actually gut-level) residue hidden under a bland um-
caused by lack of arousal, the general sex ther- brella feeling of lack of interest in sex. The
apy procedures and the specific techniques for purpose of the affectual awareness stage of
enhancing female arousal and orgasm are used therapy is to get under this umbrella and
(O’Donohue & Geer, 1993). When the pain is make the patient aware that she is not just
caused by scars or lesions, the couple can be naturally uninterested in sex but that some-
taught positions for intercourse that do not put thing is blocking the normal biological sex
pressure on the traumatized sites. Since most drive.
cases of dyspareunia are caused by undiagnosed • Insight: The second phase of therapy helps pa-
physical problems, an examination by a gyne- tients understand why they have the negative
cologist who is expert in this area is essential emotions identified in the affectual awareness
(O’Donohue & Geer, 1993). phase. Negative messages from their religion,
culture, family, and current and past relation-
ships are explored. In a sense, this and the pre-
Low Sexual Desire and Aversion to Sex vious step are preparatory. The more active
Low sexual desire refers to a condition in which treatment follows.
the patient is markedly lacking in sexual drive • Cognitive and emotional change: In this
and interest. Although the judgment of just phase, cognitive techniques are applied to the
how low sexual desire must be to be dysfunc- irrational thoughts and emotions that inhibit
tional is somewhat subjective and frequently sexual desire. Patients generate “coping state-
societally determined, most patients who expe- ments” that help them change their negative
rience this dysfunction have virtually no sexual emotions and thoughts. Typical statements
interest. Sexual aversion is not just a lack of in- might be “If I allow myself to enjoy sex, it
terest in sex but an actual negative emotional doesn’t mean I’ll lose control,” and “When I
reaction such as revulsion, fear, or disgust that was younger I learned to feel guilty about
occurs when sexual activity is attempted. Al- sex, but I’m a grown-up now, and I don’t
though the steps for addressing hyposexual de- have to feel that way anymore.”
sire are addressed in this overview, which fo- • Behavioral interventions: It is at this stage
cuses on female sexual dysfunctions, the same that sensate focus, skill training, and other
procedures have been applied with equal suc- general sex therapy procedures are intro-
cess to male patients. duced. Sex drive is heightened in a number
Because of the many difficult psychological of ways: having patients keep a “desire di-
issues that are likely to underlie hypoactive ary” in which they record sexual thoughts
sexual desire and sexual aversion, these dys- and feelings, having them read books and
functions typically require a longer and more view films with good erotic content, and en-
complex program of treatment than others. Pri- couraging them to develop their own sexual
dal and LoPiccolo (2000) have described a fantasies. All of these activities make sexual
widely used four-element sequential treatment thoughts and cues more readily available to
model for hypoactive drive and aversion. the patient. Nonsexual affection, consisting
of simple hugs, squeezes, and pats, and plea-
• Affectual awareness: The first stage of ther- surable shared activities such as dancing and
apy focuses on helping the client become walking together are also encouraged to help
 61 • assessing and reducing risk of infection 291

strengthen feelings of sensual enjoyment Masters, W. H., & Johnson, V. E. (1970). Human
and sexual attraction. sexual inadequacy. Boston: Little, Brown.
O’Donohue, W., & Geer, J. H. (Eds.). (1993). Hand-
This type of program seems to be fairly suc- book of sexual dysfunctions: Assessment and
treatment. Boston: Allyn and Bacon.
cessful. In one study of the approach, frequency
Pridal, C. G., and LoPiccolo, J. (2000). Multielement
of sex increased from once a month to once a
treatment of desire disorders: Integration of
week for men who had experienced hypoactive cognitive, behavioral and systemic therapy. In
sexual desire and from once every two weeks to S. R. Leiblum & R. C. Rosen, (Eds.), Principles
more than once a week for female patients. and Practice of Sex Therapy (pp. 57 – 84). New
Women who had experienced sexual aversion York: Guilford.
increased sexual intercourse from less than Schover, L., & LoPiccolo, J. (1982). Treatment effec-
once every two weeks to more than once a week tiveness for dysfunctions of sexual desire. Jour-
(Schover & LoPiccolo, 1982). nal of Sex and Marital Therapy, 8, 179 –197.
Zeiss, A. M., Rosen, G. M., & Zeiss, R. A. (1977).
Orgasm during intercourse: A treatment strat-
References & Readings egy for women. Journal of Consulting and
Courtois, C. A. (1988). Healing the incest wound. Clinical Psychology, 45, 891– 895.
New York: Norton.
Heiman, J. R., & LoPiccolo, J. (1988). Becoming or- Related Topics
gasmic: A sexual and personal growth program
for women. New York: Simon and Schuster. Chapter 59, “Assessing and Treating Male Sexual
LoPiccolo, J. (1980). Becoming orgasmic [Videotape]. Dysfunction”
(Available from Focus International, 14 Oregon Chapter 62, “Guidelines for Treating Women in
Drive, Huntington Station, NY 11746.) Psychotherapy”
LoPiccolo, J. (1981). Treating vaginismus [Video- Chapter 63, “Assessment and Treatment of Les-
tape]. (Available from Focus International, 14 bians, Gay Men, and Bisexuals”
Oregon Drive, Huntington Station, NY 11746.) Chapter 78, “Guidelines for Conducting Couple and
LoPiccolo, J. (1985). Sex therapy: A postmodern Family Therapy”
model. In S. Lynn & J. P. Garske (Eds.), Con-
temporary psychotherapies. Pacific Grove, CA:
Brooks/Cole.

ASSESSING AND REDUCING RISK OF

61 INFECTION WITH THE HUMAN
IMMUNODEFICIENCY VIRUS

Michael P. Carey

Epidemiologic data from the Centers for Dis- acquired immunodeficiency syndrome (AIDS)
ease Control and Prevention confirm that the can affect anyone who comes into contact with
292 part iii • individual psychotherapy and treatment

the human immunodeficiency virus (HIV). Al- mission to occur, an infected person’s blood, se-
though AIDS was originally thought to be a men, vaginal secretions, or breast milk must en-
disease that affected only gay men, recent data ter the bloodstream of another person. The
refute this notion. In the United States, rates of three most common routes of transmission are
new infections among gay men have declined, (a) unprotected sexual intercourse (anal, vagi-
whereas rates among heterosexual men and nal, or oral) with an infected partner; (b) shar-
women have increased. HIV does not discrim- ing unsterilized needles (most commonly in the
inate among persons on the basis of sexual context of recreational drugs but also in tattoo-
orientation, gender, or race. In the United ing, steroid use, and other needle uses) with an
States, 800,000 – 900,000 persons are infected infected person; and (c) maternal-child trans-
with HIV, and there have been more than mission (e.g., infection through the placenta be-
800,000 documented cases of AIDS; of the per- fore birth and perhaps through breast-feeding
sons with AIDS, more than 468,000 have al- after birth) when the mother is infected. Trans-
ready died. AIDS is a leading cause of death mission can also occur through blood transfu-
among young adults in the United States; more sions (when receiving but not when giving blood)
deaths result from AIDS than from accidents, and through a variety of accidental exposures
murders, suicides, cancer, or heart disease in (e.g., trauma situations, occupational needle-
this age-group. sticks), but these routes are relatively rare.
Neither cure nor vaccine exists for HIV and
AIDS; thus, behavioral avoidance of the virus
provides the only protection against infection. ASSESSMENT OF RISK
Every psychologist is obliged to know the ba-
sics of HIV transmission and prevention, to Careful listening serves as the cornerstone of
evaluate clients for their risk of infection, and to the assessment process. Some clients may
provide risk reduction counseling when indi- freely offer their concerns about HIV-related
cated. Because few psychologists have the time risk as a reason for therapy. Despite the impor-
to become experts in infectious disease or sex- tance of sexual health, not all health profes-
ual behavior, in this chapter I overview three sionals know how to listen when it comes to the
areas necessary for ethical practice. First, I sexual sphere. It is not uncommon for clients to
summarize the key information regarding HIV report that they had tried previously to discuss
transmission. Second, I provide guidelines for sexual concerns with a health care professional
the screening of HIV risk in a time-efficient but were met with avoidance, embarrassment,
manner; by asking a few simple questions, a or apparent lack of interest; as a result, the
psychologist will communicate concern for his clients did not pursue their concerns. Thus, the
or her clients’ safety and, in some cases, help first guideline is to be open to clients’ self-dis-
them to identify their risk of contracting a life- closures regarding sexual, drug use, and other
threatening disease. Third, I provide basic guide- risk behaviors and to be aware of subtle mes-
lines for counseling clients regarding risk re- sages you might convey to discourage the dis-
duction. Finally, I identify resources for further closure of such material.
study and consultation. Even when a therapist is open to self-disclo-
sure on such topics, many clients will be reluc-
tant to independently raise their concerns re-
HIV TRANSMISSION garding sexual or other risk behaviors. In these
cases, the therapist will need to actively assess
The good news about HIV transmission is that the client’s risk in a sensitive and efficient man-
HIV is a fluid-borne agent. What this means is ner. Assessment of risk should take place after a
that, unlike tuberculosis or other airborne in- client and therapist have established a basic rap-
fectious agents, HIV is not spread through port and the therapist has assured the client of
sneezing, coughing, sharing eating utensils, or confidentiality. Specific risk assessment should
other forms of casual contact. For HIV trans- always begin with an appropriate introduction
 61 • assessing and reducing risk of infection 293

for the client. During this time the reasons for Given these process considerations, the con-
asking questions about sexual and other socially tent of the risk screening follows the transmis-
sensitive behaviors should be provided. For ex- sion categories identified earlier. We advise in-
ample, one might say that a standard practice is quiring about each of the following domains and
to inquire about risk for HIV just as one rou- pursuing follow-up questions as appropriate.
tinely inquires about suicidal ideation, personal
safety, and other important matters; thus, all 1. “When were you last tested to determine if
clients get asked, and no client will feel singled you are infected with HIV (the virus that
out as being at unique risk. Although sensitiv- causes AIDS)? What were the results of that
ity is advised, it is also important to ask ques- test?” Knowledge of the date of the test is
tions in a direct fashion, without apology or important for the determination of subse-
hesitancy (Kinsey, Pomeroy, & Martin, 1948). If quent risk activity. Because of the “window
the clinician appears embarrassed about or un- period” (i.e., the amount of time between
sure of the appropriateness of the questions, a exposure to and infection with the virus and
client may sense this and provide incomplete or the development of antibodies detectable
ambiguous responses. After the introductory with serological tests), one should assess risk
remarks, the client should be invited to ask any behavior going back at least 6 months prior
questions he or she might have. to the most recent antibody test. If a client
When assessing sexual behavior, we have discloses that he or she is infected with HIV
found it helpful to adopt certain assumptions in (i.e., is HIV-positive or HIV+), you will
order to gather the most accurate information need to address the many health, relation-
without wasting time and effort (Wincze & ship, and social issues associated with HIV
Carey, 2001). These assumptions reflect the disease. This is a complex set of clinical chal-
preferred direction of error. Thus, for example, lenges that is beyond the scope of this chap-
it is better to assume a low level of under- ter. Kalichman (1995) provides an excellent
standing on the part of the client so that infor- guide to mental health care for infected per-
mation is conveyed in a clear, concrete manner. sons.
Other examples of useful assumptions include 2. “Since your last HIV antibody test, have
the notions that (a) clients will be embarrassed you received a blood transfusion (or treat-
about and have difficulty discussing sexual ment for a blood clotting problem)? If so,
matters; (b) clients will not understand medical was it between 1977 and 1985?” Since 1985,
terminology; and (c) clients will be misin- donated blood has been tested for antibod-
formed about HIV and AIDS. As the clinician ies to HIV; thus, the risk of receiving HIV-
learns more about the client, these assump- infected blood during a transfusion in the
tions are adjusted. United States is extremely low (1 in 60,000).
Depending on the client and the context, it 3. “Since your last HIV antibody test, with
may be useful to sequence the inquiry from the how many men have you had sex (oral, anal,
least to the most threatening questions. Thus, or vaginal)? Did you always use condoms
questions about receipt of blood transfusions when having sex? If yes, did you use con-
might precede questions regarding needle shar- doms during every penetrative contact, in-
ing or sexual behavior. Experience in the as- cluding oral sex? Did you always use latex
sessment of sexual behavior also suggests that condoms? Have any of your male partners
it can be helpful to place the “burden of denial” had sex with other men?” Most experts
on the client (Kinsey et al., 1948). That is, agree that anal sex is more risky than vagi-
rather than ask whether a client has engaged in nal sex, and that both are much more risky
a particular activity, the clinician might ask the than oral sex. Experts disagree regarding the
patient how many times he or she has engaged probability of HIV transmission through
in it. Use of this strategy will depend on the na- oral sex, although this vector of transmis-
ture of the relationship that has been estab- sion has been demonstrated in a few epi-
lished with the client. demiologic studies. Experts agree that con-
294 part iii • individual psychotherapy and treatment

doms protect against HIV only when used gaged in any high-risk activity (e.g., unpro-
consistently and correctly with all partners. tected intercourse), it may be appropriate to en-
Because HIV is smaller than sperm cells, courage the client to seek testing for HIV. Early
natural or lambskin condoms allow the detection of infection can help clients to obtain
virus to pass through and should not be preventive medical care, as well as psychosocial
used. Gay and bisexual men still account for services. Knowledge of serostatus may enhance
the majority of infected persons in the motivation for risk reduction practices in order
United States, but infections among hetero- to avoid infecting others. The recommendation
sexual women are on the increase. to seek antibody testing is complex, involving
4. “Since your last HIV antibody test, with legal, ethical, and political issues (e.g., confi-
how many women have you had sex (oral, dentiality, possible discrimination, and duty to
anal, or vaginal)? Did you always use con- warn).
doms or other barrier protection (e.g., dental Clients who express concern despite appar-
dam) when having sex?” Transmission of ent low risk may also be advised to consider
HIV from an infected woman is less likely testing. Clients who have been abstinent or
than from an infected male, but some risk is those who strongly believe themselves to have
still involved. been in a mutually monogamous sexual rela-
5. “How many times have you shared or bor- tionship with a HIV-negative partner and have
rowed a needle, or used another person’s never shared an injection drug needle can be re-
works (cotton, corker, cooker), to prepare or assured and counseled to maintain low risk.
inject drugs? Did you disinfect the needle Information about HIV-antibody testing is
prior to reusing it? If so, how did you do available from numerous sources, including
this?” Contaminated needles are responsible American Red Cross chapters and local health
for the second-largest number of infections departments. Two types of testing are available:
in the United States. Although needles can with confidential testing, the results are re-
be properly disinfected (e.g., by flushing corded in the client’s medical files and may be
with a bleach solution two or more times), disclosed to those with legal access to records;
they are typically shared without cleaning with anonymous testing, a code number is
or after improper cleaning. given when blood is drawn, and this number
6. “Have you ever had sex with a person who must be presented by the client to receive the
used injection drugs?” All else being equal, results. The client’s name is not associated with
injection drug users (IDUs) are more likely test results. Many states offer anonymous and/
to be infected with HIV than are non-IDUs. or confidential tests without charge. Although
7. “Have you ever had a sexual partner whom sites that offer HIV testing are required to pro-
you knew or suspected was HIV infected or vide pretest and posttest counseling, therapists
had AIDS? If so, did you always use con- should be prepared to supplement such coun-
doms when you had sex?” Having a partner seling, regardless of the outcome.
known to be infected with HIV introduces A second level of counseling involves simple
the greatest risk of infection. education. If a client is misinformed about the
8. “Are you at all concerned that you might basics of HIV and AIDS or has questions about
have been infected with the virus?” This transmission and prevention of HIV infection,
leaves the door open for people who may most psychologists should be able to help im-
not have felt comfortable responding to the mediately. If a client has been involved in risky
earlier questions. sexual or drug-use practices, he or she should
be advised promptly and specifically which be-
haviors enhance risk and what preventive ac-
RISK REDUCTION COUNSELING tion can be taken to reduce risk for infection. An
at-risk client may require more than simple ed-
Three levels of counseling may be appropriate. ucation, however.
First, if a client reports that he or she has en- The third level of intervention involves the
 62 • guidelines for treating women in psychotherapy 295

provision of intensive risk reduction counsel- Centers for Disease Control (n.d.). HIV/AIDS Pre-
ing. Intervention programs have been devel- vention division home page. Retrieved 2004
oped that are well grounded in psychological from http://www.cdc.gov/hiv
theory and have been evaluated in clinical trials Joint United Nations Programme on HIV/AIDS.
(n.d.). UNAIDS home page. Retrieved 2004
with many populations (Carey, 1999; Carey &
from http://www.unaids.org.
Vanable, 2003). An excellent example of such a
Kalichman, S. C. (1995). Understanding AIDS: A
program is Kelly’s (1995); his readable manual guide for mental health professionals. Wash-
provides a step-by-step guide for implementing ington, DC: American Psychological Associa-
an empirically validated risk reduction pro- tion.
gram. Psychologists can also refer to the sources Kalichman, S. C., Carey, M. P., & Johnson, B. T.
cited herein and can call local, state, and na- (1996). Prevention of sexually transmitted HIV
tional hot lines to learn of additional resources infection: A meta-analytic review of the behav-
(e.g., National AIDS Hotline at 800-342-AIDS; ioral outcome literature. Annals of Behavioral
National AIDS Hotline TTY/TDD service at Medicine, 18, 6 –15.
800-243-7889; and National AIDS Information Kelly, J. A. (1995). Changing HIV risk behavior:
Practical strategies. New York: Guilford Press.
Clearinghouse at 800-458-5231).
Kinsey, A. C., Pomeroy, W. B., & Martin, C. E.
(1948). Sexual behavior in the human male.
References, Readings, & Internet Sites Philadelphia: Saunders.
Wincze, J. P., & Carey, M. P. (2001). Sexual dysfunc-
AIDS Treatment News. (n.d.). AIDS.org resource tion: A guide for assessment and treatment
page. Retrieved 2004 from http://www.aids.org (2nd ed.). New York: Guilford.
Carey, M. P. (1999). Prevention of HIV infection
through changes in sexual behavior. American
Journal of Health Promotion, 14, 104 –111. Related Topics
Carey, M. P., & Vanable, P. A. (2003). HIV/AIDS. In Chapter 54, “Treatment Matching in Substance
A. M. Nezu, C. M. Nezu, & P. A. Geller (Eds.), Abuse”
Comprehensive handbook of psychology, Vol. Chapter 55, “Motivational Interviewing”
9: Health psychology (pp. 219 –244). New Chapter 63, “Assessment and Treatment of Les-
York: Wiley. bians, Gay Men, and Bisexuals”

GUIDELINES FOR TREATING

62 WOMEN IN PSYCHOTHERAPY

Laura S. Brown & Felicia A. Mueller

Women are a diverse and complex group, vary- chotherapy with any set of problems and dis-
ing from one another on almost every dimen- tress, although certain diagnoses, such as major
sion, including culture, ethnicity, sexual orien- depression, eating disorders, and posttraumatic
tation, age, disability, and religious or spiritual stress, are found at higher rates among women
affiliation (Brown, 1994). Women enter psy- than among men, and others, such as the para-
296 part iii • individual psychotherapy and treatment

philias, are found at markedly lower rates (Bal- & Nutt, 1986), revised and updated in 1996,
lou & Brown, 2002). Women come into therapy and the latest revision was adopted by the APA
as individuals, as members of heterosexual or Divisions on Women in Psychology and Coun-
same-sex couples, in their roles as parents, as seling Psychology. Now titled Guidelines for
caregivers of their own parents, as workers. Psychological Practice With Girls and Women
How, then, can such a diverse and complex (Nutt, Rice, & Enns, 2002), this latest draft is
group be subsumed under one set of guidelines divided into three themes: diversity, social con-
for psychotherapy? text, and power; professional responsibility; and
The answer, of course, is that no one set of best practices, A brief summary of this most re-
norms and rules will cover all bases for psy- cent document follows.
chotherapy with every woman. Nonetheless,
the therapist undertaking to work with women Guideline 1: Psychologists strive to recog-
clients can find a rich body of information to nize and validate that all girls and women
consider when the client is a woman, be she a are socialized into multiple social-group
second-generation Asian-American lesbian po- memberships and identities, and that girls
lice officer or a Euro-American heterosexual and women have both shared and unique
full-time homemaker. identities.
Starting in the early 1970s, with the publi- Guideline 2: Psychologists strive to recog-
cation of a classic study by Broverman and col- nize how the positions of oppression and
leagues (1970), which served as the impetus for privilege associated with each social group
the APA Task Force on Sex Bias and Sex Role membership and identity affect girls and
Stereotyping in Psychotherapy, the profession women.
of psychology began to be alerted to the perva-
sive presence of gender-based biases in psy- Guideline 3: Psychologists strive to under-
chotherapy with women. These biases were stand women’s and girls’ diverse experiences
found to affect multiple aspects of training and within the context of institutional and social
practice in psychotherapy, and to adversely relationships and how these factors are det-
affect the quality of treatment received by rimental to or facilitate girls’ and women’s
women. physical and mental health.
Several specific concerns were identified dur- Guideline 4: Psychologists strive to be aware
ing this initial period, including: of how potentially oppressive biases, values,
and actions are embedded in psychological
• Androcentric biases in the construction of theory, research, and practice, and they
disorder and normalcy, with tendencies to- strive to create and use culturally sensitive,
ward overrepresentation of feminine gen- flexible, and affirming practices with girls
dered behaviors in constructions of disorder. and women.
• Lack of attention to the interaction between Guideline 5: Psychologists strive to be aware
individual and social context in both diag- of their socialization, social identities, values
nostic formulation and treatment planning. and attitudes, and positions of privilege and
• Sexist power dynamics in the psychotherapy oppression that may affect their practice
relationship in which the therapist mirrored with diverse girls and women by engaging
and transmitted nonconscious biases toward in continuous self-reflection, professional
women clients. education, and consultation.
• Inadequate scientific foundation for psycho-
logical practice with women, and overreliance Guideline 6: Psychologists strive to create
on data derived solely from clinical, rather and implement strategies, applications and
than population, samples. approaches that are most appropriate for
girls and women.
A set of guidelines for psychotherapy with Guideline 7: Psychologists strive to foster
women was first published in 1986 (Fitzgerald professional, educational, and therapeutic al-
 62 • guidelines for treating women in psychotherapy 297

liances and practices that empower girls and manners in which normative gendered issues
women and honor their strengths. can create risk factors for distress.
Guideline 8: Psychologists strive to provide • In all instances, psychologists who themselves
appropriate nonbiased assessments and diag- belong to a target group need to take care not
noses that affirm rather than pathologize to create false equivalencies of target experi-
women’s and girls’ normal development. ences — for example, “I understand what it’s
like to be a woman with a disability because
Guideline 9: Psychologists strive to concep-
I’m a lesbian, even though I’m able-bodied.”
tualize girls’ and women’s issues in their so-
• In psychological assessment, psychologists
ciopolitical context, attending to gender, cul-
need to carefully read manuals to determine
tural factors, and dynamics of power.
whether tests were constructed with a repre-
Guideline 10: Psychologists strive to become sentative sample of diverse groups of women.
acquainted with and utilize relevant mental Care should be taken in the use of computer-
health, education, and community resources ized interpretations of standardized tests,
for girls and women. since many of these interpretations contain
Guideline 11: Psychologists strive to assume sexist assumptions and fail to take context
responsibility for challenging unhealthy into account. Women survivors of violence
power dynamics influencing girls and women have been shown to be especially at risk for
at interpersonal, institutional, and systemic misdiagnosis when cookbook approaches or
levels. blind interpretations of testing are used
(Rosewater, 1985).
Practically speaking, these translate into • When gender-role identification is assessed,
specific behaviors: the psychologist needs to learn whether it is
being inappropriately conceptualized as a
• Psychologists need to remain aware of the continuous variable running from masculin-
emerging research on women, girls, and gen- ity to femininity or whether, consistent with
der. This can be construed as insuring the scholarship, it is constructed as two separate
competency necessary for ethical practice. continuous variables of masculinity and fem-
• Psychologists need to become acquainted ininity. When a woman’s fitness for parent-
with the range of women’s diversity. Women ing is being assessed, care must be taken that
clients from one cultural, social, or age group standards not be higher for her than for a
should not be assumed to be similar to or male partner. Psychological evaluations in
predictive of women clients from different forensic matters where issues of gender ha-
groups. Psychologists who focus their prac- rassment or discrimination are being raised
tice on specific groups of women, such as must demonstrate familiarity with the re-
women of color (Comas-Diaz & Greene, search on women’s test performance in those
1994), women with disabilities (Asch & Fine, situations.
1988), lesbian or bisexual women (Falco, • Psychologists need to carefully attend to
1991; Firestein, 1996) or Jewish women power dynamics in the therapy relationship
(Siegel & Cole, 1991), to name a few such (Brown, 1994; Mirkin, 1994; Worell & Re-
groups, need to become familiar with schol- mer, 1992) and to the development of thera-
arship pertaining specifically to that group. peutic strategies that empower the female
Health psychologists working with women client. Models for gender-aware psychother-
must acquaint themselves with information apy with women can be found in almost
both on gender-specific women’s health con- every major theoretical orientation, includ-
cerns such as reproductive and breast cancer ing psychodynamic, family systems, and
or infertility and medical disorders occurring cognitive behavioral. Feminist practice, an in-
at higher rates in women. Child clinical psy- tegrative, technically eclectic theory, offers a
chologists need to attend to the gendered paradigm specifically constructed around is-
components of girls’ development and the sues of gender and power (Brown, 1994).
298 part iii • individual psychotherapy and treatment

• Emphasize the development of an egalitarian health. Journal of Consulting and Clinical Psy-
relationship between therapist and client. chology, 34, 1– 7.
Use a paradigm of collaboration, respect, and Brown, L. S. (1994). Subversive dialogues: Theory in
client-as-expert, so that the client’s experi- feminist therapy. New York: Basic Books.
Comas-Diaz, L., & Greene, B. (Eds.). (1994). Women
ence of being in therapy is empowering.
of color: Integrating ethnic and gender identi-
• Pay attention to social and political context.
ties in psychotherapy. New York: Guilford Press.
Women’s and girls’ lives, and the problems Falco, K. (1991). Psychotherapy with lesbian clients:
they bring into therapy, are affected by Theory into practice. New York: Brunner/Mazel.
changes in law and social policy and by cur- Firestein, B. (Ed.). (1996). Bisexuality: The psychol-
rent social norms about femininity. ogy and politics of an invisible minority. Thou-
• Psychologists working with women and girls sand Oaks, CA: Sage.
are most likely to be effective when they in- Fitzgerald, L., & Nutt, R. (1986). The Division 17
tentionally interweave knowledge of gender, Principles Concerning the Counseling/Psy-
as salient for the particular client, into treat- chotherapy of Women: Rationale and imple-
ment planning. Psychologists conducting mentation. Counseling Psychologist, 14, 180 –
216.
therapy with women clients should become
Jordan, J., Kaplan, A., Miller, J. B., Stiver, I., & Sur-
conversant on norms of women’s psycholog-
rey, J. (Eds.). (1991). Women’s growth in con-
ical development (Jordan, Kaplan, Miller, nection: Writings from the Stone Center. New
Stiver, & Surrey, 1991), female sexuality, and York: Guilford Press.
women’s experiences in relationships and the Mirkin, M. P. (Ed.). (1994). Women in context: To-
workplace. ward a feminist reconstruction of psychother-
apy. New York: Guilford Press.
Women and men therapists alike can work Nutt, R., Rice, J. K., & Enns, C. Z. (Eds.). (2002).
effectively with women when gender is taken Guidelines for psychological practice with girls
explicitly into account from the very inception and women, 12/11/02 draft. Washington, DC:
of the professional relationship. Even when American Psychological Association Society for
Counseling Psychology and Society for the
clients do not themselves punctuate gender, a
Psychology of Women.
diagnostic formulation that integrates the real-
Rosewater, L. B. (1985). Schizophrenic, borderline,
ities of gender socialization and gendered expe- or battered? In L. E. A. Walker & L. B. Rose-
riences for women clients will lead to greater water (Eds.), Handbook of feminist therapy:
precision of understanding and to more em- Women’s issues in psychotherapy. New York:
powerment of the client herself. Springer.
Siegel, R. J., & Cole, E. (Eds.). (1991). Jewish women
References, Readings, & Internet Sites in therapy: Seen but not heard. New York: Ha-
worth.
APA Task Force in Intimate Partner Violence. (n.d.). Society for the Psychology of Women. (n.d.). Home
Report. Retrieved 2004 from http://www.apa. page. Retrieved 2004 from http://www.apa.org/
org/pi/iparv.pdf divisions/div35/
Asch, A., & Fine, M. (Eds.). (1988). Women with dis- Worell, J. K., & Remer, P. (1992). Feminist perspec-
abilities. Philadelphia: Temple University Press. tives in therapy: An empowerment model for
Ballou, M., & Brown, L. S. (Eds.). (2002). Rethink- women. New York: Wiley.
ing mental health and disorder: Feminist per-
spectives. New York: Guilford Press.
Related Topic
Broverman, I. K., Broverman, D., Clarkson, F. E.,
Rosenkrantz, P., & Vogle, S. (1970). Sex role Chapter 66, “Sexual Feelings, Actions, and Dilem-
stereotypes and clinical judgments of mental mas in Psychotherapy”
 ASSESSMENT AND
63 TREATMENT OF LESBIANS,
GAY MEN, AND BISEXUALS

Robin A. Buhrke & Douglas C. Haldeman

Over 30 years have passed since psychology ASSESSMENT GUIDELINES

and psychiatry, in consideration of the scientific
evidence, removed homosexuality from the list The assessment of sexual orientation is made
of mental disorders (Bayer, 1981). Since that challenging by the fluid nature of the construct
time, the database supporting this decision has itself. Early work (e.g., Kinsey, Pomeroy, &
grown exponentially. We know that lesbian, Martin, 1948) defined sexual orientation as a
gay, and bisexual individuals exist everywhere, continuum, as opposed to dichotomous. Subse-
do not always self-identify, and, because of so- quent models (e.g., Coleman, 1987) have in-
cially instituted stigma, are more likely to be cluded gender-based, social, and affectional vari-
consumers of psychological services than het- ables in the construction of sexual orientation.
erosexuals (Garnets, Hancock, Cochran, Peplau, Regardless of the model, sexual orientation is a
& Goodchilds, 1991). A study commissioned complex phenomenon; for some, the behavioral
by the American Psychological Association’s aspects thereof may not be the most significant.
(APA’s) Committee on Lesbian and Gay Con- That is, one can identify as lesbian, gay, or bi-
cerns (Garnets et al., 1991) found that 90% of sexual without ever having engaged in same-sex
psychologists surveyed had treated a lesbian or sexual behavior. Similarly, one can engage in
gay individual, yet many reported a wide range same-sex sexual behavior and not identify as
of prejudicial and unfounded assumptions lesbian, gay, or bisexual. Sense of identity, in-
about lesbians and gay men. Given the lack of ternalized sociocultural expectations, impor-
attention to this issue in most training pro- tance of social/political affiliations, and fantasies
grams, guidance for practitioners and trainers is are some of the variables that need to be exam-
necessary. ined in order to assist the patient in arriving at
In this brief overview, guidelines on the as- a cogent self-perception of sexual orientation.
sessment and treatment of lesbian, gay, and bi- This makes the process of identifying as lesbian,
sexual individuals are addressed. Assessment gay, or bisexual laden with both practical and ex-
focuses on the construct of sexual orientation istential considerations.
and how best to assist those struggling with Competence in serving lesbian, gay, and bi-
sexual orientation–related concerns. Our dis- sexual patients is measured by the ability to
cussion of treatment will focus on concerns that recognize and neutralize antigay bias and to re-
are common among lesbian, gay, and bisexual frain from assuming that normalcy implies
individuals. heterosexuality. This may be accomplished by
familiarizing oneself with the extant literature,
as well as by developing a sense of “cultural lit-
eracy”— that is, an understanding of what the
normative life experiences of lesbians, gay men,
and bisexuals may entail. Ultimately, this im-

299
300 part iii • individual psychotherapy and treatment

plies a familiarity with normative developmen- This is not meant to encourage clinicians to
tal, familial, social, and vocational concerns impose a “pro-gay” agenda, or any agenda at
faced by many lesbians, gay men, and bisexu- all, upon the confused or questioning patient.
als throughout the life span (D’Augelli & Pat- Rather, it is the clinician’s responsibility to pro-
terson, 1994). Further, an appreciation for the vide a safe, value-neutral environment for ex-
added burdens of social stigma and the potential ploration, as well as accurate, scientific informa-
for discrimination and violence faced by many tion about same-gender sexual orientation. The
lesbians, gay men, and bisexuals is necessary to therapeutic task with many lesbian, gay, and bi-
adequately understand the experiences of these sexual patients is the neutralization of the toxic
groups. Finally, the clinician may benefit from effects of internalized social opprobrium. This
an examination of personal values around cannot be accomplished if the clinician is un-
same-gender sexual orientation. aware of the scientific data regarding sexual ori-
Psychological research has firmly estab- entation, is unacquainted with the lives of well-
lished that same-gender sexual orientation is adjusted, high-functioning lesbians, gay men,
not, in itself, a sign of poor psychological ad- and bisexuals, or attempts to work while har-
justment, psychopathology, or emotional dis- boring unexamined antigay prejudices.
turbance (e.g., Gonsiorek, 1991; Reiss, 1980). Thus, a clinician who bases treatment on an-
Lesbians and gay men do not differ from het- tiquated and scientifically unproven theories
erosexual women and men on measures of psy- about the nature of same-gender sexual orien-
chological adjustment and self-esteem or in the tation can do little more than reinforce the so-
capacity for decision making, vocational adjust- cietal stigma that causes many lesbian, gay, and
ment, or competence in family roles (as parent bisexual individuals to seek help in the first
or spouse). Further, the development of a posi- place. This is particularly true with patients
tive lesbian or gay identity is correlated with who seek to change their sexual orientation.
better psychological adjustment for lesbians Davison (1991) views “reparative” or “conver-
and gay men. Self-identifying as lesbian or gay, sion” therapy as part of the inhospitable social
accepting this as an aspect of identity, self- context that causes many distressed lesbians
disclosing, and feeling accepted by others have and gay men to seek sexual orientation change.
been found to be strongly related to psycholog- Conversion therapy programs are founded on
ical adjustment (Bell & Weinberg, 1978; Mur- unproven and biased theories and yield no sup-
phy, 1989). Similarly, a more positive lesbian or port to the notion that sexual orientation can be
gay male identity has been found to be corre- changed, even if it were desirable to do so
lated with significantly fewer symptoms of (Haldeman, 1994). Recent research in this area
neurotic or social anxiety, higher ego strength, suggests that the potential negative conse-
less depression, and higher self-esteem (Ham- quences for the individual who “fails” conver-
mersmith & Weinberg, 1973; Savin-Williams, sion therapy can be serious (Shidlo & Schroe-
1989). Generally, psychological adjustment ap- der, 2002). Such individuals need to be treated
pears to be highest among gay men and lesbian with additional consideration to the problems
women who are committed to their lesbian, gay, that may have been compounded by conversion
or bisexual identity, reject the notion that ho- treatments (Haldeman, 2002). No clinician
mosexuality is an illness, are uninterested in should attempt to change an individual’s sexual
changing their homosexuality, and have close orientation, or instruct a homosexually ori-
and supportive associations with other gay peo- ented individual in heteroerotic activities, with-
ple (Bell & Weinberg, 1978). Recent random- out carefully assessing the history and motives
ized survey research suggests that the level of behind such a request and making certain that
emotional distress among lesbian, gay, and bi- the patient is well aware of the damaging ef-
sexual persons may be higher than among het- fects of internalized antigay prejudice and is ac-
erosexuals (Cochran & Mays, 2002). Still, this quainted with the normative life experiences of
may likely be attributed to the harmful effects lesbians, gay men, and bisexuals.
of internalized social stigma. What, then, should the clinician who is in-
 63 • assessment and treatment of lesbians, gay men, and bisexuals 301

terested in conducting competent assessments der individuals) may present unique challenges
with lesbians, gay men, and bisexuals take into in the psychotherapy setting. Some of these is-
consideration? Garnets et al. (1991) identify sues are considered more fully in the following
several themes that reflect exemplary practice: section.

1. Clinicians recognize that same-gender sex-

ual orientation is not pathological. TREATMENT CONSIDERATIONS
2. Clinicians do not automatically attribute a
patient’s concerns to his or her sexual orien- Most often, when lesbians, gay men, and bisex-
tation and are able to recognize that negative uals come to treatment, they do so to address
attitudes about homosexuality, as well as ex- the same types of issues that their heterosexual
periences of rejection, harassment, and dis- counterparts address: depression, anxiety, self-
crimination, can cause emotional distress. esteem, career concerns, relationship problems,
3. Clinicians affirm that lesbians and gay men and so on. There are a great deal more similar-
can and do lead productive and fulfilling ities between heterosexual patients and lesbian,
lives and participate in healthy, long-term gay, and bisexual patients than there are differ-
relationships, despite the lack of institu- ences. However, there are important experi-
tional support for them. ences that are unique for lesbians, gay men, and
bisexuals, and these issues may arise in treat-
These themes, together with the literature on ment.
which they are based, form the foundation for A significant major issue facing lesbians, gay
APA’s Guidelines for Psychotherapy with Les- men, and bisexuals is that of “coming out.”
bian, Gay, and Bisexual Clients (APA, 2002). Coming out is the developmental process in
These practice guidelines, which are aspira- which lesbians, gay men, and bisexuals become
tional in nature, are categorized along the fol- aware of their sexual orientation (Gonsiorek &
lowing thematic lines: attitudes toward homo- Rudolph, 1991). This process occurs over a pe-
sexuality and bisexuality, relationships and riod of time, ranging anywhere from a few days
families, diversity issues, and education. Guide- to years, and may be extended for many bisex-
lines in the first category call upon the psy- uals (Matteson, 1996). Many times, because of
chologist to be knowledgeable about sexual ori- being raised in environments that are antigay
entation, and to strive to understand how mis- or stigmatizing, early awareness of same-sex
information, internalized social prejudice, and attractions may result in anxiety, shame, fear,
trauma may affect a client’s presentation. Psy- and guilt. Patients who are questioning their
chologists are also encouraged to examine their sexual orientation may present to clinicians
own prejudices and beliefs about sexual orien- with confusion and sometimes even requests
tation and their potential impact on treatment. for help in ridding themselves of these un-
Psychologists are further encouraged to be pleasant feelings. It is important for clinicians
knowledgeable about and respect the impor- to help patients work through these feelings,
tance of lesbian, gay, and bisexual families, identify environmental pressures that con-
which may often include persons who are not tribute to these feelings, and find resolution and
legally or biologically related. Issues related to affirmation, regardless of the outcome of their
lesbian, gay, and bisexual individuals as parents explorations.
are also considered. The diversity section calls Coming out also refers to disclosing one’s
upon psychologists to be aware that ethnic mi- sexual orientation to others. If clinicians are
nority lesbian, gay, and bisexual individuals, bi- heterosexually biased— that is, if they assume
sexual people, and lesbian, gay, and bisexual that all patients are heterosexual — they may
persons with physical and/or sensory disabili- never know otherwise. If a clinician responds to
ties may face particular challenges due to mul- a male patient’s statements about his “partner”
tiple minority status. Finally, generational dif- with questions about “her,” a gay or bisexual
ferences (lesbian, gay, and bisexual youth or el- man will be less likely to disclose that his part-
302 part iii • individual psychotherapy and treatment

ner is male. Keeping his sexual orientation hid- how to tell the children, how to deal with
den not only reinforces homophobic bias but schools, and so on. For those who want chil-
also establishes a barrier between the patient dren but don’t have them, creating a family is
and the clinician, which undermines the thera- more difficult, whether by natural or adoptive
peutic process. means.
Because most lesbians, gay men, and bisexu- Additionally, it is important to be sensitive
als are invisible to the heterosexual majority, a to the potential for internalized reactions to
number of consequences occur: There is a con- prejudice, discrimination, and violence in les-
siderable underestimation of the numbers of bian, gay, and bisexual clients. In most jurisdic-
lesbians, gay men, and bisexuals; we tend to tions, it is legal to deny housing, employment,
stereotype based on those who are out and vis- and custody of children solely on the basis of
ible or those who come to treatment; and few sexual orientation. This reality places a high
role models exist for newly coming out les- level of stress on many lesbians, gay men, and
bians, gay men, and bisexuals. This invisibility bisexuals. Falco (1996) presents eight stressors
often creates marginalization and isolation, and strengths that are common among lesbian
which clinicians can avoid perpetuating by ed- and bisexual women, which may be generalized
ucating themselves about normative lesbian, to gay men as well. Clinicians should be mind-
gay, or bisexual life experience and refraining ful of the level of stress this lack of protection
from making heterosexist assumptions about may place on many lesbians, gay men, and bi-
patients’ lives. sexuals.
Marginalization and isolation are often mag-
nified for lesbians, gay men, and bisexuals of • Disclosure choices are continual: Coming
color because of their multiple-minority status. out or disclosing one’s sexual orientation is
An African American lesbian is often forced to not a onetime occurrence. It is a lifelong
choose between her sexual orientation and her process, with decisions to be made about how
ethnicity by overt or covert questions such as much to tell and to whom with each new per-
“Are you Black or are you gay?” It is important son met. And each decision to disclose has
for the clinician to not perpetuate this splitting the potential to be met with antipathy and
of patients’ identities and to recognize each pa- rejection.
tient as an integrated whole. It is also important • Nondisclosure generalizes to other areas:
to recognize that these same patients may not Most lesbians, gay men, and bisexuals do not
feel at home in the lesbian, gay, and bisexual disclose to everyone they meet. The process
community because of being Black, while at the of hiding one aspect of oneself may general-
same time, because of being gay, they are not ize to other areas, and self-esteem may suffer
accepted in the Black community. as a result of interpreting “hidden” aspects as
Family issues may raise particular prob- “bad.”
lems for lesbians, gay men, and bisexuals. In • Lack of support: The absence of social sup-
many jurisdictions, lesbians, gay men, and bi- port for and negative cultural attitudes about
sexuals can lose custody of their children sim- lesbians, gay men, and bisexuals can affect
ply because of their sexual orientations. This one’s sense of self, as well as the stability of
places an incredible stress on parents in choos- relationships. Bisexuals may be particularly
ing between acknowledging their sexual ori- prone to marginalization, since they are not
entations and risking their families. Without often accepted in either the heterosexual or
knowing clear boundaries of confidentiality, the lesbian and gay communities.
patients may be reluctant to disclose their sex- • Absence of role models and cultural history:
ual orientations to their clinicians for fear that Although lesbians, gay men, and bisexuals
that information may later be used against have a rich culture and history, most of it is
them in court cases. For lesbians, gay men, and invisible. As a result, many mistakenly be-
bisexuals who have children, blending families lieve that they are “the only one.”
can pose some unique problems — what and • Internalized homophobia: Some lesbians,
 63 • assessment and treatment of lesbians, gay men, and bisexuals 303

gay men, and bisexuals have internalized the frame of reference. This means approaching
negative messages about homosexuality treatment with a nonstigmatizing view of sex-
from their culture, and they, too, believe that ual orientation and avoiding a heterocentric
heterosexuality is preferred. This can create model for intervening. These basic principles
a great deal of conflict and anguish for the enable the lesbian, gay, or bisexual individual to
patient. grow in a therapeutic environment free of the
• Identity development: The process of estab- stigma that is so widespread in the sociocultural
lishing a lesbian, gay, or bisexual identity is environment.
complex and complicated. Although few indi-
viduals march through the stages of develop-
References & Readings
ment in a lockstep manner, the models can be
useful for clinicians in understanding their Bayer, R. (1981). Homosexuality and American
patients and in formulating appropriate in- psychiatry: The politics of diagnosis. Princeton,
terventions. NJ: Princeton University Press.
• Androgyny and ego strength: In order to Bell, A. P., & Weinberg, M. S. (1978). Homosexuali-
recognize and accept their same-sex attrac- ties: A study of diversity among men and
women. Bloomington: Indiana University Press.
tions, lesbians, gay men, and bisexuals must
Cabaj, R. P., & Stein, T. S. (Eds.). (1996). Textbook of
deviate from social norms. This calls for a homosexuality and mental health. Washing-
certain amount of ego strength. Further, les- ton, DC: American Psychiatric Association.
bians and gay men tend to have a greater ca- Cochran, S. (2001). Emerging issues on lesbians’ and
pacity for both feminine and masculine traits, gay men’s mental health: Does sexual orienta-
which is generally associated with better psy- tion really matter? American Psychologist, 56,
chological health (Falco, 1991). 931– 947.
• Gender socialization and its impact on re- Coleman, E. (1987). The assessment of sexual orien-
lationships: Same-sex relationships are, by tation. Journal of Homosexuality, 14, 9 –24.
their very nature, composed of two people D’Augelli, A. R., & Patterson, C. J. (1995). Lesbian,
with similar gender socialization histories. gay, and bisexual identities over the lifespan.
New York: Oxford University Press.
While this may serve as a source of com-
Davison, G. (1991). Constructionism and morality
monality and connection, it can also create in therapy for homosexuality. In J. Gonsiorek
some difficulties. For example, as a result of & J. Weinrich (Eds.), Homosexuality: Research
their female socialization, both women in a implications for public policy (pp. 137 –148).
lesbian or bisexual relationship may be sexu- Newbury Park, CA: Sage.
ally unaggressive and reluctant to initiate in- Division 44 Committee on Lesbian, Gay and Bisex-
timate contact. ual Concerns Joint Task Force. (2000). Guide-
• Sexual identity as fluid: For some individu- lines for psychotherapy with lesbian, gay and
als, sexual orientation may be experienced as bisexual clients. American Psychologist, 55,
variable over the lifespan. This may result in 1440 –1451.
an identification that may or may not match Falco, K. L. (1991). Psychotherapy with lesbian
clients. New York: Brunner/Mazel.
the individual’s sexual behavior or relation-
Falco, K. L. (1996). Psychotherapy with women who
ship choices. In any case, the individual re- love women. In R. P. Cabaj & T. Stein (Eds.),
tains the right to determine her or his own Textbook of homosexuality and mental health
identity. (pp. 397 – 412). Washington, DC: American
Psychiatric Association.
The life experiences of lesbian, gay, and bi- Garnets, L., Hancock, K., Cochran, S., Peplau, L., &
sexual individuals presenting for psychother- Goodchilds, J. (1991). Issues in psychotherapy
apy are tremendously varied. Competent clini- with lesbians and gay men: A survey of psychol-
ogists. American Psychologist, 46, 964 –972.
cal practice with these groups does not require
Garnets, L. D., & Kimmel, D. C. (Eds.). (1993). Psy-
one to be lesbian, gay, or bisexual. Rather, it is chological perspectives on lesbian and gay
based on the ability to understand the lesbian, male experiences. New York: Columbia Uni-
gay, or bisexual individual in his or her own versity Press.
304 part iii • individual psychotherapy and treatment

Gonsiorek, J. D. (1982). Homosexuality and psy- Matteson, D. R. (1996). Psychotherapy with bi-
chotherapy: A practitioner’s handbook of affir- sexual individuals. In R. P. Cabaj & T. Stein
mative models. New York: Haworth. (Eds.), Textbook of homosexuality and mental
Gonsiorek, J. (1991). The empirical basis for the health (pp. 433 – 450). Washington, DC: Amer-
demise of the illness model of homosexuality. ican Psychiatric Association.
In J. Gonsiorek & J. Weinrich (Eds.), Homosex- Murphy, B. (1989). Lesbian couples and their par-
uality: Research issues for public policy (pp. ents: The effects of perceived parental attitudes
115 –136). Newbury Park, CA: Sage. on the couple. Journal of Counseling and De-
Gonsiorek, J. D., & Rudolph, J. R. (1991). Homosex- velopment, 68, 46 – 51.
ual identity: Coming out and other develop- Reiss, B. F. (1980). Psychological tests in homosexu-
mental events. In J. D. Gonsiorek & J. D. Wein- ality. In J. Marmor (Ed.), Homosexual behav-
rich (Eds.), Homosexuality: Research implica- ior: A modern reappraisal (pp. 296 –311). New
tions for public policy (pp. 161–176). Newbury York: Basic Books.
Park, CA: Sage. Savin-Williams, R. C. (1989). Coming out to par-
Gonsiorek, J. D., & Weinrich, J. D. (Eds.). (1991). ents and self-esteem among gay and lesbian
Homosexuality: Research implications for pub- youth. Journal of Homosexuality, 13, 101–
lic policy. Newbury Park, CA: Sage. 109.
Haldeman, D. C. (1994). The practice and ethics of Shidlo, A. & Schroeder, M. (2002). Changing sexual
sexual orientation conversion therapy. Journal orientation: A consumers’ report. Professional
of Consulting and Clinical Psychology, 62, Psychology, 33(3), 249 –259.
221–227. Weinberg, M. S., & Williams, C. J. (1974). Male ho-
Haldeman, D. (2002). Therapeutic antidotes: Help- mosexuals: Their problems and adaptations.
ing gay and bisexual men recover from conver- New York: Oxford University Press.
sion therapies. Journal of Lesbian and Gay
Psychotherapy, 5, 119 –132.
Hammersmith, S. K., & Weinberg, M. S. (1973).
Related Topics
Homosexual identity: Commitment, adjust-
ments, and significant others. Sociometry, 36, Chapter 58, “Assessing and Treating Normative
56 –78. Male Alexithymia”
Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. Chapter 62, “Guidelines for Treating Women in
(1948). Sexual behavior in the human male. Psychotherapy”
Philadelphia: Saunders.
 PSYCHOTHERAPY WITH
64 OLDER ADULTS

Margaret Gatz & Bob G. Knight

1. Case formulation: When seeing any older high in older adults with comorbid medical dis-
adult for treatment, an initial task of therapy is orders, in both inpatient and outpatient medical
to create a picture of the older adult, including care settings, and among those who are living
the individual’s strengths and ways of func- in nursing homes. (Review chapters concerning
tioning in the world, as well as the nature of the the influence of physical disease and medication
problem that has brought the person to treat- can be found in Carstensen, Edelstein, & Dorn-
ment. This picture can be conceptualized in any brand, 1996).
of several ways: as building a model of the per- 4. Age of onset: Early in the assessment, a
son, as describing the individual’s characteristic key question is to evaluate whether the current
defense mechanisms, or as identifying pre- problem is a new situation altogether or whether
ferred coping styles. it is a continuation, recurrence, or exacerbation
2. Cohort and culture: In understanding an of a previous problem. This consideration influ-
older adult client, it may be helpful to bring con- ences both inferences about etiology and choices
cepts from the study of cultural differences. The about treatment.
identity of an older adult will inevitably reflect 5. Differential diagnosis: In older adults who
the historical time during which she or he has are seen by the mental health care system, it is
matured. Working with a person who matured typical that multiple problems coexist; these
in a different time is similar in many ways to may include emotional distress, cognitive im-
working with clients who matured in a different pairment, chronic physical conditions, and
cultural context; the therapist must be careful changes in social network or environmental
about cohort- or culture-bound assumptions, context. The classical differential diagnostic dis-
word use, and values. Cohorts and cultures can tinction is between depression and dementia;
also interact in the sense that earlier-born older indeed, one frequent assessment question con-
adults may have a specific and strong sense of cerns the explanation for perceived changes in
ethnic identity with regard to ethnicities that memory. A more encompassing way to consider
are no longer identified as separate or disadvan- differential diagnosis is through a decision tree:
taged, for example, Irish or Italian. first, whether the pattern of functioning reflects
3. Epidemiology of disorder: Other than the normal aging versus some pathological process;
dementias, prevalence of psychological disor- second, what combination of emotional distress
ders is lower in older adults than in people of versus neuropathological changes (e.g., Alz-
other ages. This statement flies in the face of heimer’s disease, Parkinson’s disease) is sug-
stereotypes of old age as inevitably depressing gested; third, what aspects of the problem are
or anxiety-provoking. In fact, most older adults reversible. Sometimes following a case over
seem to have developed sufficient psychological time is the most certain way of distinguishing
resilience that they do not develop new disor- among assessment hypotheses. (Review chap-
ders in response to the transitions and life stres- ters about assessing dementia and depression as
sors that accompany aging. At the same time, well as a directory of instruments and norms
depression and other disorders may be quite can be found in Storandt & VandenBos, 1994.)

305
306 part iii • individual psychotherapy and treatment

6. Assessment: Psychological assessment is ered in the treatment plan, at the same time re-
often complex in older adults and frequently re- specting the confidentiality of the patient
quires a working knowledge of neuropsycho- (Qualls, 1996).
logical assessment, as well as the use of person- 11. End-of-life issues: Grief work is an
ality and emotional assessment techniques with inevitable part of psychotherapy with older
appropriate age norms. Simple screening de- adults. Increasingly, too, psychologists are in-
vices, such as mental status examinations and volving themselves in end-of-life care, includ-
brief scales to measure depression and anxiety, ing work at hospices and palliative care settings
can be helpful in day-to-day practice if their (Lawton, 2001).
limitations are understood (See Lichtenberg, 12. Spectrum of interventions: As different
1999, for a general resource about assessment.) theoretical approaches to psychotherapy have
7. Emergencies: Often older adults seem- emerged, each has been applied to older
ingly wait to see a mental health professional adults—for example, psychoanalysis, behavior
until there is some emergency, whether finan- modification, community mental health con-
cial or psychiatric or physical. In such in- sultation, and cognitive therapy. In addition, ef-
stances, the therapist must first resolve the forts have been made to use the knowledge base
emergency and only then deal with the psycho- from research about developmental processes in
logical circumstances (Scogin, 2000, covers later life in order to inform intervention. Re-
these issues). search has shown that older adults respond well
8. Suicide: Older adults, and especially older to a variety of forms of psychotherapy. Cogni-
white males, are in the age group at highest risk tive-behavioral, brief psychodynamic, and in-
for suicide (Conwell and Duberstein, 2001). terpersonal therapies have shown utility in the
This is due, in part, to the fact that the ratio of treatment of depression, anxiety, and sleep dis-
suicide attempts to suicide completions is much turbance; and 12-step programs have shown
lower among older adults. Older adults with de- utility with older alcohol abusers. Cognitive
pression, substance abuse, and those with de- training techniques, behavior modification strate-
menting illnesses who are aware of their cogni- gies, and environmental modifications have rel-
tive impairment and depressed about it should evance for improving functional abilities in
be assessed for suicide risk. Older clients can, cognitively impaired older adults. Finally, use
and do, make distinctions among not wanting to of reminiscence or life review is common with
live, wanting to die, and wanting to kill them- older adults, both as an element of other thera-
selves. While society debates the legality of ra- pies and as a separate, special technique. (The
tional suicide and assisted suicide, psychologists empirical evidence is summarized in Gatz et al.,
must be alert to those whose suicidal impulses 1998. Overview chapters about implementing
are motivated by psychological distress (APA this array of treatments may be found in Zarit
Working Group on Assisted Suicide and End- and Knight, 1996, while Karel, Ogland-Hand,
of-Life Decisions, 2000). and Gatz, 2002, focuses on depression.)
9. Access: The majority of older adults who 13. Relationship issues: From the beginning
meet diagnostic criteria for a mental disorder of psychotherapeutic work with older adults,
are not seen by any mental health professional. therapists have noted the potential for differ-
For this reason, the role of the psychologist in- ences in the therapeutic relationship when the
cludes home visits, medical hospital and nurs- client is older than the therapist. Older clients
ing home consultation, outreach to senior cen- confront the therapist with aging issues in an
ters, and cooperation with primary care physi- “off time” way— that is, the therapist confronts
cians (Smyer, 1993). reactions to aging, illness, disability, and death
10. Family: The family constitutes the pri- before these issues have arisen in the therapist’s
mary social context of older adults. If an older own life. Older clients may remind the therapist
adult is declining physically or cognitively, his of older relatives and elicit countertransferential
or her health-related dependencies and needs reactions related to parents, grandparents, and so
for assistance have radiating effects on the fam- forth (Knight, 1996). Therapists may share so-
ily. Consequently, the family must be consid- cial stereotypes about the elderly and expect
 64 • psychotherapy with older adults 307

their older clients to be boring, unattractive, or Conwell, Y., & Duberstein, P. R. (2001). Suicide in el-
asexual. Biases may also influence diagnosis; ders. Annals of the New York Academy of Sci-
therapists are inclined to interpret the same ences, 932, 132–150.
symptoms as reflecting brain disorder in an Gatz, M., Fiske, A., Fox, L. S., Kaskie, B., Kasl-
Godley, J. E., McCallum, T. J., et al. (1998).
older person but depression in a younger client.
Empirically-validated psychological treatments
14. Interface with medical care system:
for older adults. Journal of Mental Health and
Older adults with significant mental health Aging, 4, 9 – 46.
problems are most often seen by various non- Karel, M. J., Ogland-Hand, S., & Gatz, M. (2002).
specialists, such as primary care physicians. Assessing and treating late-life depression: A
Psychologists who see older adults must be pre- casebook and resource guide. New York: Basic
pared to work in interdisciplinary settings and Books.
to cooperate with other professionals (Zeiss & Knight, B. G. (1996). Psychotherapy with older
Steffen, 1996). Moreover, they must inform adults (2nd ed.). Thousand Oaks, CA: Sage.
themselves about the reimbursement system Koenig, H. G., George, L. K., & Schneider, R. (1994).
and become advocates for making the system Mental health care for older adults in the Year
2020: A dangerous and avoided topic. Gerontol-
responsive to their clients (Koenig, George, &
ogist, 34, 674 – 679.
Schneider, 1994).
Lawton, M. P. (2001). Quality of life and the end of
15. When to refer to a specialist or to seek life. In J. E. Birren & K. W. Schaie (Eds.), Hand-
more training in clinical geropsychology: book of the psychology of aging (5th ed., pp.
When older clients have problems similar to 592–616). San Diego: Academic Press.
younger clients and there is no reason to sus- Lichtenberg, P. A. (Ed.). (1999). Handbook of assess-
pect a dementing illness, psychotherapy with ment in clinical gerontology. New York: Wiley.
older adults is very similar to therapy with Qualls, S. H. (1996). Family therapy with aging fami-
younger adults. As assessment issues become lies. In S. H. Zarit & B. G. Knight (Eds.), A guide
more complex and more subtle, such as needing to psychotherapy and aging (pp. 121–137). Wash-
to disentangle multiple possible causes of symp- ington, DC: American Psychological Association.
Scogin, F. (2000). The first session with seniors: A
toms, more specialized knowledge is needed.
step-by-step guide. San Francisco: Jossey-Bass.
Practitioners working in an age-segregated en-
Smyer, M. A. (Ed.). (1993). Mental health and ag-
vironment (e.g., nursing homes) or becoming ing. New York: Springer.
more specialized in treating older adults need Storandt, M. A., & VandenBos, G. R. (Eds.). (1994).
more training in clinical geropsychology. Con- Neuropsychological assessment of dementia
tinuing education in clinical geropsychology and depression in older adults: A clinician’s
can often be found through the American Psy- guide. Washington, DC: American Psychologi-
chological Association, sponsored by Section 2 cal Association.
(Clinical Geropsychology) of Division 12 (Clin- Zarit, S. H., & Knight, B. G. (Eds.). (1996). A guide
ical Psychology), or by Division 20 (Adult De- to psychotherapy and aging: Effective clinical
velopment and Aging), by the Gerontological interventions in a life-stage context. Washing-
ton, DC: American Psychological Association.
Society of America at its annual meeting,
Zeiss, A. M., & Steffen, A. M. (1996). Interdiscipli-
through state and local psychological associa-
nary health care teams: The basic unit of geri-
tions, and through some universities and med- atric health care. In L. L. Carstensen, B. A. Edel-
ical centers, especially those with Alzheimer’s stein, & L. Dornbrand, L. (Eds.), The practical
disease research centers. handbook of clinical gerontology (pp. 423 –
450). Thousand Oaks, CA: Sage.
References, Readings, & Internet Sites
APA Working Group on Assisted Suicide and End- Related Topics
of-Life Decisions. (2000). Report to the Board of Chapter 2, “Mental Status Examination”
Directors. Retrieved 2004 from http://www. Chapter 7, “Adult Neuropsychological Assessment”
apa.org/pi/aseol/introduction.html Chapter 57, “Psychological Interventions in Adult
Carstensen, L. L., Edelstein, B. A., & Dornbrand, L. Disease Management”
(Eds.). (1996). The practical handbook of clini- Chapter 72, “Psychotherapy With Cognitively Im-
cal gerontology. Thousand Oaks, CA: Sage. paired Adults”
 65 REFUSAL SKILLS TRAINING

Robert H. Woody & Jennifer K. H. Woody

Regardless of service context (e.g., schools, clin- This is clearly an educational approach, and it
ics, hospitals, agencies, or private practices), requires astute teaching methods and highly
psychologists need strategies and techniques relevant informational materials. Normative
for helping clients solve everyday or real-world influence is directed at the pressures or rein-
problems. Moreover, the diminishing availabil- forcers that the client encounters, especially
ity of mental health services for persons of all those emitted by other persons such as peers.
ages, particularly today’s children and youth Generally, training programs rely on infor-
(with the behavioral problems and conduct dis- mational influence disseminated by a pamphlet
orders endemic to and seemingly epidemic in or other material, perhaps supplemented with
that age group), supports the need for evi- brief individual or group counseling. The nor-
denced-based interventions that have proven mative influence is offered through behavioral
efficacy. Since most mental health services now rehearsal or modeling techniques (either in
occur in schools, educationally oriented profes- vivo or by videotape). A variety of studies indi-
sionals and clinical practitioners alike must be cate that electronic media, especially those in-
competent in brief strategies that are adaptable volving video stimuli, can enhance learning
to a myriad of therapeutic objectives and com- (Herrmann & McWhirter, 1997). While there
patible with the mission of schools. are innumerable variables to be considered, it
This chapter presents a clear-cut approach would appear that normative influence may be
that promotes behavior change in an efficacious the most effective for behavior change (Poler,
manner, namely evidence-based Refusal Skills Warzak, & Woody, 2003).
Training (RST). With a cognitive-behavioral RST employs multiple interventions that
basis, RST uses short-term interventions that may vary in the psychological processes that are
focus on specific or targeted behavior problems emphasized. Goldstein, Reagles, and Amann
(Shechtman, 2002; Woody, 2004) and capital- (1990) suggest six types of interventions: cog-
izes on social support (Demaray & Malecki, nitive, environmental, affective/interpersonal,
2002). Further, RST is suited for use by educa- therapeutic, school alternative, and social learn-
tors or clinicians, and is compatible with the ing. While all of these approaches could be
overall “educational” mission of schools. implemented proactively, the therapeutic and
school alternative approaches are most often re-
active (i.e., after the problem has occurred).
FORMS AND EXAMPLES OF Cognitive interventions promote informa-
RST PROGRAMS tional influence but can also involve normative
influence. Using a variety of techniques and
RST emphasizes two forms of influence: infor- formats, the cognitive approach provides infor-
mational influence and normative influence. mation that will presumably enable the client/
Informational influence is directed at the pres- student to make informed decisions (e.g., not
sures or reinforcers experienced by the client to use drugs). Similarly, some strategies have
in everyday life, such as advertisements of sought cognitive change through aversive in-
products and mass media depictions of behav- formation, say, about detrimental substances or
iors that could reinforce unhealthy outcomes. behaviors. Fear-arousing and punishment tac-

308
 65 • refusal skills training 309

tics have proved ineffective in altering high- ternative school or group residence). The alter-
risk behavior; moreover, Hansen et al. (1988) native approach, if managed properly, makes
found that informational programs, such as ex- normative influence possible; if managed poorly,
plaining how a drug or alcoholic substance adverse modeling can occur.
works or what it looks like, might actually Social learning interventions most closely
arouse curiosity or promote experimentation. parallel the normative influence approach. This
The latter result might occur especially if the strategy commonly incorporates observational
information is presented in, say, a peer context learning, behavioral rehearsal, and reinforce-
and the positive message is subverted by ad- ment contingencies. The majority of social skill
verse normative influence. and refusal skill curricula fall under this rubric.
Environmental interventions are those that Most often, these programs rely on providing
target the context in which the high-risk be- information, developing social and self-regula-
havior takes place. For example, since the school tory skills, skill enhancement through guided
is a critical site in a young person’s life and has practice and social support for behavioral change.
legal authority to restrict behavior, schools A social learning approach can function in a
have implemented drug intervention strategies, preventive as well as a corrective manner. Fur-
such as strict policies, detection methods, and ther, behavioral rehearsal allows students to
prevention/intervention organizations (Gold- practice these skills in a socially valid context
stein et al., 1990). This approach combines the (e.g., with their peers, in a school setting).
possibility of informative and normative influ-
ence.
Affective/interpersonal interventions, which EMPIRICAL RESEARCH ON
emphasize information and instruction, target RST PROGRAMS
the student’s self-concept, self-acceptance, and
decision-making processes. Again, research on Increasingly, research has demonstrated the ef-
these strategies, such as values clarification, has fectiveness of RST that employs social learn-
shown little assured effect on behavioral change ing/normative approaches (Goldstein, 1981,
(Goodstat & Sheppard, 1983). Although infor- 1988; Katz, Robisch, & Telch, 1989; Reardon,
mative influence dominates, a group program Sussman, & Flay, 1989; Schinke & Blythe,
or the descriptions in the information can draw 1982; Schinke & Gilchrist, 1984). Clearly, ad-
upon normative influence. ditional research is needed to evaluate the ef-
Therapeutic interventions involve the stu- fectiveness of RST with lower-income and mi-
dent entering into individual or group counsel- nority populations.
ing. The therapeutic focus is on the high-risk The research results for RST are, for the
behavior or maladaptive behavior. Beyond any most part, efficacy studies. Despite an effort to
change that might occur from insight (e.g., im- carefully structure the intervention and the use
proved definition of personal needs or develop- of a particular educationally oriented program
ment of coping abilities), the interpersonal re- that can be defined, the research seldom, if ever,
lationships introduce normative influence. Cer- controls and measures the presence or absence
tainly, counseling provided in a group context (or degree of influence from) the interpersonal
creates the possibility of powerful normative conditions that could facilitate learning and be-
influence. havioral change for the client. Consequently,
School alternative interventions, like the the effects of the interpersonal conditions re-
therapeutic approach, tend to be employed main unmeasured and likely contaminate the
when a problem already exists. With the for- efficacy attributed to RST. In addition, the var-
mer, the student enters into individual or group ious RST programs contain unique contents,
counseling, with a focus on the high-risk be- and “making comparison across programs is in-
havior. With the latter, the student with an in- herently difficult” (Herrmann & McWhirter,
corrigible behavior pattern is placed in an en- 1997, p. 177).
vironment that includes treatment (e.g., an al- Since RST programs are finding ready re-
310 part iii • individual psychotherapy and treatment

ception in schools, the use of peers as models or Transfer-enhancing procedures may include
leaders, either in vivo or by video recordings, is such strategies as overlearning, stimulus vari-
common. As would be expected, the results ability, and mediated generalization (e.g., self-
have been positive, such as enhancing the ef- recording, self-reinforcement). Maintenance-
forts of teachers or counselors (Perry, 1989). enhancing strategies incorporate the use of
From their review of the research, Herr- prompt fading, reinforcement fading/with-
mann and McWhirter (1997) conclude that drawal, booster sessions, and natural rein-
RST (which they refer to as Refusal and Resis- forcers (Goldstein et al., 1990).
tance Skills, or RRS) programs defy generaliza-
tion: “In other words, neither general endorse-
Clarifying the Intervention
ments nor general criticisms of RRS programs
are appropriate because a number of different Each RST program has an indiosyncratic theo-
mediating factors (including target behaviors retical basis, which means that even if the
and process variables) interact to determine the interventions appear to be the same or compa-
efficacy of different programs. Moreover, the rable, the underlying nuances may be quite dif-
quality of program delivery plays an important ferent and, thus, the effects are like the pro-
role in determining overall program effective- verbial “apples and oranges.” For example, the
ness” (p. 184). They also believe that the re- majority of RST programs rely, to varying de-
search supports early intervention; caution that grees, on learning theory, yet there is also use
it remains unproved that refusal and resistance of interpersonal relationships (which may or
skills will actually be implemented behav- may not actually adhere to a reinforcement
iorally; and endorse a comprehensive preven- paradigm). Analysis of the RST programs re-
tion curriculum and use of peer facilitation. veals both behavioral modification and cogni-
Certainly, it is known that most therapeutic tive restructuring techniques, as evidenced by
interventions, especially those based on pro- “(1) an emphasis on the present and near fu-
moting insight, do not modify maladaptive be- ture; (2) a problem-solving orientation that fo-
havioral problems, such as tobacco smoking, cuses on changing cognitions and/or overt be-
substance abuse, and risky sexual activity. havior; and (3) attention to conscious rather
Therefore, there is nothing to lose and poten- than to unconscious determinants of behavior”
tially much to gain from capitalizing on the (Robertson & Woody, 1997, p. 178). Thus, the
proven informational and normative influences practitioner should carefully delineate the
that can be included in behaviorally based RST change mechanisms for the purposes of practice
programs. If supplemented with nurturance, improvement and clinical research.
empathy, and other facilitative conditions, RST
programs, particularly in a peer-group context,
most likely will lead to cognitive restructuring GUIDELINES FOR PRACTICE
and behavioral shaping and become the inter-
vention of choice for smoking, alcohol and sub- There is solid behavioral science for imple-
stance abuse, delinquency, gang behavior, and menting RST programs, especially for preven-
risky sexual activity. tion; other behavioral modification approaches
may be as good as or better than RST for
changing existing maladaptive behaviors. Be-
Promoting Maintenance
fore offering an RST program, the practitioner
Possibly the most important criterion for the should, of course, be mindful of previous state-
success of RST programs is maintenance. The ments regarding promoting maintenance and
question becomes: How can professionals en- clarifying the intervention. The following 10
sure that a student who masters a skill within guidelines provide a step-by-step approach.
the therapeutic context will, in fact, use the skill
in real-world experiences? Skill generaliza- 1. Determine the characteristics of the clients/
tion should be addressed in any RST program. students. While it is feasible to establish a
 65 • refusal skills training 311

given RST program and then select clients/ RST program. Empathic understanding
students who are seemingly compatible, it and other facilitative conditions should
is preferable to first evaluate the pool of po- preface any information that might be per-
tential clients/students. Knowing the char- ceived as confrontive by the clients/stu-
acteristics of possible recipients of RST ser- dents; these qualities should continue
vices allows one to tailor the program to throughout the RST program. Each client/
their needs. student should be comfortable with the
2. Delineate and define the behavior that is to professional and the other clients/students
be targeted (e.g., tobacco smoking, sub- before being challenged by an RST task.
stance abuse, or risky sexual activity), and The client/student who is insecure, shy, or
establish reinforcement contingencies that easily threatened or who lacks expressive
rely on information and/or normative in- skills may merit special attention, within
fluence. These decisions should be stated in or outside the group.
writing and critiqued by at least one other 8. Group dynamics should be monitored and
professional source. managed. If a group format is used, special
3. Determine whether the format will be in- attention should be given to promoting co-
dividual or group. Given the importance of hesion. Care should be taken to avoid in-
peer interactions, generally a group format terpersonal conflicts that cannot be used
should be considered before deciding on an therapeutically, as well as unnecessary dis-
individual format. In keeping with re- sonance and cleavage. Gamelike strategies
search on group dynamics, five to eight may be useful for reinforcing critical dy-
students is appropriate to facilitate peer in- namics in the group.
teractions. 9. Techniques for maintaining the effects of
4. If using a group format, structure for het- the RST program outside the sessions
erogeneity of skill proficiency. Clients/stu- should be applied. It is often helpful to use
dents with more proficient refusal skills homework assignments, self-monitoring,
provide supportive modeling and rein- journal writing, or booster sessions (in
forcement for the group members with less person or by telephone with, say, a desig-
proficient refusal skills. nated “buddy” from the same program or
5. Communication of information should be with the professional). Family and social
tailored to the developmental, emotional, contacts should be enlisted to help the
and cognitive levels of the clients/students. clients/students progress in real-life situ-
Stated simply, the content and delivery ations. The results of these external efforts
style should be understandable to the or events should be discussed in the ses-
clients/students. sions.
6. Determine and adhere strictly to a behav- 10. When an RST program is completed, make
ior management plan. In accord with the a thoughtful evaluation of the successes
behaviors that were delineated, introduce, and failures, individually and at the group
monitor, and maintain rules. A behavior/ level. By understanding the effects of an
rule contract signed by each client/student RST program, professionals will poten-
is advisable (e.g., required attendance, com- tially design more effective future offer-
pleting homework assignments). Relying ings.
on the behavior management plan allows
individual and group behaviors to be rein-
forced systematically. At least initially, References, Readings, & Internet Sites
natural/tangible reinforcers are needed. Demaray, M. K., & Malecki, C. K. (2002). Critical
7. From the initial session and throughout, levels of perceived social support associated
emphasis should be placed on establishing with student adjustment. School Psychology
client/student rapport with the profes- Quarterly, 17, 213 –241.
sional and motivation to benefit from the Goldstein, A. P. (1988). The Prepare Curriculum:
312 part iii • individual psychotherapy and treatment

Teaching prosocial skill competencies. Cham- fessionals’ preferences. Unpublished manu-

paign, IL: Research Press. script, University of Nebraska Medical Center.
Goldstein, A. P., Reagles, K. W., & Amann, L. L. Reardon, K. K., Sussman, S., & Flay, B. R. (1989).
(1990). Refusal skills: Preventing drug use in Are we marketing the right message: Can kids
adolescents. Champaign, IL: Research Press. “just say no” to smoking? Communication
Goodstat, M., & Sheppard, M. (1983). Three ap- Monographs, 56, 307 –324.
proaches to alcohol education. Journal of Stud- Resource Center for Adolescent Pregnancy Preven-
ies on Alcohol, 44, 362–380. tion. (n.d.). Home page. http://www.etr.org/
Hansen, W. B., Graham, J. W., Wolkenstein, B. H., recapp
Lundy, B. Z., Pearson, J., Flay, B. R., et al. Robertson, M. H., & Woody, R. H. (1997). Theories
(1988). Differential impact of three alcohol pre- and methods for practice of clinical psychol-
vention curricula on hypothesized mediating ogy. Madison, CT: International Universities
variables. Journal of Drug Education, 18, 143 – Press.
153. Schinke, S. P., & Blythe, B. (1982). Cognitive-
Herrmann, D. S., & McWhirter, J. J. (1997). Refusal behavioral prevention of children’s smoking.
and resistance skills for children and adoles- Child Behavior Therapy, 3, 25 – 42.
cents: A selected review. Journal of Counseling Schinke, S. P., & Gilchrist, L. D. (1984). Life skills
and Development, 75, 177 –187. counseling with adolescents. Baltimore: Uni-
Katz, R. C., Robisch, C. M., & Telch, M. J. (1989). versity Park Press.
Acquisition of smoking refusal skills in junior Shechtman, Z. (2002). Child group psychotherapy
high school students. Addictive Behaviors, 14, in the school at the threshold of a new millen-
201–204. nium. Journal of Counseling & Development,
McQuillen, J. S., Higginbotham, D. C., & Cum- 80, 293 –299.
mings, M. C. (1984). Compliance-resisting be- Utah Education Network. (n.d.). Resource sites.
haviors: The effects of age, agent, and types of http://www.uen.org/utahlink and www.uen.
requests. In R. N. Bostrom (Ed.), Communica- org/lessonplan
tion yearbook 9 (pp. 747 – 762). Beverly Hills, Woody, R. H. (2004). Group therapy: An integra-
CA: Sage. tive cognitive social-learning approach. Sara-
No More Drugs. (n.d.). Home page. http://www. sota, FL: Professional Resource Press.
nodrugs.com
Perry, C. L. (1989). Prevention of alcohol use and
abuse in adolescence: Teacher- vs. peer-led in-
Related Topics
tervention. Crisis, 10, 52– 61.
Poler, M., Warzak, W. J., & Woody, R. H. (2003). Chapter 55, “Motivational Interviewing”
Acceptability of refusal skills training modal- Chapter 66, “Sexual Feelings, Actions, and Dilem-
ities: A comparison of adolescents’ and pro- mas in Psychotherapy”
 SEXUAL FEELINGS, ACTIONS,
66 AND DILEMMAS IN
PSYCHOTHERAPY

Kenneth S. Pope

A HISTORY OF THE PROHIBITION the female therapists reported engaging in sex

AGAINST THERAPIST-PATIENT SEX with a client.
Data from these studies, as well as others
The prohibition against engaging in sex with a (e.g., anonymous surveys of patients, anony-
patient is ancient, reaching back not only to the mous surveys of therapists working with pa-
Hippocratic oath, which emerged in the 3rd or tients who have been sexually involved with a
4th century B.C., but also to the earlier codes of prior therapist; records of disciplinary actions),
the Nigerian healing arts (Pope, 1994). The suggest that therapist-patient sex is consistent
modern codes of clinical ethics contained no ex- with other forms of abuse such as rape and
plicit mention of this topic until research began incest: the perpetrators are overwhelmingly
revealing that substantial numbers of therapists (though not exclusively) male, and the victims
were violating the prohibition. Although the are overwhelmingly (though not exclusively)
codes had not highlighted this particular form female (Pope, 1994).
of patient exploitation by name, therapist- This significant gender difference has long
patient sex violated various sections of the codes been a focus of scholarship in the area of ther-
prior to the 1970s (Hare-Mustin, 1974). The apist-patient sex, but it is still not well under-
long history of prohibition against therapist- stood. Holroyd and Brodsky’s (1977) report of
patient sexual involvement has also been rec- the first national study of therapist-patient sex
ognized by the courts (see, e.g., the judge’s concluded with a statement of major issues that
statement in Roy v. Hartogs, 1976, p. 590). had yet to be resolved: “Three professional is-
sues remain to be addressed: (a) that male ther-
apists are most often involved, (b) that female
SURVEY DATA, OFFENDERS, patients are most often the objects, and (c) that
VICTIMS, AND GENDER PATTERNS therapists who disregard the sexual boundary
once are likely to repeat” (p. 849). Holroyd sug-
Despite the prohibition, a significant number of gested that the significant gender differences
therapists report that they became sexually in- reflected sex role stereotyping and bias: “Sexual
volved with at least one patient. When data contact between therapist and patient is perhaps
from national studies published in peer- the quintessence of sex-biased therapeutic prac-
reviewed journals are pooled, 5,148 psycholo- tice” (Holroyd, 1983, p. 285).
gists, psychiatrists, and social workers provide Holroyd and Brodsky’s (1977) landmark re-
anonymous self-reports (Pope, 1994). Accord- search was followed by a second national study
ing to these pooled data, about 4.4% of the focusing on not only therapist-patient but also
therapists reported becoming sexually involved professor-student sexual relationships (Pope,
with a client. The gender differences are signif- Levenson, & Schover, 1979), which found: “When
icant: 6.8% of the male therapists and 1.6% of sexual contact occurs in the context of psychol-

313
314 part iii • individual psychotherapy and treatment

ogy training or psychotherapy, the predomi- treat the emotional closeness that de-
nant pattern is quite clear and simple: An older velops in therapy with sufficient at-
higher status man becomes sexually active with tention, care, and respect.
a younger, subordinate woman. In each of the 9. Time out: Therapist fails to acknowledge
higher status professional roles (teacher, super- and take account of the fact that the thera-
visor, administrator, therapist), a much higher peutic relationship does not cease to exist
percentage of men than women engage in sex between scheduled sessions or outside the
with those students or clients for whom they therapist’s office.
have assumed professional responsibility. In the 10. Hold me: Therapist exploits patient’s desire
lower status role of student, a far greater pro- for nonerotic physical contact and possible
portion of women than men are sexually active confusion between erotic and nonerotic
with their teachers, administrators, and clinical contact.
supervisors” (Pope et al. 1979, p. 687).

WORKING WITH PATIENTS WHO

COMMON SCENARIOS OF HAVE BEEN SEXUALLY INVOLVED
THERAPIST-PATIENT SEXUAL WITH A THERAPIST
INVOLVEMENT
National survey research suggests that most
It is useful for therapists to be aware of the clinicians are likely to encounter at least one pa-
common scenarios in which therapists sexually tient who has been sexually involved with a
exploit their patients. It is important to empha- prior therapist (Pope & Vetter, 1991). Special-
size, however, that these are only general de- ized treatment approaches, based on research,
scriptions of some of the most common pat- have been developed for this population (Pope,
terns, and many instances of therapist-patient 1994). One of the first steps toward gaining
sexual involvement will not fall into these 10 competence in this area is recognition of the di-
scenarios, which were discussed by Pope and verse and sometimes extremely intense reac-
Bouhoutsos (1986, p. 4): tions that a subsequent therapist can experience
when encountering a patient who reports sex-
1. Role trading: Therapist becomes the “pa- ual involvement with a former therapist. The
tient,” and the wants and needs of the ther- following list of common (but not universal)
apist become the focus. clinical reactions to victims of therapist-patient
2. Sex therapy: Therapist fraudulently pre- sexual involvement is adapted from Pope,
sents therapist-patient sex as valid treatment Sonne, and Holroyd (1993, pp. 241–261):
for sexual or related difficulties.
3. As if . . . : Therapist treats positive transfer- 1. Disbelief and denial: The tendency to reject
ence as if it were not the result of the thera- reflexively— without adequate data gather-
peutic situation. ing—allegations about therapist-patient sex
4. Svengali: Therapist creates and exploits an (e.g., because the activities described seem
exaggerated dependence on the part of the outlandish and improbable).
patient. 2. Minimization of harm: The tendency to as-
5. Drugs: Therapist uses cocaine, alcohol, or sume reflexively — without adequate data
other drugs as part of the seduction. gathering— that harm did not occur or that,
6. Rape: Therapist uses physical force, threats, if it did, the consequences were minimally, if
and/or intimidation. at all, harmful.
7. True love: Therapist uses rationalizations 3. Making the patient fit the textbook: The
that attempt to discount the clinical, profes- tendency to assume reflexively — without
sional, and fiduciary nature of the profes- adequate data gathering and examination—
sional relationship and its responsibilities. that the patient must inevitably fit a partic-
8. It just got out of hand: Therapist fails to ular schema.
 66 • sexual feelings, actions, and dilemmas in psychotherapy 315

4. Blaming the victim: The tendency to at- stances, the therapist may seek consultation to
tempt to make the patient responsible for help gain perspective and understanding.
enforcing the therapist’s professional re-
sponsibility to refrain from engaging in
sex with a patient, and holding the patient SEXUAL ATTRACTION TO
responsible for the therapist’s offense. PATIENTS AND OTHER (SOMETIMES)
5. Sexual reaction to the victim: The clini- UNCOMFORTABLE FEELINGS
cian’s sexual attraction to or feelings about
the patient. Such feelings are normal but Sexual attraction to patients seems to be a
must not become a source of distortion in prevalent experience that evokes negative reac-
the assessment process. tions. National survey research suggests that
6. Discomfort at the lack of privacy: The clin- over 4 out of 5 psychologists (87%) and social
ician’s (and sometimes patient’s) emotional workers (81%) report experiencing sexual at-
response to the possibility that under cer- traction to at least one client (Bernsen, Tabach-
tain conditions (e.g., malpractice, licensing, nick, & Pope, 1994; Pope, Keith-Spiegel, &
or similar formal actions against the of- Tabachnick, 1986). Yet simply experiencing the
fending therapist; a formal review of as- attraction (without necessarily even feeling
sessment and other services by the insur- tempted to act on it) causes most of the thera-
ance company providing coverage for the pists who report such attraction (63% of the
services) the raw data and the results of the psychologists; 51% of the social workers) to
assessment may not remain private. feel guilty, anxious, or confused about the at-
7. Difficulty “keeping the secret”: The cli- traction.
nician’s possible discomfort (and other emo- That sexual attraction causes such discom-
tional reactions) when he or she has knowl- fort among so many psychologists and social
edge that an offender continues to practice workers may be the reason that graduate train-
and to victimize other patients but cannot, ing programs and internships tend to neglect
in light of confidentiality and/or other con- training in this area. Only 9% of psychologists
straints, take steps to intervene. and 10% of social workers in these national
8. Intrusive advocacy: The tendency to want studies reported that their formal training on
to guide, direct, or determine a patient’s de- the topic in graduate school and internships had
cisions about what steps to take or what been adequate. A majority of psychologists and
steps not to take in regard to a perpetrator. social workers reported receiving no training
9. Vicarious helplessness: The clinician’s dis- about such attraction. This discomfort may also
comfort when a patient who has filed a for- explain why scientific and professional books
mal complaint seems to encounter unjusti- seem to neglect this topic:
fiable obstacles, indifference, lack of fair
hearing, and other responses that seem to In light of the multitude of books in the areas of hu-
ignore or trivialize the complaint and fail man sexuality, sexual dynamics, sex therapies, un-
to protect the public from offenders. ethical therapist-patient sexual contact, management
10. Discomfort with strong feelings: The cli- of the therapist’s or patient’s sexual behaviors, and so
nician’s discomfort when experiencing strong on, it is curious that sexual attraction to patients per
feelings (e.g., rage, neediness, or ambiva- se has not served as the primary focus of a wide
lence) expressed by the patient and focused range of texts. The professor, supervisor, or librarian
on the clinician. seeking books that turn their primary attention to
exploring the therapist’s feelings in this regard
Awareness of these reactions can prevent would be hard pressed to assemble a selection from
them from blocking the therapist from render- which to choose an appropriate course text. If some-
ing effective services to the patient. The thera- one unfamiliar with psychotherapy were to judge
pist can be alert to such reactions and can sort the prevalence and significance of therapists’ sexual
through them should they occur. In some in- feelings on the basis of the books that focus exclu-
316 part iii • individual psychotherapy and treatment

sively on that topic, he or she might conclude that Unfortunately, it is all too easy to consider
the phenomenon is neither wide-spread nor impor- such data intellectually but remain unaware of
tant. (Pope, Sonne, & Holroyd, 1993, p. 23) the ways in which the therapist’s sexual feel-
ings, anger, hatred, fear, and other responses af-
These and similar factors may form a vicious fect clinical services. Specific, structured train-
circle: Discomfort with sexual attraction may ing exercises and other programs (e.g., Pope et
have fostered an absence of graduate training al., 1993) may be helpful in graduate training
and relevant textbooks; in turn, an absence of programs, internships, continuing education
programs providing training and relevant text- workshops, and other settings to enable thera-
books in this area may sustain or intensify dis- pists to encounter such responses in a way that
comfort with the topic. The avoidance of the will enhance or at least not distort the effec-
topic may produce a real impact. tiveness of clinical services.
These studies reveal significant gender ef-
fects in reported rates of experiencing sexual at-
traction to a patient. About 95% of the male WHEN THE THERAPIST IS UNSURE
psychologists and 92% of the male social work- WHAT TO DO
ers, compared with 76% of the female psychol-
ogists and 70% of the female social workers, What can the therapist do when he or she
reported experiencing sexual attraction to a pa- doesn’t know what to do? One of the most im-
tient. The research suggests that just as male portant steps is to realize that the complexity of
therapists are significantly more likely to be- therapeutic work and the uniqueness of the hu-
come sexually involved with their patients, man individual prevent any one-size-fits-all
male therapists are also more likely to experi- “answers” to what sexual feelings about pa-
ence sexual attraction to their patients. tients mean or their implications for the ther-
These national surveys suggest that a sizable apy. Nor can one look to ethics codes for easy
minority of therapists carry with them— in the answers.
physical absence of the client— sexualized im-
ages of the client and that a significantly greater Ethics codes cannot do our questioning, thinking,
percentage of male than female therapists expe- feeling, and responding for us. Such codes can never
rience such cognitions. About 27% of male be a substitute for the active process by which the
psychologists and 30% of male social workers, individual therapist or counselor struggles with the
compared with 14% of female psychologists sometimes bewildering, always unique constellation
and 13% of female social workers, reported en- of questions, responsibilities, contexts, and compet-
gaging in sexual fantasies about a patient while ing demands of helping another person. . . . Ethics
engaging in sexual activity with another person must be practical. Clinicians confront an almost
(i.e., not the patient). unimaginable diversity of situations, each with its
National survey research has found that own shifting questions, demands, and responsibili-
46% of psychologists reported engaging in sex- ties. Every clinician is unique in important ways.
ual fantasizing (regardless of the occasion) about Every client is unique in important ways. Ethics that
a patient on a rare basis and that an additional are out of touch with the practical realities of clini-
26% reported more frequent fantasies of this cal work, with the diversity and constantly changing
kind (Pope, Tabachnick, & Keith-Spiegel, 1987), nature of the therapeutic venture, are useless. (Pope
and 6% have reported telling sexual fantasies to & Vasquez, 1998, pp. xiii –xiv)
their patients. Such data may be helpful in un-
derstanding not only how therapists experience The book Sexual Feelings in Psychotherapy
and respond to sexual feelings but also how (Pope et al., 1993) suggests a 10-step approach
therapists and patients represent (e.g., remem- to such daunting situations that places funda-
ber, anticipate, think about, fantasize about) each mental trust in the individual therapist, ade-
other when they are apart and how this affects quately trained and consulting with others, to
the therapeutic process and outcome. draw his or her own conclusions. Almost with-
 66 • sexual feelings, actions, and dilemmas in psychotherapy 317

out exception therapists learn at the outset the consistent with that communication? Does
fundamental resources for helping themselves the contemplated action needlessly cloud the
explore problematic situations. Depending on clarity of that communication? The therapist
the situation, they may: introspect, study the may be intensely tempted to act in ways that
available research and clinical literature, con- stir the patient’s sexual interest or respond
sult, seek supervision, and/or begin or resume in a self-gratifying way to the patient’s sex-
personal therapy. But sometimes even after the uality. Does the contemplated action repre-
most sustained exploration, the course is not sent however subtly a turning away from
clear. The therapist’s best understanding of the the legitimate goals of therapy?
situation suggests a course of action that seems 4. Clarification: The fourth consideration in-
productive yet questionable and perhaps poten- vites therapists to ask if the contemplated ac-
tially harmful. To refrain from a contemplated tion would be better postponed until sexual
action may cut the therapist off from legiti- and related issues have been clarified. As-
mately helpful spontaneity, creativity intuition, sume, for example, that a therapist’s theo-
and the ability to respond effectively to the pa- retical orientation does not preclude physi-
tient’s needs. On the other hand, engaging in cal contact with patients and that a patient
the contemplated action may lead to disaster. has asked that each session conclude with a
When reaching such an impasse therapists may reassuring hug between therapist and pa-
find it useful to consider the potential interven- tient. Such ritualized hugs could raise com-
tion in light of the following 10 considerations plex questions about their meaning for the
(Pope et al., 1993): patient about their impact on the relation-
ship and about how they might influence the
1. The fundamental prohibition: Is the con- course and effectiveness of therapy. It may
templated action consistent with the funda- be important to clarify such issues with the
mental prohibition against therapist-patient patient before making a decision to conclude
sexual intimacy? Therapists must never vi- each session with a hug.
olate this special trust. If the considered 5. The patient’s welfare: The fifth considera-
course of action includes any form of sexual tion is one of the most fundamental touch-
involvement with a patient it must be re- stones of all therapy: Is the contemplated ac-
jected. tion consistent with the patient’s welfare?
2. The slippery slope: The second consideration The therapist’s feelings may become so in-
may demand deeper self-knowledge and tensely powerful that they may create a con-
self-exploration. Is the contemplated course text in which the patient’s clinical needs may
of action likely to lead or to create a risk for blur or fade away altogether. The patient
sexual involvement with the patient? The may express wants or feelings with great
contemplated action may seem unrelated to force. The legal context— with the litigious-
any question of sexual exploitation of a ness that seems so prevalent in current so-
patient. Yet depending on the personality ciety— may threaten the therapist in a way
strengths and weaknesses of the therapist, that makes it difficult to keep a clear focus
the considered action may constitute a sub- on the patient’s welfare. Despite such com-
tle first step on a slippery slope. In most peting factors and complexities, it is crucial
cases the therapist alone can honestly ad- to assess the degree to which any contem-
dress this consideration. plated action is consistent with, is irrelevant
3. Consistency of communication: The third to, or is contrary to the patient’s welfare.
consideration invites the clinician to review 6. Consent: The sixth consideration is yet an-
the course of therapy from the start to the other fundamental touchstone of therapy: Is
present: Has the therapist consistently and the contemplated action consistent with the
unambiguously communicated to the pa- basic informed consent of the patient?
tient that sexual intimacies cannot and will 7. Adopting the patient’s view: The seventh
not occur and is the contemplated action consideration urges the therapist to em-
318 part iii • individual psychotherapy and treatment

pathize imaginatively with the patient: How 9. Uncharacteristic behaviors: The ninth con-
is the patient likely to understand and re- sideration involves becoming alert to un-
spond to the contemplated action? Therapy is usual actions: Does the contemplated action
one of many endeavors in which exclusive fall substantially outside the range of the
attention to theory, intention, and technique therapist’s usual behaviors? That an action
may distract from other sources of informa- is unusual does not, of course, mean that
tion, ideas, and guidance. Therapists-in- something is necessarily wrong with it.
training may cling to theory, intention, and Creative therapists will occasionally try
technique as a way of coping with the anxi- creative interventions, and it is unlikely
eties and overwhelming responsibilities of that even the most conservative and tradi-
the therapeutic venture. Seasoned therapists tion-bound therapist conducts therapy the
may rely almost exclusively on theory, in- same way all the time; however, possible
tention, and technique out of learned reflex, actions that are considerably outside the
habit, and the sheer weariness that ap- therapist’s general approaches likely war-
proaches burnout. There is always risk that rant special consideration.
the therapist will fall back on repetitive and 10. Consultation: The final consideration con-
reflexive responses that verge on stereotype. cerns secrecy: Is there a compelling reason
Without much thought or feeling, the anx- for not discussing the contemplated action
ious or tired therapist may, if analytically with a colleague consultant or supervisor?
minded, answer a patient’s question by ask- Therapists’ reluctance to disclose an action
ing why the patient asked the question; if to others is a “red flag” for a possibly in-
holding a client-centered orientation, the appropriate action. Therapists may consider
therapist may simply reflect or restate what any possible action in light of the following
the client has just said; if gestalt-trained, the question: If they took this action would
therapist may ask the client to say something they be reluctant to let their professional
to an empty chair; and so on. One way to colleagues know they had taken it? If the
help avoid responses that are driven more by response is yes, the reasons for the reluc-
anxiety, fatigue, or other similar factors is to tance warrant examination. If the response
consider carefully how the therapist would is no, it is worth considering whether one
think, feel, and react if he or she were the pa- has adequately taken advantage of the op-
tient. Regardless of the theoretical sound- portunities to discuss the matter with a
ness, intended outcome, or technical sophis- trusted colleague. If discussion with a col-
tication of a contemplated intervention, how league has not helped to clarify the issues,
will it likely be experienced and understood consultation with additional professionals,
by the patient? Can the therapist anticipate at each of whom may provide different per-
all what the patient might feel and think? spectives and suggestions, may be useful.
The therapist’s attempts to try out, in his or
her imagination, the contemplated action,
References, Readings, & Internet Sites
and to view it from the perspective of the pa-
tient may help prevent, correct, or at least Bernsen, A., Tabachnick, B. G., & Pope, K. S. (1994).
identify possible sources of misunderstand- National survey of social workers’ sexual at-
ing, miscommunication, and failures of em- traction to their clients: Results, implications,
pathy (Pope et al., 1993, pp. 185 –186). and comparison to psychologists. Ethics and Be-
havior, 4, 369 –388.
8. Competence: The eighth consideration is
Bouhoutsos, J. C., Holroyd, J., Lerman, H., Forer, B.,
one of competence: Is the therapist compe- & Greenberg, M. (1983). Sexual intimacy be-
tent to carry out the contemplated interven- tween psychotherapists and patients. Profes-
tion? Ensuring that a therapist’s education, sional Psychology: Research and Practice, 14,
training, and supervised experience are ade- 185 –196.
quate and appropriate for his or her work is Gartrell, N. K., Herman, J. L, Olarte, S., Feldstein,
a fundamental responsibility. M., & Localio, R. (1986). Psychiatrist-patient
 67 • six steps to improve psychotherapy homework compliance 319

sexual contact: Results of a national survey, I: sults and implications of a national survey.
Prevalence. American Journal of Psychiatry, American Psychologist, 34, 682–689. http://kspope.
143, 1126 –1131. com
Hare-Mustin, R. T (1974). Ethical considerations in Pope, K. S., Sonne, J. L., & Holroyd, J. (1993). Sexual
the use of sexual contact in psychotherapy. Psy- feelings in psychotherapy: Explorations for
chotherapy: Theory, Research, and Practice, 11, therapists and therapists-in-training. Wash-
308 –310. ington, DC: American Psychological Associa-
Holroyd, J. (1983). Erotic contact as an instance of tion.
sex-biased therapy. In J. Murray & E. R. Abram- Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, R.
son (Eds.), Bias in psychotherapy (pp. 285 – (1987). Ethics of practice: The beliefs and be-
308). New York: Praeger. haviors of psychologists as therapists. American
Holroyd, J., & Brodsky, A. (1977). Psychologists’ at- Psychologist, 42, 993 –1006. http://kspope.com
titudes and practices regarding erotic and Pope, K. S., & Vasquez, M. J. T. (1998). Ethics in psy-
nonerotic physical contact with clients. Ameri- chotherapy and counseling: A practical guide
can Psychologist, 32, 843 – 849. (2nd ed.). San Francisco: Jossey-Bass.
Pope, K. S. (1994). Sexual involvement with thera- Pope, K. S., & Vetter, V. A. (1991). Prior therapist-
pists: Patient assessment, subsequent therapy, patient sexual involvement among patients seen
forensics. Washington, DC: American Psycho- by psychologists. Psychotherapy, 28, 429 – 438.
logical Association. http://kspope.com
Pope, K. S., & Bouhoutsos, J. C. (1986). Sexual inti- Roy v. Hartogs, 381 N.Y.S. 2d 587 (1976); 85
macies between therapists and patients. New Misc.2d 891.
York: Praeger Greenwood.
Pope, K. S., Keith-Spiegel, P., & Tabachnick, B. G.
Related Topics
(1986). Sexual attraction to patients: The hu-
man therapist and the (sometimes) inhuman Chapter 65, “Refusal Skills Training”
training system. American Psychologist, 41, Chapter 113, “How to Confront an Unethical Col-
147 –158. http://kspope.com league”
Pope, K. S., Levenson, H., & Schover, L. R. (1979). Chapter 123, “Recognizing, Assisting, and Reporting
Sexual intimacy in psychology training: Re- the Impaired Psychologist”

SIX STEPS TO IMPROVE

67 PSYCHOTHERAPY
HOMEWORK COMPLIANCE

Michael A. Tompkins

Clinicians’ growing interest in briefer forms of are assigned homework do not always do it, nor
psychotherapy has popularized the use of home- do they always do it well (Hansen & Warner,
work assignments (Kazantizis & Deane, 1999); 1994).
however, most clinicians know that clients who Improving homework compliance begins with
320 part iii • individual psychotherapy and treatment

careful attention to how homework assign- client who spends the bulk of his day in bed is
ments are structured and implemented, as ther- not likely to be able to hike all day Saturday
apists have far more control over the nature of with friends, even though he thinks he should
homework assignments than they do over a be able to do this because he did it in the past.
client’s particular psychological variables that To assess whether a homework assignment is
may also influence homework noncompliance realistic given a client’s current level of func-
(Tompkins, 2002). For this reason, it makes tioning, therapists can ask themselves two
sense that therapists take as much care as pos- questions: (1) Is the client already doing the
sible when setting up homework assignments homework assignment (or some variation of the
so that most clients, regardless of their partic- assignment) and how difficult is it? and (2) Has
ular psychological variables, can complete the client done the homework assignment (or
them. Similarly, it makes sense that therapists some variation of it) in the past, how long ago
strive to maintain a manner with clients that was that, and how difficult was it then? Thera-
(all things being equal) is likely to enhance pists can ask clients to rate the difficulty or dis-
clients’ compliance with homework assign- comfort of the task on a 10-point scale (where
ments. This article presents six steps to improve 10 is most difficult or uncomfortable). As a
compliance with psychotherapy homework: rule, it is best when beginning treatment to
start with homework assignments that expect
1. Make the homework doable. clients to do what they are already doing 30%
2. Give a clear rationale for the homework as- of the time or more. For example, a client who
signment. sought treatment to become more assertive
3. Make a homework backup plan. identified several types of people with whom
4. Make a set of written homework instruc- she had trouble being assertive, ranked in order
tions. of the percentage of time she was assertive with
5. Practice the homework assignment in ses- that person. She and her therapist decided that
sion. at first she would focus on increasing her as-
6. Be curious, collaborative, and consistent sertiveness with a coworker she liked and with
when setting up and reviewing homework. whom she was able to be assertive 40% of the
time.
Make the homework assignment doable. Give a clear rationale for the homework as-
Doable homework assignments are concrete, signment. Clients are more likely to complete a
specific, and appropriate to the client’s current homework assignment if they understand how
skill level. Concrete and specific homework as- doing it will help them accomplish their treat-
signments are easier to carry out than vague as- ment goals. If the client’s goal is to become less
signments (Levy & Shelton, 1990; Shelton & depressed, then it must make sense to the client
Levy, 1981) and include details about when, how a particular homework assignment will
where, with whom, for how long, and using help him or her feel less depressed. A home-
what materials. A concrete and specific home- work rationale can be quite simple: “We’ve
work assignment might read, “Sit down at agreed that when you’re doing certain activi-
your desk at 9 a.m., Monday through Friday, ties, like having lunch with a friend, you feel
and work on your dissertation for 10 minutes less depressed. How about if we schedule sev-
each day; use pencil and paper and disconnect eral activities like that this week?”
the telephone before beginning to write; and, Therapists should not make a homework as-
after you have written for 10 minutes, reward signment if the client has not understood and
yourself by reading the sports section of the accepted its rationale. Clients who reject a
morning newspaper.” In contrast, a vague homework rationale may be less open to change
homework assignment might read, “Work a lit- (Addis & Jacobson, 2000); perhaps because they
tle on your dissertation everyday.” are hopeless about anything helping, they have
A doable homework assignment also consid- clear beliefs about what will and will not help
ers the client’s level of functioning. A depressed them solve their problems that the therapist has
 67 • six steps to improve psychotherapy homework compliance 321

not explored, or they don’t understand the rea- doable given the client’s current level of func-
son for doing it. To check whether a client has tioning. Or ask clients to rate the likelihood (0
accepted the homework rationale, therapists can to 100%, where 100% is highly likely) that
ask, “Do you understand why I’m suggesting they will do the homework as agreed. Low
you schedule activities this week?” Or, “To numbers can alert therapists to potential home-
what degree does the homework match your work obstacles. Therapists can then explore
ideas about what needs to change to solve your with clients why they believe they may not do
problem? (on a scale of from 0 to 10, where 10 the homework and alter the homework assign-
means the homework completely matches with ment or plan a different assignment altogether,
your ideas about what needs to change)?” such as monitoring the problem the client is not
Initially, the therapist provides the rationale ready to tackle.
for homework. However, over time and partic- Therapists can use covert rehearsal (Beck,
ularly when a homework assignment is re- 1995) to identify obstacles to completing home-
peated, the therapist can ask clients the reason work assignments. In covert rehearsal, the
for a homework assignment: “Grace, why do client is asked to imagine going through all the
you think it might be a good idea for you to steps involved in completing the homework as-
write down what you eat during the day and signment, talking aloud to the therapist, who
whether you binge or not?” Not only does this listens for potential obstacles. For example,
encourage clients to take greater responsibility Christine, a depressed childcare worker who
for designing and implementing their home- also worked nights and weekends as a waitress,
work assignments, but also it is a good check seldom found time to go out with friends or to
that the client understands the homework ra- do anything fun. She agreed to take a bubble
tionale. bath as a pleasurable activity to improve her
Make a homework backup plan. Spend some mood and decrease her stress level. During
time during the session anticipating potential covert rehearsal, Christine imagined, out loud,
homework obstacles and making a backup plan to each step of the process. As she imagined reach-
handle them. For example, Josh, a depressed soft- ing for the bubble bath, she remembered that
ware engineer, agreed to call Philip, a friend, she had run out of bubble bath several weeks
later in the day to invite him to go to for a jog. At ago. Christine and her therapist then discussed
the agreed-upon time, Josh dutifully called how and when she would go to the grocery
Philip, but when he heard a busy signal, he hung store to buy bubble bath and this task became
up the telephone and did not try again. Had Josh her homework assignment. Had Christine not
and his therapist planned how Josh would han- rehearsed her homework assignment before-
dle this situation if it arose (e.g., who would hand, she might have thrown up her hands and
Josh call if he couldn’t reach Philip), Josh might gone to bed when she encountered the empty
have completed his homework assignment. bubble-bath bottle.
There are a number of ways to uncover po- Make a set of written homework instruc-
tential homework obstacles. Therapists can ask tions. Many clients will be able to remember
their clients directly: “Do you see any obstacles the details of a homework assignment and fol-
that would make it hard for you to carry out the low through with what they have agreed to do.
assignment?” Therapists can ask clients if they However, it is usually better to formalize these
have tried similar homework assignments in agreements with a set of written homework in-
the past and, if so, how they turned out. What structions (Shelton & Ackerman, 1974). Writ-
problems did they encounter? Watch for clients ten homework instructions serve as a record of
who hesitate or are uncertain: “I think that I what the client has agreed to do, which can cir-
can handle that if it happens,” or who quickly cumvent misunderstandings and disagreements
dismiss the therapist’s concerns: “No, there that erode the therapeutic alliance. At the min-
won’t be any problem.” Ask these clients how imum, written homework instructions should
they would handle a typical homework problem describe exactly what the client will do (e.g.,
and see whether the solution is appropriate and “Call Julio Thursday at 7 p.m. and invite him
322 part iii • individual psychotherapy and treatment

to the ballgame this Saturday”), and what they ence of intense negative affect, such as fear,
will do (e.g., “If Julio can’t attend the ballgame, anger, guilt, or shame. For example, Katherine,
then call Bob, then George, then Frank”) if they a depressed young human resource manager,
run into problems (Tompkins, 2004). sought help because she had a difficult relation-
Practice the homework assignment in ses- ship with her mother, who often arrived unan-
sion. Although it is useful for clients to practice nounced at her apartment and would look
in session every homework before they try it through her drawers and listen to the messages
on their own, there are times when in-session on her telephone answering machine. Kather-
homework practice is particularly warranted: ine was quite anxious about dating or inviting
(1) when clients lack the necessary skill and men to her apartment for fear that her mother
knowledge; (2) when clients try a homework would appear at the door. As a step toward
assignment for the first time; and (3) when greater assertiveness with her mother, Kather-
clients are to perform a homework assignment ine agreed to tell her that she couldn’t speak to
in the presence of strong emotion. her right then when she called that evening, as
In-session practice enables therapists to ob- was her routine. Katherine practiced the home-
serve whether their clients can complete the work assignment while the therapist played the
homework as devised. Paul, a depressed and re- role of her mother. Katherine did well until her
cently divorced civil engineer, wanted to start therapist began to whine and tell her that she
dating again and agreed to a homework assign- was an ungrateful and spiteful daughter; when
ment in which he would introduce himself to a she heard this, Katherine burst into tears. The
woman at the company Christmas party. Paul therapist stopped the role-play and praised
assured the therapist he knew how to handle Katherine for hanging in there as long she did
this kind of situation, but the therapist was not and reviewed with her the rationale for the
so confident. At the therapist’s urging, however, homework. The therapist and Katherine then
Paul agreed to role-play the planned interac- developed a set of adaptive responses she was to
tion. Paul began his introduction by staring at read through to help her better tolerate her feel-
the floor while mumbling under his breath, ings of guilt. With more practice, Katherine
“Hi, I don’t suppose you’re interested in talking was able to hold her ground in the role-plays
to me.” After feedback from his therapist, Peter with her therapist and in interactions with her
agreed that further skills training was needed mother.
before he attempted this particular homework Be curious, collaborative, and consistent when
assignment. setting up and reviewing homework. Therapists
In-session practice is advisable when clients are important reinforcers of client behavior
are trying a newly learned skill or response for and, as such, it is essential that they maintain
the first time. For example, the typical response a manner when speaking with their clients that
of anxious clients is to avoid what makes them increases the likelihood that homework will be
uncomfortable. Therapists can help these clients tried and completed (Tompkins, 2003). Thera-
by modeling for them the new response (ap- pists can enhance homework compliance if they
proach the feared object or situation) and coach are: (1) curious, (2) collaborative, and (3) con-
them to practice this response in session. If a sistent.
dog-phobic client agrees to touch a picture of a Curiosity rather than firm certainty avoids
dog in a book three times during the coming assumptions that can lead to misunderstandings
week, it is best that the therapist show the that derail attempts to set up or review home-
client that he wants her to look at the picture work. Clients always have more information
the entire time while she presses the picture about what contributed to an unsuccessful home-
with the full palm of her hand and holds it there work assignment than their therapists, and a
for 5 minutes. curious stance recognizes and takes advantage
In-session practice is particularly helpful of this fact. A curious stance encourages clients
when therapists anticipate that clients will have to become curious about the homework them-
to perform homework assignments in the pres- selves, including the obstacles they encounter
 67 • six steps to improve psychotherapy homework compliance 323

or may encounter and their role in homework tougher exposure assignment this week,” nod,
noncompliance. Last, and perhaps most impor- smile, and praise them. Similarly, avoid rein-
tant, curious therapists shift the responsibility forcing homework noncompliance. Avoid say-
for solving homework compliance problems to ing, “That’s okay,” “No problem,” No big deal,”
clients. Over-responsible therapists suggest, when it’s not, or “Better luck next time,” when
“Try this next time,” while curious therapists luck had nothing to do with it. When clients
probe, “Tell me what you might try next complete homework assignments, congratulate
time.” Therapists should start any discussion of them and chat for a few minutes (if they enjoy
potential homework assignments by asking the chatting) to reinforce homework compliance.
client “Perhaps you have an idea for a home- Take care that the praise is appropriate to the
work assignment that would help you with this effort and is not overblown or exaggerated.
problem?” When clients fail to do homework, respond in
Collaboration between therapist and client a neutral but curious manner and focus on
when designing and implementing homework identifying problems that may have con-
offers several advantages. First, clients who tributed to homework noncompliance. If the
have input into homework may perceive them- homework was not completed (or attempted),
selves as having greater control of the assign- set aside the entire session to review why the
ment itself. This may lessen their anxiety and homework was not done, once again, as some-
thereby increase the likelihood that the assign- one who is curious and puzzled by this turn of
ment will be tried. Second, when the therapist events. Did we make the homework too diffi-
and client successfully work through a misun- cult? Were the homework instructions unclear?
derstanding or disagreement to set up home- Did some unanticipated problem arise?
work, the therapeutic relationship is strength- When clients attempt the homework and
ened. Third, clients usually understand more some part of it was successful, focus on that
fully than their therapists what is or is not a part and praise their efforts: “Although we
useful homework assignment and what diffi- agreed that you would walk 5 minutes 3 times
culties may arise. Therapists who consult with this week, you walked 5 minutes one day. Con-
their clients about potential obstacles to home- gratulations for walking 5 minutes that one
work increase the likelihood that the homework day.” Then, negotiate with the clients any mod-
will be completed. At times, clients may sug- ifications to their homework assignments so
gest a homework assignment that seems unre- that they can do a bit more next time and reas-
lated to the focus of the therapy or to the sign: “Now, let’s take a look at how we can help
client’s treatment goals. Rather than dismissing you meet your goal of 5 minutes each day.
the assignment out of hand, therapists can ex- What do you say?” However, if a client contin-
plore the client’s rationale for the assignment, ues to fail to complete homework assignments,
perhaps soliciting the advantages and disadvan- consider breaking future assignments into
tages of this homework assignment over an- smaller doable pieces. In that way, the client can
other one the therapist suggests. Sometimes, be reinforced for completing the entire home-
after each contributes an idea for a homework work assignment, even if it is smaller. Take care
assignment, it may be necessary for the client that clients do not interpret the therapist’s ef-
and therapist briefly to negotiate a mutually forts to shape approximations to the desired
agreeable homework assignment. Successful homework to mean that the therapists accept
negotiations such as this can strengthen the incomplete homework. The goal of rewarding
therapeutic alliance and thereby foster greater small steps is to have clients always complete
motivation to try this and future homework as- their homework consistently and as agreed
signments. upon.
Consistently reinforce all pro-homework The six steps presented here assume that
behavior. When clients say, “I thought about therapists can improve homework compliance
what I learned from the homework on my drive through careful attention to how they set up
here today,” or, “Perhaps I could try a little and review homework assignments. To that
324 part iii • individual psychotherapy and treatment

end, I encourage therapists to first consider Kazantizis, N., & Deane, F. P. (1999). Psychologists’
whether they have done what they can do to use of homework assignments in clinical prac-
improve homework compliance before assum- tice. Professional Psychology: Research and
ing that clients fail to do homework because of Practice, 30, 581– 585.
Levy, R. L., & Shelton, J. L. (1990). Tasks in brief
their psychopathology. However, when clients
therapy. In R. A. Wells & V. J. Giannetti (Eds.),
consistently fail to complete the homework
Handbook of brief psychotherapies (pp. 145 –
they have agreed to do, client factors come to 163). New York: Plenum.
the fore and therapists must manage homework Shelton, J. L., & Ackerman, J. M. (1974). Homework
noncompliance as they would manage any in counseling and psychotherapy: Examples of
other client behavior that interferes with pro- systematic assignments for therapeutic use by
gress toward the client’s treatment goals. In mental health professionals. Springfield, IL:
these instances, therapists will benefit from a Charles C. Thomas.
case formulation that explains why a particular Shelton, J. L., & Levy, R. L. (1981). Behavioral as-
client at a particular point in therapy might fail signments and treatment compliance: A hand-
to complete his or her homework, as well as the book of clinical strategies. Champaign, IL: Re-
search Press.
psychological, interpersonal, and behavioral
Tompkins, M. A. (1999). Using a case formulation to
problems for which the individual has sought
manage treatment nonresponse. Journal of
treatment in the first place (Eells, 1997; Tomp- Cognitive Psychotherapy, 13, 317 –330.
kins, 1999). Tompkins, M. A. (2002). Guidelines for enhancing
homework compliance. Journal of Clinical Psy-
References & Readings chology, 58, 565 – 576.
Tompkins, M. A. (2003). Effective homework. In
Addis, M. E., & Jacobson, N. S. (2000). A closer look R. L. Leahy (Ed.), Overcoming roadblocks in
at the treatment rationale and homework com- cognitive therapy (pp. 49 –66). New York: Guil-
pliance in cognitive-behavioral therapy for de- ford Press.
pression. Cognitive Therapy and Research, 24, Tompkins, M. A. (2004). Using homework in psy-
313 –326. chotherapy: Strategies, guidelines, and forms.
Beck, J. S. (1995). Cognitive therapy: Basics and be- New York: Guilford Press.
yond. New York: Guilford Press.
Eells, T. T. (Ed.). (1997). Handbook of psychotherapy
case formulation. New York: Guilford Press. Related Topics
Hansen, D. J., & Warner, J. E. (1994). Treatment ad- Chapter 42, “Enhancing Adherence”
herence of maltreating families: A survey of Chapter 43, “Methods to Reduce and Counter Resis-
professionals regarding prevalence and en- tance in Psychotherapy”
hancement strategies. Journal of Family Vio-
lence, 9, 1–19.
 STIMULUS CONTROL
68 INSTRUCTIONS FOR THE
TREATMENT OF INSOMNIA

Richard R. Bootzin

Stimulus control instructions were derived Do this as often as is necessary throughout

from a learning analysis of sleep. They are a set the night.
of instructions designed to help the person with 5. Set your alarm and get up at the same time
insomnia establish a consistent sleep-wake every morning irrespective of how much
rhythm, strengthen the bed and bedroom as sleep you got during the night. This will
cues for sleep, and weaken them as cues for ac- help your body acquire a consistent sleep
tivities that might interfere with sleep. rhythm.
6. Do not nap during the day.

STIMULUS CONTROL The focus of the instructions is primarily on

INSTRUCTIONS sleep onset. For sleep maintenance problems,
the instructions are to be followed after awak-
The following rules constitute the stimulus ening when the patient has difficulty falling
control instructions (Bootzin, 1972; Bootzin & back to sleep. Although stimulus control in-
Nicassio, 1978): structions appear simple and straightforward,
compliance is better if the instructions are dis-
1. Lie down intending to go to sleep only when cussed individually and a rationale is provided
you are sleepy. for each rule (Bootzin & Epstein, 2000; Boot-
2. Do not use your bed for anything except zin, Epstein, & Wood, 1991).
sleep— that is, do not read, watch television,
eat, or worry in bed. Sexual activity is the • Rule 1. The goal of this rule is to help the pa-
only exception to this rule. On such occa- tients become more sensitive to internal cues
sions, the instructions are to be followed af- of sleepiness so that they will be more likely
terward when you intend to go to sleep. to fall asleep quickly when they go to bed.
3. If you find yourself unable to fall asleep, get • Rule 2. The goals here are to have activities
up and go into another room. Stay up as that are associated with arousal occur else-
long as you wish and then return to the bed- where and to break up patterns that are asso-
room to sleep. Although we do not want you ciated with disturbed sleep. If bedtime is the
to watch the clock, we want you to get out of only time patients have for thinking about
bed if you do not fall asleep immediately. the day’s events and planning the next day,
Remember the goal is to associate your bed they should spend some quiet time doing
with falling asleep quickly! If you are in bed that in another room before they go to bed.
more than about 10 minutes without falling Many people who do not have insomnia read
asleep and have not gotten up, you are not or listen to music in bed without problems.
following this instruction. This is not the case for insomniacs, however.
4. If you still cannot fall asleep, repeat Step 3. This instruction is used to help those who

325
326 part iii • individual psychotherapy and treatment

have sleep problems establish new routines recommended. In the elderly, late afternoon
to facilitate sleep onset. naps have the advantage of providing addi-
• Rules 3 and 4. In order to associate the bed tional energy for evening activities.
with sleep and disassociate it from the frus-
tration and arousal of not being able to sleep, Cognitive-behavioral treatments for insom-
the patients are instructed to get out of bed nia, including stimulus control instructions, are
after about 10 minutes (20 minutes for those primarily self-management treatments. The
over 60 years old). This is also a means of treatments are carried out by the patients at
coping with insomnia. By getting out of bed home. Consequently, compliance may be a
and engaging in other activities, patients are problem. Most compliance problems can be
taking control of their problem. Conse- solved by direct discussion with the patient. A
quently, the problem becomes more manage- common problem is the disturbance of the
able and the patient is likely to experience spouses’ sleep when the insomniacs get out of
less distress. bed. Discussions with the spouses are often
• Rule 5. Insomniacs often have irregular sleep helpful in ensuring full cooperation. During
rhythms because they try to make up for the winter in cold climates, some patients may
poor sleep by sleeping late or by napping the be reluctant to leave the warmth of their beds.
next day. Keeping consistent wake times Suggestions for keeping warm robes near the
helps patients develop consistent sleep rhy- beds and keeping an additional room warm
thms. In addition, the set wake times mean throughout the night, along with encourage-
that the patients will be somewhat sleep- ment to try to follow instructions, are usually
deprived after a night of insomnia. This will effective in promoting compliance.
make it more likely that they will fall asleep
quickly the following night, strengthening
the cues of the bed and bedroom for sleep. EFFECTIVENESS OF STIMULUS
Often insomniacs will want to follow a dif- CONTROL INSTRUCTIONS
ferent sleeping schedule on weekends or
nights off than they do during the work- Stimulus Control Instructions has been evalu-
week. It is important to have as consistent a ated either as a single-component treatment or
schedule as possible, seven nights a week. as part of multicomponent interventions with
The goal is to produce variability of no more adults of all ages. Reviews of outcome studies
than one hour in the wake time on days off (Morin, Culbert, & Schwartz, 1994; Morin et
than on work or school days. However, it al., 1999; Murtagh & Greenwood, 1995) have
may be necessary to approach that goal grad- found that stimulus control instructions consti-
ually over a few weeks, using successive ap- tute one of the most effective, if not the most
proximations, if the deviations are large as effective, single-component nonpharmacologi-
often seen in adolescents and college stu- cal therapy. In fact, in a practice parameters re-
dents. port on nonpharmacological treatments of in-
• Rule 6. The goals of this rule are to keep in- somnia published by the American Academy of
somniacs from disrupting their sleep pat- Sleep Medicine (Chesson et al., 1999), stimulus
terns by irregular napping and to prevent control instructions is listed as the only treat-
them from losing the advantage of the sleep ment to achieve the category of “standard”
loss of the previous night for increasing the treatment of care.
likelihood of faster sleep onset the following Multicomponent treatments are often found
night. A nap that takes place seven days a to be effective. The components employed,
week at the same time would be permissible. however, vary substantially from study to
For those elderly insomniacs who feel that study. It is important to include treatment com-
they need to nap, a daily late afternoon nap ponents, such as stimulus control instructions,
of 30 to 45 minutes or the use of 20 to 30 that have empirical support within the multi-
minutes of relaxation as a nap-substitute is component package.
 69 • parent management training for childhood behavior disorders 327

References & Readings Practice parameters for the nonpharmacologic

treatment of chronic insomnia. Sleep, 22, 1128 –
Bootzin, R. R. (1972). A stimulus control treatment
1133.
for insomnia. American Psychological Associa-
Morin, C. M., Culbert, J. P., & Schwartz, S. M.
tion Proceedings, 395 –396.
(1994). Nonpharmacological interventions for
Bootzin, R. R., & Epstein, D. R. (2000). Stimulus
insomnia: A meta-analysis of treatment effi-
control instructions. In K. L. Lichstein & C. M.
cacy. American Journal of Psychiatry, 151,
Morin (Eds.), Treatment of late-life insomnia
1172–1180.
(pp. 167 –184). Thousand Oaks, CA: Sage.
Morin, C. M., Hauri, P. J., Espie, C. A., Spielman,
Bootzin, R. R., Epstein, D., & Wood, J. M. (1991).
A. J., Buysee, D. J., & Bootzin, R. R. (1999).
Stimulus control instruction. In P. Hauri (Ed.),
Nonpharmacologic treatment of chronic insom-
Case studies in insomnia (pp. 19 –28). New
nia: An American Academy of Sleep Medicine
York: Plenum.
Review. Sleep, 22, 1134 –1156.
Bootzin, R. R., Manber, R., Loewy, D. H., Kuo, T. F.,
Murtagh, D. R. R., & Greenwood, K. M. (1995).
& Franzen, P. L. (2001). Sleep disorders. In H. E.
Identifying effective psychological treatments
Adams & P. B. Sutker (Eds.), Comprehensive
for insomnia: A meta-analysis. Journal of Con-
handbook of psychopathology (3rd ed., pp.
sulting and Clinical Psychology, 63, 79 – 89.
671–711). New York: Plenum.
Bootzin, R. R., & Nicassio, P. (1978). Behavioral
treatments for insomnia. In M. Hersen, R. Related Topic
Eisler, & P. Miller (Eds.), Progress in behavior
Chapter 67, “Six Steps to Improve Psychotherapy
modification (Vol. 6, pp. 1– 45). New York: Aca-
Homework Compliance”
demic Press.
Chesson, A. L., Jr., Anderson, W. M., Littner, M.,
Davila, D., Hartse, K., Johnson, S., et al. (1999).

PARENT MANAGEMENT
69 TRAINING FOR CHILDHOOD
BEHAVIOR DISORDERS

Laura J. Schoenfield & Sheila M. Eyberg

Until recently, individual psychotherapy was for this group of disorders (Brestan & Eyberg,
the most common form of treatment for child- 1998; Nock, 2003). In fact, Brestan and Eyberg
hood behavior disorders. However, the trend to- found that the only well-established treatments
ward evidence-based treatments has led to an for childhood disruptive behavior were PMT
increasing realization that the involvement of programs. These programs, designed to give
parents is crucial to the maintenance of treat- parents skills to manage their children’s behav-
ment gains. Two reviews of treatments for dis- ior effectively, can decrease unwanted behav-
ruptive behavior disorders found that parent iors and increase prosocial behaviors while also
management training (PMT) is well supported increasing the warmth of the parent-child rela-
by empirical research as an effective treatment tionship. Parent training programs have been
328 part iii • individual psychotherapy and treatment

implemented for children with a range of dis- or child problem-solving skills training, teacher
orders and have targeted specific populations of training, or medications.
parents at risk for poor parenting as well. Although PMT programs are designed pri-
Parent management training probably began marily to treat the kinds of disruptive behaviors
with the work of Gerald Patterson, whose Liv- that characterize oppositional defiant disorder
ing with Children program was the first well- (ODD) or conduct disorder (CD), PMT is used to
established PMT program (see Patterson, 1976). treat children with a range of disorders that have
This program, based on social learning theory, frequently co-occurring disruptive behavior,
teaches parents to use positive reinforcers, such such as developmental delays and attention-
as stickers, snacks, or small toys, to increase pos- deficit/hyperactivity disorder (ADHD). PMT
itive behaviors while using timeout to decrease programs for other disorders are similar to those
negative behaviors such as temper tantrums. for ODD and CD, typically with the addition of
Parents focus on one particular problem behav- components specific to the primary diagnosis.
ior at a time. First, they observe the behavior For example, PMT programs for children with
and count the number of times it occurs each ADHD often include parent ADHD education or
day or week. Then, they continue to track the group discussion on topics such as realistic ex-
child’s progress by charting the frequency of pectations, due to the persistence of characteris-
problem behaviors throughout treatment while tics such as impulsiveness, or safety issues such
giving stickers and small rewards when the child as child-proofing the home, due to the tendency
abstains from the negative behavior. At the of children with ADHD to be more clumsy and
same time, parents use time-out for each in- accident prone than other children at similar de-
stance of the negative behavior. Parents are also velopmental levels (Pisterman et al., 1989). A re-
instructed to identify behaviors that are incom- cent review of the literature on treatments for
patible with the problem behaviors, called com- children with ADHD found that the efficacy of
peting behaviors, such as talking nicely instead particular PMT programs is well supported by
of whining. Positive reinforcement is used to in- research (Pelham, Wheeler, & Chronis, 1998).
crease the frequency of competing behaviors.
Patterson has emphasized the importance of
consistency in discipline by punishing every oc- LONG-TERM EFFECTIVENESS OF
currence of the negative behavior and rewarding PARENT MANAGEMENT TRAINING
every occurrence of the competing, positive be-
havior. As one problem behavior decreases, a Disruptive behavior disorders are usually con-
new problem behavior can be targeted using the sidered chronic conditions (Nock, 2003). For
same principles of behavior change. this reason, to be truly effective, treatments for
As treatment research has progressed, PMT these problems must show long-term mainte-
has frequently been combined with other nance of treatment gains. Unfortunately, a re-
treatments, and new methods of treatment de- view of the literature found that most studies of
livery of the core components of PMT have treatment efficacy did not follow up partici-
emerged as well. For example, programs may pants for longer than one year (Eyberg, Ed-
use modeling, role-playing, in vivo coaching, wards, Boggs, & Foote, 1998). The few longer-
or videotaped demonstrations to teach parent- term studies suggested that only about 50% of
ing skills. The training may occur in individ- children maintained treatment gains. Families
ual, family, or group sessions including the for whom treatment does not last may have
parents alone or in sessions that include the certain risk factors associated with poor main-
child. Treatment may take place in the clinic, in tenance, such as poverty or parental psycho-
a family’s home, or in community facilities pathology. However, due to the small number
such as the school. PMT is often implemented of studies and methodological issues associated
in conjunction with other types of interven- with follow-up studies, it is not possible to
tions, such as child social skills training, parent draw firm conclusions at this time.
 69 • parent management training for childhood behavior disorders 329

Several strategies are used in PMT pro- EXAMPLES OF PARENT MANAGE-

grams to increase the likelihood that treatment MENT TRAINING PROGRAMS
gains will continue after treatment has ended.
These strategies are similar to those used in In this section we describe three evidence-based
other treatments for many types of disorders. PMT programs. Each program incorporates ba-
They include increasing parents’ problem-solv- sic PMT based on principles of social learning
ing skills so that they will be able to manage theory into a unique program of treatment for
similar problems in the future, fading of treat- children with disruptive behavior.
ment sessions, contact by phone or mail after
treatment has ended, and booster sessions. Problem-Solving Skills Training
and Parent Management Training

PARENTS AT RISK Kazdin (1996) developed a treatment program

for disruptive children up to age 13 that com-
PMT not only targets child and adolescent dis- bines individual PMT with problem-solving
orders, but also serves parents at risk for poor skills training (PSST) for children. The PMT
parenting skills who, in turn, have children at component of Kazdin’s treatment program is
risk for behavior disorders. Studies of PMT conducted in separate sessions with the child’s
with single parents, parents in poverty, and par- parent. Through modeling and role-playing,
ents involved with child protection services the parent is taught to use effective commands
have all demonstrated significant benefits for and consistent consequences. The parent is also
children. For example, recently separated moth- taught to establish a token economy in the
ers have reported improved discipline tech- home to reinforce the child’s appropriate be-
niques and increased positive involvement with havior. To deal with behavior problems the
children after attending group PMT meetings child presents in the classroom, the therapist
(Forgatch & DeGarmo, 1999). Low-income par- sets up a system of reinforcement wherein the
ents of children in Head Start who received par- parent provides contingent consequences at
ent training focused on increasing parenting home for behavior at school.
competence and involvement in Head Start re- PSST provides a step-by-step guide for the
ported a significant decrease in harsh and criti- child on how to approach difficult situations
cal parenting styles and an increase in positive and choose the best solution. During the course
discipline (Webster-Stratton, 1998). Their chil- of 20 sessions, the child learns to use the five
dren’s behavior also improved after treatment, steps of problem solving: identify the problem,
characterized by a decrease in noncompliance create possible solutions, focus on and evaluate
and negative affect that was maintained at one- the solutions, choose a response, and evaluate
year follow-up. the outcome. The therapist uses a token econ-
Abusive parents are often referred to PMT omy during therapy with the child as rein-
programs. In addition to teaching positive dis- forcement for using the problem-solving steps
cipline skills, these programs typically teach appropriately. Parents are trained to help their
methods of coping with negative child behavior, children use the problem-solving steps cor-
such as relaxation and anger-management rectly outside the therapy sessions.
training. A study of PMT for parents under su- By working individually with the child as
pervision by child protection services found well as the parent, Kazdin’s combined PMT plus
that at three-month follow-up, children whose PSST program has the advantage of treating
parents received PMT had less frequent and peer relation difficulties, which may be less eas-
less intense behavior problems and fewer ad- ily targeted by PMT. In addition, although the
justment problems associated with maltreat- program components are manualized, the for-
ment (Wolfe, Edwards, Manion, & Koverola, mat allows the possibility of adding sessions
1988). based on both the child’s and parent’s progress,
330 part iii • individual psychotherapy and treatment

which ensures flexibility in response to indi- academic readiness, educational activities at home,
vidual families. and creating connections between home and
school. One of the benefits of The Incredible
Years program is the cost-effectiveness of the
The Incredible Years: Parents,
group format used in all program components.
Teachers, and Children Training
In addition, the use of videotapes to present in-
Series
formation, along with the detailed group lead-
Developed by Webster-Stratton (2001), The In- ers’ manuals, makes the program easy to im-
credible Years is a multicomponent treatment plement in many communities.
for disruptive behavior in children ages 4 to 8.
Although all components may be used sepa-
Parent-Child Interaction Therapy
rately, the combination of PMT, problem-solv-
ing and social skills training with the child, and Developed by Eyberg (Brinkmeyer & Eyberg,
teacher training addresses many areas where 2003) for the treatment of preschoolers with
impairment may be present. Each component is disruptive behavior and their parents, Parent-
conducted in group format and includes discus- Child Interaction Therapy (PCIT) is based on
sion of videotaped vignettes. developmental theory, emphasizing authori-
The original PMT component is a 12-week tative parenting and children’s needs for
group treatment program for parents that in- both nurturance and firm limits. PCIT pro-
cludes vignettes designed to teach skills such as gresses through two distinct phases. The first
positive reinforcement, logical consequences, phase, Child-Directed Interaction (CDI), re-
problem solving, and nonphysical discipline sembles traditional play therapy and focuses on
techniques. Discipline techniques include the strengthening the parent-child attachment, in-
use of time-out and ignoring. The group lead- creasing positive parenting, and improving
ers use the videotaped scenes to stimulate group child social skills. The second phase, Parent-
discussion and problem solving. Parents refine Directed Interaction (PDI), resembles clinical
their skills by role-playing in the group and behavior therapy and focuses on improving
practicing at home. parents’ expectations, ability to set limits, con-
The teacher component of The Incredible sistency and fairness in discipline, and reducing
Years involves discussion of videotaped vi- child noncompliance and other negative behav-
gnettes, in groups of 15 to 25 teachers, covering iors.
topics such as the importance of teacher atten- PCIT sessions are conducted once a week and
tion, encouragement, and praise; motivating are one hour in length. The principles and skills
children through incentives; preventing prob- of each phase of treatment are first taught to
lems proactively; decreasing inappropriate be- the parents alone in a teaching session. In sub-
havior; building positive relationships with sequent sessions, parents are coached in the
students; and teaching social skills and prob- skills as they play with their child. Families
lem-solving skills in the classroom. In addition continue in treatment until the parents demon-
to videotaped modeling, child sessions include strate mastery of the skills and the child’s be-
fantasy play, use of puppets, and role play to havior comes to within normal limits. The av-
help children deal with problems at school and erage length of treatment is 13 sessions.
with peers, such as being teased, lying, and During the CDI, parents are taught to follow
feeling left out. the child’s lead by refraining from commands,
Three additional components are available if questions, and criticism. They learn to use the
needed: Advance addresses potential areas of nondirective Pride skills: praising the child’s
family dysfunction and includes parent coping behavior; reflecting the child’s statements; im-
skills, self-control, and marital conflict; School itating the child’s play; describing the child’s ac-
Age can be used as a prevention program for tivities, and using enthusiasm as they play with
culturally diverse children up to age 10; and the child. The parents learn to change child be-
Supporting Your Child’s Education focuses on havior by directing the Pride skills to the child’s
 69 • parent management training for childhood behavior disorders 331

appropriate play and ignoring the child’s nega- parent and child behaviors, and it is now con-
tive behaviors. The parents practice the skills at sidered the standard of care for disruptive be-
home in daily 5-minute play sessions called havior. Although variations in format and em-
“special time.” In the CDI coaching sessions, phasis have been developed, and PMT has been
the therapist is able to observe the parent’s combined in various ways with other treat-
progress firsthand and provide immediate feed- ments for disruptive children and related disor-
back, encouraging and praising the parents’ new ders of the child and family, the basic behav-
skills and catching mistakes on-the-spot before ioral tenets of social learning theory have re-
they become habits. CDI coaching sessions con- mained at its core. In this chapter, we have
tinue until the parents meet criteria for skill provided examples of three evidence-based
mastery, as assessed by a 5-minute direct ob- PMT programs for disruptive behavior that il-
servation at the start of each session. It is lustrate the variation in parent training as well
through the CDI coaching that the therapist as the similarities in approach. Research pro-
conveys important developmental expectations vides promising early evidence of maintenance
for child behavior and points out specific effects of change for a sizable percentage of children.
of the parent’s behavior on the child. Coaching Now the goal of PMT is to identify strategies
may also teach stress management or anger that will engender enduring treatment gains
management skills to the parent as they inter- for all children.
act with their child.
During the PDI, the parents learn to direct References, Readings, & Internet Sites
the child’s behavior when necessary with effec-
tive commands and specific consequences for Brestan, E. V., & Eyberg, S. M. (1998). Effective psy-
chosocial treatments of conduct-disordered chil-
compliance (enthusiastic labeled praise and a re-
dren and adolescents: 29 years, 82 studies, and
turn to CDI) and noncompliance (a time-out
5,272 kids. Journal of Clinical Child Psychol-
warning that begins an algorithm of parent re- ogy, 27, 180 –189.
sponses to compliance or noncompliance at each Brinkmeyer, M. Y., & Eyberg, S. M. (2003). Parent-
step until the child complies). The use of time- child interaction therapy for oppositional chil-
out is introduced gradually, first in the treat- dren. In A. E. Kazdin & J. R. Weisz (Eds.), Evi-
ment room where the therapist is able to coach dence-based psychotherapies for children and
the parent through all of the steps with the adolescents (pp. 204 –240). New York: Guilford
child before the parent uses it at home. Parents Press.
then practice the PDI skills in brief sessions af- Eyberg, S. M., Edwards, D., Boggs, S. R., & Foote, R.
ter the CDI play sessions. Homework assign- (1998). Maintaining the treatment effects of
parent training: The role of booster sessions and
ments proceed gradually to use of the PDI pro-
other maintenance strategies. Clinical Psychol-
cedure throughout the day. In the last few ses- ogy: Science and Practice, 5, 544 – 552.
sions, parents are taught variations of the PDI Forgatch, M. S., & DeGarmo, D. S. (1999). Parenting
procedure to deal with aggressive behavior and through change: An effective prevention pro-
public misbehavior, as they approach mastery gram for single mothers. Journal of Consulting
of the PCIT skills and assume increasing re- and Clinical Psychology, 67, 711– 724.
sponsibility for applying the principles to new Kazdin, A. E. (1996). Problem solving and parent
situations. management in treating aggressive and antiso-
cial behavior. In E. D. Hibbs & P. S. Jensen
(Eds.), Psychosocial treatments for child and
SUMMARY
adolescent disorders: Empirically based strate-
gies for clinical practice (pp. 377 – 408). Wash-
ington, DC: American Psychological Associa-
Parent management training is a widely used tion.
treatment for child disruptive behavior disor- Nock, M. K. (2003). Progress review of the psy-
ders. Based on social learning theory, this ap- chosocial treatment of child conduct problems.
proach to treatment has a strong evidence base Clinical Psychology: Science and Practice, 10,
supporting its effectiveness in changing both 1–28.
332 part iii • individual psychotherapy and treatment

Patterson, G. R. (1976). Living with children: New Webster-Stratton, C. (1998). Preventing conduct
methods for parents and teachers. Springfield, problems in Head Start children: Strengthening
IL: Research Press. parenting competencies. Journal of Consulting
Pelham, W. E., Wheeler, T., & Chronis, A. (1998). and Clinical Psychology, 66, 715 – 730.
Empirically supported psychosocial treatments Webster-Stratton, C. (2001). The Incredible Years:
for attention deficit hyperactivity disorder. Jour- Parents, teachers, and children’s training series.
nal of Clinical Child Psychology, 27, 190 –205. Residential Treatment for Children and Youth,
Pisterman, S., McGrath, P., Firestone, P., Goodman, J. 18, 31– 45.
T., Webster, I., & Mallory, R. (1989). Outcome Wolfe, D. A., Edwards, B., Manion, I., & Koverola, C.
of parent-mediated treatment of preschoolers (1988). Early intervention for parents at risk of
with attention deficit disorder with hyperactiv- child abuse and neglect: A preliminary investi-
ity. Journal of Consulting and Clinical Psy- gation. Journal of Consulting and Clinical Psy-
chology, 57, 628 –635. chology, 56, 40 – 47.
Schaefer, C. E., & Briesmeister, J. M. (Eds.). (1998)
Handbook of parent training: Parents as co-
Related Topic
therapists for children’s behavior problems
(2nd ed.). New York: Wiley. Chapter 12, “Interviewing Parents”
The Incredible Years. (2003). Home page. Retrieved
2004 from http://www.incredibleyears.com

HYPNOSIS AND RELAXATION

70 SCRIPTING

Douglas Flemons

As you’ve no doubt discovered during anxious derfully effective means to relax their efforts at
or stressful times, purposefully trying to relax relaxing, opening the possibility for nonvo-
is like trying to fall asleep or trying to have litional change. In this chapter, I’ll provide
fun — the expended effort undermines the in- some guidelines and illustrations for how to in-
tended goal. Any time your clients pit their corporate it into your practice, but for that dis-
conscious will against their racing thoughts or cussion to make sense, I first need to talk a bit
uptight bodies, attempting to compel them- about the differences between conscious aware-
selves to unwind or let go, they initiate a bat- ness and hypnotic experience.
tle they can only lose. Their thoughts refuse to
slow down and their bodies stay tense, leaving
them feeling frustrated and defeated. UNDERSTANDING HYPNOSIS
Relaxation can’t be dictated; it must be in-
vited to develop, which is where hypnosis In the everyday process of consciously perceiv-
comes in. Bridging the chasm between mind ing stuff, you typically distinguish yourself as
and body, hypnosis offers your clients a won- an observer, separate from what you observe.
 70 • hypnosis and relaxation scripting 333

When the object of your perception lies outside scripted induction, read a few scripted “thera-
of you, and particularly when it is somehow peutic” stories, and read some scripted direc-
unpleasant— that annoying song blasting from tives. Good hypnotic technique requires some-
the radio; the threatening clouds forming on thing quite different. Rather than focusing on a
the horizon; the odor emanating from the bunch of words on a page, you must be focused
locker at the gym — you tend to experience a on your clients—attuned to, and in sync with,
self-other split between you and it. But this their experience. Of course, if you’re going to
same division between observer and observed work this way, you have to know what to do
also gets evoked when you’re perceiving your- with what you get from them. So, instead of
self, especially when you don’t like what you’re giving you some scripts to read, I want to offer
noticing— the damn itch on your legs; the cold you some ideas and suggestions to think
nausea that’s been gripping you as tonight’s through and try out:
speech looms ever closer; the troubling mem- 1. Communicate your empathic under-
ory that keeps popping up at inopportune standing. The best way to begin helping your
times. clients change their relationship with them-
In everyday awareness, you often stay one selves, facilitating a shift in their internal
step (or more) removed from your surround- boundaries and the development of relaxation,
ings and your experience, as if there were an in- is to help them change their relationship with
visible wall erected between your “Observing- you and their surroundings. Hypnosis doesn’t
I” and the rest of the world, including the rest begin when you start delivering an “induction”;
of you—your body, your thoughts, your emo- it begins when your clients start trusting that
tions. This is the experiential source not only of you have a good handle on the intricacies of
alienation but also of the Cartesian mind-body their experience. You help them relax into this
split. trust by proving that you deserve it — by em-
During hypnosis and related activities — pathically communicating your understanding
meditation, prayer, reading, making love, play- of the details and emotional nuances of their ex-
ing sports, watching movies, playing or listen- perience.
ing to music — the invisible wall disperses,
CLIENT: . . . and by then I’m so stressed out that
allowing the insular separateness of your Ob-
when it comes time to go to sleep, all I can do
serving-I to dissolve. This accounts for the non-
is lay there and replay what happened dur-
volitional character of hypnotic experience (Fle-
ing the day, over and over.
mons, 2002). As your sense of self moves from
THERAPIST: It’s bad enough that you have to go
outside to inside your experience, facilitating
through it the first time during the day, but
the emergence and merging of an embodied
then to have to live through it again and
mind and mindful body, no insular Observing-
again, instead of drifting off to sleep—I bet
I remains to claim ownership of, or responsibil-
you just want to scream.
ity for, the arm that’s levitating, the numbness
CLIENT: Exactly. I do.
that’s spreading, or the warm heaviness that’s
increasing. As a result, these and other hyp- You know that you’re connecting well with
notic phenomena seem to “just happen.” Such your clients when they’re agreeing with your
an environment is ideal for your clients to learn empathic statements. This is the rapport you
how to relax without trying. need to move forward.
2. Use permissive words, inviting possibili-
ties. Imagine walking into a bank and having
INVITING HYPNOSIS, INVITING the manager say, in a commanding tone, “You
RELAXATION will open an account right now and deposit
your money into it. I will count backwards
Over the years, clients have told me stories of from 10 to 1, and as I do, you will find yourself
therapists they’ve had who, when it came time signing your name on these forms, and you
to do hypnosis, put on their glasses and read a will give me all your money: 10, 9, 8, . . .” You’d
334 part iii • individual psychotherapy and treatment

head straight for the door, right? Well your make a metaphorical statement about gain-
clients are no different. What many therapists ing understanding] on how you can feel so
regard as resistance, I view as clients’ healthy uptight, the temperature in the room help-
reluctance to go along with a course of action ing you, perhaps, to warm you to the real-
that doesn’t fit for them (Flemons, 2002). My ization that warm light is light, that the
reluctance would certainly be heightened if a lightness of warm air, the warmth of light
therapist were to start ordering me around: air, takes it up, up, up [utilizing the too-
warm room as part of a metaphorical ex-
THERAPIST: Now I want you to just relax as you
pression (“to warm up to something”) that
look at me and listen to my voice. As I count
suggests positive feelings, and to indirectly
backwards from 10 to 1, you will find your-
explore possibilities of developing sensations
self unable to look away from me, as if I
of lightness]. And I wonder just how high
were at the end of a dark tunnel and you
up, just how light, that feeling of being up-
could see nothing else. Soon that darkness
tight can take you [utilizing being “uptight”
will envelop you and your eyes will close all
as helpful in creating this movement up],
the way as you completely relax.
like an updraft, perhaps accompanied by a
Yuk! Forget looking through a tunnel —I’d developing sense, somewhere, probably not
be looking at the therapist through the office yet in your shoulders, maybe somewhere
window, shaking my head as I headed back to else already warming up to the possibility
my car. Rather than issuing directives, you’ll be [again utilizing the temperature in the
much better off offering suggestions and pos- room] of sinking comfortably down, like wa-
sibilities, phrasing them with permissive words ter, aided by gravity, moving down through
(O’Hanlon & Martin, 1992): pipes [utilizing the sound of a toilet flush-
ing], effortlessly moving along with nothing
THERAPIST: I don’t know if you’ll be more com-
getting in the way.
fortable closing your eyes or keeping them
No need to bother trying to help me out,
open. If they stay open for a while, they
as the cars and trucks out there, also rushing
might want to rest somewhere as I talk. You
in their own way, speed by, and you can ef-
can listen to what I’m saying or you can let
fortlessly follow the sound of their move-
your mind wander—either is fine. Certainly
ment, rushing ahead of rush hour [utilizing
there’s no need to pay attention, or to try to
the sound of traffic]. And what a rush it can
make something happen or to try to help me
be for it to slowly dawn on you, like the light
out.
of dawn [utilizing puns to change mean-
3. Utilize what the surroundings and your ings], that the pace outside can be nicely
clients offer up. Is your office too bright or complemented by the pace inside, that their
warm or cold for you to do hypnosis? Are the zooming out can remind you how to more
seats too uncomfortable? Are the walls too thin easily float in, like floating in the silence be-
to block out the sounds of traffic, voices, tween each of the rings of the telephone.
phones, and plumbing? Are your clients too up- Such a relief that brief silence is [utilizing
tight to let go? Are they too intent on main- the incessant ringing of a telephone] more
taining control to experience hypnosis? It appreciated because of the lovely way it con-
makes sense that you’d entertain such concerns, trasts with the rings on either side of it, be-
but if you approach hypnosis as an opportunity fore and after it, and that voice out there an-
for utilization (Erickson, 1980), you can see swering, giving you the freedom to question
each of these apparent roadblocks as possibili- [utilizing a voice answering the phone to
ties for furthering hypnosis and relaxation. move to the idea of questioning], going
round and round, wondering what to make
THERAPIST: You can allow the sunshine stream-
of hypnosis, knowing that you can question
ing in through the window to shed light
both before and after you experience it,
[utilizing the amount of light in the room to
wondering how your body is able to per-
 70 • hypnosis and relaxation scripting 335

fectly monitor and control your experience, and another, a former competitive ski racer,
just as it does when you’re sleeping or oth- who always skis a half a breath in front of
erwise occupied in some absorbing activity. himself, staying on the leading edge of him-
self, effortlessly careening down the moun-
4. Offer both-and suggestions. If you think
tain, taking all the time he needs to ever . . .
of contrasts — relaxed/tense; slow/fast; up/
so slowly . . . carve . . . each screeching turn.
down — as exclusive opposites, you’ll assume
that obtaining the desirable side of any distinc-
5. Look for and bring forth small shifts,
tion requires the elimination of the other. But if
rather than dramatic transformations. I grew
you treat contrasts as compatible and mutually
up in Canada, where I gained a lot of experience
important, as I did in the example above, then
liberating cars from snow banks. When a vehi-
one side of a contrast can coexist with, or be the
cle is stranded, you rock it forward and back,
conduit to, the other. Rather than lecturing my
while the driver alternates between hitting the
clients about this, I tell stories or vignettes that
gas and engaging the clutch. The goal isn’t in-
allow them to vicariously experience the ideas.
stantaneous liberation but a process of every-
For example, if a client’s thoughts are racing, I
increasing trajectories of change.
might talk about how wolf packs work:
You’ll enjoy greater success if you adopt the
THERAPIST: Wolves protect themselves by con- same attitude in helping clients. Instead of try-
tinually patrolling the perimeter of their ing to get their shoulders to relax, help them
territory, but if all of the wolves in a pack discover that one of their fingers feels a little
were to patrol all the time, none of them numb. A small change in sensation there can
would get any rest. So they take turns. Part be the first step to an ever so slightly bigger
of the pack keeps moving, always moving, change somewhere else.
along the edge of their territory, making 6. Offer interactive relaxation (via weird
sure everything is safe and secure, while the body conversations). Many hypnotherapists
rest are able, in the center, to rest deeply, re- offer their clients some form of progressive
laxing and sleeping. Why not allow part of (sometimes called Jacobson) relaxation, which
you to continue patrolling the perimeter of involves purposefully contracting and then re-
your awareness, ensuring that everything is leasing different muscle groups for 10 or 15
safe and secure, while the rest of you rests? seconds at a time. Other clinicians combine this
with deep breathing techniques, timing exhala-
A both-and approach to offering suggestions
tions with the releasing of tension. Still others
helps you not presume that quiet, calm thoughts
offer guided imagery, taking clients to a vividly
are a necessary precursor for hypnosis, and it
described beach or an alpine meadow, or some
helps clients not to have to try to slow down
other potentially relaxing setting, offering sug-
their thinking or breathing. Hypnosis makes it
gestions for enjoying the surroundings and re-
unnecessary for them to be at odds with them-
laxing into the experience.
selves. Here are some more both-and contrasts
Although these can all prove helpful, I, for
I sometimes offer, allowing clients to experience
the reasons I outlined earlier, invariably take a
something new without having to first not ex-
less directive path. I ask clients to find a place in
perience something else. Notice how the juxta-
their body that feels particularly tense, and I
position of stories creates a both-and relation-
get them to describe the sensations there with
ship among my descriptions.
as much detail as possible. I then have them go
THERAPIST: Isn’t it fascinating how you can be in search of a relaxed place— some part of them
zipping along in a car at 80 mph and yet feel that is comfortable or numb or so relaxed that
like you’re going 20? How is it that some- they haven’t even noticed it for a while — and
thing so fast can feel so slow? Your thoughts ask what they’re able to describe about it, too. I
can race on ahead or along side or just be- then provide a rationale for why it would make
hind me. I have a friend who, when we walk sense for the two areas to get into a kind of
together, is always a half-step in front of me, developing “conversation,” each one sharing
336 part iii • individual psychotherapy and treatment

some important information with the other. As help them develop their hypnotic ability.
we proceed, I frequently check in on what is Watching their nonverbal responses to your
changing and then fold that into what I say next suggestions will keep you partially apprised of
(see below). what they are currently experiencing, but if
you can get them to tell you in words, do it.
THERAPIST: Okay, so you feel the tension most in
Then, base your next suggestion on the infor-
your shoulders, like a sharp, radiating ache.
mation you’ve just received.
CLIENT: Yes.
THERAPIST: And your right thigh feels warm and THERAPIST: What’s happening now?
comfortable—almost asleep. CLIENT: My right hand is warm and soft, but my
CLIENT: Pretty much, yeah. shoulders are still tight.
THERAPIST: Great. You know, just as your lungs THERAPIST: Great. Your right hand was first off
and heart work together to deliver oxygen to the mark in adopting some important under-
the cells throughout your body, they also co- standing from your thigh. And we didn’t
ordinate with each other in the extraction even know it was listening! So now I don’t
and transportation of carbon dioxide from know if your thigh will continue to help
your body into the atmosphere. At a smaller your hand develop that sensation while it
level, the various cells of your immune sys- engages in contact with your shoulders or
tem communicate with each other about in- whether your hand will serve as an interme-
truders and, based on this shared informa- diary of some sort. Could be that your hand
tion, they coordinate an appropriate re- passes along the information to your shoul-
sponse. So your body knows a lot about how ders, maybe directly, or maybe by way of
to communicate within and between organs some other body part.
and systems, and it does this without your Let’s let things continue, and let’s see if
having to consciously understand how it your shoulders get in on the action at this
happens. point, or if some other part will first.
So as you sit there and listen to me, why
shouldn’t your shoulders get into a body 8. Teach self-hypnosis and self-reliance. The
conversation with your right thigh? You can hypnosis sessions you offer in your office may
listen to me or think about whatever comes be all your clients require to change how
to mind, confident that your shoulders and they’ve been orienting to the stresses in their
your thigh can communicate in a way that lives. Nevertheless, by teaching them how to do
you and I could never understand. But as self-hypnosis, you will give them the skill to
your thigh keys into the sharp radiating ten- invite relaxation on their own (Sanders, 1993).
sion there in your shoulders, it might learn I suggest to clients that since all hypnosis is, in
something about how to allow sensations to a way, self-hypnosis, they, having already ex-
radiate outward. If pain can radiate, why not perienced it in my office, know almost every-
comfort? I don’t know how the muscles thing they need to know in order to practice on
there in your thigh have figured out so bril- their own.
liantly how to become so easily warm and
THERAPIST: Find a comfortable place to sit or lie
loose, but your shoulders might as well get
down at home, in your office, or wherever,
in on the secret. So let’s let them get into a
and begin by noticing external and internal
body conversation of sorts while you tell me
things or events that grab your attention—
what you’re noticing.
sounds and sights before and after you close
7. Practice extemporaneous collaboration. your eyes; the sound and feel of your
Just as it is useful to encourage different parts breathing; sensations on your skin; thoughts
of your clients’ bodies to get into conversation and feelings; smells or tastes; and so on. De-
with each other, so too it is vitally important for vote one breath to each thing you notice,
you to stay in touch with your clients as you silently naming it in time with your exha-
 70 • hypnosis and relaxation scripting 337

lations: “The dog barking . . . birds chirping Society for Clinical and Experimental Hypno-
. . . jaw tense . . . the kids arguing downstairs sis, and the Milton H. Erickson Foundation (see
. . . tight shoulders . . . the fan clicking . . . References for Web site URLs), and some offer
left hand heavy . . . ” The more you practice, certification. Your state licensing board may
the easier it will be for you to invite yourself also have a list of approved workshop providers
into hypnosis, not needing to try to make in your area.
anything happen, not needing to try to re-
lax. References, Readings, & Internet Sites
If clients attempt to give themselves sugges- American Society for Clinical Hypnosis. (n.d.). Re-
tions in the midst of self-hypnosis, they will re- sources for research and teaching. Retrieved
invoke the split between the Observing-I (a.k.a. 2004 from http://www.hypnosis-research.org/
the Bossing-Around-I) and the rest of the self, hypnosis/index.html
and the hypnotic experience will end. To help American Society of Clinical Hypnosis. (n.d.). Home
them avoid this problem, I suggest, passing page. Retrieved 2004 from http://www.asch.
along an idea of Milton Erickson’s: that they be- net
Erickson, M. H. (1980). Further clinical techniques of
gin each self-hypnosis time by posing a ques-
hypnosis: Utilization techniques. In E. L. Rossi
tion to themselves — for example, “I wonder (Ed.), The collected papers of Milton H. Erick-
how my body will relax?”— and then let that son (Vol. 1, pp. 177 –205). New York: Irvington.
wondering hover around them as they proceed Flemons, D. (n.d.). Of one mind. New York: W. W.
with noticing their experience. Norton.
9. Trust yourself. If you’re just getting Flemons, D. (n.d.). Web site: Theory and practice of
started with hypnosis, you might feel inclined, hypnosis; hypnosis links. Retrieved 2004 from
despite my earlier cautions, to use some of my http://www.ofonemind.com
examples as scripts for use with your clients. Milton H. Erickson Foundation. (n.d.). Home page.
You’ll be much better off studying them Retrieved 2004 from http://www.erickson
closely, exploring diverse examples of other foundation.org
O’Hanlon, W. H., & Martin, M. (1992). Solution-
hypnotic work, and then leaving them behind
oriented hypnosis: An Ericksonian approach.
as you develop your own style. New York: W. W. Norton.
10. Get training. Check with your state li- Sanders, S. (1993). Clinical self-hypnosis: Transfor-
censing board to find out whether you must ob- mation and subjectivity. In J. W. Rhue, S. J.
tain approved training in hypnosis prior to em- Lynn, & I. Kirsch (Eds.), Handbook of clinical
ploying it in your practice. Even if there’s no hypnosis (pp. 251–270). Washington, DC:
regulation to this effect in place, I highly rec- American Psychological Association.
ommend getting hands-on experience and su- Society for Clinical and Experimental Hypnosis.
pervision. Workshops are regularly offered by (n.d.). Home page. Retrieved 2004 from http://
several professional organizations, including www.sunsite.utk.edu/IJCEH/scehframe.htm
the American Society of Clinical Hypnosis, the
 WORKING WITH THE
71 RELIGIOUSLY COMMITTED
CLIENT

P. Scott Richards & Kari A. O’Grady

The religious landscape of North America is ular counselor will (a) ignore spiritual con-
breathtaking in its diversity and vibrancy. cerns, (b) treat spiritual beliefs and experiences
Members of all of the major world religions and as pathological or merely psychological, (c) fail
countless smaller ones have found their homes to comprehend spiritual language and concepts,
in the United States or Canada. Over 80% of (d) assume that religious clients share nonreli-
people in North America claim affiliation with gious cultural norms (e.g., premarital cohabita-
Christianity (Berrett & Johnson, 1998) , but tion, premarital intercourse, divorce), (e) rec-
there is great diversity within the Christian ommend therapeutic behaviors that clients con-
tradition. The Yearbook of American and sider immoral (e.g., experimentation with
Canadian Churches (Bedell, 1997) lists over homosexuality), or (f) make assumptions, in-
160 different religious denominations. terpretations, and recommendations that dis-
Although religious affiliation alone may re- credit revelation as a valid epistemology” (p.
veal little about religious belief or commitment, 425). These fears are rooted in a public aware-
there is evidence that large numbers of people ness of the reality that many psychologists
believe in and are devoutly committed to their during the past century have endorsed anti-
faith. Recent polls have found that over 95% of religious, hedonistic, and atheistic values and
Americans profess belief in God, 64% are practices that conflict with those of traditional
members of a church, and 62% said that reli- religious communities (Bergin, 1980; Richards
gion can answer all or most of today’s problems & Bergin, 1997).
(Gallup Foundation, 2003). In light of these sta- Given their fears about psychotherapy, it is
tistics, most psychotherapists will work with not surprising that members of many traditional
religiously committed clients from a variety of religious communities, especially more devout
traditions during their careers. But if they are members, appear to significantly underutilize
not adequately prepared, psychotherapists may mental health services (Richards & Bergin,
find it particularly challenging to work sensi- 2000). Furthermore, there is some evidence that
tively and effectively with them (Shafranske & religious persons often seek professional therapy
Malony, 1996). as a last resort, after first seeking assistance from
There is evidence that many religiously family, friends, and their clergy. When they do
committed people, including religious leaders, seek psychotherapy, several studies have shown
have an unfavorable view of the mainstream, that devoutly religious persons often express a
secular mental health professions and a distrust preference for working with therapists from their
of the process of psychotherapy. Worthington own faith, or at least with a religious therapist
(1986) identified several possible concerns de- (Worthington, Kurusu, McCullough, & Sanders,
vout Christian clients may have about thera- 1996).
pists: “Conservative Christians fear that a sec-

338
 71 • working with the religiously committed client 339

THERAPEUTIC GUIDELINES • Establish a spiritually safe environment. We

recommend that therapists explicitly let their
clients know it is permissible to explore spir-
• Develop multicultural spiritual sensitivity.
itual issues should they so desire. Therapists
The foundations of an ecumenical therapeu-
can do this in the written informed consent
tic stance are the attitudes and skills of effec-
documents they give clients at the beginning
tive multicultural therapists, but it goes be-
of treatment and/or they can do so verbally
yond most contemporary multicultural ap-
during the course of therapy. Clients who
proaches to include training and competency
fear that the therapist might view their spir-
in working with religious and spiritual issues
itual beliefs as pathological could also be al-
(Richards & Bergin, 1997, 2000). Therapists
layed in the informed consent document.
with good ecumenical skills are aware of their
• Respect other worldviews. Therapists should
own religious and spiritual heritage and are
deal with religious differences and value con-
sensitive to how they could impact their work
flicts with clients in a respectful and tolerant
with clients from different religious and spir-
manner. Differences in religious affiliation
itual traditions. They are capable of commu-
and disagreements about specific religious
nicating interest, understanding, and respect
doctrines or moral behaviors can threaten
to clients who have spiritual beliefs that are
the therapeutic alliance if they are disclosed
different from their own. They seek to learn
prematurely or addressed inappropriately.
more about the spiritual beliefs and cultures
When such value conflicts become salient
of clients with whom they work. They make
during therapy, it is important for therapists
efforts to establish trusting relationships with
to openly acknowledge their values, while
members and leaders in their clients’ religious
also explicitly affirming clients’ rights to dif-
communities and seek to draw upon these
fer from therapists without having their in-
sources of social support when it seems ap-
telligence or morality questioned. Therapists
propriate. They use spiritual resources and
should also openly discuss with clients
interventions that are in harmony with their
whether the belief or value conflict is so
clients’ beliefs when it appears that this could
threatening that referral is advisable.
help their clients cope and change.
• Conduct a multisystemic assessment. We
• Adopt a denominational therapeutic stance
recommend that when therapists first begin
with some clients. A denominational stance is
working with clients that they globally as-
one that is tailored for clients who are mem-
sess the following systems or dimensions of
bers of a specific religious denomination
human functioning: physical, social, behav-
(Richards & Bergin, 1997, 2000). A denomi-
ioral, intellectual, educational-occupational,
national approach builds upon the foundation
psychological-emotional, and religious-
laid earlier in therapy by the therapist’s
spiritual (Richards & Bergin, 1997). Thera-
ecumenical stance, but differs in that the ther-
pists can also include questions about clients’
apist uses assessment methods and interven-
religious and spiritual backgrounds on an in-
tions that are tailored more specifically to
take questionnaire.
the clients’ unique denomination. Therapists
should use a denominational approach only
During the initial global phase of the assess-
with clients who view them as able to deeply
ment process, we recommend that therapists
understand and respect their spiritual beliefs.
collect only information that will help them
Such an approach can give therapists added
understand whether their clients’ religious
leverage to help clients because it can assist
background may be relevant to their presenting
them in more fully addressing the fine nu-
problems and treatment planning. Asking the
ances of a client’s religious and spiritual is-
following questions may help therapists make
sues, as well as tapping into the resources of
such a determination: (a) Is the client willing to
the client’s religious tradition.
discuss religious and spiritual issues during
340 part iii • individual psychotherapy and treatment

treatment? If not, this must be respected, al- terventions. There is a growing body of evi-
though the issue may be returned to if new in- dence that religious and spiritual practices
formation warrants it. (b) If so, what is the can both prevent problems and help promote
client’s current religious-spiritual affiliation? coping and healing where problems have oc-
How important is this affiliation to the client? curred (Benson, 1996; Koenig, McCullough,
How orthodox and devout is the client? & Larson, 2001). In general, people who are
(c) Does the client believe his or her spiritual religiously and spiritually devout, but not
beliefs and lifestyle are contributing to his or extremists, tend to enjoy better physical
her presenting problems and concerns in any health and psychological adjustment, and
way? (d) Does the client have any religious and lower rates of pathological social conduct
spiritual concerns and needs? (e) Is the client than those who are not (Koenig et al., 2001;
willing to participate in spiritual interventions Richards & Bergin, 1997). Examples of spir-
if it appears that they may be helpful? (f) Does itual interventions that may be used by psy-
the client perceive that his or her religious and chotherapists include praying for clients, en-
spiritual beliefs and/or community are a poten- couraging clients to pray, discussing theolog-
tial source of strength and assistance? ical concepts, making reference to scriptures,
using spiritual relaxation and imagery tech-
• Set appropriate spiritual therapy goals. The niques, encouraging repentance and forgive-
purpose of psychotherapy is to help clients ness, helping clients live congruently with
cope with and resolve their presenting prob- their spiritual values, self-disclosing spiritual
lems and to promote their long-term well- beliefs or experiences, consulting with reli-
being. Although not all religiously commit- gious leaders, and recommending religious
ted clients wish to explore religious issues or bibliotherapy (Richards & Bergin, 1997;
pursue spiritual goals, many do. There are Shafranske, 2000). Most of these spiritual in-
several general spiritual goals that may be terventions are actually practices that have
appropriate for therapy, depending on the been engaged in for centuries by religious
clients’ unique concerns: (a) help clients ex- believers.
amine and better understand what impact • Seek continuing education opportunities.
their religious and spiritual beliefs may be Psychotherapists can increase their compe-
having on their presenting problems and tency to work with religiously committed
their lives in general; (b) help clients identify clients from diverse backgrounds by: (a)
and use the religious or spiritual resources in reading books on the psychology and sociol-
their lives to assist them in their efforts to ogy of religion; (b) reading literature about
cope, heal, and change; (c) help clients exam- religion and spirituality in mainstream men-
ine and resolve religious and spiritual con- tal health journals; (c) taking a workshop or
cerns that are pertinent to their disorders; (d) class on religion and mental health and spir-
help clients examine how they feel about itual issues in psychotherapy; (d) reading
their spiritual well-being and, if they desire, books or taking a class on world religions; (f)
help them determine how they can continue acquiring specialized knowledge about reli-
their quest for spiritual growth. gious traditions that they frequently en-
• Refer as needed. Therapists need not neces- counter in therapy; (g) seeking supervision or
sarily be religious or spiritually oriented consultation from colleagues when they first
themselves to pursue these goals (Lovinger, work with a client from a particular religious
1984). At the same time, therapists will feel tradition; and (h) seeking supervision or con-
uncomfortable working on spiritual issues sultation when they first begin using reli-
because of lack of training or their personal gious and spiritual interventions (Richards &
views. In such circumstances, it would be ap- Bergin, 1997, 2000).
propriate and ethical for them to refer clients.
• Appropriately use spiritual resources and in-
 71 • working with the religiously committed client 341

References, Readings, & Internet Sites Richards, P. S., & Bergin, A. E. (1997). A spiritual
strategy for counseling and psychotherapy.
Bedell, K. B. (Ed.). (1997). Yearbook of American
Washington, DC: American Psychological Associ-
and Canadian Churches. Nashville, TN: Abing-
ation.
don Press.
Richards, P. S., & Bergin, A. E. (Eds.). (2000). Hand-
Benson, H. (1996). Timeless healing: The power and
book of psychotherapy and religious diversity.
biology of belief. New York: Scribner.
Washington, DC: American Psychological Associ-
Bergin, A. E. (1980). Psychotherapy and religious
ation.
values. Journal of Consulting and Clinical Psy-
Shafranske, E. P. (2000). Religious involvement and
chology, 48, 75 –105.
professional practices of psychiatrists and other
Berrett, D. B., & Johnson, T. M. (2002). Religion.
mental health professionals. Psychiatric Annals,
Britannica Book of the Year, p. 303. Chicago En-
30, 525 – 532.
cyclopedia Britannica.
Shafranske, E. P., & Malony, H. N. (1996). Religion
Gallup Foundation (2003). Public gives organized
and the clinical practice of psychology: A case for
religion its lowest rating: The Gallup Poll Tuesday
inclusion. In E. P. Shafranske (Ed.), Religion and
briefing. (January 7, 2003, pp. 1–2). Princeton,
the clinical practice of psychology (pp. 561– 586).
NJ: Gallup Organization.
Washington, DC: American Psychological Associ-
Koenig, H. G., McCullough, M. E., & Larson, D. B.
ation.
(2001). Handbook of religion and health. New
Worthington, E. L., Jr. (1986). Religious counseling:
York: Oxford University Press.
A review of published empirical research. Journal
Lovinger, R. J. (1984). Working with religious issues
of Counseling and Development, 64, 421– 431.
in therapy. New York: Jason Aronson.
Worthington, E. L., Jr., Kurusu, T. A., McCullough,
Melton, J. G. (1996). Encyclopedia of American re-
M. E., & Sanders, S. J. (1996). Empirical research
ligions. Detroit: Gale Research.
on religion and psychotherapeutic processes and
Miller, W. R. (1999). Integrating spirituality into
outcomes: A ten-year review and research pro-
treatment: Resources for practitioners. Washing-
spectus. Psychological Bulletin, 119, 448 – 487.
ton, DC: American Psychological Association.
 PSYCHOTHERAPY
72 WITH COGNITIVELY
IMPAIRED ADULTS

Kathleen B. Kortte, Felicia Hill-Briggs,

& Stephen T. Wegener

Individuals with cognitive impairments may Mild Adult Traumatic Brain Injury
present for psychotherapy with a range of cog- Individuals who suffer a mild traumatic brain
nitive, behavioral, and emotional symptoms. injury (mTBI) tend to experience headache,
The goal of psychotherapy is to assist them in dizziness, fatigue, memory decrement, and at-
adapting to the changes in their lives and them- tention problems. These symptoms typically
selves. The three primary diagnostic groups ad- subside approximately three to six months fol-
dressed in this overview are adult traumatic lowing a brief disruption in consciousness sec-
brain injury, stroke, and cognitive impairment ondary to a head injury (Mittenberg, Canyock,
and dementia in older adults. This chapter re- Condit, & Patton, 2001). However, approxi-
views the key issues influencing psychological mately 30% of these cases continue to experi-
functioning for these populations and suggests ence these problems for longer periods of time,
specific approaches and modifications to psy- as well as symptoms of depression, anxiety, or
chotherapy to accommodate for cognitive im- preoccupation with these symptoms (Mitten-
pairment. berg et al., 2001). When this constellation of
symptoms occurs and there is no objective evi-
dence of marked impairment on neuropsycho-
TREATMENT POPULATIONS
logical evaluation, the resulting syndrome is
known as post-concussion syndrome (PCS).
A central feature of psychotherapy that cuts Brief psychoeducational intervention provided
across diagnostic groups is the development of early in the recovery process can have a signif-
a therapeutic alliance (Prigatano, 1999; icant effect on reducing subsequent develop-
Sohlberg & Mateer, 2001). Because many pa- ment of PCS (Mittenberg et al., 2001). The fo-
tients with cognitive impairments are referred cus of therapy with this diagnostic group in-
by family members, community agencies, or cludes education of what to expect following
medical professionals, they may have a limited mTBI, review of the typical course of recovery
appreciation of the reason for psychotherapy. and prognosis for complete recovery, and rec-
Initial goals focus on developing the collabora- ommendations about gradual resumption of
tive relationship necessary to improve aware- normal activities.
ness of self and behavior. The therapeutic
alliance and the individual’s specific brain
functioning provide the basis for tailoring Moderate to Severe Adult
psychotherapy. Traumatic Brain Injury
The most enduring effects of traumatic brain
injury are emotional, behavioral, and psycho-

342
 72 • psychotherapy with cognitively impaired adults 343

logical ones (Ben-Yishey & Daniels-Zide, 2000). 20% to 50% (Robinson, 1998). Supportive
These effects can arise as a direct result of dam- psychotherapy for disability, loss, depression,
age to the brain and/or within the personal and and anxiety is often provided during acute re-
social context of the injury. Treatment follow- habilitation; however, there are very few stud-
ing moderate to severe TBI is implemented ies of their effectiveness in this population
generally within the context of the rehabilita- (Frank & Elliot, 2000). Cognitive-behavioral
tion setting. Treatment goals are often oriented interventions that focus on education, activity
toward facilitating community reintegration scheduling, and modifying unhelpful thoughts
and vocational rehabilitation, and therefore, in- (e.g., Lincoln & Flannaghan, 2003) have demon-
terventions are collaborative and involve an in- strated only limited effectiveness, and identifi-
terdisciplinary team (e.g., speech, occupational, cation of how these approaches are adapted for
and physical therapists; case managers; social use with varying levels of cognitive impair-
workers; physicians), family and caregivers, ment is still needed. Intervention for caregiver
and community agencies and resources (Frank burden is important both for caregiver coping
& Elliot, 2000). Psychotherapy is focused on and for survivor well-being (Frank & Elliot,
providing education about brain injury, im- 2000). Group approaches for families that focus
proving self-monitoring skills, facilitating skills on teaching active coping skills, providing ed-
for impairment compensation, assisting the in- ucation about stroke, and facilitating social sup-
dividual in integration of the changes associ- port can be effective in increasing disease
ated with TBI, and managing psychiatric symp- knowledge and use of coping strategies (van den
toms. Heuvel et al., 2002).
One of the most challenging aspects of
working with TBI patients is their limited
Cognitively Impaired Older
awareness of the changes in their functioning.
Adults
One treatment goal is to facilitate understand-
ing of changes in their behavior and, if they do The value of psychotherapy for maximizing the
not grasp the usefulness of psychotherapy, then functioning and quality of life of older adults
they may resist treatment or only passively en- with cognitive impairment and dementia is in-
gage in it (Prigatano, 1999). creasingly recognized since cognitively im-
Structured group therapy, either alone or in paired older adults are typically referred to psy-
combination with individual treatment, has chotherapy by others. The therapy process in-
particular advantages for addressing social and volves communication and collaboration with
emotional aspects of neuropsychological im- the individuals and systems involved in the
pairment. This format provides opportunities person’s care. Both the cognitively impaired
for peer comparison of strengths and limita- older adult and the caregiver(s) benefit from
tions, feedback for self-evaluation, sharing of psychoeducational approaches to increase un-
compensatory strategies, and an improvement derstanding of sequelae of neuropsychological
in feeling helpful to and accepted by others impairment. Therapy addresses the agitation
(Langer et al., 1999). Interventions focus on re- and behavioral disturbance that often presents
building basic social skills (e.g., eye contact, with dementia. Here, the psychological inter-
voice volume, listening, and body language) vention involves identifying triggers for dis-
and providing practice for managing emotional ruptive verbal (e.g., screaming, cursing, temper
reactions (social exercises, instruction, cuing, outbursts) or physical (e.g., pacing, hitting,
modeling, role-playing, and educational pre- scratching) behaviors, gaining understanding
sentations). of the meaning of the behaviors for the older
person, developing environmental and behav-
ioral approaches to decrease disturbance, and
Stroke
working with nursing-home staff or caregivers
Research suggests that the prevalence of clini- to implement the behavioral strategies (Lawton
cal depression following stroke ranges from & Rubenstein, 2000).
344 part iii • individual psychotherapy and treatment

The focus is on abilities rather than pointing For cognitively impaired individuals, cogni-
out deficits. Cognitive-behavioral approaches to tive remediation techniques are incorporated
treat depression and anxiety have been the focus into the process to facilitate receptive and ex-
of the majority of research with demented indi- pressive communication, to help patients focus
viduals (e.g., Laidlaw, Thompson, Dick-Siskin, and learn during sessions, and to promote car-
& Gallagher-Thompson, 2003). Cognitive psy- ryover of behavioral change and treatment
chotherapy goals are, first, to break down prob- goals to the home and community. Below are a
lems into basic components to reduce the per- series of specific strategies.
son’s feeling overwhelmed and, second, to teach
cognitive strategies to facilitate adaptive ways of
Communication
viewing the specific problem. Behavioral inter-
ventions are utilized with more moderately to • Use short, simple sentences.
severely demented persons; they focus on in- • Minimize the amount that is said at one time
creasing positive activities and decreasing nega- and in one session.
tive activities (Lawton & Rubenstein, 2000). • Speak slowly and clearly.
Modified psychodynamic approaches with de- • When repeating information, use the same
mentia patients focus on goals of providing an words.
environment for emotional outlet, enhancement • Summarize key points throughout session.
of self-esteem and role functioning, minimizing • Allow the patient extra time to respond.
psychological and behavior problems, and in-
creasing coping skills through modified therapy
Environment
techniques including keeping notebooks and
providing summaries, telling stories, or using • Meet with the patient more frequently, but
pictures (Haussman, 1992). for shorter therapy sessions.
Group treatments often utilized for persons • Promote consistency by having a set meeting
with dementia who reside in long-term care situ- time and structure.
ations provide emotional support through group • Hold sessions at the individual’s best time of
interaction and may effectively reduce depression day.
that stems from a lost sense of self (Brody & • Be receptive to between session contacts to
Semel, 1993). Reminiscence or life-review groups assist individual in carrying over informa-
promote positive affect and reconnection with tion.
events of personal significance. Visual prompts • Plan for longer duration of treatment.
(e.g., photographs of or clothing from a particu- • Minimize distractions in therapy environ-
lar era) or auditory prompts (e.g., a popular song ment.
of an era) may be used to facilitate memory and
discussion of the reminiscence topic.
External Aids
• Write notes either by or for the individual.
MODIFICATION OF • Employ diagrams, drawings, and checklists.
PSYCHOTHERAPY • Use rating or scaling techniques to anchor
changes in subjective experiences.
Psychotherapy is useful following changes to • Have a session agenda.
brain functioning in assisting individuals in • Audiotape or videotape sessions for later re-
adapting to the changes in their functioning view.
(Prigatano, 1999). However, the approach to • Use pictures, photos, and scrapbooks.
psychotherapy must be modified. The typical
structure of psychotherapy requires direct
communication and discussion of presenting is- METATHERAPEUTIC ISSUES
sues, therapeutic goals, and steps to achieving
those goals. Such discussions require high-level Identifying personal biases and assumptions
cognitive processes. will help the psychotherapist avoid subscribing
 72 • psychotherapy with cognitively impaired adults 345

to a moral or medical model of disability. Such References, Readings, & Internet Sites
a model may bias the psychotherapist toward Alexopoulos, G. S., Raue, P., & Arean, P. (2003).
viewing persons with impairments as individu- Problem-solving therapy versus supportive
als with shameful conditions or innately dis- therapy in geriatric major depression with ex-
abled, causing the therapist to assume a pater- ecutive dysfunction. American Journal of Geri-
nalistic role (Olkin, 1999). An alternative and atric Psychiatry, 11, 46 – 52.
potentially more productive model is a social or Ben-Yishay, Y., & Daniels-Zide, E. (2000). Examined
minority perspective, in which the disability is lives: Outcome after holistic rehabilitation. Re-
viewed as occurring at the interface of the per- habilitation Psychology, 45, 112–129.
son and his or her environment. Adopting this Bowen, A., Chamberlain, M. A., Tennant, A., Neu-
mann, V., & Conner, M. (1999). The persistence
model encourages the therapist to be aware of
of mood disorder following traumatic brain in-
the strengths and abilities of the individual and jury: A 1-year follow-up. Brain Injury, 13,
to focus on the interpersonal and physical envi- 547 – 553.
ronment as key targets for intervention. Brain Injury Association. (n.d.). Home page. Re-
The psychotherapist must also guard against trieved 2004 from http://www.biausa.org
the bias that individuals with cognitive impair- Brody, C. M., &. Semel, V. G. (Eds.). (1993). Strate-
ments will not benefit from psychotherapy or gies for therapy with the elderly: Living with
that behavior change is not possible because the hope and meaning. New York: Springer.
impairment results from neurologic insult. In- Frank, R. G., & Elliot, T. R. (Eds.). (2000). Handbook
dividuals with these deficits do benefit from of rehabilitation psychology. Washington, DC:
psychotherapy to improve psychosocial func- American Psychological Association.
Hausman, C. (1992). Dynamic psychotherapy with
tion. Further, there is no evidence to suggest
elderly demented patients. In G. Jones & B.
that nonspecific variables of psychotherapy—a Miessen (Eds.), Care-giving in dementia (pp.
confiding relationship, empathy, instillation of 181–198). London: Tavistock/Routledge.
hope, increased perceived mastery — are any Laidlaw, K., Thompson, L. W., Dick-Siskin, L., &
less important in achieving positive therapeutic Gallagher-Thompson, D. (2003). Cognitive be-
outcomes. Due to the multiple physical and haviour therapy with older people. New York:
psychosocial impairments concomitant in per- Wiley.
sons with cognitive deficits, psychologists must Langer, K. G., Laatsch, L., & Lewis, L. (Eds.). (1999).
develop a team of professionals with whom Psychotherapeutic interventions for adults
they work. Physician consultation for medica- with brain injury or stroke: A clinician’s treat-
tion evaluation is common and effective for ment resource. Madison, CT: International
Universities Press.
managing symptoms (Langer et al., 1999).
Lawton, M. P., & Rubinstein, R. L. (Eds.). (2000). In-
While rehabilitation programs usually have es- terventions in dementia care: Toward improv-
tablished interdisciplinary teams, psychothera- ing quality of life. New York: Springer.
pists in the community would benefit from de- Lincoln, N. B., & Flannaghan, T. (2003). Cognitive
veloping a network of consultants and re- behavioral psychotherapy for depression fol-
sources. These resources may include lowing stroke: A randomized controlled trial.
relationships with independent living centers, Stroke, 34, 111–115.
vocational rehabilitation services, community Mittenberg, W., Canyock, E. M., Condit, D., & Pat-
services for the elderly, peer support groups, ton, C. (2001). Treatment of post-concussion
and advocacy groups, as well as rehabilitation syndrome following mild head injury. Journal
personnel— physicians, speech-language thera- of Clinical and Experimental Neuropsychology,
23, 829 – 836.
pists, and physical and occupational therapists.
National Stroke Association. (n.d.). Home page. Re-
Finally, to effectively assist persons with dis- trieved 2004 from http://www.stroke.org
abilities, psychotherapists must have a working Olkin, R. (1999). What psychotherapists should
knowledge of the Americans with Disability know about disability. New York: Guilford
Act (ADA) of 1990 (P.L.101-336) and the indi- Press.
vidual’s rights under that law. These resources Prigatano, G. P. (1999). Principles of neuropsycho-
ensure access to necessary services and provide logical rehabilitation. New York: Oxford Uni-
the framework for maximizing independence. versity Press.
346 part iii • individual psychotherapy and treatment

Robinson, R. G. (1998). The clinical neuropsychiatry gram for informal caregivers of stroke patients:
of stroke. New York: Cambridge University Which caregivers benefit the most? Patient Ed-
Press. ucation and Counseling, 47, 291–299.
Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive
rehabilitation: An integrative neuropsycholog-
Related Topics
ical approach. New York: Guilford Press.
Toseland, R. W. (1995). Group work with the elderly Chapter 57, “Psychological Interventions in Adult
and family caregivers. New York: Springer. Disease Management”
Van den Heuvel, E. T. P., de Witte, L. P., Stewart, R. Chapter 64, “Psychotherapy With Older Adults”
E., Schure, L. M., Sanderman, R., & Meyboom- Chapter 91, “Medical Conditions That May Present
de Jong, B. (2002). Long-term effects of a group as Psychological Disorders”
support program and an individual support pro-

EARLY TERMINATION AND

73 REFERRAL OF CLIENTS IN
PSYCHOTHERAPY

Manferd D. Koch

Early identification of a nontherapeutic client- gests that therapists learn to identify clients
therapist relationship is important in designing with whom they cannot or should not work and
strategies for effective treatment intervention. refer them immediately and appropriately to
Responsibility is placed on the therapist to avoid causing the client personal discomfort
construct a therapeutic environment where or stress. Therapists can identify specific ego
healthy change can occur. When a therapeutic deficits and environmental circumstances that
impasse develops, clinicians are encouraged to predict premature psychotherapy termination,
undergo self-evaluation and make every at- such as motivation frustration tolerance, coun-
tempt to facilitate progress by considering al- tertransference issues, and life circumstances
ternative treatment approaches, consulting (Frayn, 1992). Psychologists are directed to ter-
with colleagues, and seeking formal supervi- minate therapy when the client/patient is not
sion. Certain problems and populations require likely to benefit or is harmed by continuing
specific skills for effective intervention, and treatment (American Psychological Associa-
client-therapist mismatches may become inef- tion, 2002). One or more of the following is-
ficient or even countertherapeutic. Therapists sues may be a potential reason to refer a client
are not expected to have the specific expertise to another psychotherapist:
necessary to treat all clinical populations; there-
fore, referral of the client to another practi- • Competence to treat: A cornerstone of
tioner may be indicated. Koocher (1995) sug- American Psychological Association (APA)
 73 • early termination and referral of clients in psychotherapy 347

ethical principles is to maintain high stan- not clinically contra-indicated, and when the
dards of competence by providing services resulting arrangement is not exploitative
for which one is qualified or making appro- (APA, 2002). Consultation of collleagues is
priate referrals (2002). Historically, thera- recommended. Referral is essential when dual
pists have demonstrated competence through relationships are unavoidable and are deemed
education, training, experience, research, li- to be harmful or exploitative.
censure, and recognition by colleagues. Tech- • Countertherapeutic transference: A client
nical competencies may be demonstrated by may develop unconscious feelings and be-
adherence to a training manual for specific haviors toward a therapist based on signifi-
therapies, such as experiential therapy (Green- cant relationships and conflicts originating
berg, Rice, & Elliot, 1993). General abilities early in the client’s life. Such transference
like sensitivity and insightfulness are harder may eventually result in the client’s having a
to demonstrate. The boundaries of a thera- positive infatuation toward the therapist or
pist’s competence may be questioned in mal- acting as if the therapist were infallible. Re-
practice actions when the therapist has been living previously repressed positive feelings
found to have used nontraditional therapies, in the form of a transference neurosis may
to have limited experience with a unique cul- have therapeutic value. However, the out-
tural population, to have had little training in come of the therapy is dependent on the ther-
working with addiction or suicide, or to have apist’s helping the client analyze and deal
not restricted practice. Limited self-study with maladaptive transference styles. In
may not be sufficient to demonstrate compe- some cases, clients are so fearful of change
tence. Formal continuing education provided that they refuse to abandon positive trans-
by professional organizations is essential ference; consequently, the therapy should
given the knowledge explosion in psychol- terminate, since continuation is not likely to
ogy, where the half-life of professional com- produce significant change. In other in-
petence may be 10 years. stances, the client may quickly devalue the
• Dual relationships: In psychotherapy, dual re- therapist and develop negative transference
lationships occur when the therapist, the per- when the therapist cannot fulfill all of the
son in power, enters into a significantly client’s needs. In other cases, transference is
different relationship with the client. Whether negative initially, and the client acts out feel-
sequential or concurrent, such relationships ings of mistrust, ambivalence, hostility, or
may unintentionally produce inappropriate aggression almost from the inception. The
influence over the client and impair the ther- client who develops strong negative transfer-
apist’s judgment by blurring and distorting ence may be unconsciously motivated to act
professional boundaries. When in doubt, the out hostile feelings in an escalating fashion
therapist should consult with the client and and to passive-aggressively sabotage the
colleagues concerning possible adverse con- therapy, even becoming suicidal and in rare
sequences prior to the development of po- instances homicidal. A client’s verbal abuse
tential dual relationships, such as therapist and threats of physical harm can produce ex-
and social friend, therapist and business part- treme anxiety and concerns about self-
ner, and therapist and supervisor or teacher preservation for the therapist (Maier, 1993).
(Bennett, Bryant, VandenBos, & Greenwood, Such actions on the part of the client and re-
1990). Sexual relationships with clients in actions from the therapist are counterther-
therapy are always judged to be exploitative, apeutic and potentially dangerous. These
forbidden, and in several states a felony actions indicate that consultation with col-
crime (APA, 2002). Nonerotic touching of leagues, referral to another therapist with
clients in therapy is controversial and may be different skills, or placement in a controlled
misinterpreted as sexual. Bartering for ser- facility is appropriate.
vices and accepting gifts are questionable • Unresolvable countertransference: Subjec-
practices and should be avoided except when tive reactions of the therapist toward the
348 part iii • individual psychotherapy and treatment

client are termed countertransference. As client participation. Others resist entering

with transference, these feelings may be pos- into a closely bonded relationship, while the
itive, such as being overly attracted and so- fear of change may keep some clients from
licitous toward a client, or negative, as in dis- forming an alliance. Therapist tolerance for
liking and acting in a rejecting fashion to- maladaptive acts during therapy inadver-
ward the client. Therapist reactions may be tently encourages the continuation of prob-
the consequence of the manner in which the lematic behaviors outside of therapy. Strupp
client treats the therapist, unresolved issues (1980) found little evidence that therapists
on the part of the therapist, or a combination confronted clients’ hostility and negativity.
of both. Positive and negative reactions of the Often a poor therapy outcome was the con-
therapist are real and need to be recognized sequence of a negative cycle of client hostil-
but not acted out toward the client. In some ity and therapist counterhostility, ultimately
instances the therapist’s feelings may con- destroying the therapeutic alliance. If it be-
tain important information that could exert comes clear after observation and consulta-
a therapeutic effect when shared with the tion that elements of the client-therapist in-
client. Therapists can use their reactions to teraction block productive work, transferring
help the client understand the impact the the client should be considered.
client has on relationships with significant • Resistance and therapeutic impasse: Analy-
others. It is a therapeutic skill to recognize sis of resistance has been a central element of
one’s personal countertransference attitudes, analytic therapy. Because therapy can be
feelings, and biases and not act them out in painful and threatens current psychic struc-
the therapy. Eventually therapists will en- tures, clients maintain their defenses, which
counter people who make them feel angry or control anxiety. Typically, resistance on the
frustrated or whom they simply dislike. part of the client results from the fear that
Every attempt should be made by the thera- change will force one to give up a desired
pist to deal with countertransference issues, object, feeling, or behavior. The therapist
including consultation, supervision, and per- should accept the existence of this process
sonal therapy. However, if these actions are while at the same time helping the client
not productive, referral is indicated, since identify what is threatening. Resistance may
strong unresolved positive or negative feel- take the form of withholding information,
ings and actions toward the client will in- attempts to manipulate the therapist, violat-
evitably result in dissolution of the thera- ing rules of the therapy, and even open hos-
peutic relationship (Kleinke, 1993). tility. Transference resistance is the conse-
• Failure to form a therapeutic alliance: To quence of dynamic issues between therapist
make progress in therapy, a client and ther- and client, which typically are a repetition of
apist must form a working alliance with earlier modes of interacting with significant
agreed-upon goals, rules, and responsibili- others. Another form of resistance is the re-
ties. A productive alliance involves bond-ing sult of the client’s belief that talk therapy will
together and collaborating to accomplish the not be useful in problem solving, while oth-
tasks of the therapy. Misalliance can be the ers may experience therapist intervention as
consequence of the actions or failure to act on a loss of personal freedom. When resistance
the part of either the client or the therapist. hinders the process of change, therapists
The therapist may contribute to the misal- should encourage the client to work through
liance through poorly designed, planned, and the dysfunctional resistance. Nevertheless,
executed interventions; inappropriate atti- resistance may become so strong that it cur-
tudes; and lack of self/other understanding tails effective treatment and results in a ther-
and by allowing disruptive outside influences apeutic impasse. Therapists may also impede
to enter the therapy. Clients may believe that the therapeutic process by engaging in coun-
benefit should be derived solely from efforts terresistance, which serves to preserve the
on the part of the therapist, without active therapist’s psychological status quo. This re-
 73 • early termination and referral of clients in psychotherapy 349

sults in therapist and client collusion to pre- References & Readings

serve and defend dysfunctional role interac-
tions (Stearn, 1993). When these conditions American Psychological Association. (2002). Ethical
occur, referral to another therapist with dif- principles of psychologists and code of conduct.
ferent skills is indicated. American Psychologist, 57, 1060 –1073.
• Compassion fatigue: It is essential that ther- Bennett, B. E., Bryant, B. K., VandenBos, G. R., &
Greenwood, A. (1990). Professional liability
apists maintain their own mental health when
and risk management. Washington, DC: Amer-
working with others. Therapists should be
ican Psychological Association.
aware of signs of fatigue, distress, burnout, Figley, C. R. (1995). Compassion fatigue: Toward a
or other impairment within themselves (Ben- new understanding of the cost of caring. In
nett et al., 1990). Compassion stress and B. H. Stamm (Ed.), Secondary traumatic stress:
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effects felt by mental health professionals educators (pp. 3 –25). Lutherville, MD: Sidran.
who work repeatedly with highly trauma- Frayn, D. H. (1992). Assessment factors associated
tized people. Therapists are encouraged to with premature psychotherapy termination.
recognize their shortcomings and special vul- American Journal of Psychotherapy, 46, 250 –
nerabilities to stress and fatigue and to de- 261.
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Fa-
velop strategies for prevention of compassion
cilitating emotional change: The moment-by-
fatigue (Figley, 1995). Some categories of
moment process. New York: Guilford Press.
clients are more demanding, difficult to treat, Kleinke, C. L. (1993). Common principles of psy-
and problematic than others. Clients with chotherapy. Pacific Grove, CA: Brooks/Cole.
borderline personality disorder, severe de- Koocher, G. P. (1995). Ethics in psychotherapy. In B.
pression, terminal illness, psychosis, or sui- Bongar & L. E. Beutler (Eds.), Comprehensive
cidal or homicidal tendencies or those who textbook of psychotherapy: Theory and prac-
have recently lost a child may be emotionally tice (pp. 456 – 473). New York: Oxford Univer-
taxing for the therapist. Professionals are sity Press.
wise to restrict their caseload to only a few of Maier, G. J. (1993). Management approaches for the
these difficult clients at any one time. After repetitively aggressive patient. In W. H. Sledge
& A. Tasman (Eds.), Clinical challenges in
working extensively with emotionally drain-
psychiatry (pp. 181–213). Washington, DC:
ing clients, the mental health professional
American Psychiatric Association.
may experience signs of burnout, which re- Stearn, H. S. (1993). Resolving counter-resistance
sult in increased mental and physical fatigue, in psychotherapy. New York: Brunner/Mazel.
irritability, distancing from clients, and im- Strupp, H. H. (1980). Success and failure in time-
pairment of competence to treat. Because it is limited psychotherapy: Further evidence. Ar-
essential that therapists maintain emotional chives of General Psychiatry, 37, 947 – 954.
integrity until their own mental well-being
is restored, they should refer rather than
treat additional demanding clients. Psychol- Related Topics
ogists are advised to be aware of personal Chapter 38, “Patients’ Rights in Psychotherapy”
problems that interfere with professional Chapter 76, “Choice of Treatment Format”
performance and take measures to obtain
consultation, or assistance and decide whether
to limit, suspend or terminate their profes-
sional work (APA, 2002).
 GUIDELINES FOR RELAPSE
74 PREVENTION

Katie Witkiewitz & G. Alan Marlatt

Relapse is the modal outcome for alcohol and all treatment effects demonstrated that RP was
substance abuse treatment programs that pro- a successful intervention for reducing substance
mote abstinence goals. Treatment approaches use and improving psychosocial adjustment.
have often focused on changing behavior (e.g., Carroll (1996) conducted a narrative review
promoting abstention from all substances), but of controlled clinical trials evaluating RP in the
not necessarily on maintaining positive changes treatment of smoking, alcohol, and other drug
over time. Individuals often left treatment pro- use. Across substances, RP was found to be gen-
grams without specific knowledge about how to erally effective compared with no treatment
maintain treatment gains. This situation led to and as good as other active treatments. One in-
a “revolving door” phenomenon, whereby sev- teresting finding was that some RP treatment
eral treatment completers returned to treat- outcome studies identified sustained main ef-
ment following a relapse. Clearly, during treat- fects for RP, suggesting that RP may provide
ment more emphasis needs to be placed on the continued improvement over a longer period of
problem of relapse and skills for preventing its time (indicating a “delayed emergence effect”),
occurrence. whereas other treatments may be effective over
Relapse prevention (RP) is an intervention only a shorter duration. This delayed emer-
that focuses on the maintenance stage of change gence effect is consistent with the skills acqui-
and the problem of relapse through an integra- sition basis of the RP approach. As with learn-
tion of behavioral skills training, cognitive in- ing any new skill, clients become more experi-
terventions, and lifestyle change procedures enced in acquiring and performing the skill,
(Marlatt & Gordon, 1985). Although initially leading to overall improvements in perfor-
developed for alcohol-use disorders, the princi- mance over time.
ples and concepts of RP have been adapted to
other addictive and nonaddictive disorders, in-
cluding depression (Teasdale et al., 2000), eat- CLINICAL PRACTICE OF RP
ing disorders (Mitchell & Carr, 2000), erectile
dysfunction (McCarthy, 2001), bipolar disor- Relapse prevention is a cognitive-behavioral
ders (Lam et al., 2001), schizophrenia (Herz et self-management training program designed
al., 2000), and sexual offenses (Laws, 1995). to enhance the maintenance of the behavior
The effectiveness of RP has been reasonably change process. Focusing on skills training, RP
well established across disorders. Irvin and col- teaches clients how to (1) understand the re-
leagues (1999) conducted a meta-analysis on lapse process; (2) identify high-risk situations
the efficacy of RP techniques in the improve- for relapse; (3) learn how to cope with craving
ment of substance abuse and psychosocial out- and urges to engage in the addictive behavior;
comes. Twenty-six studies representing a sam- (4) reduce the harm of relapse by minimizing
ple of 9,504 participants were included in the the negative consequences and learning from
review, which focused on alcohol use, smoking, the experience; and (5) achieve greater lifestyle
polysubstance use, and cocaine use. The over- balance. These five key themes, as well as sug-

350
 74 • guidelines for relapse prevention 351

gestions on how to implement them in clinical spent, etc.), along with a brief description of
practice, are described below. additional situational factors (where, who
was present, doing what); events that may
have occurred prior to the target behavior
Reframe Relapse as a Process
(what was happening, how you were feel-
Begin by exploring the client’s subjective asso- ing); amount consumed (be specific); and
ciations with the term relapse. Relapse can be consequences associated with use (what hap-
described as either an outcome — the dichoto- pened afterward, how you felt, what you
mous view that the person is either ill or well— were thinking). Self-monitoring can also be
or a process, encompassing any transgression in used as an assessment device, to monitor
the cyclic process of behavior change (Brow- urges to use, along with records of coping
nell, Marlatt, Lichtenstein, & Wilson, 1986). responses and whether or not the urge was
Many clients view relapse in dichotomous followed by engaging in substance use. Psy-
terms (“I was either able to maintain abstinence chological reactivity to self-monitoring can
or not”). Alternatively, we can teach clients to serve as an intervention strategy, since the
use the term lapse to describe the first episode client’s awareness of the target behavior in-
of the behavior after the commitment to absti- creases as the assessment continues and can
nence. A lapse is a single event, a reemergence lead to reductions in the monitored behavior.
of a previous habit, which may or may not lead 2. Autobiographies: Have clients provide a de-
to a complete relapse. When a slip is defined as scriptive narrative of the history and devel-
a lapse, it implies that if a corrective action can opment of their problem. Ask the client how
be taken, the outcome can still be considered and why he or she initiated or first became
positive (called a prolapse). Small setbacks can involved with the addictive behavior; how
be described as opportunities for new learning the patterns of engaging in the addictive be-
and the reevaluation of coping strategies in havior may have changed over time; and
high-risk situations, rather than indications of what people, places, and events are associ-
personal failure or a lack of motivation (Mar- ated with the problematic behavior patterns.
latt, 1996). 3. Assessment tools: Numerous self-report
measures and observational techniques have
been developed to help clinicians and their
Identify High-Risk Situations
clients identify and prioritize their individ-
The initial component in RP is the identification ual high-risk situations. These include the
of a client’s unique profile of high-risk situa- Inventory of Drug-Taking Situations (An-
tions for relapse and evaluating the client’s abil- nis, 1985), the Inventory of Drinking Situ-
ity to cope with these high-risk situations. A ations (Annis, 1982), and the Identifying
high-risk situation is one in which the individ- High-Risk Situations Inventory (Daley,
ual’s sense of perceived control is threatened. 1986). Once high-risk situations are identi-
High-risk situations can include environmental fied, it is helpful to assess the client’s degree
influences, an interpersonal interaction, or in- of self-confidence in his or her ability to
trapersonal factors (such as affective states, resist urges and maintain abstinence in
cognitions, and physiological states). The pro- those situations. The Situational Confidence
cedures available to identify high-risk situa- Questionnaire (Annis & Graham, 1988) is a
tions differ based on the readiness of the client useful measure of an individual’s perceived
and whether or not the client is engaged in the self-efficacy in specific high-risk situations.
target behavior at the time of the assessment.
Learn How to Cope With Urges to
1. Self-monitoring: Ask the client to keep a
Use in High-Risk Situations
continuous, daily record of the target behav-
ior (what time the behavior began and 1. Assess coping skills: Any situation can be
ended, amount consumed, amount of money considered “high-risk” if the person is inca-
352 part iii • individual psychotherapy and treatment

pable or unwilling to respond to that situa- tively attend to the positive expectancies of
tion with an effective coping response. use. Help clients develop a decisional matrix
Therefore it is critical that the clinician focus that summarizes both immediate and de-
on the assessment of a client’s coping skills layed negative consequences of engaging in
with regard to previous, or probable, high- the prohibited behavior. A reminder card
risk situation. (also referred to as an emergency card) is one
2. Teach effective coping behavior: Following way of listing both cognitive and behavioral
assessment, the clinician should teach the techniques that can be used in the event a
client how to respond to cues (that occur be- client has an urge to use.
fore or during a high-risk situation) by en- 5. Train clients to be on the lookout for warn-
gaging in an alternative effective coping ing signs: Clients can be taught to look for
behavior. Coping skills can be behavioral impending high-risk situations and to take
(action or action), cognitive (planning, re- preventive action at the earliest possible
minders of negative consequences, “urge point. Depending on the situation and the
surfing”), or a combination of cognitive and client’s self-efficacy, the recommended action
behavioral coping processes. The goal is to might be to avoid the high-risk situation.
teach clients how to respond to early warn- However, not all high-risk situations can be
ing signs of relapse, such as the rationaliza- identified in advance. Many situations arise
tion of making seemingly unimportant deci- suddenly without warning — for example,
sions that eventually lead to a lapse (e.g., being with a supposed non-using friend who
maybe I should buy a bottle of vodka and offers drugs. In this type of situation, the in-
keep it in the house, just in case guests drop dividual must rely on previously acquired
by). RP combines practice in general prob- coping responses. Emphasize that the earlier
lem-solving skills and specific coping re- one intervenes in the chain of events leading
sponses. Skills training methods incorporate up to a high-risk situation and possible re-
components of direct instruction, modeling lapse, the easier it will be to prevent the
and behavioral rehearsal and coaching, and lapse from occurring.
therapist support and feedback. In those
cases in which it is not practical to use new
Minimize the Negative
coping skills in real-life settings, the thera-
Consequences of a Lapse by
pist can utilize imagery or role-plays to rep-
Learning From the Experience
resent high-risk situations.
3. Teach “urge-surfing”: Urge-surfing is a 1. Explain the abstinence violation effect
metaphor for coping with the conditioned (AVE): The client’s attributional response
response to stimuli associated with the ad- to a slip can further increase the probabil-
dictive behavior (coping with reactivity to ity of a full-blown relapse. Clients who
cue exposure). It is based on the analogy view relapse as inevitable following the oc-
that urges are like ocean waves, in that they currence of a lapse are setting themselves
have a specific course of action, with a given up for an even larger transgression of be-
latency of onset, intensity, and duration. Re- havior. This abstinence violation effect re-
mind clients that urges will arise, subside, sults from two cognitive-affective ele-
and pass away on their own. In this tech- ments: cognitive dissonance (conflict and
nique, the client is taught to label internal guilt) and a personal attributional effect
sensations and cognitive preoccupations as (blaming oneself as the cause of the uncon-
an urge, and to foster an attitude of detach- trollable relapse). Clients should be in-
ment from that urge. The goal is to identify, structed that a slip does not have to result
accept, and “surf ” the urge, keeping one’s in a major relapse and that lapses provide
balance so as to not get wiped out by the an opportunity for corrective action. A
temptation to give in. lapse may turn out to be a valuable learn-
4. Develop a decisional matrix: Clients who ing experience (prolapse) that raises con-
are on the verge of using may only selec- sciousness and teaches the client informa-
 74 • guidelines for relapse prevention 353

tion about possible high-risk situations and A meta-analytic review. Journal of Consulting
sources of stress or lifestyle imbalance. and Clinical Psychology, 67, 563 – 570.
2. Conduct relapse debriefings: One way to Lam, D. H., Bright, J., Jones, S., Hayward, P., Schuck,
learn from lapses is through the use of re- N., Chisholm, D., & Sham, P. (2000). Cognitive
therapy for bipolar illness—A pilot study of re-
lapse debriefings. Explore all aspects of the
lapse prevention. Cognitive Therapy and Re-
chain of events leading up to the relapse (or
search, 24, 503 – 520.
a particular temptation or lapse), including Larimer, M. E., Palmer, R. S., and Marlatt, G. A.
details concerning the high-risk situation, (1999). Relapse prevention: An overview of
alternative coping responses, and inappro- Marlatt’s cognitive-behavioral model. Alcohol
priate and appropriate cognitions. Research and Health, 23(2), 151–160. Re-
trieved March 10, 2003, from the National In-
stitute of Alcohol Abuse and Alcoholism publi-
Achieve Lifestyle Balance cations Web site: http://www.niaaa.nih.gov/
Intervene in the client’s overall lifestyle to in- publications/arh23-2/151-160.pdf
crease the capacity to deal with perceived has- Laws, D. R. (1995). Central elements in relapse pre-
vention procedures with sex offenders. Psychol-
sles or responsibilities (“shoulds”) and per-
ogy, Crime and Law, 2, 41– 53.
ceived pleasures or self-gratification (“wants”).
Marlatt, G. A. (1996). Taxonomy of high-risk situa-
A key goal for a lifestyle intervention is to pro- tions for alcohol relapse: Evolution and develop-
vide alternative sources of reward and to replace ment of a cognitive-behavioral model of relapse.
the addictive behavior with other positive ac- Addiction, 91(Suppl.), 37 – 50.
tivities or positive addictions. A “positive ad- Marlatt, G. A., & Gordon, J. R. (1985). Relapse pre-
diction” is a behavior that may be experienced vention: Maintenance strategies in the treat-
negatively at first, but is highly beneficial in ment of addictive behaviors. New York: Guil-
the long-range effects and may become a lasting ford Press.
habit. Examples include aerobic exercise, relax- Marlatt, G. A., Parks, G. A., and Witkiewitz, K.
ation training, or meditation. (2002, December). Clinical Guidelines for Im-
plementing Relapse Prevention Therapy. Re-
trieved March 10, 2003, from the Behavioral
References, Readings, & Internet Sites Health Recovery Management Web site: http://
www.bhrm.org/guidelines/RPT%20guideline.
Annis, H. M. (1982). Inventory of Drinking Situa- pdf
tions. Toronto: Addiction Research Foundation. McCarthy, B. W. (2001). Relapse prevention strate-
Annis, H. M. (1985). Inventory of Drug-Taking Situ- gies and techniques with erectile dysfunction.
ations. Toronto: Addiction Research Foundation. Journal of Sex and Marital Therapy, 27, 1–8.
Annis, H. M., & Graham, J. M. (1988). Situational Mitchell, K., & Carr, A. (2001). Anorexia and bu-
Confidence Questionnaire (SCQ-39) user’s limia. In A. Carr (Ed.), What works for children
guide. Toronto: Addiction Research Foundation. and adolescents? A critical review of psycho-
Brownell, K. D., Marlatt, G. A., Lichtenstein, E., & logical interventions with children (pp. 233 –
Wilson, G. T. (1986). Understanding and prevent- 257). London: Routledge.
ing relapse. American Psychologist, 41, 765 –782. Teasdale, J. D., Segal, Z. V., Williams, J. M. G.,
Carroll, K. M. (1996). Relapse prevention as a psy- Ridgeway, V. A., Soulsby, J. M., & Lau, M. A.
chosocial treatment: A review of controlled (2000). Prevention of relapse/recurrence in ma-
clinical trials. Experimental and Clinical Psy- jor depression by mindfulness-based cognitive
chopharmacology, 4, 46 – 54. therapy. Journal of Consulting and Clinical
Daley, D. (1986). Relapse prevention workbook for Psychology, 68, 615 – 623.
recovering alcoholics and drug dependent per- Walton, M. A., Blow, F. C., & Booth, B. M. (2001).
sons. Holmes Beach, FL: Learning Publications. Diversity in relapse prevention needs: Gender
Herz, M. I., Lamberti, J. S., Mintz, J., Scott, R., and race comparisons among substance abuse
O’Dell, S. P., McCartan, L., & Nix, G. (2000). A treatment patients. American Journal of Drug
program for relapse prevention in schizophre- and Alcohol Abuse, 27, 225 –240.
nia: A controlled study. Archives of General
Psychiatry, 57, 277 –283.
Related Topic
Irvin, J. E., Bowers, C. A., Dunn, M. E., & Wang,
M. C. (1999). Efficacy of relapse prevention: Chapter 55, “Motivational Interviewing”
 GUIDELINES FOR
75 TERMINATING
PSYCHOTHERAPY

Oren M. Shefet & Rebecca C. Curtis

The end of the psychotherapy is a crucial part of ronment is also important with patients
the therapeutic endeavor. Mistakes made in this whose previous circumstances were major
stage cannot usually be corrected in later ses- factors in their hospitalization or substance
sions. Both the client and the therapist will abuse.
evaluate the successes and failures of the treat- 3. Avoid surprise: If either the therapist or the
ment and consolidate achievements. Termina- client is surprised by termination, there can
tion can also be viewed as a stage in therapy be a problem. Termination should usually
rather than as the end (Fox, 1993; Tyson, 1996). come from the client’s initiative, and a mu-
tual agreement between the client and the
therapist should be reached concerning its
TIMING: WHEN SHOULD THE time and manner of execution. Clients often
THERAPY END? forget about termination dates and need re-
minders of the plan discussed. When the
The criteria for treatment termination are as therapist must take time off or end treat-
numerous as the theoretical orientations. How- ment, it is preferable to let the client know in
ever, general guidelines have been provided in advance that this will be happening, even if
the literature. the exact date is not known. Therapists may
wish to avoid letting patients know about
1. Avoid perfectionistic tendencies: That is, medical or other problems, but such avoid-
avoid setting criteria that are too high. The ance is not in the patient’s interest.
patient who is leaving therapy does not have 4. Recognize treatment failure: A therapist
to be completely healthy, positive, efficient, who reaches the conclusion that the client’s
or conflict free. problems cannot be helped in the existing
2. Assess attainment of treatment goals: Most therapy should also terminate and make a
therapies stress the importance of the goals referral (Werner, 1982).
set by the client (Goldfried, 2002). Termina- 5. Negotiate a termination date: Clients often
tion, however, will often be when the mo- pick a date in which the therapy would have
mentum of the work and motivation for come to a halt even without the termination,
therapy have decreased (Greenberg, 2002). such as the beginning of a vacation or a ma-
Major goals are usually the alleviation of jor holiday. This can be viewed as an attempt
symptoms and improvement in handling life to avoid the feelings the termination creates.
problems on one’s own. Psychodynamic ori- Therapists might point this out to clients
entations also aim for increased ability to and encourage them to pick a date without
tolerate emotions (Curtis, 2000) and resolu- other meanings, a date that will stand on its
tion of transference issues (Weiner, 1998). own as the end of the therapy.
The goal of a new living or working envi-

354
 75 • guidelines for terminating psychotherapy 355

THE TERMINATION PROCESS Spaced terminations, on the other hand, im-

ply that this is a test. The therapist and the
Setting a Termination Date
client enter a process of lessening the therapy,
Setting and reminding the client of a proposed which can be hastened or slowed as needed.
termination date has distinct advantages and Upon each spaced session, they examine the ef-
disadvantages. Once a termination date has fect of the further spacing on the client. The
been agreed upon, the therapy may change. On client and therapist may feel that the termina-
the one hand, setting a date allows the client to tion is an option, which may or may not come
prepare herself for the post-treatment period into being. The choice between the two options
and engage in the separation process. Knowing will depend upon the therapist’s clinical orien-
that the end of the process is near may motivate tation and the client’s presumed ability to han-
the client to work harder. On the other hand, dle the emotions that a set termination date will
the client may be reluctant to be engaged in the raise.
work, due to sadness over abandonment or
other feelings, and this may disrupt a psy-
The Client’s Reaction
chotherapy that has been going quite well until
that point. Clients vary in their reactions to termination.
Setting a termination date is difficult not Some, especially in relatively short treatments,
only for the client, but also for the therapist do not have a strong reaction. Therapists should
(Curtis, 2002). Therapists may avoid discussing beware of attempting to provoke and “uncover”
or initiating terminations for their own rea- feelings that do not exist. Some clients, how-
sons, as previously mentioned, rather than their ever, while saying they feel little about the up-
patients’ interests. Therapists are advised to coming end, nevertheless experience a wide
identify such a pattern in themselves (Fox, range of emotions, and ignoring those emotions
1993; Weissman, Markowitz, & Klerman, is a mistake. In those cases, the therapist should
2000). encourage clients to discover their reactions,
and may even raise suggestions concerning var-
ious emotions that clients might feel (Weiss-
Time-Limited and Spaced
man et al., 2000). Deciding whether clients who
Terminations
“do not feel anything” are covering for strong
Announcing the end of the treatment and end- emotional reactions or not requires great deal
ing the treatment in the same session is usually of clinical judgment.
not advised. Such a pace would not allow either Most clients, especially those who partici-
the client or the therapist to deal with the dif- pate in long therapies, will experience strong
ficult emotions the termination may bring emotions around termination. The pleasant
about and prevent coming to terms with the emotions may include a sense of relief from
treatment and its ending. This leads to the the financial and time pressures surrounding
question of the time line between the termina- psychotherapy, pride of accomplishment and
tion announcement and the final session. “graduation” from a stage in life, and joy in a
In timed-limited terminations, sessions oc- sense of agency and independence (Tyson,
cur with the same regularity as before, until 1996). While not ignoring the negative emo-
the final session, when they stop. In spaced ter- tions, the therapist should acknowledge these
minations, the session frequency is gradually feelings and share in the client’s pleasure.
lessened, with the final session perhaps a month A wide spectrum of negative emotions may
or more after the one before it. Time-limited arise. According to psychoanalytic theory, pa-
terminations imply to the client that the ther- tients are likely to mourn the loss of the rela-
apy is complete. The termination date that was tionship (Fox, 1993; Garcia-Lawson & Lane,
set seems final, and the client continues to work 1997; Tyson, 1996; Weissman et al., 2000).
on his reactions to this date in a manner not Kübler-Ross’s stage theory of mourning can
very different from other therapeutic work. help the therapist understand the client’s reac-
356 part iii • individual psychotherapy and treatment

tions (Fox, 1993). In the first stage — denial — it can allow the client and therapist to work
patients may ignore the upcoming termination, through those archaic fears before the termina-
deny their feelings about the termination, and tion of the therapy.
make relatively few attempts to approach the The second pattern of interaction is the feel-
subject. In the second stage—anger— patients ing of a romantic rejection. Some clients de-
may feel rage about “being abandoned” by the velop strong romantic yearnings toward their
therapist. In this stage, they may accuse their therapists, and the termination signals to clients
therapists of being hostile and uncaring, and de- that their yearnings will remain unfulfilled.
value them and the therapy they offered. Such Like any rejected lover, the patient may feel
a tactic, however, can decrease the client’s abil- jealous of the therapist’s other clients, or of the
ity to consolidate the gains achieved in the therapist’s family, colleagues, or friends. Those
therapy and leave him or her with a sense of feelings of jealousy may also promote emotions
failure. A temptation exists to avoid the issue of of guilt and loss of self-esteem. Other patients
termination in order to avoid the patient’s dis- may develop a fantasy that would allow them to
comfort or devaluation, and retain the image of retain some contact with the therapist, such as
oneself as a “good therapist.” This temptation writing a book about the therapy or using the
should be avoided. therapist as a future mentor. The therapist’s
In the third stage — bargaining — clients task will be to help the client renounce his un-
may attempt to find a way to prolong the ther- realistic ambitions and come to terms with this
apy. They may try to renegotiate the therapeu- loss.
tic contract. Another common strategy is find- Some patients idealize their therapists and
ing a new problem or symptom, or relapsing wish to emulate them. The process at termina-
into symptoms that were resolved during the tion may be similar to the one some adolescents
therapy. In the fourth stage—depression— the experience as they begin to see the limitations
client will not attempt to work through his or of their parents and develop values that may
her affective reactions, but rather obsess on differ from theirs. At termination it is useful if
them, perhaps with a growing sense of help- clients who have heretofore focused primarily
lessness to change the coming end of the ther- on the positive qualities of the therapist see the
apy. Only in the fifth stage—acceptance— will therapist more realistically and value their own
the client come to terms with the termination. independence. Some clients plunge to an oppo-
This is perhaps one of the best stages of the site extreme and devalue the therapy and ther-
therapy to work on separation/individuation. apist, while fearing a future that is relatively
One of the reasons for the severity of the empty of important relationships. The therapist
mourning is that patients may mourn not just should aid in helping clients remain aware of
the current relationship but also important past positive and negative qualities in themselves
relationships that ended in separation. Clients and others simultaneously. This will help the
may cast the therapist in three roles that led to client feel hopeful and empowered concerning
separation in their earlier experience: the all- future relationships, without overvaluing or
powerful parent, the rejecting lover, or the ideal devaluing the therapist.
mentor (Tyson, 1996). A prevalent client reaction is to induce a pre-
The first is the parent-infant interaction. In emptive strike. The client would himself at-
some cases, patients create a highly dependent tempt to terminate the therapy, fearing that the
relationship with the therapist, whom they therapist will announce one. The positive side
construe as an omnipotent benevolent parental of this attempt is that the client turns himself
figure (Frank, 1999). In such cases, separation into the active agent of the termination, and
from the therapist revives anxieties that were thus acquires a sense of control and agency.
experienced in very early childhood or infancy, This premature termination, however, is often
leading to rage against the therapist combined the result of avoidance of the complicated and
with deep feelings of helplessness and loss. This painful emotions involved in the termination
need not be a detriment to the therapy because process, and may interfere with the termination
 75 • guidelines for terminating psychotherapy 357

tasks, such as the consolidation of the therapeu- rative of the therapeutic change can also help
tic gains. It is better to deal with the frustra- the client retain the therapeutic gains.
tions of the therapy and the therapy’s end dur- 4. Empower the client. Clients should feel a
ing the therapy itself, rather than leave the sense of empowerment and an ability to re-
client to deal with those issues alone in the solve their own problems. This can be done
post-treatment stage not just by reviewing the gains, but also by
In some cases the reaction of the client, as reviewing the client’s contribution to the
expressed by eleventh-hour problems, relapse, therapeutic process. Expressing confidence in
or distress, will be extremely severe. In those the client’s future may also help the client
cases, it is advised to reconsider the termina- feel empowered and may even act as a self-
tion. The therapist should not fear to do so, fulfilling prophecy.
even at the price of appearing inconsistent or 5. Create a more egalitarian relationship. A
unresolved (Tyson, 1996). more egalitarian relationship can be done by
increasing the personal revelations of the
therapist and initiating direct discussions of
TERMINATION TASKS the therapeutic process (Curtis, 2002; Fox,
1993; Greenberg, 2002). Another mecha-
The therapist should take several steps upon nism is to focus on the client’s initiative and
terminating the therapy: actions that led to the therapeutic change.
6. Discuss future problems. An important task
1. Work through the separation anxiety. The of the termination stage is to discuss possi-
therapist should be aware of the complex ble problems that may occur in the future,
emotions induced by the termination and and various actions and coping skills the
help the client work through them. client may utilize to solve them.
2. Resolve any unrealistic views of the thera- 7. Address the possibility of relapse. Clients
pist. In therapies that have centered on should be aware of the possibility of relapse,
transference resolution as a therapeutic especially with disorders such as depression.
mechanism, steps should be taken to resolve The client should learn to recognize early
any unrealistic perceptions. In the psycho- warning signs, that would allow her to seek
analytic tradition, this will be achieved by help sooner rather than later. The client
interpretation of the transference relation- should be made aware that such a relapse is
ship (Tyson, 1996). Other authors, such as not a failure and that the therapist would be
Weiner (1998) and Curtis (2002), advise available to the client, if such a relapse, or
therapists to gradually abandon the “blank- another problem, occurs.
slate” position and allow their real personal- 8. Consider attribution of responsibility for
ities to enter the therapeutic relationship di- therapeutic failure. When psychotherapies
rectly. Strengthening the real relationship end due to the client’s lack of improvement,
will diminish any remaining tendency to the therapist should explain to the client that
idealize the therapist. it is the therapy that has failed the individ-
3. Consolidate therapeutic gains. The therapist ual, rather than the individual that has
should review with the client the problems failed the therapy. Moreover, the therapist
that led her to the therapy and the new ways should point to other therapies that may
of coping that she learned to utilize. The help the client, such as pharmacotherapy or
therapist should point out specific instances different orientations, and encourage the
in which the client used new ways to react to client to continue in his or her search for a
situations and gently point to recent inci- cure, in spite of the failure (Greenberg,
dences in which the client could have done 2002).
so. In some therapies, creating a ritual to 9. Asking questions about the therapy. It is
consolidate the gains may be helpful useful to ask the client about the psy-
(Greenberg, 2002). In others, creating a nar- chotherapy and to inquire what was helpful,
358 part iii • individual psychotherapy and treatment

what was not helpful, and what the client and clients who have not changed much in their
felt led to the therapeutic gains. Such ques- lives before treatment.
tions will allow the therapist to view the
therapy through the client’s eyes and per-
haps alter therapeutic techniques with SPECIAL CONSIDERATIONS FOR
other clients. CHILD THERAPY
10. Address post-termination contacts. It is
helpful if therapists inquire of clients what Most of the guidelines elaborated in this chap-
sort of conversation they want and how ter apply also to child psychotherapy. Specific
they should be introduced should they en- case examples of saying goodbye to children are
counter each other elsewhere in the future. provided by Schmukler (1991). Several matters
Depending upon the type of termination deserve special consideration.
and many other factors, the therapist may
wish to tell the client to feel free to return 1. The client often is conceptualized not only
in the future should another problem de- as suffering from specific symptoms but also
velop where the client thinks the therapist as lagging in development. An important
might be helpful. criterion for termination is the resumption
11. Express hope of hearing from the client. of development and the overcoming of the
Therapists may wish to tell clients that developmental gap. Viewed in this way, the
they would be pleased to hear from them at termination is the beginning of a new stage
some point in the future. Hearing from in the child’s life (Chazan, 1997).
clients after the therapy has ended allows 2. Children who have suffered losses, such as
therapists to find out more about the effects parental loss due to death or divorce, are fre-
of the therapy and to listen to clients’ views quent clients. These children confront a re-
after some time has passed. Moreover, it is lationship with an inevitable end — that is,
an extremely human wish to know what entering a relationship with a caregiver who
happened to a person whom one has known will also leave them. Therefore, the therapy
well, and there is no reason for denying as a whole is endangering a repetition of
this to the therapist (Curtis, 2002). their loss, with the narcissistic injury and
reduced self-esteem. In these cases, the ther-
apy should be geared toward its end from
ASSESSING AND AVOIDING the first session. Announcing the therapeu-
PREMATURE TERMINATIONS tic termination a few weeks, or even months,
before the termination date may not be suf-
Because of the serious consequences of prema- ficient with children who have already suf-
ture termination, therapists should routinely fered caregiver separation traumas. The
assess at the outset of treatment those variables therapist is advised to encourage verbaliza-
associated with clients’ ending treatment pre- tions of reactions toward termination even
maturely. These include delays in the com- when the termination is not imminent (Be-
mencement of treatment, missing sessions, mbry & Ericson, 1999).
history of alcohol or drug abuse, self-destruc- 3. Unlike adult treatment, which is dyadic,
tiveness, unemployment, paranoid ideation, di- child treatment is usually a triangular rela-
vorced marital status, lack of health insurance, tionship, involving the child, the therapist,
closed-mindedness, problems in relationship and the child’s caregivers. The latter,
formation, somatization, narcissism, paucity of through their financial control and their
a support system, seeing the therapist as not emotional power on the child, are in a
trustworthy and not expert, weak alliance with unique position to prematurely terminate
the therapist, low in contemplation of change, the therapy. The risk of premature termina-
low in self-reevaluation, low in self-liberation, tion is especially strong in child therapies,
 75 • guidelines for terminating psychotherapy 359

and the degree of threat can be a derivative Thoughts on termination: Practical considera-
of the parents’ internalized hostility (Ven- tions. Psychoanalytic Psychology, 14, 239 –257.
able & Thompson, 1998), their wish to avoid Goldfried, M. R. (2002). A cognitive-behavioral per-
the guilt implied by the fact that their child spective on termination. Journal of Psychother-
apy Integration, 12, 364 –372.
is in need of a therapy (Hailparn & Hail-
Greenberg, L. S. (2002). Termination of experiential
parn, 2000), or their own relationship with
therapy. Journal of Psychotherapy Integration,
the therapist. A child therapist should try to 12, 358 –363.
assess the caregivers’ commitment, attempt Hailparn, D. F., & Hailparn, M. (2000). Parent as
to involve them in the beginning stages of saboteur in the therapeutic treatment of chil-
the therapy, assuage their guilt by praising dren. Journal of Contemporary Psychotherapy,
their dedication and care for the child whom 30, 341–351.
they bring to therapy, and remain aware of Schmukler, A. G. (Ed.). (1991). Saying goodbye: A
the effect of the therapy on the parents casebook of termination in child and adolescent
(Hailparn & Hailparn, 2000). analysis and therapy. Hillsdale, NJ: Analytic
4. The wish to hear about the client’s progress Press.
Tyson, P. (1996). Termination of psychoanalysis and
after the therapy has been completed is
psychotherapy. In E. Neressian & R. G. Kopf
more prevalent and accepted in child thera-
(Eds.), Textbook of psychoanalysis (pp.
pies (Chazan, 1997). Further interventions 501– 524). Washington, DC: American Psychi-
can be suggested if the need arises. atric Press.
Venable, W. M., & Thompson, B. (1998). Caretaker
psychological factors predicting premature ter-
References & Readings
mination of children’s counseling. Journal of
Bembry, J. X., & Ericson, C. (1999). Therapeutic ter- Counseling & Development, 76, 286 –293.
mination with the early adolescent who has ex- Weiner, I. B. (1998). Principles of psychotherapy
perienced multiple losses. Child & Adolescent (2nd ed.). New York: Wiley.
Social Work Journal, 16, 177 –189. Weissman, M. M., Markowitz, J. C., & Klerman,
Chazan, S. E. (1997). Ending child psychotherapy: G. L. (2000). Comprehensive guide to interper-
Continuing the cycle of life. Psychoanalytic sonal psychotherapy. New York: Basic Books.
Psychology, 14, 221–238. Werner, H. D. (1982). Cognitive therapy: A human-
Curtis, R. (2002). Termination from a psychoana- istic approach. London: Collier Macmillan.
lytic perspective. Journal of Psychotherapy In-
tegration, 12, 350 –357.
Related Topics
Fox, R. (1993). Elements of the helping process: A
guide for clinicians. New York: Haworth. Chapter 73, “Early Termination and Referral of
Frank, G. (1999). Termination revisited. Psychoana- Clients in Psychotherapy”
lytic Psychology, 16, 119 –129. Chapter 121, “A Model for Clinical Decision Mak-
Garcia-Lawson, K. A., & Lane, R. C. (1997). ing With Dangerous Patients”
This page intentionally left blank
PART IV
Couples, Family, and
Group Treatment
This page intentionally left blank
 76 CHOICE OF TREATMENT FORMAT

John F. Clarkin

The goal of psychological treatment is symp- mediating and final goals of treatment. Table 1
tom relief, whether it be one or a constellation summarizes several of these selection criteria.
of symptoms or conflicts in interpersonal rela- Because the individual treatment format is
tionships. However, for the mental health pro- familiar, private, relatively flexible, and built
fessional operating on a clinical (i.e., single case) on the basic trust inherent in a dyadic relation-
basis, making the initial probes required to de- ship, it remains the most prevalent format of
termine a treatment plan necessitates focusing psychological treatment. Over the past 40 years,
on patient symptoms and diagnosis, the natural partly because the limitations of an individual
course of those symptoms, the personality of format have become more widely appreciated
the patient, and process and mediating goals of and partly because the field has shifted toward
the therapy. The key treatment planning factors interpersonal models, clinicians have increas-
include the patient’s diagnosis and related prob- ingly used couples/family and group treatment
lem areas; mediating and final goals of treat- formats.
ment; patient enabling factors; and treatment There are clinical, cultural, and economic is-
choice points (treatment setting, format, tech- sues that guide the clinician in choosing among
nique, somatic treatments, and duration and individual, couples/family, and group treat-
frequency; Clarkin, Frances, & Perry, 1992). ment formats: (a) patient problem/diagnosis;
The focus of this chapter is to articulate the (b) problem demonstration, that is, in marital,
principles guiding the choice of treatment for- family, or group display; (c) model of treatment
mat (i.e., individual, couples/family, group), intervention; (d) patient preference; and (e) ef-
given the information of patient diagnosis and ficiency of treatment.

363
364 part iv • couples, family, and group treatment

table 1. Selection Criteria for Format: Individual, Couples/Family, and Group

Individual Couples/Family Group

1. Adolescent who is striving for 1. Relationship problems are presented 1. Patient’s problems are
autonomy as such interpersonal, both outside
2. Patient symptoms based on internal 2. Symptoms are predominantly and inside family situations.
conflict that is expressed in within the couples/family situation 2. Patient presents with problems
environmental situations 3. Family presents with current that fit the focus of specialized
structured difficulties in its groups (e.g., alcohol or drug
relationships abuse)
4. Adolescent acting-out behavior
5. Sexual dysfunction in a couple

PATIENT PROBLEM/DIAGNOSIS it a hostility problem in a 43-year-old male

who has this problem with his wife but not in
Many patient problems and diagnoses lend social and work situations? Or, alternately, is
themselves to specific treatment formats. For he hostile in multiple environments in his
example, a sexual dysfunction with one’s spouse life? Thus, the environment in which the
in the context of marital disputes and with no problem arises is a clue to the selection of the
physical reasons for the dysfunction may lend treatment format.
itself to treatment in the couples format, where
the contributions of both parties to the dys-
function can be identified and explored. Alter- MEDIATING GOALS OF TREATMENT
nately, an adolescent acting-out problem can be
explored in the family therapy context to ad- The alleviation of a particular symptom com-
dress a possible interaction between adolescent plex is the typical final goal of treatment. How-
impulsivity and parental skills in setting limits. ever, the mediating goals of treatment — those
The Axis V diagnosis or GAF rating may be intermediate goals that must be reached in
of particular importance in choosing a treat- order to achieve the final goals — are not al-
ment format. Independently of the particular ways so obvious. They are dictated by the model
Axis I (and Axis II) diagnosis, the relative level of the diagnosis/problem area or successive
of the GAF score may relate to the nature and steps to health. These mediating goals will de-
process of differential treatment planning. In pend on the particular diagnosis/problem area,
several contexts it has been suggested that rela- the theoretical orientation of the assessor, and
tively healthy individuals (those with GAF current understanding of the particular prob-
scores roughly between 100 and 70) are most lem area in question. The nature and extent of
likely to respond to most formats of therapeutic these mediating goals provide the indications
intervention and may even be the most likely to for the therapeutic formats, strategies/techniques,
be able to cope with difficulties without inter- somatic treatments, and treatment durations.
vention. At the other end of the spectrum, those Therefore, in the evaluation and treatment
patients with severe and chronic difficulties planning, the clinician must be as precise as
(with GAF scores of roughly 30 to 0) may im- possible about the mediating goals of treat-
prove relatively little from most interventions ment.
without the assistance of significant others. This These mediating goals of treatment go be-
would suggest a family format of treatment. yond the mere description of the symptoms
and hypothesize causal relationships between
the symptoms and other biological, intrapsychic,
PROBLEM DEMONSTRATION and environmental factors. There are many
pathways to a common descriptive diagnosis of,
Where is the problem presented by the indi- for example, major depression (Beutler, Clarkin,
vidual patient demonstrated? For example, is & Bangar, 2000). Thus, treatment will depend
 76 • choice of treatment format 365

not only on the descriptive diagnosis but also TREATMENT EFFICIENCY

on the variables that contribute to this symp-
tom state. Psychologists increasingly function in a man-
The phrase “mediating goals of treatment” aged care world that emphasizes treatment ef-
refers to those essential subgoals that must be ficiency. The most efficient treatment format is
achieved for the treatment or combination of obviously group treatment, in which one (or
treatments to achieve their final goal. There are two) professionals can treat some eight pa-
two types of mediating goals: (a) the goals of tients at one time. Therefore, a guiding issue is
the treatment process itself and (b) the succes- what treatment can be delivered as effectively
sive approximations to health that are expected in a group format as in other formats? In fact,
to occur sequentially in the patient’s/family’s there may be situations in which the group
behavior. The former goals are related to the format is not only more efficient than the indi-
enabling factors that the patient brings to ther- vidual format but also more effective because
apy; the latter are related to the model of the of the mutual support and confrontation of fel-
illness that is being treated and to the particu- low patients.
lar school of therapy and its understanding of
the covariance of certain patient behaviors. References & Readings
One can articulate mediating goals of treat-
Beutler, L. E., & Clarkin, J. F. (1990). Systematic
ment that are consistent with each of the treat-
treatment selection. New York: Brunner/Mazel.
ment formats. Individual treatment is consis- Beutler, L. E., Clarkin, J. F., & Bangar, B. (2000).
tent with mediating goals of changes in the in- Guidelines for the systematic treatment of the
dividual patient’s cognitions and attitudes. depressed patient. New York: Oxford Univer-
Couples treatment is consistent with mediating sity Press.
goals of changes in the interaction between two Clarkin, J. F., Frances, A., & Perry, S. (1992). Differ-
partners. Family treatment is congruent with ential therapeutics: Macro and micro levels of
changes in parenting behavior toward a child treatment planning. In J. Norcross & M. Gold-
or adolescent. Group treatment is consistent fried (Eds.), Handbook of psychotherapy inte-
with goals in the change of social behavior in gration. New York: Basic Books.
Feldman, L. B. (1992). Integrating individual and
the individual.
family therapy. New York: Brunner/Mazel.
Frances, A., Clarkin, J. F., & Perry, S. (1984). Differ-
ential therapeutics: A guide to the art and sci-
PATIENT PREFERENCE ence of treatment planning in psychiatry. New
York: Brunner/Mazel.
Most patients, as thinking individuals and Perry, S., Frances, A., & Clarkin, J. F. (1990). A
problem solvers in their own right, have hy- DSM-III-R casebook of treatment selection.
potheses about what caused their problems and New York: Brunner/Mazel.
what changes are necessary to alleviate them. Pinsof, W. M. (1995). Integrative problem-centered
Couples who call a therapist for conjoint treat- therapy. New York: Basic Books.
ment have a different conceptualization of the
problem than a married individual who calls
Related Topics
for individual treatment. The family that sends
the adolescent to individual treatment is differ- Chapter 39, “Compendium of Empirically Sup-
ent from the family that together seeks assis- ported Therapies”
tance in dealing with the teenager’s acting out. Chapter 45, “Systematic Assessment and Treatment
These patient preferences for a particular treat- Matching”
Chapter 47, “Psychotherapy Treatment Plan Writ-
ment format confront the clinician with a deci-
ing”
sion. The clinician should heed the ideas of the
patient, at least initially, and whenever possible
follow the treatment preferences of the patient
and significant others.
 GENOGRAMS IN
77 ASSESSMENT AND THERAPY

Sueli S. Petry & Monica McGoldrick

The genogram is a practical, visual tool for as- talize assessment and treatment. Each interac-
sessment of family patterns and context, as tion with the family informs the assessment
well as a therapeutic intervention in itself. and thus influences the next intervention.
Genograms allow clinicians to quickly concep- We include on the genogram the nuclear
tualize the individual’s context within the and extended family members, as well as sig-
growing diversity of family forms and patterns nificant nonblood “kin” who have ever lived
in our society. Using the genogram to collect with or played a major role in the family’s life.
historical and contextual assessment informa- We also note on the side of the genogram sig-
tion is a collaborative, client-centered thera- nificant events and problems (Figure 1). Cur-
peutic process. By its nature, the process in- rent behavior and problems of family members
volves the telling of stories and emphasizes can be traced on the genogram from multiple
respect for the client’s perspective, while en- perspectives. The index person (the IP, or per-
couraging multiple views and possible out- son with the problem or symptom) may be
comes. While the genogram has been used for viewed in the context of various subsystems,
decades, it is a tool in progress, and clinicians such as siblings, triangles, and reciprocal rela-
use it for assessment of functioning, relational tionships, or in relation to the broader commu-
patterns, ethnicity, spirituality, migration, nity, social institutions (schools, courts, etc.),
class, and other socioeconomic factors (Carter and sociocultural context.
& McGoldrick, 1999; Congress, 1994; Dunn & The genogram usually includes cultural and
Dawes, 1999; Hardy & Laszloffy, 1995; Mc- demographic information about at least three
Goldrick, 1995, 1998; McGoldrick, Giordano, & generations of family members, as well as
Pearce, 1996; Walsh, 1999) and for therapeutic nodal and critical events in the family’s history,
interventions such as the creative play therapy particularly as related to family changes (mi-
genogram (Gil, 2002, 2003). gration, loss, and the life cycle). When family
Gathering genogram information should be members are questioned about the present sit-
seen as an integral part of a comprehensive, uation in relation to the themes, myths, rules,
clinical assessment. There is no quantitative and emotionally charged issues of previous
measurement scale by which the clinician can generations, repetitive patterns become clear.
use a genogram in a cookbook fashion to make Copies of both figures and more extensive il-
clinical predictions. Rather, the genogram is a lustrative genogram materials are included on
subjective, interpretive tool that enables clini- the Web site accompanying this book.
cians to generate tentative hypotheses for fur-
ther evaluation in a family assessment. Typi-
cally, the genogram is constructed from infor- THE FAMILY INFORMATION NET
mation gathered during the first session and
revised as new information becomes available. The process of gathering family information
Thus, the initial assessment forms the basis for can be thought of as casting out an information
treatment. Of course, we cannot compartmen- net in larger and larger circles to capture rele-

366
 77 • genograms in assessment and therapy 367

ORTIZ - BROWN FAMILY

Irish ancestry

Migrated from Cuba in 1963

TRIANGLES: 1928–4/12/83 1930 –12/8/02 M.D. 1928–
1929 –4/1/93
Patterns repeat 55 72
64 75
1–IP close to father, Pedro good at business headaches Mary
John
hostile with mother;
mother-father distant

2 –Susan close to father,

cut-off from mother;
mother-father distant $25,000
$400,000
office manager Cut-off in 63–
3 –Peter close to mother, 53 – 1989 40
distant with father; 50 – 52 50
mother-father hostile Carol
successful asthma severe colitis
4–Pedro close to middle lawyer from childhood began to have symptoms in 1989
daughter, hostile with
wife; mother and $12,000
$60,000 (till he lost his job) substitute teacher SIGNIFICANT EVENTS:
daughter distant
2/49 – 60 –
High blood pressure 43 Susan Anniversary dates:
5 –Peter close to middle Peter 54
daughter (IP), distant with business failures ‘89, ‘03 — both grandfathers’ deaths
wife; mother and daughter hostile within a day of IP’s birthdate 4/11; 4/12; 4/10
— coincides with date
6 –IP close to father and applied for treatment—4/9/03
to paternal grandmother; — father migrated at age 14,
reinforced hostile same age as IP now
relationship with mother — Susan’s cut-off with mother
ad Carol’s illness all
PRESENTING PROBLEM: occurred same year as IP’s birth
Susan sought treatment on 4/8/03 — Peter approaching age his father died
because Barbara’s 93 – Patterns:
behavior was “out of control: 18 4/11/89 14 10 asthma — Youngest daughters susceptible
truant from school,
to psychosomatic symptoms
staying out late and hostile” Cynthia Barbara Stephanie
leaving for college this year I.P. Family life cycle issues:
— Cynthia is preparing to leave for college

figure 1 Ortiz-Brown Family Genogram

vant information about the family and its presenting problem and its impact on the im-
broader context. The net spreads out in a num- mediate household. The clinician asks the
ber of different directions: name, age, gender, and occupation of each per-
son in the household in order to sketch the im-
• From the presenting problem to the larger mediate family structure. Other revealing in-
context of the problem formation is elicited through inquiring about
• From the immediate household to the ex- the problem. This is also a good time to inquire
tended family and broader social systems about previous efforts to get help for the prob-
• From the present family situation to a lem, including previous treatment, therapists,
chronology of historical family events hospitalizations, and the current referring per-
• From easy, nonthreatening queries to diffi- son.
cult, anxiety-provoking questions Next the clinician spreads the information
• From obvious facts to judgments about func- net into the current family situation. This line
tioning and relationships to hypothesized of questioning usually follows naturally from
family patterns questions about the problem and who is in-
volved:
The IP usually comes with specific prob-
lems, which are the clinician’s starting point. • What has been happening recently in your
At the outset, the IP is told that some basic in- family?
formation about the family is needed to fully • Have there been any recent changes in the
understand the problem. Such information family (e.g., people coming or leaving, ill-
usually grows naturally out of exploring the nesses, job problems)?
368 part iv • couples, family, and group treatment

Male Female Gay/Lesbian Birth Date Age = Inside Symbol Death Date Death = X Death Date
‘41– –96 ‘41–96

Bisexual written above left written inside

Transgendered Person of symbol symbol written above right
of symbol

Marriage Living Together or Affair Lesbian Couple Gay Couple

m 1970 LT 75 m 91 LT 93

LT = Living together

Marital Separation Divorce Getting Back Together after Divorce

m 70 s 85 m 70 s 85 d 87 d 87 remar 90

Children: List in birth order beginning with the oldest on left

77–77
71– 73– 76– –79 –81
83– 83– 85– 85– 98–
27 25 22
Stillbirth
Miscarriage Abortion
Biological Foster Adopted Pregnancy
Child Child Child Twins Identical
Twins

In Recovery from
Drug or Alcohol Abuse Drug or Alcohol Abuse
Drug/Alcohol Abuse and AA Therapist
Physical or Mental Problem
Serious Mental or
Suspected Abuse Physical Problem Significant
Institutional
Connection Psychiatrist

Symbols Denoting Interactional Patterns between People

Close Distant Close–Hostile Focused On

Physical or Sexual Abuse

Fused Hostile Fused–Hostile Cutoff

figure 2 Standard Symbols of Genograms

It is important to inquire about recent life The clinician looks for an opportunity to ex-
cycle transitions as well as anticipated changes plore the wider family context by asking about
in the family situation (especially exits and en- the extended family and cultural background of
trances of family members—births, marriages, all the adults involved. The interviewer might
divorces, deaths, or the departure of family move into this area by saying, “I would now
members). like to ask you something about your back-
 77 • genograms in assessment and therapy 369

ground to help make sense of your present lems and current relationships in context. When
problem.” the questioning expands to the extended fam-
ily, it is a good point to begin exploring issues
of ethnicity, since the birthplace of the grand-
DEALING WITH A FAMILY’S parents has now been established. Exploring
RESISTANCE TO DOING A GENOGRAM ethnicity and migration history helps establish
the cultural context in which the family is op-
When family members react negatively to erating and offers the therapist an opportunity
questions about the extended family or com- to validate family attitudes and behaviors de-
plain that such matters are irrelevant, it often termined by such influences. It is important to
makes sense to redirect the focus back to the learn what the family’s cultural traditions are
immediate situation until the connections be- about problems, health care, and healing, and
tween the present situation and other family where the current family members stand in re-
relationships or experiences can be established. lation to those traditional values. It is also im-
Gentle persistence over time will usually result portant to consider the family’s cultural expec-
in obtaining the information and demonstrat- tations about relationships with health care
ing its relevance to the family. professionals, since this will set the tone for
The clinician inquires about each side of the their clinical responses.
family separately, beginning, for example, with Furthermore, class background between
the mother’s side: family members or between family members
and the health care professional may create dis-
• Let’s begin with your mother’s family. Your comfort, which will need to be attended to in
mother was which one of how many chil- the meeting. Questions to ascertain class as-
dren? sumptions pertain not just to the family’s cur-
• When and where was she born? rent income but also to cultural background,
• Is she alive? If not, when did she die? What education, and social status within their com-
was the cause of her death? munity. Once the clinician has a clear picture of
• If alive, where is she now? What does she the ethnic and cultural factors influencing a
do? How is her health? family (and, it is hoped, keeping his or her own
• When and how did your mother meet your biases in check), it is possible to raise delicate
father? When did they marry? questions geared to helping families identify
• Had she been married before? If so, when? any behaviors that — while culturally sanc-
Did she have children by that marriage? tioned — may be keeping them stuck, such as
• Did they separate or divorce or did the traditional gender roles (see McGoldrick et al.,
spouse die? If so, when was that? 1996).

And so on. In like fashion, questions are

asked about the father. Then the clinician might DIFFICULT QUESTIONS ABOUT
ask about each parent’s family of origin (i.e., INDIVIDUAL FUNCTIONING
father, mother, and siblings). The goal is to get
information about at least three or four gener- Assessment of individual functioning may or
ations, including grandparents, parents, aunts, may not involve much clinical judgment. Alco-
uncles, siblings, spouses, and children of the IP. hol abuse, chronic unemployment, and severe
symptomatology are facts that directly indicate
poor functioning. However, many family mem-
ETHNIC AND CULTURAL HISTORY bers may function well in some areas but not in
others or may cover up their dysfunction.
It is essential to learn something about the Often, it takes careful questioning to reveal the
family’s socioeconomic, political, and cultural true level of functioning. A family member
background in order to place presenting prob- with a severe illness may show remarkable
370 part iv • couples, family, and group treatment

adaptive strengths and another may show transitions: particularly changes in function-
fragility with little apparent stress. Questions ing and relationships that correspond with
about individual functioning may be difficult critical family life events and untimely life
or painful for family members to answer and cycle transitions—for example, births, mar-
must be approached with sensitivity and tact. riages, or deaths that occur “off schedule.”
The family members should be warned that
questions may be difficult and they should let Awareness of possible patterns makes the
the clinician know if there is an issue they clinician more sensitive to what is missing.
would rather not discuss. The clinician will Such missing information about important
need to judge the degree of pressure to apply if family members or events and discrepancies in
the family resists questions that may be essen- the information offered frequently reflects
tial to dealing with the presenting problem. charged emotional issues in the family. The
Clinicians need to exercise extreme caution clinician should take careful note of the connec-
about when to ask questions that could put a tions family members make or fail to make to
family member in danger. For example, if vio- various events.
lence is suspected, a wife should never be asked
about her husband’s behavior in his presence,
since the question assumes she is free to re- MAPPING THE GENOGRAMS OF
spond, which may not be the case. It is the clin- THOSE WHO GROW UP IN
ician’s responsibility to take care that the ques- MULTIPLE SETTINGS
tions do not put a client in jeopardy.
Many children grow up in multiple settings
because their parents divorce, die, remarry, mi-
SETTING PRIORITIES FOR grate, or have other special circumstances that
ORGANIZING GENOGRAM require the child to live for a while or even per-
INFORMATION manently in a different setting. Genograms are
an exceptionally useful tool to track children’s
One of the most difficult aspects of genogram experiences through the life cycle, taking into
assessment remains setting priorities for inclu- account the multiple family and other institu-
sion of family information on a genogram. tional contexts to which they have belonged
Clinicians cannot follow every lead the geno- (Carter & McGoldrick, 1999). The more clearly
gram interview suggests. Awareness of basic the clinician tracks the actuality of this history,
genogram patterns can help the clinician set however complex, the better able he or she is to
such priorities. As a rule of thumb, the data are validate the child’s actual experience and multi-
scanned for the following: ple forms of belonging. Such a map can begin
to make order out of the at times chaotic place-
• Repetitive symptoms, relationship, or func- ment changes a child must go through when
tioning patterns across the family and over sudden transitions or shifts in placement are
the generations. Repeated triangles, coali- necessary because of illness, trauma, or other
tions, cut-offs, patterns of conflict, over- and loss. It can also help validate for a child the re-
under-functioning are central to genogram alities of his or her birth and life connections
interpretation. that vary from traditional norms.
• Coincidences of dates. For example, the death Sometimes the only feasible way to clarify
of one family member or anniversary of this where children were raised is to take chrono-
death occurring at the same time as symp- logical notes on each child in a family and then
tom onset in another, or the age at symptom transform them into a series of genograms that
onset coinciding with the age of problem de- show the family context each child has grown
velopment in another family member. up in. When the “functional” family is differ-
• The impact of change and untimely life cycle ent from the biological or legal family, as when
 77 • genograms in assessment and therapy 371

children are raised by a grandparent or in an the family to construct a genogram of their

informal adoptive family, it is useful to create immediate and extended family, then family
a separate genogram to show the functional members are asked to choose a miniature that
structure (see Watts Jones, 1998). Where chil- best shows their thoughts and feelings about
dren have lived as part of several families—bi- everyone in the family, including themselves.
ological, foster, and adoptive — separate geno- Clinicians observe the selection process for the
grams may help to depict the child’s multiple type and level of interactions between family
families over time. members. The interactions between family
members will inform the clinician about the
family’s current relationship styles and pat-
PLAY GENOGRAMS FOR INDIVIDUAL terns of relating. Encouraging family members
CHILD AND FAMILY THERAPY to make their choices at the same time will
yield a broader range of assessment informa-
Gil (2002, 2003) developed the play genogram tion. Conflicts about specific miniatures are
technique during her consultations at the Mul- more likely to arise when the family is engaged
ticultural Family Institute in Highland Park, in activity together, and as conflicts arise the
New Jersey, as a natural expansion of the as- clinician observes the family patterns of prob-
sessment and therapeutic benefits of the lem solving.
genogram. The play genogram can be used When everyone has made his or her choice,
with individual children, and with families, as family members are encouraged to look at the
an assessment tool and to facilitate therapeutic family play genogram, and to make comments
conversation. The basic genogram is drawn on and ask questions. Clinicians should not ask
a large sheet of easel paper. When working family members to explain why they chose a
with individual children, clinicians invite the particular object. It is more useful to facilitate
child to “choose a miniature that best shows an open dialogue in which family members
your thoughts and feelings about everyone in volunteer a broad range of information. The
the family, including yourself” and to place the first person to speak tends to set the tone for
miniature on the squares and circles on the the type of information that will be provided.
easel paper. The clinician may give reluctant Thus, the clinician should ask expansive ques-
children examples of concrete and abstract tions in order to promote a more extensive dia-
choices to encourage the child to explore logue, for example, “Can you tell me more
choices freely. When completed, the individual about that?” (For more details and examples,
play genogram will have one miniature on see accompanying Web site.)
each circle or square. After the initial play genograms, the clini-
Some individuals may use more than one cian may request a second level of activity by
miniature to represent family members. This asking family members to choose a miniature
may reflect the complexity of a relationship or that best represents their relationships with
self-image. When working with children in other family members; this yields other valu-
foster care or other family situations where able information. Clinicians ask permission to
children have had multiple caretakers, it is take a photograph of the individual or family
helpful to construct a series of genograms on play genogram. The family may take the pho-
the same sheet of paper. Children may include tograph home with them to facilitate additional
friends, therapists, teachers, pets, or other im- conversation, or clinicians can keep the pictures
portant relationships, both past and present. to recreate play genograms at a later time for
This helps children to reference and prioritize a continuation of the therapeutic dialogue. The
their world and gives the clinician a complex, play genogram technique is just one of the
yet easily scanned assessment. many ways that the genogram facilitates ther-
The directives for the family play genogram apy.
are the same as for individuals: clinicians help
372 part iv • couples, family, and group treatment

CONCLUSION C. Medical history. Since the genogram is

meant to be an orienting map of the family,
The genogram, which is a highly condensed there is room to indicate only the most im-
map of a rich and complex family, is an awe- portant factors. Thus, list only major or
some lesson to anyone who is unable to see be- chronic illnesses and problems. Include
yond the cutoffs that may occur in a family dates in parentheses where feasible or ap-
(McGoldrick, Gerson, & Shellenberger, 1999). plicable. Use DSM-IV categories or recog-
We believe that no relationship is to be disre- nized abbreviations where available (e.g.,
garded or discounted. All our relationships in- cancer: CA, stroke: CVA).
form the wholeness of who we are and where D. Other information. Family information of
we come from; more important, they can give special importance may also be noted on the
us the possibility of making constructive, con- genogram: (1) ethnic background and migra-
scious choices about who we will choose to be tion date; (2) religion or religious change; (3)
in the future. education; (4) occupation or unemployment;
One of the most powerful aspects of (5) military service; (6) retirement; (7) trou-
genograms is the way in which they can steer ble with the law; (8) physical or sexual abuse
us to the rich ongoing possibilities of complex or incest; (9) obesity; (10) alcohol or drug
kin relationships, which continue throughout abuse; (11) smoking; (12) dates when family
life to be sources of connection and life support. members left home: LH ’74; and (13) current
It is not just our shared history that matters location of family members. It is useful to
but also the spiritual power of our history of have a space at the bottom of the genogram
survival, as well as our current connections for notes or other key information. This
that strengthen us and can enrich our future. would include critical events, changes in the
All our relationships inform the wholeness of family structure since the genogram was
who we are and where we came from, and more made, hypotheses, and other notations of
important, can give us the possibility of mak- major family issues or changes. These nota-
ing constructive and conscious choices about tions should always be dated, and should be
who we will choose to become. kept to a minimum, since every extra piece
of information on a genogram complicates it
and therefore diminishes its readability.
GENOGRAM FORMAT
References & Readings
The following section provides fundamental
instructions for completion of the relevant Carter, B., & McGoldrick, M. (Eds.). (1999). The ex-
genogram elements as illustrated in the accom- panded family life cycle: Individual, family
and social perspectives (3rd ed.). Boston: Allyn
panying sample genograms.
& Bacon.
Congress, E. P. (1994, November). The use of cultur-
A. Symbols. These describe basic family mem- agrams to assess and empower culturally di-
bership and structure (include on genogram verse families. Families in Society, 79, 531–
significant others who lived with or cared 540.
for family members — place them on the Dunn, A. B., & Dawes, S. J. (1999). Spiritually-
side of the genogram with a notation about focused genograms: Keys to uncovering spiri-
who they are). tual resources in African American families.
B. Family interaction patterns. The relation- Journal of Multicultural Counseling & Devel-
ship indicators are optional. The clinician opment, 27(4), 240 –255.
may prefer to note them on a separate sheet. Gil, E. (2002). Family play therapy: Rationale and
techniques. [Videotape and accompanying
They are among the least precise informa-
text.] Fairfax, VA: Starbright Training Institute
tion on the genogram, but may be key indi- for Family and Child Play Therapy.
cators of relationship patterns the clinician Gil, E. (2003). Play genograms. In C. F. Sori & L. L.
wants to remember. Hecker (Eds.), The therapist’s notebook for
 78 • guidelines for conducting couple and family therapy 373

children and adolescents: Homework, hand- (1999). Genograms: Assessment and interven-
outs, and activities for use in psychotherapy tion (2nd ed.). New York: Norton.
(pp. 97 –118). New York: Haworth Press. McGoldrick, M., Giordano, J., & Pearce, J. K. (Eds.)
Hardy, K. V., & Laszloffy, T. A. (1995). The cultural (1996). Ethnicity and family therapy (2nd ed.).
genogram: Key to training culturally compe- New York: Guilford Press.
tent family therapists. Journal of Marital and Walsh, F. (Ed.). (1999). Spiritual resources in family
Family Therapy, 21(3), 227 –237. therapy. New York: Guilford Press.
McGoldrick, M. (1995). You can go home again: Re- Watts Jones, D. (1998). Towards an African-Ameri-
connecting with your family. New York: Nor- can genogram. Family Process, 36(4), 373 –383.
ton.
McGoldrick, M. (Ed.). (1998). Revisioning family
Related Topic
therapy: Culture, class, race, and gender. New
York: Guilford Press. Chapter 4, “The Multimodal Life History Inven-
McGoldrick, M., Gerson, R., & Shellenberger, S. tory”

GUIDELINES FOR CONDUCTING

78 COUPLE AND FAMILY THERAPY

Jay L. Lebow

The following guidelines stem from a review emerges as far more understandable when
of the couple and family therapy literature; the surrounding conditions are understood.
from research assessing couples, families, and For example, a child’s school phobia or a
couple and family therapy; and from clinical spouse’s depression frequently becomes
experience. The goal of this chapter is to sug- more intelligible when its meaning in the
gest widely accepted generic guidelines for life of the family system is recognized.
practice that transcend the numerous schools of 3. Understand multiple perspectives: The
couple and family therapy. therapist should attempt to grasp and com-
municate understanding of the respective
1. Develop a systemic perspective: A system viewpoints of various family members,
consists of interacting components; in a which may vary considerably.
family, these include such subsystems as 4. Examine potential circular pathways of
couple, sibling, and individual. Individuals causality that may maintain problems:
do not function in a vacuum but continu- The therapist should attempt to understand
ally influence one another through feed- ways in which family members are influ-
back. enced within circular pathways in which
2. Always consider context in attempting to the behavior, thoughts, and feelings of one
understand couples and families: Behavior person promote those of another, which in
that appears to make little sense often turn promote those of the first person. Al-
374 part iv • couples, family, and group treatment

though not all causal pathways are circu- 8. Determine and clarify who will be included
lar, and even among circular causal chains in treatment: There are a variety of meth-
the participation of family members may ods in family therapy, ranging from some
not be coequal, such cycles frequently that include multiple generations to others
block problem resolution. For example, that include only a few or even one mem-
parents’ angry and punitive behavior may ber of the family. Who is and who is not
both lead to and flow from the acting-out part of the therapy always needs to be
behavior of a child. Regardless of where clearly designated and understood. In gen-
the cycle begins, the punitive behavior by eral, it is easier to include additional mem-
the parents leads to more acting out by the bers of the family earlier in treatment,
child, which, in turn, leads to more par- rather than later, by which time alliances
ental punitive behavior. are well set. Involving fathers as well as
5. Respect the diversity of family forms: Fam- mothers (who tend more readily to make
ilies assume many forms, including single- themselves available) in the treatment of
parent, remarried, and gay and lesbian. The children promotes better outcome.
therapist should become knowledgeable 9. Begin with an emphasis on engagement
about typical life across this range of forms and alliance building: The therapist must
and, along with the families, should develop build an alliance with each member of the
therapeutic goals that honor the family’s family, with each subsystem, and with the
form and culture. family as a whole. Techniques such as elic-
6. Understand the special ethical consider- iting input from each family member,
ations of couple and family therapy, par- joining with each around some aspect of
ticularly concerning confidentiality: Cou- the problem, and assimilating and adapting
ple and family therapists face special eth- to the culture of the family help build such
ical dilemmas, such as deciding who is the alliances. Pay particular attention to the al-
client and who is entitled to confidentiality liance with those member(s) of the family
of communication. All individuals who at- who have most say in whether the therapy
tend conjoint sessions become clients and will continue. Alliance with the therapist
should retain the same rights. In couple appears to predict outcome regardless of
and family therapy, confidentiality should the form of couple or family therapy.
be broken only with agreement of all par- 10. Assess through history gathering and ob-
ticipants, except in those circumstances in serving interaction: Assessment should
which legal duty to report or warn takes have multiple foci, including the family
precedence. The therapist should articulate system, its subsystems, and individuals.
a clear position about confidentiality for Assessment typically is intermingled with
confidences made outside of sessions, as treatment, rather than a distinct phase. The
well as for when participants vary across intervention strategy should be grounded
sessions. Therapists should understand in the assessment.
state law about these and similar matters, 11. Understand that certain difficulties in
as well as ethical guidelines. family life are grossly underreported:
7. Begin assessment and intervention with Family violence, sexual abuse, infidelity,
the first phone call: Couple and family alcoholism, and drug abuse, among other
therapies require more effort before the problems, are typically reported at much
first session on the part of the therapist lower frequencies than they occur. In-
than do other therapies. Active efforts be- quire about them in a standard noninva-
fore the first session to engage family sive way.
members who are clearly important to the 12. Understand each client’s expectations and
problem or its solution substantially in- how well they are satisfied: Family mem-
crease participation in therapy and thereby bers bring a range of expectations about
impact on treatment outcome. such issues as money, sex, and intimacy.
 78 • guidelines for conducting couple and family therapy 375

These expectations are manifested at sev- gates the dangers of losing focus. This road
eral levels ranging from expectations about map may require revision as treatment
behavior to expectations about deeper lev- progresses.
els of object relations. Relationship satis- 20. Employ individual, biological, couple, fam-
faction is often more the product of unmet ily, and macrosystemic interventions in
expectations than of particular problematic the context of the treatment: Empirical
patterns. Help family members articulate support is strongest for approaches that
and negotiate their expectations. combine intervention with the whole fam-
13. Compile a genogram to understand how ily with other intervention strategies.
family of origin factors affect the system: Treatment of severe mental illness almost
Elaborating on who is in the extended invariably should include the use of med-
family, what the key experiences have ication; treatment of adolescent disorders
been in the life of the family, and repeti- focuses on school and peer systems; and
tive issues across the generations increases treatment of depression should include “in-
mutual understanding, promotes the work- dividual” intervention that addresses the
ing through of experiences, and poten- depression.
tially sets the stage for exploring individ- 21. Teach empathy, communication, how to
ual and interactive patterns. deliver reinforcement, and other skills when
14. Remember that couple and family therapy such skills are inadequately developed:
is usually brief: Families typically are only Many couples and family members lack
willing to engage in therapies of under 10 the requisite skills to perform essential
sessions. Keep therapy accordingly focused. conjoint tasks. Instruction, modeling, in-
15. Promote better family relationships: Rela- session practice, and homework can help
tionships have a variety of positive effects family members master these skills. Such
beyond their intrinsic value in promoting instruction and practice can help premarital
better individual mental health, individual couples significantly reduce their risk of di-
health, and child functioning. vorce and parents reduce the likelihood of
16. Promote solutions, a focus on coping, and child behavior problems.
a view of family health: Families respond 22. Suggest tasks that have a high likelihood
far better to a focus on creating solutions. of being carried out successfully: Sugges-
Reframe behavior in a form that can be tions that are not followed are likely to
more positively understood. Stress the nor- increase client reactivity and resistance.
mal developmental aspects of what the cou- For example, repeatedly proposing com-
ple or family is experiencing. munication exercises to a family that is not
17. Negotiate clear goals for treatment: Fam- ready to utilize them is likely to retard
ily life presents endless possible goals, progress.
and participants often begin with varying 23. Develop contracts between family mem-
agendas. Negotiating an agreed set of goals bers that are mutually satisfying: Couples
for therapy is an essential task early in and families who are dissatisfied with their
treatment. Goals may be added or modified relationships typically have much lower
as therapy progresses. rates of positive exchange and higher rates
18. Establish control: Therapists in couple and of coercion. Negotiating positive quid pro
family therapy must intervene actively to quo exchanges leads to more satisfying re-
move clients from habitual patterns. For lationships.
example, the therapist must be able to in- 24. Promote clear family structure: Flexible
terrupt habitual patterns of destructive ar- yet clear boundaries, stable yet not rigid
guing in couples. patterns of alliance, and an age-appropri-
19. Develop a clear plan: Couple and family ate distribution of power promote family
therapy is innately complex and typically health.
has multiple foci. A clear road map miti- 25. Understand the personal narratives of fam-
376 part iv • couples, family, and group treatment

ily members and promote the development 30. Recognize and target Gottman’s four
of a positive understanding of the narra- signs of severe relationship difficulty and
tives of other family members: The stories imminent divorce —criticism, contempt,
created by family members often carry defensiveness, and stonewalling: Clients
with them the seeds of difficulties. Exam- presenting such patterns should be warned
ining these narratives and helping create of their risk of divorce, and initial work
new ones that frame motives and behav- should center directly on developing alter-
iors in a more positive way promote more native patterns of relating. Couples are un-
harmonious family life and problem reso- likely to benefit from treatment unless
lution. these signs change.
26. Coach individuals to take responsibility 31. In divorcing and remarried systems, pro-
for their own behavior: Blame leads to mote good-enough communication to al-
endless cycles of misunderstanding and low for coparenting: Help families un-
alienation. Helping clients assume an “I” derstand the typical stresses and coping
stance about their own behavior helps strategies. Refer for mediation if substan-
break such cycles. tial conflicts arise between coparents.
27. Promote the expression of underlying 32. Utilize psychoeducational interventions
softer affect that lies behind anger and when dealing with severe mental illness:
criticism: Individuals often express defen- Families in which there is severe individual
sive reactions rather than feelings such as dysfunction often fail to understand the
sadness or fear. Exploring such underlying origins of disorders and feel blamed when
feelings in a safe environment promotes encountering therapists. An educative
understanding and empathic connection. stance that teaches about the disorder and
For example, uncovering the sad affect that about typical family processes is enor-
lies behind anger expressed toward a spouse mously helpful in gaining cooperation and
in couple therapy can alter typical dysfunc- reducing symptoms and recidivism. Re-
tional patterns of conflict. ducing expressed emotion (i.e., highly
28. See couples with relationship distress con- emotional critical affect) appears to have
jointly: Conjoint couples therapy is the particularly great value in the context of
only demonstrated effective form of treat- severe mental illness. Treatment that in-
ment for couple relationship problems. Al- creases emotional arousal and conflict in
though spouses who are unhappy with these families is contraindicated.
their relationships frequently seek indi- 33. In disorganized families, promote the cre-
vidual therapy, there is no evidence that ation of stabilizing rituals: In particular,
this helps the couple relationship and some families with members with alcohol and
evidence that it has a deleterious effect. substance use disorders fare much better
29. Focus a major part of treatment on conjoint when they maintain such rituals as a reg-
couple therapy when there is coexisting re- ular dinner hour.
lationship difficulty along with depression 34. In family violence and abuse, protect
in an individual: Individual treatment of safety first: At times, couples and families
depression does not appear to impact on the present in situations where contact is dan-
relationship problems, and the presence of gerous. The ethical obligation must be first
relationship difficulties predicts poor prog- to safety and then to other goals of therapy.
nosis over time for depression. Depressed 35. In child behavior problems, train parents
individuals who do not have comorbid cou- to engage in predictable schedules of rein-
ple difficulties do not require couple ther- forcement to reward positive behaviors
apy, although there is benefit from includ- and extinguish problematic behaviors: Re-
ing conjoint sessions centered in psycho- inforcement may focus on a single behav-
education about depression as part of the ior or may utilize a point system to focus
treatment. on a constellation of targets.
 78 • guidelines for conducting couple and family therapy 377

36. In oppositional children and in adolescent considerable evidence that many difficult-
conduct disorder and substance abuse, uti- to-engage clients, such as alcoholics, sub-
lize family therapy as part of a multisys- stance abusers, and oppositional and delin-
temic approach that also addresses other quent adolescents are more easily engaged
relevant systems, such as school, peer, and with couple and family therapy. Specifi-
legal systems, as well as the individual cally, engaging another member of the
child, or adolescent: The relevant social family system who recognizes the problem
system in these cases does not stop at the first can dramatically increase the rates of
boundary of the family but extends into engagement and retention of individuals
various other domains. Research suggests with these difficulties in treatment.
treatment is more effective when these 43. Consider the effects on the family system
parts of the social system are considered. of any therapy you conduct: Potent effects
37. Attend to tasks of termination, such as of psychotherapy extend beyond the indi-
planning for the future, throughout the vidual. When seeing a couple, consider the
treatment: Families often end treatment effects on children and extended family.
abruptly, despite the best efforts of thera- When seeing an individual, consider the
pists for planned termination. Addressing effects on spouse, parents, children, and
termination issues as the treatment un- other members of the family.
folds lessens the negative effect of un- 44. Expect treatment to have an impact: Cou-
planned termination. ple and family therapies have been
38. Assess the impact of treatment on each in- demonstrated to be effective in 75% of
dividual, each subsystem, and the system cases and have been shown to have effect
as a whole, as well as on the presenting sizes much like those of individual ther-
problem: Outcome in family systems is apy. Specifically, couple and family ther-
complex, including many stakeholders and apy has been demonstrated efficacious in
numerous foci, such as the presenting helping alleviate couple relationship prob-
problem, individual functioning, and fam- lems, depression in unhappily married
ily functioning. women, schizophrenia, manic-depressive
39. Promote the maintenance of change: All disorder, agoraphobia, panic disorder, ado-
treatment effects appear to wane over time. lescent substance abuse, adolescent delin-
Promote maintenance of change through quent behavior, childhood oppositional be-
follow-up sessions, tasks, and through the havior and conduct disorder, childhood
family’s continuing homework, and self- attention deficit disorder, alcohol and sub-
monitoring of their processes after treat- stance use disorders, eating disorder, and
ment. the psychological consequences of physi-
40. Be aware of the meanings of gender and cal illness.
culture in therapy: The therapist’s work
should be informed by an understanding of
References, Readings, and Internet Sites
the impact of gender and culture. Therapist
gender and culture also affect treatment Alexander, J. F., Holtzworth-Munroe, A., & Jame-
process, regardless of therapist behavior. son, P. (1994). The process and outcome of mar-
41. Coordinate with other therapists, health ital and family therapy: Research review and
providers, and agencies involved with a evaluation. In A. E. Bergen & S. L. Garfield
(Eds.), Handbook of psychotherapy and be-
family: Coordinating goals and interven-
havior change (4th ed.). New York: Wiley.
tion strategies often is a major factor in American Association of Marriage and Family Ther-
treatment success; inconsistent goals and apists. (n.d.). Home page. Retrieved 2004 from
methods frequently create obstacles to suc- http://www.aamft.org
cess. American Family Therapy Academy. (n.d.). Web re-
42. Utilize couple and family therapies to en- sources page. Retrieved 2004 from http://www.
gage difficult-to-engage cases: There is afta.org/resources.html
378 part iv • couples, family, and group treatment

American Psychological Association Division of ing couple and family therapy. Annual Review
Family Psychology. (n.d.). Home page. Re- of Psychology, 46, 27 – 57.
trieved 2004 from http://www.apa.org/divisions/ Lebow, J., & Gurman, A. (1998). Family systems and
div43 family psychology. In E. Walker (Ed.). Com-
Family Process. (n.d.) Home page. http://www.family prehensive clinical psychology, volume one:
process.org Foundations of clinical psychology. New York:
Goldner, V. (1985). Feminism in family therapy. Pergamon.
Family Process, 24, 31– 48. Lebow, J. (Vol. Ed.), & Kaslow, F. W. (Series Ed.)
Gottman, J. M., & Levenson, R. W. (1992). Marital Comprehensive handbook of psychotherapy:
processes predictive of later dissolution: Behav- Vol. 4. Integrative/Eclectic. New York: Wiley.
ior, physiology, and health. Journal of Person- MFT Source.com. (n.d.). Home page. Retrieved
ality and Social Psychology, 63, 221–233. 2004 from http://www.mftsource.com
Gurman, A. S., & Jacobson, N. S. (Eds.). (2002). Mikesell, R. H., Lusterman, D. D., & McDaniel,
Clinical handbook of couple therapy (3rd ed.) S. H. (Eds.) (1995). Integrating family therapy:
New York: Guilford Press. Handbook of family psychology and systems
Gurman, A. S., & Kniskern, D. P. (Eds.). (1981). therapy. Washington, DC: American Psycho-
Handbook of family therapy. New York: Brun- logical Association.
ner/Mazel. Pinsof, W. M., & Wynne, L. (Eds.) (1995). Special
Gurman, A. S., & Kniskern, D. P. (Eds.). (1991). issue: The effectiveness of marital and family
Handbook of family therapy (Vol. 2). New therapy. Journal of Marital and Family Ther-
York: Brunner/Mazel. apy, 21.
Gurman, A. S., Kniskern, D. P., & Pinsof, W. M. Sprenkle, D. H. (Ed.). (2002). Effectiveness research
(1986). Research on marital and family thera- in marriage and family therapy. Washington,
pies. In S. L. Garfield & A. E. Bergin (Eds.), DC: AAMFT Press.
Handbook of psychotherapy and behavior Walsh, F. (Ed.). (2003). Normal family processes
change (3rd ed., pp. 565 – 624). New York: (3rd ed.). New York: Guilford Press.
Wiley. Weeks, G., Sexton, T., & Robbins, M. (Eds.). (2004).
Gurman, A. S., & Lebow, J. (2000). Family and cou- Handbook of family therapy. New York:
ple therapy. In H. Sadock & R. Sadock Compre- Brunner-Mazel.
hensive textbook of psychiatry (Ed.), VII. New
York: Williams & Wilkins.
Lebow, J. (2000). What does research tell us about Related Topics
couple and family therapies. Journal of Clinical Chapter 79, “Treating High-Conflict Couples”
Psychology: In Session, 56, 1083 –1094. Chapter 80, “Treatment of Marital Infidelity”
Lebow, J., & Gurman, A. S. (1995). Research assess-

TREATING HIGH-CONFLICT
79 COUPLES

Susan Heitler

1. Arrange the therapy room for symmetry equilateral triangle. Rollers on the therapist’s
and interaction: Place the three chairs in an chair are preferable so that the therapist can
 79 • treating high-conflict couples 379

roll closer to the couple or to one or the other • Build skills so the partners learn to re-
partner for interventions and then roll back solve conflicts without angry fighting
when the couple’s dialogue flows cooperatively.
5. Define conflict levels, assessing ceilings
Do not seat the couple side by side on a sofa be-
and frequency. If the symptom checklist or
cause this arrangement encourages the couple
your interview questions indicate that anger
to talk to the therapist rather than to each other.
outbursts have been occurring, obtain detailed
2. Set up equipment for audiotaping the
reports of exactly what happens at these times,
treatment sessions: Explain that you will hand
bearing in mind the tendency to minimize and
the audiotapes to the couple at the end of each
deny rages, emotional abuse, and physical vio-
session; the tapes are for them, not for you. Ex-
lence (Holtzworth-Munroe, Beatty, & Anglin,
plain that listening to their session tapes as
1995). Early clarification of the dangerousness
homework can accelerate and consolidate their
of a couple’s conflict escalations is essential in
learning.
order to know whether treating the couple in
Be certain that participants complete a con-
marital format will be safe or could lead to dan-
sent-to-taping form (in their initial paperwork)
gerous post-session fights, and to know whether
before beginning any recording. Taping is con-
immediate separation or safe house options
traindicated if court involvement or divorce
need to be made available.
proceedings are likely lest the tapes be used in a
To obtain information about escalation lev-
way that could be detrimental to either partici-
els, meet with each partner privately for a few
pant.
minutes, and ask direct questions. Using ex-
3. Begin the therapy by welcoming the
plicit words like “shouts,” “curses you,” or “hits
couple, and by asking what each partner has
you” can make it easier for spouses to admit to
come to therapy to accomplish. Alternatively,
what is actually happening. Ask each what is
ask the partners to discuss with each other
the worst their partner does when angry, and
what they each have come to accomplish. This
what they themselves do. Ask when the couple
technique enables you to observe capacity for
tends to fight, how frequently, and whether
dialogue at the same time as you secure infor-
drugs or alcohol tend to be present.
mation about treatment goals.
Clarify how the anger in these fights is ex-
4. Obtain a threefold diagnostic picture:
pressed verbally. Verbally expressed anger usu-
• A history of each individual’s symptoms. ally begins with blame and criticism, can esca-
Accelerate this assessment by having each late to deprecating or demanding words and
partner fill out a symptom checklist before tone of voice, and can further escalate to abu-
beginning treatment sive levels with trumped up accusations, angry
• A laundry list of conflicts about which the shouting, intimidating threats, and name-call-
couple fights ing. In highest conflict levels of verbal abuse, a
• An initial assessment of communication batterer berates his wife so she will feel bad
and conflict resolution skills and deficits about herself and be weakened with guilt and
shame. In his verbal harangues the abuser
This threefold diagnostic workup organizes di- builds a case to justify his anger, his urge to
agnostic information to correspond to the three dominate and harm, and forthcoming violence.
main strands of treatment: Clarify next if anger escalates to physical
aggression. Violence may include (in order of
• Eliminate symptoms (excessive anger, de-
increasing escalation level):
pression, etc.)
• Resolve each conflict on the laundry list • Threatening physical acts such as shaking
and, in the process of resolving the con- a fist in front of the wife’s face
flicts, gain understanding of the central • Throwing objects and breaking things
problematic relationships of childhood • Pushing
and their reenactments in the marriage • Punching, slapping, choking
(Lewis, 1997) • Sexual aggression
380 part iv • couples, family, and group treatment

• Use of weapons such as a heavy object or dling the couple treatment, unless special ex-
knife pertise such as medications is necessary (Heit-
• Killing, the culmination of violent escala- ler, 2001). Two therapists tend to pull the sys-
tions tem apart, and results in the couple therapist
being uninformed about critical individual is-
While most high-conflict couples escalate to
sues essential to the couple’s progress. When
a standard ceiling of emotional agitation and
one therapist conducts both the individual and
then disengage, batterers tend to gradually es-
the couple treatment components, however,
calate their levels. The violence of one day must
confidentiality policies, such as whether infor-
be stepped up the next to effect the same emo-
mation from individual sessions will be shared
tional potency. Batterers’ rhetoric becomes in-
in the couple sessions, must be made explicit
creasingly virulent over time, and their physi-
from the outset.
cal attacks become increasingly harmful. At
7. Ensure safety: Early in treatment teach
some point even batterers do set a ceiling on es-
disengagement/reengagement routines to pre-
calation, but some do not set a ceiling until
vent hurtful fights (see Table 1). Practice these
they reach the level of murder.
routines in the session. Inquire intermittently
While the term “high conflict” usually
about the couple’s experiences with their exit
refers to high and frequent levels of escalation,
routines to ensure their plan is fully effective.
couples who do not escalate angrily can still
8. Initiate a collaborative set: Create a
lock into persistently adversarial stances. The
shared perspective on the part of each spouse
treatment strategies in this chapter also pertain
that they are mutually responsible for the
to these couples. Persistent conflict may be
problems in the relationship and that they both
manifested in anxious tension (when conflicts
need to change themselves if the relationship is
hover but do not get directly addressed), de-
going to improve (Christensen et al., 1995). To
pression (giving up instead of fighting), disen-
help make a transition from conflict to coopera-
gagement (for fear of fights), passive-aggres-
tion, develop face-saving explanations for the
sive patterns, or addictive or other obsessive-
conflicts:
compulsive behavior (which distracts from
conflicts). • Define the last comfortable phase of mar-
6. Note contraindications for couple therapy: riage and then identify external or devel-
opmental stresses that may subsequently
• Unwillingness to agree that violence is
have overloaded the system (e.g., arrival
out of bounds, at home and in the therapy
of children, illness, financial setbacks).
session
• Explain the role of insufficient communi-
• Poor impulse control or other signs that
cation and conflict resolution skills.
therapy may be unsafe
• Identify conflict resolution models in
• Reprisals for talking openly about con-
each spouse’s family of origin. Alleviate
cerns in the sessions
blaming of parents by looking compas-
• A paranoid-like blaming stance with a
sionately at parents’ family of origin his-
rigid set of beliefs about the other (a fixed
tories.
ideational system), ego-syntonic control-
ling behavior, and projection 9. Set and fulfill agendas: Just as in the ini-
• Drug or alcohol abuse tial session, you ask what each spouse wants to
accomplish overall from therapy, begin each
If these symptoms can be addressed with in-
subsequent session by asking what each spouse
dividual treatment or medication, subsequent
wants to focus on in that session (e.g., skills, a
couple treatment may be productive. Also, in-
difficult feeling or issue, an argument from the
dividual therapy for the healthier partner can
prior week).
help him or her to cope more effectively with
Close sessions by summarizing progress on
the spouse. Both partners’ individual therapies
each agenda item. Connect side issues to the
may be best accomplished by the therapist han-
focal concerns. In general, in a 45- to 50-minute
 79 • treating high-conflict couples 381

table 1. Time-Out Routines for Emotional Safety at Home

Initiate Time-outs When Either of You
• Feels too upset or negative to talk constructively.
• Senses that the other is getting too emotional to dialogue constructively.
To Initiate a Time-out
• Use a nonverbal signal, such as sports signals.
• Go to separate spaces immediately, without any further discussion.
• Self-soothe by doing something pleasant.
• Write in a journal if it feels helpful, but write primarily about yourself,
not your partner.
To Reengage
• Wait until you both have regained normal humor.
• Reengage first in normal activity before you attempt to talk again about a
difficult subject.
• If a difficult subject again provokes unconstructive discussion, save it for
therapy.
Exit Rules
• No door slamming or parting comments.
• Never block the other from leaving or pursue the other when he or she
needs to disengage.
• As soon as the going gets even a little bit hot, keep cool and exit.
Prevention is preferable to destruction.

session, one main conflict can be brought to res- Detoxify the incident by reframing the con-
olution and one main skill improved. tents of the outburst in nonblaming language.
If violence is involved, immediate steps 11. Explain that ability to resolve conflicts
must be taken to remove guns from the home, sustains couple harmony; insufficient conflict
to assure escape options, to address impacts of resolution skills produce psychopathology.
alcohol and drugs on safety, to teach ways of Anger may serve as a means of coercion in cou-
controlling anger, to ensure that both partners ples that settle their differences by means of
understand the high danger of even “minor” dominant-submissive, winner-loser strategies.
violence (e.g., a small push can cause a serious Anger expresses frustration when stances have
head injury), and to implement a temporary polarized and defensiveness has replaced listen-
separation if violence risk is high. Firmly adopt ing. Anger energizes increased voice volume in
the stance that no violent acts are acceptable order to be heard or to have one’s viewpoint
(Holtzworth-Munroe et al., 1995). prevail. It also may serve to prevent discussion
10. Intervene immediately if anger esca- of hidden behavior (e.g., gambling, an affair,
lates in a session: If the angry partner contin- drugs).
ues to escalate, stand between the two spouses Other poor conflict-resolution strategies
and/or ask one spouse to step out for a few mo- also commonly occur in high-conflict couples.
ments. Simplifying the situation by having one Anxiety arises when conflicts hover unad-
partner leave enables tempers to de-escalate and dressed. Depression is the by-product of dom-
calm to return. If an angry spouse threatens to inant-submissive conflict resolution, that is, of
leave the session, agree, inviting him or her to submitting to the preferences or will of the
return when he or she feels calmer. Thank him other. Addictive and obsessive-compulsive dis-
or her for demonstrating self-awareness and orders (including eating disorders and hypo-
self-control. chondria) indicate attempts to escape from con-
After an angry outburst, reiterate the angry flicts by means of distraction. These syndromes
person’s underlying concerns in a quiet voice so generally can be removed by readdressing con-
that dialogue resumes in a calm mode and the flicts with healthier dialogue and conflict resolu-
angry person knows he or she is being heard. tion patterns.
382 part iv • couples, family, and group treatment

12. Teach about anger: Explain that when There are times, however, when it can be
we are angry, we may feel like we are “seeing helpful to funnel the dialogue through you:
red.” Rather than attacking when we see red, as
if we were bulls, we can interpret the red as a • To de-escalate tensions when anger is esca-
stop sign. Anger tells us to stop, look to iden- lating
tify the difficulty, listen to our and to our part- • To discuss a conflict in the early phases of
ner’s concerns, and then choose a safe route for treatment when the couple’s skills are poor
continuing. Angry feelings enable us to iden- • To accelerate the resolution of a specific con-
tify problems; angry actions, however, seldom flict when time remaining in a session is
effectively ameliorate problems. short
13. Resolve current disputes: Guide conflicts
16. Identify core concerns: Hot spots in a di-
through the three stages of conflict resolution:
alogue indicate strongly felt concerns. As you
discuss conflicts, certain underlying concerns
• Express initial positions. Be sure that
will surface repeatedly, raising strong feelings
both spouses speak up and listen to each
each time. Luborsky, Crits-Christoph, and Mel-
other.
lon (1986) call these transference issues— such
• Explore underlying concerns. Be sure both
as “I don’t want to be controlled” or “People
spouses talk about their own thoughts and
disappoint me by not doing what they should”
feelings, not about their partner’s, and
—core conflictual themes. I call them core con-
that both listen to absorb, not to criticize.
cerns. Identify these.
• Design a mutually satisfying plan of ac-
Note where spouses’ core concerns dovetail,
tion, a solution set responsive to all the
repeatedly reengaging the other’s central con-
concerns of both spouses.
cerns in what Wachtel (1993) calls vicious cycles.
14. Utilize the four Ss that are essential in For instance, her thought “I can’t seem to please
conflict resolution (Heitler, 1997): him” and resultant depressive withdrawal may
interact with his “I never get the affection I
• Specifics lead to resolution; generalities want” and angry complaining stance. Her de-
breed misunderstandings. pressive withdrawal triggers his anger; his
• Short segments mean that for conflicts to angry complaints trigger her withdrawal. Estab-
move toward resolution, participants need lish new solutions for these concerns, replacing
to speak a paragraph at a time, not mul- negative cycles with positive ones (e.g., she
tiple pages. For spouses who ramble or greets him warmly when he comes home from
lecture, suggest a three-sentence rule. work; he expresses appreciation for her dinner).
• Symmetry of air time gives a sense of 17. Access family of origin roots of core con-
fairness and equal power. cerns: Deeper concerns are less accessible to
• Summaries consolidate understanding conscious thought and generally arise from his-
and propel conflict resolution forward. torically earlier life experiences (Norcross,
1986). During explorations of the family of ori-
15. Have spouses talk with each other, not gin roots of current emotionally potent con-
through you: High-conflict couples need to cerns, the spouse listens, holding his or her
learn to talk with each other when they have comments for the discussion afterwards.
differences. To redirect comments when the 18. Allow only healthy communication:
partners are speaking to you, suggest that • Intervene immediately as soon as dia-
the couple talk directly with each other. Look at logue slips off the track of healthy, safe,
the listener rather than the speaker, or using a and constructive dialogue. Do not allow
hand or head gesture to indicate that the part- blaming, criticizing or inadequate listen-
ners are to talk with each other, to further ing to pass un-remarked. Allow zero
guide couples who resist talking directly to crossovers (you-statements), which occur
each other. with particular frequency in couples
 79 • treating high-conflict couples 383

prone to anger. Rephrase inappropriate the other is saying, cooperative partners lis-
comments, or have the speaker restate the ten to learn, to sponge in what makes sense
comment more constructively— translat- in what their partner says. “But . . . ,” by
ing “don’t likes” to “would likes” and contrast, indicates that the prior comments
shifting you-statements to I-statements. are being deleted, not digested.
Ask listeners who listen for what is • Bilateral listening: Two-sided listening to
wrong in what their partner says, “What both self and other enables both partners’
was right or made sense about what you viewpoints to count. Bilateral listening
just heard?” (Heitler, 1997). contrasts with either-or thinking and the
• Prevent poor skills by prompting spouses belief that if one person is right the other
before they speak. For example, to prompt is wrong.
effective listening, suggest, “What makes
20. Convert blame after upsets to apologies
sense to you in what your spouse just
and learning: Teach the couple to piece together
said?”
the puzzle of what happened, with each spouse
• If you did not succeed with prevention,
describing his or her own feelings, thoughts, ac-
rectify skill errors by inviting a redo.
tions, and mistakes. Attribute the problem to a
• Alternatively, serve as translator, convert-
“mis-” (e.g., a misunderstanding, mistake, mis-
ing provocative comments into better
communication). Guide apologies, with each
form. For instance, after an accusatory
spouse owning his or her part in the difficulties.
“You don’t do your part in keeping up
Conclude with each having learned something
the house,” pull your chair next to the
that will help to prevent future similar upsets
speaker and reiterate for him or her, “I
(Heitler, 1997).
feel like I’m doing more than my share.”
21. Terminate therapy when the symptoms
• Repeat frequently simple iterations of ba-
have been ameliorated (i.e., anger is no longer
sic communication rules, such as “You can
contaminating the relationship), the conflicts
talk about yourself or ask about the other;
have been resolved, and dialogue is consistently
it’s out of bounds to talk about the other.”
cooperative.
“What’s right, what makes sense, what’s
useful in what your partner is saying?”
Learning increases with repetition. References, Readings, & Internet Sites

19. Coach communication skills: Design Christensen, A., Jacobson, N. S., & Babcock, J.
(1995). Integrative behavioral couple therapy.
practice exercises to teach and consolidate es-
In N. S. Jacobson & A. S . Gurman (Eds.), Clin-
sential skills such as:
ical handbook of couple therapy (pp. 31– 64).
New York: Guilford Press.
• Insightful self-expression: Good spousal Heitler, S. (1993). From conflict to resolution. New
communication involves expressing one’s York: Norton.
own concerns and feelings instead of crit- Heitler, S. (1995). The angry couple: Conflict-focused
icizing the other. Explain the difference treatment. New York: Newbridge.
between self-expression and “crossovers” Heitler, S. (1997). The power of two. Oakland, CA:
(my term for crossing the boundary be- New Harbinger.
tween self and other by talking about Heitler, S. (2001). Combined individual/marital
what you think the other is thinking or therapy: A conflict resolution framework and
ethical considerations. Journal of Psychother-
feeling or telling them what to do). Prac-
apy Integration, 11, 349 –383.
tice self-expressive when-you’s (“When Holtzworth-Munroe, A., Beatty, S. B., & Anglin, K.
you left early, I felt rejected”). Emphasize (1995). The assessment and treatment of mari-
that the subject of a when-you is the pro- tal violence: An introduction for the marital
noun I. therapist. In N. S. Jacobson & A. S. Gurman
• Digestive listening: Instead of listening like (Eds.), Clinical handbook of couple therapy
an adversary for what’s wrong with what (pp. 317 –339). New York: Guilford Press.
384 part iv • couples, family, and group treatment

Intimate Partner Abuse and Relationship Violence. TherapyHelp.com. (n.d.) Materials on psychother-
(n.d.). Home page. Retrieved 2004 from http:// apy with conflictual couples. Retrieved 2004
www.apa.org/pi/iparv.pdf from http://www.therapyhelp.com
Lewis, J. M. (1997). Marriage as a search for heal- Wachtel, P. (1993). Therapeutic communication.
ing. New York: Brunner/Mazel. New York: Guilford.
Luborsky, L., Crits-Christoph, P., & Mellon, J.
(1986). Advent of objective measures of the
Related Topics
transference concept. Journal of Consulting
and Clinical Psychology, 54, 39 – 47. Chapter 78, “Guidelines for Conducting Couple and
Norcross, J. (1986). In J. O. Prochaska (Ed.), Integra- Family Therapy”
tive dimensions for psychotherapy. Interna- Chapter 80, “Treatment of Marital Infidelity”
tional Journal of Eclectic Psychotherapy, 5,
256 –274.

TREATMENT OF MARITAL
80 INFIDELITY

Don-David Lusterman

Estimates of extramarital sex (EMS) vary ple agrees that extramarital sex is acceptable, no
widely. Glass and Wright (1992) found that infidelity has occurred. A negative answer to
44% of husbands and 25% of wives had at least the therapist’s question “Could you discuss
one extramarital experience. They found a cor- your actions comfortably with your mate?”
relation between extramarital involvement helps the patient to understand the relationship
(EMI) and low marital satisfaction. A full- between deceit and infidelity. A wife’s discov-
probability study (N = 1,200) conducted annu- ery that her husband has been involved in a
ally over a 5-year period (Smith, 1993) reports “computer romance” might be as shocking to
a roughly 15% incidence, including 21% of her as the discovery that he had been involved
men and 12% of women. All studies find that in a sexual adventure. If a partner in a four-
married men are more frequently involved some becomes secretly involved with another
than are married women. The discovery of member of the foursome, it becomes an infi-
EMI is traumatic for spouses and the couple’s delity. The violation of intimacy boundaries
children, families, and friends. The following may be much more crucial than that of sexual
observations and guidelines are based on clini- boundaries; an intense and secretive platonic
cal experience and the research literature. relationship may be more threatening than a
1. Definition: Infidelity is the breaking of sexual relationship.
trust. While often thought of as sexual mis- 2. Types of marital infidelity: Humphrey
conduct, it may also include nonsexual but se- (1987) categorizes EMI by the following criteria:
cret relationships. The most distinguishing
characteristic of all types of infidelity is secrecy. • Time
Most discoverers report that deceit is the most • Degree of emotional involvement
traumatic element of discovery. Thus, if a cou- • Sexual intercourse or abstinence
 80 • treatment of marital infidelity 385

• Single or bilateral EMS alike find that clear information brings a degree
• Heterosexual or homosexual of relief and often helps to restore marital com-
munication.
An additional criterion is the number of EMI 5. Therapeutic ground rules: The couple
partners. Glass and Wright (1992) use three should be told that the purpose of the therapy
categories: primarily sexual, primarily emo- is to help them change their relationship. With
tional, and combined-type. Careful question- work, they will be moving toward a better
ing of the involved partner using these sets of marriage or a better divorce. In a better di-
criteria helps the therapist to develop an under- vorce, both accept mature responsibility for the
standing of the type and degree of involvement. failure of the marriage. This lays the ground-
Such questioning may reveal philandering. work for an amicable settlement that is in the
Philanderers are compulsively driven to have best interests of their children, and it also per-
frequent and brief EMS. They avoid intimacy mits them to leave the marriage with new in-
and are primarily interested in power over the sights about future relationships. A better
other person (Pittman, 1989). They are best marriage is characterized by open and honest
seen as suffering a personality disorder NOS, communication about both positive and nega-
with narcissistic features, and they require in- tive issues.
dividual treatment parallel with conjoint ther- 6. Confidentiality: Although it is crucial to
apy. establish a relationship with the couple, it is
3. Discovery: EMI is a systemic phenome- equally important that the therapist schedule a
non, involving the discoverer and the discov- session to meet each member of the couple
ered and, if it takes the form of an affair, the alone. (Not all authorities view confidentiality
third party as well. Children, families of ori- the same way; for other views, see Brown,
gin, and friends are also often affected. Part- 1991; Glass & Wright, 1995; and Pittman,
ners in “good” marriages rate as most impor- 1989.) I believe that individual sessions enable
tant “trust in each other that includes fidelity, the therapist to see whether there are issues
integrity and feeling ‘safe’” and “permanent that one or the other is not yet ready to reveal
commitment to the marriage” (Kaslow & in conjoint sessions. Individual sessions also
Hammerschmidt, 1992). The discovery of infi- enable the therapist to know whether the affair
delity shatters these assumptions, producing or other extramarital and secret sexual activity
great trauma (Janoff-Bulman, 1992). The dis- is still going on. The therapist prepares the
coverer feels betrayed, and the discovered per- couple for individual sessions by assuring each
son is often ashamed and fearful of the discov- partner that anything discussed in such meet-
erer’s responses. ings is confidential. While nothing will be di-
4. The initial session: The discoverer often vulged to the other partner, the information
exhibits a rapid succession of conflicting emo- obtained will enable the therapist to organize
tions and behaviors. At one moment he or she a treatment plan. Making this contract with
may be sobbing, at another, ready to strike at the the couple provides the therapist with the free-
offending mate. The discovered partner may be dom to decide whether subsequent sessions
by turns apologetic, defensive, and angry. The should be held with each individual, with the
discovered person may deny the infidelity de- couple, or as some mix of individual and cou-
spite copious proof. Admission is often accompa- ples work. In some instances only one mate
nied by the demand that there be no further dis- undertakes therapy when marital infidelity is
cussion about it. The therapist’s first responsibil- involved. It may be the person who is suspi-
ity is to indicate that avoiding the topic, while it cious of or has just discovered a mate’s EMI or
may provide some momentary relief for the dis- the person who is extramaritally involved and
covered party, will in the end cause more prob- conflicted about it. A systemically oriented
lems. The therapeutic approach, while sensitive therapist will inform the person that it is prob-
to the affective issues, must also include a psy- able that the mate will be included in the ther-
choeducational aspect. Couples and individuals apy at some point. It is very important to in-
386 part iv • couples, family, and group treatment

form the involved person that at no time will to both husband and wife that these intrusive
conjoint therapy include the third party. The recollections and obsessive searching for more
involved person who decides to confess the in- details or for evidence that the infidelity con-
fidelity to the mate should be strongly cau- tinues (when the mate has denied it) are all
tioned not to do so in the therapist’s office. part of a posttraumatic stress reaction as de-
This person may require coaching in order to scribed in DSM-IV (American Psychiatric As-
develop an appropriate strategy for revealing sociation, 1994). Working together, the couple
the infidelity. Only after the person has acted can alleviate and even overcome this trauma.
on this responsibility should conjoint therapy The therapist should explain to the discovered
be undertaken. mate that he or she can play a crucial role in
7. Moratorium: It is crucial that the thera- helping the discoverer, who needs to express
pist press the involved partner to declare a grief, shock, and anger directly to the mate and
moratorium on the affair. Failing that, the in- requires honest answers to his or her ques-
volved person should be helped to disclose the tions. This process is crucial to the restoration
affair to his or her partner. Until such time, the of trust. If the offending party blocks this pro-
other partner should also be seen individually, cess, recovery is slowed. Dealing with trauma
so that both partners’ perceptions of the mar- is the first order of business. Several sessions
riage can be examined. Seeing the couple indi- may pass during which the therapist has the il-
vidually greatly increases their anxiety. This lusion that the couple is beyond the posttrau-
tension helps to break the impasse of denial and matic phase, only to discover that a fight has
brings them back to therapy to work more di- broken out between sessions because the dis-
rectly on the marital or divorce issues. coverer, once again, feels that the mate is lying,
8. Trust-building: Many discoverers con- withholding, and/or unable to empathize with
sider themselves “victims.” In such a case, it is the discoverer’s pain. The mate’s ability both to
wise for the therapist to begin by accepting this admit the deception and to express remorse is a
perceptual frame. Only when the discoverer necessary step in the restoration of communi-
feels fully supported is it possible to examine cation. In its absence, the prognosis for good
the predisposing factors that often play a role recovery from the trauma is poor.
in infidelity. There are situations in which an appropriate
9. Sequelae of victimhood: When the dis- and timely reaction to infidelity does not occur:
coverer experiences himself or herself as the
• An affair happened during the courtship
victim, the therapist must validate these feel-
or early in marriage, and only came into
ings and provide the couple with information
the discoverer’s awareness many years
about the nature of trauma. Many discoverers
later.
report or evidence the following symptoms:
• The affair happened during the courtship
• Difficulty staying or falling asleep or early in the marriage, and the discov-
• Irritability or outbursts of anger erer did not react at all at that time, or re-
• Difficulty concentrating acted only briefly.
• Hypervigilance
The discoverer’s long-delayed reaction usu-
• Exaggerated startle response
ally takes on a strongly obsessive and very
• Physiological reactivity upon exposure to
angry quality. Since it is so long “after the fact,”
events that symbolize or resemble an as-
the discovered partner is often unable to per-
pect of the traumatic event (e.g., being un-
ceive any justification for the discoverer’s in-
able to watch a TV show or movie about
tense reaction. It is the therapist’s task to indicate
infidelity)
that this is a genuine, delayed posttraumatic re-
The discoverer’s responses are best reframed as action and to validate the discoverer’s reaction.
a normal, nonpathological response to the Patients often accept the metaphor that the sup-
shock of discovery (Glass & Wright, 1995; Lus- pressed information has functioned as a time
terman, 1995). The therapist should make clear bomb in the marriage. Therapy will be most
 80 • treatment of marital infidelity 387

successful if the therapist treats the newly ac- mate that if there is a recurrence, the next stage
knowledged infidelity as if it had just occurred. will be divorce.
10. Jealousy: It is an error to label normal 13. Bibliotherapy: As part of a psychoedu-
reactive jealousy following the affair as if it cational approach, suggested readings can be
were a personality problem. Treating it as such helpful. Janoff-Bulman (1992), Lusterman (1989),
is a frequent cause of premature termination of Pittman (1989), and Vaughan (1989) have been
therapy. In rare instances, the discoverer is ob- found to be of value. A number of Web sites
sessively jealous, despite honest reassurance. If also provide an opportunity to receive informa-
careful examination reveals a history of patho- tion and participate in a bulletin board.
logical jealousy predating the marriage, this
problem may require separate treatment for References, Readings, & Internet Sites
the pathologically jealous mate, in conjunction
American Psychiatric Association. (1994). Diagnos-
with the marital therapy. Pathological jealousy
tic and statistical manual of mental disorders
is best seen as an aspect of a paranoid personal- (4th ed.). Washington, DC: Author.
ity disorder. AOL. Extramarital affairs forum: keyword: online
11. Predisposing factors: Once the couple psych; Divorce and Separation Community:
has negotiated the hurdle of discovery, it is then keyword: better health; then, under “Commu-
possible to begin a review of the prediscovery nity Connection,” go to “Divorce and Separa-
phase of the marriage. During this process, the tion”
therapist helps the couple to move beyond the Brown, E. (1991). Patterns of infidelity and their
issue of perceived victimhood and on to an ex- treatment. New York: Brunner/Mazel.
amination of factors within the marriage that Glass, S., & Wright, T. (1992). Justifications for ex-
tramarital relationships: The association be-
may have contributed to the affair. Such factors
tween attitudes, behavior, and gender. Journal
generally include low self-disclosure and conse- of Sex Research, 29, 361–387.
quent poor problem solving (Lusterman, 1989). Glass, S., & Wright, T. (1995). Reconstructing mar-
During this phase, the therapist must be alert to riages after the trauma of infidelity. In K. Hal-
the recurrence of posttraumatic signs. These can ford & H. Markman (Eds.), Clinical handbook
be precipitated, for example, by the discovery of of marriage and couple interventions. New
old evidence, hang-up telephone calls, or stalk- York: Wiley.
ing by the third party. Each time there is such a Humphrey, F. (1987). Treating extramarital sexual
recurrence, it is important to address the post- relationships in sex and couples therapy. In G.
traumatic issues before returning to the review Weeks & L. Hof (Eds.), Integrating sex and
process. Once the predisposing factors have marital therapy: A clinical guide. New York:
Brunner/Mazel.
been examined, the couple is ready for tradi-
Janoff-Bulman, R. (1992). Shattered assumptions:
tional marital therapy, with a focus on honest Towards a new psychology of trauma. New
communication. York: Free Press.
12. Termination: Couples are ready for termi- Kaslow, F., & Hammerschmidt, H. (1992). Long-
nation when they have examined the context and term “good marriages”: The seemingly essen-
meaning of the infidelity and have resolved that tial ingredients. Journal of Couples Therapy,
they can either proceed to a healthier relationship 3(2/3), 15 –38.
or move toward divorce. A better marriage in- Lusterman, D.-D. (1989, May/June). Marriage at the
cludes an improvement in mutual empathy and turning point. Family Networker, 13, 44 –51.
joint responsibility (Glass & Wright, 1995). Lusterman, D.-D. (1995). Treating marital infidelity.
Because the discoverer remains vulnerable In R. Mikesell, D.-D. Lusterman, & S. Mc-
Daniel (Eds.), Integrating family therapy:
to a possible recurrence, it is important to dis-
Handbook of family psychology and systems
cuss with both mates the importance of a detec- theory. Washington, DC: American Psycholog-
tion mechanism. The offending mate is re- ical Association.
minded that, should the discoverer need re- Pittman, D. J. (1989). Private lies: Infidelity and the
assurance, it must be patiently given. The betrayal of intimacy. New York: Norton.
discoverer is asked to agree with the offending Smith, T. (1993). American sexual behavior: Trends,
388 part iv • couples, family, and group treatment

socio-demographic differences, and risk behav- Related Topics

ior (Version 1.2). Chicago: National Opinion
Research Center, University of Chicago. Chapter 78, “Guidelines for Conducting Couple and
Vaughan, P. (1989). The monogamy myth. New Family Therapy”
York: Newmarket Press. Chapter 79, “Treating High-Conflict Couples”
Vaughan, P. (n.d.). Home page (resource site:
DearPeggy.com). Retrieved 2004 from http://
www.vaughan-vaughan.com

GROUP PSYCHOTHERAPY
81 An Interpersonal Approach

Victor J. Yalom

Group psychotherapy is an extremely effective THEORY

modality and potentially a more efficient use of
professional resources than individual psy- The interactional or interpersonal approach de-
chotherapy. Its efficacy has been demonstrated scribed here assumes that patients’ presenting
in treating a wide range of disorders, yet it con- symptoms and underlying difficulties are to a
tinues to be underutilized or misused by clini- large extent the result of maladaptive patterns
cians who are not sufficiently trained in group of interpersonal relationships. A major thera-
techniques. The current pressures toward pro- peutic factor in group psychotherapy occurs in
viding briefer, more cost-effective treatment the form of interpersonal learning — that is,
provide a renewed opportunity for a broader group members become more aware of and
utilization of group methods of treatment. modify their maladaptive interpersonal behav-
iors and beliefs. Through the course of a suc-
cessful group therapy, patients obtain direct
APPLICATIONS and repeated feedback about the effects of their
behavior on others — honest feedback, which
Psychotherapy groups generally consist of be- they are unlikely to receive in a constructive
tween 6 and 10 clients and one or two thera- and supportive manner anywhere else in their
pists. Some formats, such as multifamily groups, lives. Other important therapeutic factors in
may be much larger. Groups are run in almost groups include the feeling of support and be-
every setting, from private practice to hospi- longing, catharsis, the instillation of hope, and
tals, and are applicable for almost every con- the experience of altruism in helping other
ceivable clinical population. For some popula- members.
tions, such as substance abusers or domestic With the therapist’s active promptings, mem-
violence offenders, groups are generally con- bers will increase their awareness and under-
sidered the preferred method of treatment. standing of how their behaviors impact other
 81 • group psychotherapy 389

group members: which behaviors elicit positive members or leader. Instead, the therapist draws
reactions, such as compassion, empathy, attrac- attention to the manner in which the group
tion, and a desire for increased emotional close- member engages in, or avoids, conflict with
ness, and which provoke negative reactions, other group members — with the assumption
such as anger, hurt, fear, and a general desire to that in some way his or her troublesome rela-
withdraw. They then have the opportunity to tionship with the boss will be reenacted here.
“try out” new behaviors in the relative safety Because all the group members can witness his
of the group, learning how to develop social re- or her exchanges in the group, they are able to
lationships that are more fulfilling. Success give feedback that is more accurate and com-
begets success, and patients begin to internalize pelling.
these experiences, altering some of their nega-
tive self-images. Finally, they apply these new
social skills and internalized identities in their TASKS OF THE GROUP THERAPIST
relationships outside the group.
A basic assumption underlying this process Given the premise that interpersonal learning
of change is that the group is a “social micro- is maximized in a group that operates largely
cosm”— that is, that the types of relationships in the here-and-now, what must the therapist
patients tend to form in their daily lives will do for this to occur? First and foremost, the
eventually be re-created within the group it- therapist must actively assist patients in trans-
self. Thus the concept of transference from in- lating their presenting complaints into inter-
dividual psychotherapy is broadened to include personal issues. For example, a patient who ini-
the “parataxic distortions,” as coined by Harry tially requests therapy because of a feeling of
Stack Sullivan, which occur in all relationships. depression would be urged to explore the inter-
Because of the variety and number of group personal context of his or her depression — for
members, the opportunity to work through the example, the depression might be triggered by
multiple transferences or distortions that de- feelings of rejection by a lover, with subsequent
velop is much richer than in individual therapy. loneliness or humiliation. This initial reformu-
Because of this phenomenon, the most pow- lation of the problem must then be broadened
erful and efficacious way to learn from these so that it can be addressed in the group. With
recapitulated relationships is to focus on them additional effort the therapist might help the
as they continuously recur during the course patient restate the complaint as “I feel de-
of therapy. This is referred to as the “here-and- pressed when others don’t give me the atten-
now,” because the focus is here (in the group) tion I want, and yet I am unable to state my
and now (interactions that occur during the needs directly.” In this manner the complaint
therapy session). Accordingly, past events or has been transformed into one that can be ad-
relationships outside the group are used pri- dressed in the here-and-now of the therapy
marily as jumping-off points, which then group: the patient can explore how he or she
guide the here-and-now work in the group experiences similar feelings of rejection by
rather than remaining the central focus. other group members and yet has difficulty in
For example, if a group member complains letting them know what he or she wants from
of repeated conflicts with his or her boss, it is them.
usually of limited benefit to hear a lengthy re- The other main task of the therapist is to
counting of these conflicts, since the patient’s help the group continuously attend to the in-
report is undoubtedly a skewed one, biased by terpersonal dynamics that occur within the
the member’s needs and distorted perceptions. group. This can be broken down into two sub-
Attempts to interpret or make suggestions tasks. The first is to help plunge the group into
about the work situation are often unproduc- the here-and-now, allowing the members to
tive because the patient always has the upper interact with each other as much as possible.
hand, being privy to infinitely more informa- The second is to help them reflect on these in-
tion about the situation than the other group teractions and learn from them.
390 part iv • couples, family, and group treatment

The therapist must, in a very active manner, to content: Whereas content consists of the ac-
help the group members to interact directly tual words or topics discussed, process refers to
with each other and to share their observations the meaning that these conversations have in
and feelings about one another. During the ini- terms of the relationships between the group
tial session, it is common for the members to members. Thus, from a process orientation, the
take turns talking about themselves, including same utterance by a patient will have vastly
their reasons for seeking therapy and the areas different connotations depending on the man-
in which they would like to change. From this ner in which it was delivered, the timing, and
very first meeting, the astute therapist will the context of the group discussion.
look for every opportunity to direct the inter- Therapists thus must find ways to help the
actions toward the here-and-now. For example, group reflect back on its own process. Again
if a patient states that he or she is feeling quite this is an area where therapists must be very
anxious, a few probing questions may reveal active, since group members themselves are
that the patient invariably compares himself or unlikely to initiate this type of activity. Process
herself with others and usually concludes that comments can range from simple observations
they will look down on him or her because of by the therapist of specific incidents (e.g., “I
lack of education and sophistication. The thera- noticed that when you said that your fists were
pist can bring this general concern into the clenched”) to more generalized interpretations
here-and-now by asking, “Of the people in this (e.g., “You seem to instinctively challenge what-
group, which ones have you imagined are hav- ever the other men say in the group; I wonder
ing critical thoughts of you?” if you feel the need to be competitive with
Although the group members may initially them?”). Over the course of therapy, process
resist the leap into the here-and-now, with time comments serve to heighten patients’ aware-
and reinforcement they will begin to engage ness of how their behavior appears to others in
with each other more spontaneously. This is the group. Ultimately patients become aware of
not to suggest that the therapist can relax and how they determine the quality of the in-
expect the group to internalize these norms terpersonal world they live in, and with this
enough to be a self-correcting mechanism; awareness comes the possibility for true be-
members are far too preoccupied attending to havior change, leading to more satisfying rela-
the issues that brought them to the group. The tionships.
leader must continuously attend to the group
process and seize upon or create opportunities
to steer the group into productive here-and- COMMON ERRORS
now exchanges. But, over time, productive
working groups should require less guidance One of the most common errors of novice
into the here and now if the therapist consis- group psychotherapists is to practice some
tently reinforces this norm. form of individual psychotherapy in the group.
The experiential element of these interac- In this scenario the therapist typically spends
tions is crucial but by itself is insufficient. Ex- an inordinate amount of time focusing on some
perience, like catharsis, rarely by itself leads to issue or problem that a group member is expe-
personal change. It is necessary for the here- riencing, attempting to solve or analyze that
and-now experience to be linked with some problem. This approach has several obvious
mechanism that helps patients understand and drawbacks. The first is that it reinforces the
learn from these interactions. In other words, therapist as the expert, disempowering other
the patients need to be able to look back and re- group members. The experience group mem-
flect upon the encounters they experience in bers gain in being able to give and receive help
the group. from each other is in itself extremely therapeu-
To facilitate this, therapists must first have a tic and should be cultivated as much as possi-
clear understanding of group process. Process ble. The second drawback is that a prolonged
can be most easily defined in contradistinction exchange between the therapist and a group
 81 • group psychotherapy 391

member leaves the other members on the side- lematic. With anticipated absences and unantic-
line, uninvolved, and likely to become disin- ipated dropouts, some meetings will have as
terested. Group therapists need to be alert to few as two or three clients. These meetings lack
ensure that the unique ingredients of the psy- the richness of exchanges and overall dyna-
chotherapy group — that is, a number of indi- mism experienced in larger group sessions.
viduals who are motivated to come together to Furthermore, they are likely to engender in the
help each other grow and gain relief from suf- members (and the leader) fears about group
fering under the direction of a skilled leader — survival, which are unproductive and distract
are fully utilized. This is accomplished by keep- from the therapeutic goals.
ing the group interactive, with members par- Thus therapists need a steady referral base
ticipating fully, taking risks, and giving each or an ability to effectively market their groups.
other feedback and support. Often it is easier to publicize groups targeted to
The other most vexing misuse, or underuti- specific populations, such as incest survivors,
lization, of the group format is a failure to teens with eating disorders, or recovering alco-
work in the here-and-now. This is usually holics. Another possibility is for therapists to
caused by therapists leading groups without team up as coleaders, which allows them to
proper training or supervision. Once therapists draw patients from their combined practices,
have observed and understood the power and making it easier to fill groups and keep them
energy that here-and-now interactions gener- filled as openings occur. This also has other ad-
ate, they will be more likely to develop the vantages for the therapists, including comple-
skills necessary to use this approach. Another menting each other’s clinical skills and combat-
reason for avoiding the here-and-now is the fear ing the isolation of private practice.
that this will lead to excessive conflict. A suc- Group practices, clinics, and managed care
cessful course of group psychotherapy, as with organizations offer their own set of hurdles to
individual psychotherapy, involves the experi- developing successful group psychotherapy pro-
ence and expression of a wide range of feelings: grams. Although they have the advantage of
anger, disappointment, and hurt, as well as car- having large numbers of patients necessary for
ing, support, and even joy. The skilled therapist conducting multiple groups, they pose chal-
facilitates the direct expression of conflict lenges in appropriately and tactfully funneling
rather than going underground but also en- these patients to the therapists leading these
sures that difficult feelings are aired in a safe, groups. It is quite common to encounter a great
nonabusive manner. Only rarely does conflict deal of resistance (conscious and unconscious)
dominate the interactions and threaten group at every level of an organization—from intake
cohesion; in fact, in most settings the therapist workers to front-line therapists to administra-
needs to be more active in facilitating the ex- tors— to implementing a group program. Many
pression of conflict rather than in containing it. clinicians still have limited knowledge and
training regarding groups and view group psy-
chotherapy suspiciously as a second-class form
OBSTACLES TO FORMING AND of treatment. Unfortunately, some large insti-
STARTING GROUPS tutions that are successful in running large
numbers of groups unwittingly encourage these
Getting groups up and running can be the most beliefs by emphasizing to their staffs the neces-
challenging aspect of conducting group psy- sity to accommodate large patient populations
chotherapy. The solo private practitioner needs rather than the particular treatment benefits of
a large base of clients to put together an appro- groups.
priate mix in a timely fashion; if the process of To overcome this, each level of the organi-
group formation is stretched out too long, some zation must in essence be retrained to think
individuals may drop out before the group be- “group” as one of the treatment options for
gins. On the other hand, starting a group with each patient. Telephone intake workers should
fewer than five members is likely to be prob- think in interpersonal terms as they ask about
392 part iv • couples, family, and group treatment

presenting symptoms and should inform callers many who otherwise might not seek out psy-
of available group treatments. If a client ap- chiatric or psychological services. Once the
pears to be a good candidate for a group, he or group has been formed, the commonality, ei-
she should be referred directly to the group ther of symptoms or of life experiences among
leader, who can do a more in-depth assessment. the members, can increase the group’s cohe-
If the client is a good fit, then it is essential that sion. Because these groups are often time-
the therapist spend some time preparing the limited, a sense of cohesion is especially impor-
client for the group to increase acceptance of tant, since it accelerates the development of
the referral and decrease the likelihood of early safety and, hence, of risk taking.
dropout. Both intake workers and therapists However, the therapist should be aware of
need to fully understand how groups work so and strive to avoid potential pitfalls with ho-
they can intelligently discuss how the group mogeneous groups. There is a tendency among
will address the particular concerns of each patients to focus on the commonalties of their
client. For example, a chronically shy individ- symptoms and conditions rather than on their
ual may at first be quite reluctant to accept a re- unique individual experiences. Thus they
ferral for a social skills training group but avoid taking responsibility for their current
might become more enthusiastic when it is ex- dilemmas and the areas they would like to
plained how the therapist will assist in working change. The therapist must steer the group
directly on his or her shyness via interactions away from theoretical discourses about the
with other group members. nature of their symptoms, excessive advice
Needless to say, top administrators must giving, and personal historical accounts and
fully support any attempt to increase group instead address the ways in which their symp-
psychotherapy utilization, taking significant toms manifest in their day-to-day relation-
concrete steps to ensure the success of these ef- ships. This is not to say that a psychoeduca-
forts. Group psychotherapists should be given tional approach is not useful but to suggest
adequate training and supervision. Also, it is that ultimately the group leader should high-
important that reimbursement or other insti- light the interpersonal components of the is-
tutional rewards encourage the use of group sues or symptoms under discussion and utilize
psychotherapy. For example, if therapists are the group format to work directly on those is-
required to provide a specified amount of direct sues in the here-and-now.
services per week, a 90-minute group should be
counted as more than 11⁄2 hours because of the
extra paperwork, phone calls, and effort in-
volved in starting the group. Without institu- References & Readings
tional support, therapists are likely to be dis-
Leszcz, M. (1992). The interpersonal approach to
couraged from leading groups. group psychotherapy. International Journal of
Group Psychotherapy, 42, 37 – 62.
MacKenzie, R. K., & Grabovac, A. D. (2001). “Inter-
ISSUE-FOCUSED GROUPS personal Psychotherapy Group (IPT-G) for de-
pression.” Journal of Psychotherapy Practice
Most groups being led today are formed for and Research, 10, 46 – 51.
clients who possess shared symptoms, such Marziali, E., & Munroe-Blum, H. (1994). Interper-
as panic attacks, depression, or posttraumatic sonal group psychotherapy for borderline per-
sonality disorder. New York: Basic Books.
stress disorder, or have common life experi-
Ormont, L. (2003). Group psychotherapy. New
ences, such as incest survivors or single par- York: Jason Aronson.
ents. These homogeneous groups offer several Roller, B. (1997). The promise of group psychother-
advantages. They are often easier to form, and apy. San Francisco: Jossey-Bass.
from a community mental health perspective, Rutan, J. S., & Stone, W. N. (1993). Psychodynamic
they help to destigmatize the symptoms, thus group psychotherapy (2nd ed.). New York:
making group treatment more accessible to Guilford.
 82 • psychoeducational group treatment 393

Sadock, H., & Kaplan, B. (Eds.). (1993). Comprehen- Yalom, I. D. (1983). Inpatient group psychotherapy.
sive group psychotherapy (3rd ed.). Baltimore: New York: Basic Books.
Williams and Wilkins. Yalom, I. D. (1995). The theory and practice of group
Vinogradov, S., & Yalom, I. D. (1989). Concise psychotherapy (4th ed.). New York: Basic Books.
guide to group psychotherapy. Washington
DC: American Psychiatric Press.
Related Topics
Wilfley, D. E., MacKenzie, K. R., Ayers, V. E.,
Welch, R. R., & Weissman, M. M. (2000). In- Chapter 76, “Choice of Treatment Format”
terpersonal psychotherapy for groups. New Chapter 78, “Guidelines for Conducting Couple and
York: Basic Books. Family Therapy”

PSYCHOEDUCATIONAL
82 GROUP TREATMENT

Gary M. Burlingame & Nathanael W. Ridge

The ubiquity of the small-group treatments as Work (ASGW, 1991) identified PEGs as a sepa-
a primary vehicle to deliver services in the clin- rate type of group treatment, distinguishing it
ical, counseling, educational, and medical set- from psychotherapy, counseling, and activity
tings is indisputable. Unfortunately, the pleth- groups. A cardinal feature of PEGs is the focus
ora of available groups invariably leads to con- on developing members’ cognitive, affective, or
fusion in the consumer’s mind regarding the behavioral knowledge and skills through a
differences between distinct types of small- structured and sequenced set of procedures and
group treatments. For instance, it is a rare exercises. In particular, group psychoeducation
health care consumer who can accurately dis- separates itself from other types of group
tinguish between the goals, procedures, and treatments by its primary focus on education.
functions of support, counseling, psychoeduca-
tional, and psychotherapy groups. Indeed, the
professional literature inadvertently encour- APPLICATION AND
ages confabulation of distinct types of small- EFFECTIVENESS
group treatment when reviewers combine find-
ings from studies using different types of group The wide range of extant PEG models is par-
treatments to arrive at conclusions regarding tially reflected by diversity in settings (e.g., in-
the successful treatment of particular disorders patient, outpatient, primary care medicine,
(Burlingame, MacKenzie, & Strauss, 2003). schools, etc.), populations (e.g., psychiatric,
Nonetheless, some guidance exists regarding medically ill, normal, etc.), and professions that
the distinctive features of psychoeducational rely upon this group format. PEGs are found in
groups, or PEGs. traditional outpatient and inpatient mental
The Association of Specialists in Group health settings focusing on common psychi-
394 part iv • couples, family, and group treatment

atric disorders such as anxiety and depression, cognitive, affective, and behavioral skills em-
as well as more intractable conditions including phasized in a cancer PEG run by a nurse at a
schizophrenia, substance-related, and bipolar medical setting versus the knowledge and skills
disorders. A growing number of models are emphasized in a PEG for eating-disordered pa-
being developed to respond to survivors of nat- tients led by a social worker in an outpatient
ural and man-made disasters. PEGs played a clinic. One cannot help but wonder if these
significant role in the treatment of survivors groups have anything in common. However,
and emergency personnel associated with the careful examination of diverse PEG protocols
terrorist attacks on September 11, 2001, as well leads to three emergent components. More
as with the increasing number of victims of specifically, the typical PEG session contains a
community- and school-based violence in didactic presentation, an experiential exercise,
North America. and discussion. Herein lies the common charac-
An equally impressive number of PEGs can teristics and goals associated with PEGs.
be found in medical settings. Examples include
groups composed of patients with terminal 1. Specific learning goal and related objec-
(e.g., oncology) or chronic (e.g., cardiology, tives. Patient education is the most impor-
pain) medical conditions that have dual needs tant aim. Thus, PEGs have clearly defined
for education regarding the disease and its educational goals. For instance, the typical
treatment, as well as support for psychosocial goal of a symptom management PEG is to
sequelae associated such. Other medical appli- teach the patient about the probable etiology
cations include conditions that require patient of the disease, symptoms, and practices that
compliance with changes in lifestyle and med- are likely to hinder or assist in recovery
ication management (e.g., diabetes, HIV/AIDS). from or management of these symptoms
Such groups provide patients with needed in- (e.g., medication, lifestyle, behaviors). These
formation and an opportunity to discuss obsta- three educational goals find further opera-
cles and difficulties with others who are facing tional clarity in specific learning objectives
similar transitions. associated with each. For instance, learning
There is a dearth of independent reviews re- objectives clarify which symptoms, etiolo-
garding the effectiveness of PEGs. Rather, evi- gies, and treatments will be presented to the
dence for their effectiveness is found in single group and organize the flow of material to
studies or reviews of psychiatric or medical be presented over the course of the PEG. At
conditions that frequently rely upon this type minimum, written goals, objectives, and
of group treatment. While evidence exists for material should be available for each PEG
their effectiveness with specific populations session.
(e.g., schizophrenia; cf. Burlingame et al., 2. Incorporation of pedagogical methods that
2003), it should be emphasized that the out- enhance patient learning. Because patient
comes measured with PEGs often relate to edu- education is paramount, PEG leaders are
cational objectives and behavioral compliance sensitive to different styles of learning and
instead of symptom reduction or remission. teaching methods. Leaders are advised to
provide a framework where the “big pic-
ture” (learning goal) is initially presented
DISTINCTIVE CHARACTERISTICS and linked to session objectives establishing
OF PEGS a gestalt for the entire PEG. Sensitivity to
“how” members learn will lead to objectives
The lack of integrated reviews focused on the being ordered hierarchically. For instance,
effectiveness of PEGs in the literature may lead Brown (1998) suggests a hierarchy where
some to question whether they are a distinct facts are initially presented followed by ap-
type of group treatment. For instance, the di- plication, which then leads to an analysis
versity of foci across extant psychoeducational and synthesis of knowledge. Periodic evalu-
groups is illustrated when one considers the ation of knowledge acquisition is recom-
 82 • psychoeducational group treatment 395

mended to provide both patient and leader interventions ranging from 1 to 12 sessions
with feedback on patient understanding and that take place over a brief time period. Size
areas that lack clarity. also varies with membership spanning 5 to
3. Use of structured exercises to increase skill 100 members depending up the primary
acquisition and experiential learning. Ac- goal of the group. PEGs with a remedial
tive participation or experiential learning is focus (i.e., overcoming a specific deficit) are
a cardinal principle of long-term retention. typically smaller (fewer than 15 members)
PEGs incorporate this principle by involv- while preventative groups represent the
ing members in experiential learning larger end of the spectrum. The amount of
through structured exercises. These exer- time focused on didactic, experiential, and
cises can range from the completion of a discussion systematically varies by under-
simple self-report instrument that is tied to lying theoretical orientation. Cognitive
a learning objective (e.g., assessment of models devote more time to the didactic
symptoms) to activities that require mem- component while existential and process
bers to use a principle or practice a skill models put greater emphasis on the experi-
learned during the didactic phase of the ential and discussion components.
group. Successful structured exercises must
have a direct link to objectives in the didac-
tic presentation. SHARED CHARACTERISTICS
4. Personal analysis and synthesis through WITH OTHER TYPES OF GROUP
discussion. A danger inherent in PEGs is TREATMENTS
that members will experience the group as
an “academic” exercise having no personal PEGs are not immune to the dynamic and ther-
meaning. One method that may counteract apeutic properties that have been associated
this tendency is to include structured exer- with group treatments over the past several
cises that require member involvement and decades. Indeed, some have persuasively ar-
disclosure. Such exercises can lead to spon- gued for the importance of PEGs’ maintaining
taneous interaction regarding the topic un- the “therapeutic” quality found in traditional
der consideration, as members analyze and therapy groups by maintaining a focus on fa-
synthesize their didactic and personal expe- miliar group processes and dynamics. This is
riences with one another. Material that has not surprising given the interactive, dynamic
personal meaning leads to longer retention. nature of groups. A few of the more salient
Thus, PEG leaders are encouraged to plan considerations include the following.
for personal exchange and discussion be-
tween members in each session.
Group Dynamics
5. Focus on careful patient selection. Leaders
should select members who are well Group dynamics has been described “as the on-
matched to the educational goals of the going process in the group; the shifting, chang-
group. The content and structured exercises ing, individual, and group-as-a-whole vari-
used in the PEG should be calibrated with ables, including level of participation, resis-
the educational level and motivation of the tance, communication patterns, relationships
patient. For example, if a commercially between members and between members and
available PEG manual is used, the content the leader, nonverbal behaviors, feeling tone,
and homework within will often need to be and feelings aroused and/or expressed” (Brown,
modified to match the unique patient popu- 1998, p. 105). An understanding and apprecia-
lation. Other patient factors to consider in- tion of group dynamics can assist in developing
clude readiness and level of anxiety, both of a group environment that is conducive to
which can interfere with the learning objec- learning. These principles may be especially
tives of PEGs. important to the experiential and discussion
6. Structural features. PEGs are time-limited components of PEGs. For instance, there is
396 part iv • couples, family, and group treatment

some evidence that groups pass through pre- group, avoiding imposing the group leader’s
dictable stages of development, which, in turn, values, developing goals with member consul-
change the interactive climate and responsive- tation, and considering the issues around a
ness of members. Knowledge of such may as- member’s premature termination from group.
sist in selecting stage-appropriate activities and The foremost issue in most members’ minds is
discussion topics. that of privacy. While PEGs have lower levels
of member disclosure, clarity on this point is
essential for the leader to address at the begin-
Group Climate
ning of the group and periodically thereafter.
There is ample evidence to suggest that the re-
lationships that a member establishes in a
group are related to the ultimate benefit ob- LEADER COMPETENCIES AND
tained. Use of empirically grounded principles TRAINING
on how to manage group climate can assist PEG
leaders in creating an environment most con- A successful PEG leader must master two di-
ducive to patient learning. In addition, short mensions of knowledge and skill. The first re-
self-report measures of such (e.g., Group Cli- flects competencies specific to conducting a psy-
mate Questionnaire; MacKenzie, 1983) when choeducational group treatment. These are
used periodically throughout the course of a briefly outlined above and are more completely
group can provide invaluable information on delineated by professional association standards
patient perceptions. (e.g., ASGW) and in recent texts (Brown, 1998;
Coyne, Wilson, & Ward, 1997). The second re-
flects competencies associated with the subject
Problem Members
matter of the PEG. For instance, leaders con-
Troublesome member roles emerge in group ducting PEGs that focus on prevention (e.g.,
treatment, irrespective of the type or theoreti- HIV) or remediation (e.g., anger management)
cal orientation guiding the group. For instance, are expected to develop content mastery asso-
problematic member roles range from the over- ciated with a specific topic or psychiatric disor-
participating to the underparticipating mem- der. These skills often require specialized train-
ber, as well as those who engage in disruptive ing.
socializing conduct. Each can be detrimental to While it appears that the use of small-group
learning goals and will interrupt the group cli- treatments is increasing in mental health deliv-
mate. For instance, overparticipating members ery systems, an unsettling trend in training
might begin telling unrelated stories, use non- mental health professionals was recently re-
verbal distracting behaviors, or seek attention ported. Specifically, mental health training pro-
by any means necessary. It behooves the PEG grams (e.g., clinical psychology, social work,
leader to become familiar with the general and psychiatry) appear to be decreasing the
group process literature to learn of interven- number of didactic and experiential courses on
tions to counteract such behaviors. small-group treatment. More problematic is
that while providers of mental health services
(i.e., managed behavioral health companies)
Ethical Issues
expect an increased use of PEGs in the future,
A PEG leader should be aware of the ethical the group courses found in mental health
underpinnings behind group work. The public training programs typically do not focus on
nature of treatment in a group imposes a PEGs. This may leave the development of
unique ethical responsibility upon the leader. leader competencies to postgraduate training
Examples are such principles as allowing free- opportunities.
dom of exit, orienting and providing informa-
tion to the client regarding the nature of the
 82 • psychoeducational group treatment 397

STEPS IN FORMING AND RUNNING Prior to engaging the patients in this learning
A PEG: A PRACTICAL ILLUSTRATION hierarchy, a road map was presented to the
group that articulated the relationship between
The literature suggests six steps to form and symptoms, triggers of symptoms, and the rela-
run a PEG: (1) state a purpose; (2) establish tionship between coping with symptom trig-
goals; (3) set objectives; (4) select content; (5) gers and a prevention of a relapse. Placing
design experiential activities; and (6) evaluate. learning objectives in a logical order facilitated
The following example illustrates how these patient comprehension and also allowed mem-
were implemented in developing a PEG for se- bers to understand the importance and links be-
verely and persistently mentally ill patients at tween PEG sessions.
a state hospital. After establishing learning objectives, the
A task force at the hospital was formed to task force operationalized each objective by se-
develop a psychoeducational group program lecting content to support the didactic compo-
for the three patient groups that constituted nent of each group session. Relevant literature
the bulk of the census: schizophrenia, bipolar was culled and material was selected that was
disorder, and major depressive disorder. After engaging and matched the skills and abilities of
reviewing the available literature, the task the patient population at the hospital. After se-
force’s statement of purpose was to “provide lecting content for the didactic component, ex-
instruction on management of symptoms asso- ercises were designed that mapped the affective
ciated with the three most frequently occur- intensity of each with the stage of group treat-
ring disorders.” Although separate goals were ment (i.e., early, middle, and ending stages of
established for disorders, each was matched to group). For instance, an activity around form-
the range of patient abilities considering factors ing personal strategies to coping with symp-
such as cognitive impairment and length of tom triggers is a common element in symptom
stay. For example, a goal for each disorder was management PEGs. However, level of affective
to develop an understanding of the symptoms, intensity with respect to self-disclosure led to
symptom triggers, and coping methods for exercises with higher disclosure being sched-
symptom triggers. After establishing goals for uled for the middle stages of the group. Addi-
the patients, the task force began setting learn- tionally, less intense content was scheduled for
ing objectives that would provide a “road the beginning and ending stages of the group.
map,” or the best way for the members in the The final step for the task force was evalua-
group to reach their goals. For instance, a learn- tion, which was approached from three per-
ing objective associated with the aforemen- spectives: content mastery, application, and
tioned goal was for patients to identify their group climate. Content mastery was assessed
own symptoms, articulate the relationship be- using a pre/post measure of the symptom man-
tween their symptoms and symptom triggers, agement content presented in the didactic
and then identify personal methods to deal phase of the group. Change on this measure
with symptom triggers. This learning objective enabled the members and leader to track the
actually represented a hierarchy of learning major learning objectives of the PEG. The suc-
objectives that was laid out as a road map for cess of the application phase was assessed by a
the group. The PEG initially began with ses- self-report measure of how well the patients
sions devoted to facts (e.g., typical symptoms were coping with their target symptoms. Fi-
and symptom triggers associated with a partic- nally, a measure of group climate was taken at
ular disorder). Facts were followed by in- three times during the course of the group to
session application (e.g., identification of per- provide a behavioral assessment of group prop-
sonal symptoms and triggers), which then led erties and processes (e.g., engagement, conflict,
to an analysis and synthesis of knowledge (e.g., and avoidance).
personal methods to deal with symptom trig-
gers) that were presented in a group discussion.
398 part iv • couples, family, and group treatment

References & Readings Furr, S. R. (2000). Structuring the group experience:

A format for designing psychoeducational
Association for Specialists in Group Work. (1991).
groups. Journal for Specialists in Group Work,
Association for Specialists in Group Work: Pro-
25(1), 29 – 49.
fessional standards for training of group work-
Jones, K. D., & Robinson, E. H., III. (2000). Psycho-
ers. Journal of Specialists in Group Work,
educational groups: A model for choosing top-
17(1), 12–19.
ics and exercises appropriate to group stage.
Brown, N. W. (1998). Psychoeducational groups.
Journal for Specialists in Group Work, 25(4),
New York: Brunner-Routledge.
356 –365.
Burlingame, G., Fuhriman, A., & Johnson, J. (2002).
MacKenzie, K. R. (1983). The clinical application of
Cohesion in group psychotherapy. In J. C. Nor-
group measure. In R. R. Dies & K. R. MacKenzie
cross (Ed.), A guide to psychotherapy relation-
(Eds.), Advances in group psychotherapy: Inte-
ships that work (pp. 71–88). New York: Oxford
grating research and practice (pp. 159 –170).
University Press.
New York: International Universities Press.
Burlingame, G. M., MacKenzie, K. R., & Strauss, B.
Murphy, M. F., & Moller, M. D. (1998). My symp-
(2003). Small group treatment: Evidence for ef-
tom management workbook: A wellness expe-
fectiveness and mechanisms of change. In M. J.
dition. Nine Mile Falls, WA: Psychiatric Reha-
Lambert (Ed.), Handbook of psychotherapy
bilitation Nurses, Inc.
and behavior change (5th ed., pp. 647 – 696).
Rindner, E. C. (2000). Group process-psychoeduca-
New York: Wiley.
tion model for psychiatric clients and their
Coyne, R. K., Wilson, F. R., & Ward, D. E. (1997).
families. Journal of Psychosocial Nursing and
Comprehensive group work: What it means
Mental Health Issues, 38(9), 34 – 41.
and how to teach it. Alexandria, VA: American
Counseling Association.
Fuhriman, A., & Burlingame, G. (2001). Group psy- Related Topic
chotherapy training and effectiveness. Interna-
Chapter 81, “Group Psychotherapy: An Interper-
tional Journal of Group Psychotherapy, 51(3),
sonal Approach”
399 – 416.
PART V
Child and Adolescent Treatment
This page intentionally left blank
 PRINCIPLES OF TREATMENT
83 WITH THE BEHAVIORALLY
DISORDERED CHILD

Esther J. Calzada, Arwa Aamiry, & Sheila M. Eyberg

We provide a set of principles for effective psy- mosphere for the child in the therapeutic situ-
chosocial treatment of children and adoles- ation. Disruptive children may express their
cents with conduct-disordered behavior to initial apprehensions through behaviors that
which psychologists may refer in preparation reflect oppositionality or defiance of the unfa-
for treating these youngsters. The scope of this miliar situation in which they may not be vol-
chapter is limited to children and adolescents untarily involved. Providing a structure for the
between the ages of 2 and 16 years whose child in the initial stages of therapy will reduce
problems are related to disruptive behavior the child’s anxiety and help to motivate him or
disorders, including attention-deficit/hyperac- her to participate. This can be accomplished, for
tivity disorder, oppositional defiant disorder, example, by reading together A Child’s First
and conduct disorder. The challenges to treat- Book About Play Therapy (Nemiroff & An-
ment presented by these children and their nunziata, 1990) for the 4- to 7-year-old child,
families are considerable. The following eight which provides age-appropriate information
principles are designed to maximize treatment about therapy. Older children also require age-
effectiveness. appropriate information about the purpose and
process of therapy, presented in a positive but
noncoercive atmosphere of understanding and
ESTABLISHING AND MAINTAINING acceptance. To establish a therapeutic alliance,
RAPPORT it is always necessary to convey respect for the
child and to avoid judging (e.g., belittling, sid-
To conduct effective psychotherapy with a dis- ing with third persons) or laughing at/mini-
ruptive child or adolescent, the psychologist mizing problems.
must first establish a safe and comfortable at- Certain communication techniques help es-

401
402 part v • child and adolescent treatment

tablish and maintain rapport. The use of para- tive therapy components of treatment should
phrasing, for example, through either reflective be reserved for school-age children, although
or summary statements, conveys genuine in- certain preschoolers with exceptional cognitive
terest and concern for the child. Paraphrasing capacities will benefit from such approaches,
also increases the child’s willingness to provide just as certain school-age children will require
information and to consider it and enables the a more concrete therapeutic approach. Cogni-
psychologist to verify understanding of that in- tive tasks that involve long-term planning are
formation. Phrasing questions in ways that generally reserved for adolescents at or above a
avoid leading (e.g., closed-ended questions) or 14-year level of cognitive functioning.
blaming (e.g., “why” questions) helps the child
feel at ease and consequently increases his or
her willingness to participate as well. With dis- DETERMINING DEGREE OF PARENT
ruptive children, key strategies for managing INVOLVEMENT AND MOTIVATION
behavior must also be used to keep therapy
progressing productively, including, for exam- To a large extent, the motivation of the parents
ple, not reinforcing an adolescent for unaccept- will determine whether the child remains in
able verbalizations that are part of the target therapy. Parents who are not motivated to seek
problem constellation (such as lying, sassing) treatment for their child may skip appoint-
but conveying respect for both self and client in ments, arrive late, convey to the child that tak-
a matter-of-fact response. ing him or her to therapy is an inconvenience,
or even sabotage therapy, for example, by criti-
cizing the therapy or the therapist to the child.
CONSIDERING AGE AND DEVELOPMENTAL Through parent counseling that addresses the
LEVEL OF CHILD nature and causes of their child’s disorder and
the notion of a “no-fault disorder,” the impor-
Children are constantly undergoing biological, tance of their child’s therapy, and the expected
cognitive, social, and affective changes. The benefits for both the child and themselves, psy-
span of childhood and adolescence is a disjointed chologists may increase a parent’s motivation.
period during which there are rapid shifts in Among parents who are motivated to bring
what is deemed appropriate in children’s think- their child to therapy, there may be significant
ing, feeling, and behaving. Thus many expres- life stressors that make it difficult for them to
sions of children in therapy are ones that would do so. For example, it is not uncommon for a
characterize maladjustment in older or younger single working mother with several young
children but have no clinical significance for children to feel overwhelmed by the practical
their age-group. Psychologists who work with issues of her child’s therapy such as the finan-
children must have strong academic grounding cial responsibility, care of her other children,
in child development but also must keep cur- and transportation issues. Psychologists must
rent with fads and trends by observing normal address these issues before beginning treat-
children at different ages with their peers and ment. By anticipating practical solutions to
by examining children’s media and other these common problems, psychologists prepare
sources for developmental information. parents for possible obstacles and provide ways
It is important to keep in mind that a child’s to overcome them.
rate of development is often not consistent The decision to involve parents in the child’s
across developmental domains. Knowledge of treatment depends in large part on the degree
the child’s level of cognitive development is a to which the parents are involved in the child’s
critical domain in psychotherapy, for many po- life and the role their behavior plays in the
tential therapeutic approaches are cognitive. maintenance of the child’s symptoms. For most
Even psychologists are prey to assumptions children and adolescents, it is important to in-
about intellectual functioning based on a child’s volve their parents in treatment (McNeil,
verbosity and attractiveness. In general, cogni- Hembree-Kigin, and Eyberg, 1996).
 83 • principles of treatment with the behaviorally disordered child 403

CONSIDERING PARENT the mode of treatment (e.g., parent training, in-

PSYCHOPATHOLOGY dividual treatment), the type of treatment (e.g.,
behavioral, insight-oriented), the communica-
A child’s psychological functioning is related to tion strategies that may be beneficial (e.g., inter-
the psychological functioning of his or her own pretation, instruction), as well as the multiple
parents. Psychological dysfunction in a pri- considerations in the preparation of the individ-
mary caregiver may contribute powerfully to ual treatment activities and homework (e.g.,
maintenance of behavior problems in the child; What can the child read? How far apart can tan-
conversely, children with disruptive behavior gible incentives be used effectively? To what de-
problems create stressful situations that may gree can the child understand metaphors?).
exacerbate the parent’s dysfunction. Thus as- The initial assessment must also incorpo-
sessment of the parent and of the parent-child rate a description of the family’s strengths and
interaction must precede child treatment. To weaknesses in terms of affective, behavioral,
treat a child successfully, it may be necessary and cognitive factors to provide an understand-
to provide or obtain treatment for the parent as ing of the context in which the child’s prob-
well. lems exist. For example, factors such as strong
Parent psychopathology must also be con- parent-child bonding or borderline intellectual
sidered as it relates to the assessment of the functioning of parents would have implica-
child. Parent interview and parent report mea- tions for the child’s treatment plan. Exploring
sures are the most typical and easiest methods the physical, social, and cultural environment
of assessing the child’s problems for treatment. of the family is also important for determining
Yet parents with significant psychopathology the resources available to the child and the
may provide a distorted description and may limitations imposed by them. All these indi-
exaggerate in either direction. Thus, additional vidual child and family factors must be consid-
sources of information are critical for deter- ered in selecting the most effective treatment.
mining and guiding the course of treatment.
These may include teacher rating scales, simple
behavior coding of targeted problem behaviors MAINTAINING TREATMENT INTEGRITY
in the session, or use of other informants or
methods relevant to the treatment goals. Integrity of treatment refers to the accuracy of
application of the intended treatment. This
would include adherence to the techniques that
USING ASSESSMENT TO constitute theoretically driven therapies; to
GUIDE TREATMENT specific, session-by-session content and process
elements of manualized treatment protocols;
A thorough understanding of the affective, be- and to individual session outlines based on as-
havioral, and cognitive functioning of the child sessment information from the child and fam-
is necessary for choosing and implementing a ily in treatment. Treatment integrity is diffi-
successful treatment. To evaluate the affective cult to maintain with highly complex interven-
and behavioral domains of the child’s problems, tions or with children whose families have
multiple assessment measures with established multiple social adversities and psychopatholo-
validity and reliability — including self-report gies. Such problems are more common in the
inventories, ratings by others, and direct obser- treatment of conduct-disordered children than
vation measures — should be used. Multiple in children with some other disorders, and psy-
measures provide a fuller understanding of the chologists must guard against unproductive
presenting problem(s) and allow the psychol- sidetracking while still helping children and
ogist to draw on more than a single source of families cope with life events that impinge on
information. the progress of therapy. The integrity of a
Measures of intellectual functioning and aca- treatment is protected by preparation of de-
demic achievement are necessary to determine tailed session plans that include specific guide-
404 part v • child and adolescent treatment

lines for others involved even minimally in the frequency counts of target behaviors collected
child’s treatment, as well as circumspect imple- from parents and teachers or by the psychologist
mentation of the plans. Yeaton and Sechrest during the session.
(1995) suggest that treatment integrity is best At the time of termination, treatment out-
ensured by constant monitoring of the child’s come assessment allows the psychologist to
change. evaluate the progress of the child and family in
a comprehensive and quantified way by re-
administering measures used at the initial as-
PLANNING FOR GENERALIZATION sessment. One criterion by which outcome can
OF TREATMENT be measured is the restoration of the child to a
level of functioning attained before the prob-
Generalization occurs when the outcome of lem(s) developed. Another criterion might be
treatment results in changes extraneous to the the functioning of the child at a level typical of
original targeted change. These effects should a normative, or peer-relevant, population. In
be sought across all settings important to the some cases, the criterion might be the return of
child’s life and across all behaviors relevant to a child to school or to the home. In addition to
treatment goals. To obtain generalization, it is the target goals of treatment, the psychologist
essential to identify target behaviors that occur should document the associated or generalized
in many situations and settings. For example, areas of change, as well as the areas in which
teaching a young noncompliant child to comply problems remain.
to adult requests will have greater consequence Follow-up assessments serve to evaluate the
than teaching the child to feed the bird when re- long-term impact of treatment and provide im-
minded. Psychologists need to include general- portant information to document the degree to
ization explicitly within the treatment plan by which treatment effects last. For chronic condi-
targeting behaviors most apt to be reinforced in tions such as the disruptive behavior disorders,
dissimilar natural settings. Psychologists, too, it is important to implement multiple strategies
must reinforce occurrences of prosocial behav- for maintenance (see Eyberg, Edwards, Boggs, &
ior within the treatment session with defiant Foote, 1998, for a review). The knowledge that
children. Another technique to intensify gener- the psychologist will be checking in on the child
alization is to use diverse stimulus and response or family after treatment ends often serves to
exemplars that broaden the context in which enhance treatment maintenance. A follow-up
the child learns new and adaptive behaviors; the assessment can also catch early relapse and oc-
more diversity, the greater the generalization casion a booster session to reverse a turnaround.
(Stokes & Osnes, 1989). Psychologists should program specific strate-
gies for maintenance into each treatment plan;
discussion and planning for maintenance and
EVALUATING TREATMENT follow-up with the child and family are always
PROGRESS AND OUTCOME an important part of the treatment termination
process.
Although the most comprehensive assessment
takes place at the beginning of treatment, ongo-
ing assessment is necessary to guide the course SUMMARY
of treatment. Frequent and regular assessment
allows the psychologist to time strategic changes The principles of psychosocial treatment of
and to change strategies when progress is not children with disruptive behavior disorders
maintained. Ongoing assessment also provides outlined here address the treatment process
an objective basis on which to determine treat- from the initial assessment through follow-up
ment termination. Monitoring measures must and maintenance. The principles are applicable
be ones that can be completed quickly and easily to psychosocial treatments broadly, regardless
and typically are brief rating scales or behavioral of theoretical orientation. They highlight the
 83 • principles of treatment with the behaviorally disordered child 405

uniqueness of the individual child and family, A statistical approach to defining meaningful
as well as characteristics shared by disruptive change in psychotherapy research. In A. Kazdin
children in the therapeutic process. By follow- (Ed.), Methodological issues and strategies in
ing these principles, therapists who treat the clinical research (4th ed., pp. 631–648). Wash-
ington, DC: American Psychological Association.
consequential problems of children with be-
Jensen, P., Hibbs, E., & Pilkonis, P. (1996). From
havior disorders will have maximal efficacy
ivory tower to clinical practice: Future direc-
and the highest likelihood of success. tions for child and adolescent psychotherapy
research. In E. Hibbs & P. Jensen (Eds.), Psy-
References & Readings chosocial treatments for child and adolescent
disorders: Empirically based strategies for clin-
Bagner, D., & Eybert, S. M. (2003). Father involve- ical practice (pp. 701– 711). Washington, DC:
ment in treatment. In T. H. Ollendick & C. S. American Psychological Association.
Schroeder (Eds.), Encylopedia of clinical child Neary, E. M., & Eyberg, S. M. (2002). Management
and pediatric psychology. New York: Plenum. of disruptive behavior in young children. In-
Eyberg, S. (1992). Assessing therapy outcome with fants and Young Children, 14, 53 – 67.
preschool children: Progress and problems. Nemiroff, M. A., & Annunziata, J. (1990). A child’s
Journal of Clinical Child Psychology, 21, first book about play therapy. Washington,
306 –311. DC: American Psychological Association.
Eyberg, S., Edwards, D., Boggs, S., & Foote, R. Querido, J., Eyberg, S. M., Kanfer, R., & Krahn, G.
(1998). Maintaining the treatment effects of (2001). Process variables in the child clinical as-
parent training: The role of booster sessions sessment interview. In C. E. Walker & M. C.
and other maintenance strategies. Clinical Psy- Roberts (Eds.), Handbook of clinical child psy-
chology: Science and Practice, 5, 544 – 554. chology (3rd ed.). New York: Wiley.
Foote, R., Eyberg, S., & Schuhmann, E. (1998). Reisman, J., & Ribordy, S. (1993). Principles of psy-
Parent-child interaction approaches to the chotherapy with children (2nd ed.). New York:
treatment of child conduct problems. In T. Ol- Lexington Books.
lendick & R. Prinz (Eds.), Advances in clinical Yeaton, W. H., & Sechrest, L. (1995). Critical di-
child psychology (pp. 125 –151). New York: mensions in the choice and maintenance of suc-
Plenum Press. cessful treatments: Strength, integrity, and ef-
Harwood, M., & Eyberg, S. M. (2003). Developmen- fectiveness. In A. Kazdin (Ed.), Methodological
tal issues in treatment. In T. H. Ollendick & issues and strategies in clinical research (4th
C. S. Schroeder (Eds.), Encyclopedia of clinical ed., pp. 137 –156). Washington, DC: American
child and pediatric psychology. New York: Psychological Association.
Kluwer.
Herschell, A., Calzada, E., Eyberg, S. M., & McNeil,
C. B. (2002). Clinical issues in parent-child inter- Related Topic
action therapy. Cognitive and Behavioral Prac- Chapter 11, “Medical Evaluation of Children With
tice, 9, 16 –27. Behavioral or Developmental Disorders”
Jacobson, N., & Truax, P. (1992). Clinical significance:
 PSYCHOLOGICAL INTERVENTIONS
84 IN CHILDHOOD CHRONIC ILLNESS

Robert J. Thompson, Jr. & Kathryn E. Gustafson

Although specific childhood illnesses are rare, care are to diminish the impact of the illness
approximately 1 million children (i.e., 2%) and to prevent dysfunction (Perrin & MacLean,
have a severe chronic illness that may impair 1988). A major hypothesized mechanism of ef-
their daily functioning, and an additional 10 fect for the impact of chronic illness on chil-
million have a less serious chronic illness. Be- dren and their families is through disrupting
cause of advances in health care, children and normal processes of child development and
their families are, in increasing numbers, cop- family functioning (Perrin & MacLean, 1988).
ing with chronic illness over substantial peri- Models of adaptation that incorporate bio-
ods of their lives, which has caused concern medical, psychosocial, and developmental di-
about quality of life in general and psychologi- mensions, such as the risk and resistance and
cal adjustment in particular (Thompson & Gus- transactional stress and coping models (Wal-
tafson, 1996). lander & Thompson, 1995), suggest that the
It is estimated that children with chronic ill- impact of chronic illness can be lessened and
ness have a risk for psychological adjustment adaptation promoted through stress reduction,
problems that is 11⁄2 –3 times as high as that of enhancement of support-eliciting social prob-
their healthy peers (Pless, 1984). These chil- lem-solving skills, and effective parenting
dren seem to be particularly at risk for anxiety- (Thompson & Gustafson, 1996). Additional in-
based internalizing difficulties or a combina- tervention targets include enhancing adherence
tion of internalizing difficulties and milder to medical regimens and pain management.
forms of externalizing problems such as oppo- The effectiveness of psychological interven-
sitional disorders (Thompson & Gustafson, tions can be assessed in accordance with the cri-
1996). Parents and siblings are also at increased teria established by the Task Force on Pre-
risk for adjustment problems. However, good vention and Dissemination of Psychological
adjustment is not only possible but the norm. Procedures for “well-established” and “proba-
Therefore, attention has been focused on delin- bly efficacious” treatments, with a third cate-
eating processes that account for this variabil- gory of “promising intervention” added to in-
ity in adjustment and that may serve as salient crease applicability to children with rare health
intervention targets (Wallander & Thompson, problems (Spirito, 1999).
1995).
Systems-theory perspectives on human de-
velopment focus on the progressive accommo- ENHANCING ADAPTATION
dations that occur throughout the life span be-
tween the developing organism and his or her The focus of intervention efforts is on fostering
changing environment. Chronic illness can dis- positive adaptation by children and their fami-
rupt normal processes of child development lies to the stresses associated with a chronic ill-
and family functioning, and it can be viewed as ness. One intervention target is stress reduc-
a potential stressor to which the individual and tion through multicomponent cognitive and
family systems endeavor to adapt. The goals of behavioral treatment programs that address

406
 84 • psychological interventions in childhood chronic illness 407

cognitive processes of appraisal of stress and conducive parent-child interactions are begin-
methods of coping with stress. More specifi- ning to be designed to meet the illness-related
cally, a combination of emotion-focused and tasks of specific chronic illnesses. The multi-
problem-focused coping skills is necessary to family group intervention for children with di-
deal with the controllable and noncontrollable abetes (Satin, La Greca, Zigo, & Skyler, 1989)
aspects of chronic illness and their treatments. is an example. The family component consisted
Enhancing social skills is another interven- of three to five families meeting together for
tion target. In particular, perceived social sup- six weekly sessions during which discussion
port, especially classmate support, appears to facilitators promoted independent problem-
serve as a protective factor in adaptation to solving skills for managing diabetes. The inter-
chronic childhood illness. Social skills are nec- vention also included a 1-week simulation
essary to elicit and maintain peer support. component in which parents followed a meal
Intervention programs focus on developing and exercise plan; accomplished blood testing,
social-cognitive problem-solving skills. Fre- twice-daily injections of normal saline, and
quently these skills are developed in the con- measurement four times daily of urinary glu-
text of school reentry programs designed to cose and ketones using simulated urine; and
reintegrate the child into the school setting recorded results in a diabetes-monitoring diary.
after the diagnosis of the chronic illness or a Improvements in metabolic functioning relative
prolonged absence because of the illness and/or to controls at both the 3- and 6-month assess-
treatment regimen. This typically involves a ment periods occurred for the participants in
three-pronged approach of enhancing the child’s this multifamily group, with and without the
academic and social skills, modifying the school simulated experience component. Increasingly,
environment, and helping parents be effective interventions for children with chronic illness
advocates for the needs of their child (Thomp- are being provided within a group context.
son & Gustafson, 1996). To improve children’s Group treatment of patients, with/without col-
social skills and peer relationships, school reen- lateral parent/family groups, that target coping
try programs incorporate social skills training and disease management have been found to
and social-cognitive problem-solving training. meet criteria for “well-established” interven-
For example, one well-developed program has tion for enhancing psychological adaptation
three modules (Varni, Katz, Colegrove, & Dol- and improving physical symptoms in children
gin, 1993). The social-cognitive problem-solving and adolescents with diabetes and children
module teaches children to identify the prob- with asthma (Plante, Lobato, & Engel, 2001).
lems, explore possible solutions, and evaluate
the outcome. The assertiveness-training mod-
ule teaches children to express their thoughts, ADHERENCE
wishes, and concerns. The teasing module teaches
children how to cope with verbal and physical The estimated adherence rate for medical regi-
teasing associated with changes in their physi- mens for the pediatric population is 50% (Le-
cal appearance. The success of these multicom- manek, Kamps, & Chung, 2001). Given the less
ponent programs has been documented in chil- than one-to-one correspondence between treat-
dren with cancer (Varni et al., 1993). ment and outcome and the movement to a
Intervention programs are beginning to tar- family-centered, parent-professional, collabo-
get improved parenting as a method of foster- rative model of care, noncompliance is no longer
ing adaptation to chronic childhood illness. viewed as an indicator of irresponsibility and
More specifically, systems theory perspectives can be a well-reasoned, adaptive choice. Corre-
suggest that adaptation can be enhanced by re- spondingly, adherence intervention efforts are
ducing parental stress and distress and develop- now directed to providing knowledge, develop-
ing parenting skills conducive to child cogni- ing specific procedural skills, and tailoring a
tive and social development. Parenting inter- management plan to the specific needs and real-
vention programs to foster developmentally ities of the family situation.
408 part v • child and adolescent treatment

Educational and behavioral strategies have one of the tasks associated with chronic illness
been developed for improving adherence to (Thompson & Gustafson, 1996). Approaches to
therapeutic regimens. It is clear that knowledge pain management can involve analgesics, cog-
of the therapeutic regimen is necessary but not nitive-behavioral therapy, or a combination of
sufficient for improving adherence. There are both.
three types of behavioral strategies: stimulus Children with illnesses typically confront
control techniques include flavoring pills and two types of pain: pain associated with invasive
tailoring the drug regimen to specific daily medical procedures and recurrent pain that is a
events; self-control techniques include self- frequent symptom of a number of illnesses
regulation of dosage and self-monitoring of such as sickle-cell disease, hemophilia, juvenile
both symptoms and medications; reinforce- rheumatoid arthritis, and recurrent abdominal
ment techniques include reinforcing symptom pain. Cognitive-behavioral treatment approaches
reduction, medication use, and health contacts to managing chronic and recurrent pediatric
and feedback on whether drug levels are in the pain have been characterized by techniques to
therapeutic range. A review of psychological regulate pain perception and techniques to
interventions for nonadherence to medical modify pain behavior. The self-regulatory
regimes in patients with asthma, juvenile techniques for pain perception include muscle
rheumatoid arthritis (JRA) and type I diabetes relaxation, deep breathing, and guided imagery
found no interventions that met criteria for and active coping strategies, including divert-
“well-established” treatment (Lemanek et al., ing attention and reinterpreting pain sensa-
2001). However, interventions involving changes tions (Varni, Walco, & Katz, 1989). Pain behav-
in clinic and regimen characteristics met crite- ior regulation techniques focus on identifying
ria for “probably efficacious” and educational and modifying socioenvironmental factors that
and behavioral intervention met criteria for influence pain expression. Cognitive-behav-
“promising” for asthma; behavioral interven- ioral family interventions call attention to the
tion met criteria for “probably efficacious” for role of caregivers in providing discriminative
JRA; and multicomponent and operant learning cues and in selectively reinforcing behavioral
interventions and cognitive-behavioral inter- expressions of pain and self-management skills
ventions met criteria for “probably efficacious” through attention (Sanders, Shepherd, Cleg-
and “promising,” respectively, for diabetes (Le- horn, & Woolford, 1994). Cognitive-behav-
manek et al., 2001). Future research needs to ioral therapy meets criteria for “well-estab-
use health behavior change theories and find- lished” treatment for procedural pain (Powers,
ings regarding correlates of adherence to de- 1999), “probably efficacious” treatment for re-
velop interventions that target improved health ducing symptoms of recurrent abdominal pain
outcomes as well as adherence (Rapoff, 2001). (Janicke & Finney, 1999), and “promising” in-
Single-subject designs are particularly well tervention for reducing musculoskeletal pain
suited for examination of individual treatment (Walco, Sterling, Conte, & Engel, 1999). How-
components (Lemanek et al., 2001) and assess- ever, cognitive-behavioral interventions with
ment of adherence and disease outcome over children with cancer and sickle cell disease have
time (Rapoff, 2001). not met efficacy criteria due to small sample
sizes and absence of control groups and replic-
able treatments (Walco et al., 1999).
PAIN MANAGEMENT

Pain is a normative experience of everyday life SUMMARY

and is also associated with illness and treat-
ments. Pain involves a sensation component Interventions based on social-learning theory
and a response component, which includes the are effective in relation to primary intervention
psychological, emotional, and behavioral re- targets. More specifically, cognitive-behavioral
sponses to the sensation. Pain management is interventions improve stress management, en-
 84 • psychological interventions in childhood chronic illness 409

hance support-eliciting social problem-solving rent abdominal pain in children: A controlled

skills, enhance parental fostering of their chil- comparison of cognitive-behavioral family in-
dren’s cognitive and social development and tervention and standard pediatric care. Journal
management of children’s behavior problems, of Consulting and Clinical Psychology, 62,
306 –314.
and improve adherence and pain management
Satin, W., La Greca, A. M., Zigo, M. A., & Skyler,
skills. These cognitive-behavioral interventions
J. S. (1989). Diabetes in adolescence: Effects of
have multiple components; are beginning to be multifamily group interventions and parent
incorporated within family systems approaches; simulation of diabetes. Journal of Pediatric
and are being modified to fit the particular tasks Psychology, 14, 259 –275.
and situations associated with specific chronic Spirito, A. (1999). Introduction to special series on
illnesses. empirically supported treatments in pediatrics
psychology. Journal of Pediatric Psychology,
24, 87 – 90.
References & Readings Thompson, R. J., Jr., & Gustafson, K. E. (1996).
Adaptation to chronic childhood illness. Wash-
Janicke, D. M., & Finney, J. W. (1999). Empirically
ington, DC: American Psychological Associa-
supported treatments in pediatric psychology:
tion.
Recurrent abdominal pain. Journal of Pediatric
Varni, J. W., Katz, E. R., Colegrove, R., Jr., & Dolgin,
Psychology, 24, 115 –128.
M. (1993). The impact of social skills training
Lemanek, K. L., Kamps, J., & Chung N. B. (2001).
on the adjustment of children with newly diag-
Empirically supported treatments in pediatric
nosed cancer. Journal of Pediatric Psychology,
psychology: Regimen adherence. Journal of Pe-
18, 751– 767.
diatric Psychology, 26, 253 –276.
Varni, J. W., Walco, G. A., & Katz, E. R. (1989). A
Perrin, J. M., & MacLean, W. E., Jr. (1988). Children
cognitive-behavioral approach to pain associ-
with chronic illness: The prevention of dys-
ated with pediatric chronic disease. Journal of
function. Pediatric Clinics of North America,
Pain and Symptom Management, 4, 238 –241.
35, 1325 –1337.
Walco, G. A., Sterling, C. N., Conte, P. M., & Engel,
Plante, W. A., Lobato, D., & Engel, R. (2001). Renew
R. G. (1999). Empirically supported treatments
of group interventions for pediatric chronic
in pediatric psychology: Disease-related pain.
conditions. Journal of Pediatric Psychology, 26,
Journal of Pediatric Psychology, 24, 155 –167.
435 – 453.
Wallander, J. L., & Thompson, R. J., Jr. (1995). Psy-
Pless, I. B. (1984). Clinical assessment: Physical and
chosocial adjustment of children with chronic
psychological functioning. Pediatric Clinics of
physical conditions. In M. C. Roberts (Ed.),
North America, 31, 33 – 45.
Handbook of pediatric psychology (2nd ed., pp.
Powers, S. (1999). Empirically supported treatments
124 –141). New York: Guilford Press.
in pediatric psychology. Journal of Pediatric
Psychology, 24, 131–146.
Rapoff, M. A. (2001). Commentary: Pushing the en- Related Topics
velope: Furthering research on improving ad-
herence to chronic pediatric regimens. Journal Chapter 11, “Medical Evaluation of Children With
of Pediatric Psychology, 26, 277 –278. Behavioral or Developmental Disorders”
Sanders, M. R., Shepherd, R. W., Cleghorn, G., & Chapter 57, “Psychological Interventions in Adult
Woolford, H. (1994). The treatment of recur- Disease Management”
 METHODS TO ENGAGE THE
85 RELUCTANT ADOLESCENT

Alice K. Rubenstein

ADOPT AN INTEGRATIVE BEGIN WITH THE FIRST CONTACT

FRAMEWORK
The initial phone contact provides the opportu-
The majority of difficulties facing adolescents nity to begin assessing the presenting prob-
today are systemic, requiring an integrative lem(s) and ascertaining the adolescent’s appro-
approach in regard to both diagnosis and treat- priateness for the therapist’s skills and setting.
ment. Although effective psychotherapeutic Most often, initial contact is made by a parent
interventions draw from the more traditional and provides the opportunity to present the
therapies, treating adolescents requires system general parameters of treatment. Specific points
interventions with a focus on here-and-now to be covered include: The timing and content of
problem solving. Adolescents who are reluctant feedback to the parents; the likely need for col-
to enter treatment often believe that we have lateral contacts with the other systems and pro-
nothing to offer them. They assume we will fessionals who interact with the adolescent; the
not understand them, that we will align with responsible parties for getting the adolescent to
their parents and other authority figures his/her appointments; payment and insurance
against them, and that we have no clue about coverage procedures; expectation of their sup-
their lives. Therefore, from the moment of first port and involvement in the adolescent’s treat-
interaction, it is critical to communicate your ment; and most important, the confidential na-
allegiance to the adolescent and to demonstrate ture of your sessions with the adolescent. While
that you have some understanding of their reluctant adolescents rarely initiate treatment,
ecology. an adolescent who has been court-ordered to
seek treatment might make the first contact. In
those cases, it is most often both legally and fi-
AVOID TRADITIONAL MODELS nancially necessary to gain parental permission
for treatment.
Traditional models, developed for working
with children and adults, are frequently not
appropriate. Adolescents are beyond the play- SCHEDULE AN INITIAL MEETING
room, and most do not have the patience for WITH PARENTS
the traditional “talk” therapies. Insight can
come later. In treating reluctant adolescents, it Parents are a critical resource for gathering di-
is important to begin by focusing on their con- agnostic data. The decision to have an initial
cerns in the present. As soon as possible, you meeting with the parent(s) is based on a num-
must be able to get the reluctant adolescents to ber of factors, including the age of the adoles-
believe that you can help with something that cent; the therapist’s initial feel for the present-
matters to them. ing problems; the parents’ anxiety; and the

410
 85 • methods to engage the reluctant adolescent 411

therapist’s style. Reluctant adolescents will sessment of the adolescent’s systems. Assess-
often test a therapist’s trustworthiness by see- ment is interwoven with the ongoing process of
ing how he or she handles confidentiality. The listening, supporting, confronting, and refram-
adolescent’s confidentiality is best ensured by ing. Systems assessment is accomplished by ex-
having the initial meeting with the parents ploring the adolescent’s experience of all the sys-
prior to the first session with the adolescent. tems in which he or she interacts—for example,
Except in unusual circumstances, any addi- family, school, community—as well as accessing
tional meetings with parents should take place as much direct information as possible from and
in the presence of the adolescent or, if this is about these systems. This includes an assessment
not possible, with the adolescent’s full knowl- of relevant stressors, such as parent-adolescent
edge and permission. In addition to being a conflicts; peer group relationships; school ac-
chance to gather diagnostic information, the hievement, including possible learning disabili-
meeting with the parent(s) provides insight ties; daily stressors, including home and work re-
into parenting style and family dysfunction. It sponsibilities; and stressful life events, including
is helpful to have both parents attend this geographic relocation, divorce, and deaths. It
meeting, even in cases of separation or divorce. usually takes three sessions or more to establish
If a joint meeting is not possible, meet sepa- the rapport necessary to identify the major con-
rately with each parent. tributors to the reluctant adolescent’s dysfunc-
tional affect and behavior. Understanding the
adolescent in developmental and systemic con-
MAKE CONTACT WITH THE texts is key to engaging the reluctant adolescent.
ADOLESCENT

In most cases, the parent(s) arrange the initial EMPHASIZE THE FIRST SESSION
appointment for the adolescent. However, I rec-
ommend telephone confirmation directly with In their first few minutes of contact, adolescents
the adolescent. This direct contact not only usually determine whom they can and cannot
communicates respect for the adolescent as a trust. The first encounter with the treatment-
separate person but also provides data regard- reluctant adolescent must be handled carefully.
ing the degree of the adolescent’s resistance to If there is a parent in the waiting room, greet the
treatment. While the majority of adolescents adolescent first. Express appreciation directly to
have been bribed, forced, or prodded into en- the adolescent for coming, especially since it was
tering treatment, the reluctant adolescent poses likely not his/her decision. Cover the limits and
the greatest challenge for the therapist. Often boundaries of confidentiality as soon as possible.
feeling coerced or forced to see a therapist, they Since in most instances you will have already
feel controlled and intruded on. Many treat- met with the parent(s), share with the adoles-
ment-reluctant adolescents often have great cent what you have been told about the “prob-
difficulty owning and verbalizing their prob- lem.” Ask the adolescent if he or she agrees or
lems, and they do not see how talking to some- disagrees with what you have been told. Inquire
one whom they have never met before and who about what the adolescent thinks the problem is.
knows nothing about them can help. Find out what he or she wants. Emphasize that
you work for the adolescent, not for his/her par-
ents, school, or the court. Be honest and don’t be
CONDUCT INDIVIDUAL AND afraid to use humor.
SYSTEMS ASSESSMENTS

When a therapist is working with adolescents, REFER FOR PSYCHOLOGICAL TESTING

two diagnostic assessments are being made si-
multaneously: the traditional individual assess- Standardized assessment methods are useful
ment of the adolescent as “patient” and an as- with this population, particularly if the thera-
412 part v • child and adolescent treatment

pist suspects intellectual, learning, or neuro- a violation of confidentiality. If the adolescent

logical problems. At the same time, it is impor- suggests such a violation has occurred, the
tant to move slowly and work with the reluc- therapist should immediately inquire why he
tant adolescent to help him or her see how such or she believes that confidentiality has been
an assessment can benefit him or her. Careful compromised. The therapist should then either
consideration must be given to who will con- clarify what did or did not happen and, in ei-
duct the testing, and the adolescent must be as- ther case, express concern for the adolescent’s
sured that all test results will be shared with understandable feelings of betrayal, as well as
him or her, preferably before they are shared offer an apology if something was said that
with anyone else. No test results should be made the adolescent feel that trust had been
shared with a school or any agency without the compromised. What is most important is not to
adolescent’s knowledge or permission, unless allow this confrontation to be used as a justifi-
legally required. In light of the complexity of cation to stop treatment.
forming a therapeutic alliance with an adoles- The confidentiality agreement requires that
cent, many clinicians refer diagnostic testing to parents have assurance that the therapist is tak-
an outside resource. ing clinical responsibility for determining the
boundaries of confidentiality. Both the adoles-
cent and his/her parents should be informed
ASSURE CONFIDENTIALITY that confidentiality will be waived if the thera-
pist judges that the adolescent is in danger of
Confidentiality is essential in establishing and harming him or herself. If this becomes neces-
maintaining the integrity of a viable working sary, it is best to tell the adolescent first. In
relationship with any adolescent, but it is es- keeping with the goal of empowerment, the
pecially critical with the treatment-reluctant adolescent should be encouraged to talk di-
adolescent. The guidelines for confidentiality rectly with his/her parents, possibly in a fam-
should be established at the time of initial con- ily session. In cases where there is suspected
tact with the parents and discussed with the physical or sexual abuse, the adolescent must
adolescent at the beginning of treatment. As- be informed that you are required by law to
suring confidentiality is the first step in gain- notify the appropriate agency.
ing trust and empowering the treatment-
reluctant adolescent. Explaining to parents the
therapeutic value of confidentiality not only INVOLVE PARENTS
helps them to support the treatment process
but also provides for developmentally appro- In most cases, particularly with younger ado-
priate separation between the adolescent and lescents, therapeutic change necessitates pa-
his/her parents. rental involvement in the treatment process. At
the same time, working with treatment-reluc-
tant adolescents requires balancing parental in-
CLARIFY THE BOUNDARIES OF volvement with patient confidentiality. It is
CONFIDENTIALITY often necessary to wait for many weeks— until
there is a solid therapeutic alliance—before di-
Confidentially requires that the therapist not rectly addressing the parents’ role in the ado-
repeat anything the adolescent says (except for lescent’s dysfunctional behavior. Whenever
the legally mandated exceptions). The adoles- possible, sessions with parents should take
cent needs assurance that the therapist will not place when the adolescent is present. Having
withhold any contact the therapist has with the the adolescent directly involved in negotiations
adolescent’s parents. Treatment-reluctant ado- with his/her family system enhances develop-
lescents will often watch for any behavior on mentally appropriate empowerment. However,
the part of the therapist that can be considered the treatment-reluctant adolescent may well
 85 • methods to engage the reluctant adolescent 413

refuse to be part of any such meeting, or the FIT THE THERAPIST AND OFFICE
therapist’s clinical judgment may suggest hav- TO THE ADOLESCENT
ing separate meetings with parents before
meeting with them together with the adoles- If the adolescent is coming straight from school
cent. If the adolescent does not attend the or work, then offer a snack or beverage. The
meeting, be sure to meet, call, or e-mail the therapist’s attire should be casual, avoiding
adolescent as soon as possible after the meet- strong images of power and authority. Con-
ing. What is most important is to assure the sider your office environment. Adolescents do
adolescent that the clinician has maintained not wish to be confronted with how learned we
his/her confidentiality during the meeting and are. Shelves stacked with books and journals
share, as clinically indicated, what transpired at are often distancing. The physical environment
the meeting. should be comfortable and inviting.

INVOLVE THE ADOLESCENT IN CONSIDER MULTIPLE TREATMENT

EXTERNAL CONTACTS MODALITIES

In all situations, it is essential to involve adoles- Group therapy is often the treatment of choice
cents in decisions regarding contact with their for adolescents with dual or multiple diag-
parents, teachers, and other adults or agencies. noses, particularly in cases of substance abuse,
A signed release should be secured from the depression, and oppositional disorders. Group
parents and the adolescent before any collateral psychotherapy makes use of peer confrontation
contacts are made. This is particularly impor- and support, while providing for connection
tant in regard to medical and legal issues. In and belonging. As increased autonomy emerges
terms of the parents, this is a legal necessity; as a primary struggle during adolescence, family
with the adolescent it is a therapeutic one. therapy can help to mediate parent-adolescent
Whenever possible, work directly with the conflicts, as well as foster effective communica-
adolescent in the preparation of any court- tion through the process of separation and indi-
ordered written report. viduation. Treatment-reluctant adolescents are
surprised and affirmed when the therapist con-
fronts the parents with the fact that their sons
HANDLE PARENTAL CONTACT or daughters’ problems are not all their fault.
WITH CARE Resistance is lowered when the adolescent sees
that the therapist does not see the parents as al-
The therapist should take phone calls from par- ways being right. As with individual psy-
ents regarding their adolescents. The therapist chotherapy, confidentiality, collateral contacts,
may listen, but should not offer any informa- and parental involvement must be clearly de-
tion that might compromise confidentiality. If fined.
there is a question about how the adolescent
would feel about your sharing something with
their parents, check with the adolescent first. CULTIVATE EMPOWERMENT
You can call the parent(s) back. It is a lot more
difficult to get the treatment-reluctant adoles- Psychotherapy with adolescents requires a spe-
cent back if he or she believes you have violated cial kind of advocacy. It is a delicate balance be-
his/her trust. The therapist is free to share tween helping adolescents empower them-
with the adolescent all communications with selves while providing support, confrontation,
the parents. and direct intervention when needed. Focus on
what they need, not why they were sent or ru-
minate about their helplessness. It is important
414 part v • child and adolescent treatment

to begin to set operational goals early on. Tan- degree of dysfunction. Empowerment necessi-
gible things they want to be different. Help tates appropriate boundaries. Adolescents will
them to identify exchanges or trade-offs they not feel truly empowered unless they believe
can make with those in power— for example, a that they are primarily responsible for making
C average in exchange for being able to get a positive changes in their lives.
driving permit. It is often helpful to make
a list. Their goals might include such things as
a later curfew, increased spending money, hav- INTERVENE OUTSIDE OF THE
ing more friends, getting a job, doing better in OFFICE
school, eliminating substance abuse, reducing
delinquent behaviors, surviving in a dysfunc- Since the world of the adolescent is signifi-
tional system. Identify ways they can try to cantly impacted by other systems, it is impor-
reach their goals by brainstorming with them. tant to be willing to leave the office. This may
The process involves teaching and modeling include meetings with teachers, youth leaders,
how they can take control of their own life. Be and probation officers. Always inform the ado-
careful not to take responsibility for their lescent that such a meeting has been requested
reaching their goals. It is their job, and then the or that you would like to have such a meeting.
success is theirs. Empower adolescent patients to take an active
role in effecting change by encouraging them
to attend. If they refuse, review with them
AVOID SPLITTING WITH THE what you will say at the meeting. In seeking to
SYSTEMS engage the reluctant adolescent, the therapist
may determine that it is therapeutically appro-
Almost every adolescent who appears for treat- priate to meet with the adolescent outside the
ment is angry with one or more of the systems office setting for one or more sessions. In any
with which he or she interacts. While it is im- of these situations, do whatever is necessary to
portant for the therapist to be supportive of the ensure his/her trust and connection.
adolescent’s feelings, it is equally important not
to pair with the adolescent against all of these
systems and to engage in institutional split- BE FLEXIBLE AND AVAILABLE
ting. Adolescents want and need the support
and approval of these systems, even if they are Unlike adults, adolescents require a great deal
dysfunctional. Whenever possible, the adoles- more flexibility and availability in the course of
cent should be encouraged and helped to figure treatment. They often require far more phone
out ways to meet his/her own needs while, at contact, especially in a crisis. The therapist
the same time, find ways to work with the sys- must establish a balance between keeping ap-
tems with which he or she must interact. propriate boundaries and becoming too rigid. It
is helpful to let adolescents know if and how
they can reach you between sessions. In addi-
MONITOR COUNTERTRANSFER- tion, the course of treatment with adolescents
ENCE CAREFULLY is likely to be more variable than it is with
adults. Particularly with the reluctant adoles-
It is critical for therapists to maintain a thera- cent, it is important to balance regular contact
peutic boundary between themselves and their with offering some choice of when the next ses-
adolescent patients. Overidentification with the sion should take place. If possible, try to leave
treatment-reluctant adolescent can damage the no more than ten days between the first three
therapeutic relationship and interfere with pro- sessions.
ductive change. Adolescents must learn how to
navigate their own systems, regardless of the
 85 • methods to engage the reluctant adolescent 415

MODEL AN APPROPRIATE scend the shackles of their training and super-

TERMINATION stitions. Journal of Clinical Psychology, 46,
351–358.
The psychotherapy relationship is critical in an Mental Health Risk Factors for Adolescents. (n.d.).
adolescent’s life, and thus termination has spe- Resource page. Retrieved 2004 from http://
cial ramifications and opportunities. Emphasize www.education.indiana.edu/cas/adol/mental.html
Petersen, A., Compas, B., Brooks-Gunn, J., Stemm-
an open-ended arrangement and the ability to
ler, M., Ey, S., & Grant, K. (1993). Depression
reinitiate contact. Underscore the ongoing pro- in adolescence. American Psychologist, 48, 155 –
cess of solving life problems. Reinforce the 168.
adolescent’s successes and his/her acquired Rubenstein, A. (2003). (Ed.). Issue on adolescent
skills. Remind adolescents of any initial reluc- psychotherapy. In Session: Journal of Clinical
tance and tell them again how much you appre- Psychology, 59(11).
ciate their willingness to give you a chance to Rubenstein, A., & Zager, K. (Eds.). (1995). Adoles-
work with them. Let them know that you have cent treatment: New frontiers and new dimen-
learned things from them that will help in sions. Psychotherapy, 32, 2– 6.
your work with other adolescents. Discuss Sommers-Flanagan, J., & Sommers-Flanagan, R.
your position on posttherapy contacts, such as (1997). Tough kids, cool counseling: User-
friendly approaches with challenging youth.
writing, phone contact, graduations, holiday
Alexandria, VA: American Counseling Associa-
cards, and weddings. Encourage adolescents to tion.
discuss their feelings about termination. Within Steinberg, L. (2002). Clinical adolescent psychology.
a therapeutic context, share your own feelings What it is and what it needs to be. Journal of
about the termination. Model a healthy and ma- Consulting and Clinical Psychology, 70, 124 –
ture farewell. 128.
Surviving Adolescence. (n.d.). Home page. Retrieved
References, Readings, & Internet Sites 2004 from http://www.rcpsych.ac.uk/info/
help/adol/index.htm
Benhke, S. H., & Warner, E. W. (2002, March). Con- Weisz, J. R., & Hawley, K. M. (2002). Developmen-
fidentiality in the treatment of adolescents. tal factors in the treatment of adolescents. Jour-
Monitor on Psychology, 44 – 45. nal of Consulting and Clinical Psychology, 70,
Bratter, T. (1977). The psychotherapist as advocate: 21– 43.
Extending the therapeutic alliance with adoles- Weisz, J. R., Weiss, B., Alicke, M. D., & Klotz, M. L.
cents. Journal of Contemporary Psychother- (1987). Effectiveness of psychotherapy with
apy, 8, 119 –126. children and adolescents: Meta-analytic find-
Cauce, A. M., Domenech-Rodriguez, M., Paradise, ings for clinicians. Journal of Consulting and
M., Cochran, B. N., Shea, J. M., Srebnick, D., & Clinical Psychology, 55, 542– 549.
Baydar, N. (2002). Cultural and contextual in- Young, I., Anderson, C., & Steinbrecher, A. (1995).
fluences in mental health help seeking: A focus Unmasking the phantom: Creative assessment
on ethnic minority youth. Journal of Consult- of the adolescent. Psychotherapy, 32, 34 –38.
ing and Clinical Psychology, 70, 44 – 55.
Holmbeck, G. N., & Kendall, P. C. (2002). Introduc-
Related Topics
tion to the special section on clinical adolescent
psychology: Developmental psychopathology Chapter 78, “Guidelines for Conducting Couple and
and treatment. Journal of Consulting and Clin- Family Therapy”
ical Psychology, 70, 3 – 5. Chapter 83, “Principles of Treatment With the Be-
Kazdin, A. E. (1993). Adolescent mental health: Pre- haviorally Disordered Child”
vention and treatment programs. American Chapter 121, “A Model for Clinical Decision Mak-
Psychologist, 48, 127 –141. ing With Dangerous Patients”
Lazarus, A. A. (1995). Can psychotherapists tran-
 86 THE APSAC STUDY GUIDES

Jeannie Baker & Sam S. Hill III

The American Professional Society on the key elements that constitute the assessment of
Abuse of Children (APSAC) is the nation’s child molesters. This guide also provides direc-
largest interdisciplinary professional society tion to available research in this area.
for those working in the field of child abuse and
neglect. APSAC’s mission is to improve soci-
Introduction
ety’s response to the abuse and neglect of its
children by promoting effective interdiscipli- • Defining the sexual offender
nary approaches to the identification, interven- • Understanding child molestation as a com-
tion, treatment, and prevention of child mal- mon, transcultural, and historical occurrence
treatment. • Key differences of forensic assessment ver-
APSAC currently has three study guides sus nonforensic clinical assessments
available: • Theorizing an explanation for offender be-
havior
• Volume 1. Assessment of Sexual Offenders
Against Children (Quinsey and Lalumiere,
Characteristics of Sexual
1996)
Offenders Against Children
• Volume 2. Evaluating Children Suspected of
Having Been Sexually Abused (Faller, 1996) • Differentiating characteristics peculiar to
• Volume 3. Medical Evaluation of Physically child molesters
and Sexually Abused Children (Jenny, 1996) • Level of social competence and social skills as
a variable
These study guides are intended to provide an • Studies of sexual offenders’ cognitive beliefs
outline of information in specific aspects of and patterns
child maltreatment and to direct the profes- • Sexual preferences of child molesters as a
sional to available research material. function of sexual response patterns and sex-
They are summarized in the following ual history
pages. • Relationship between personality tests re-
sults and psychopathology
• Suggested differences in hormone and brain
APSAC STUDY GUIDE, VOLUME 1: dysfunction in child molesters
ASSESSMENT OF SEXUAL • Taxonomic research
OFFENDERS AGAINST CHILDREN • Situational determinants as predictors

The APSAC Study Guide, Volume 1, Assess-

Implications for Practice
ment of Sexual Offenders Against Children
(Quinsey & Lalumiere, 1996), is written for • Assessment utilizing the clinical interview,
health care professionals involved in assess- psychological testing, phallometric assess-
ment of child molesters. It is not intended to be ment, and polygraph tests
a “how to” manual but, rather, an outline of the

416
 86 • the apsac study guides 417

Appraising Risk sics of (alleged) child sexual abuse assessment.

• Recidivism risk appraisal The study guide also provides the reader with
information necessary to evaluate current re-
search, conduct a comprehensive evaluation,
Treatment Planning and defend his or her feelings.
• Determining treatability and treatment needs
Models for Evaluating Child
Sexual Abuse
Ethical Issues
• Determining the referral source and client • The most widely used and accepted model
• Maintaining confidentiality amid reporting for determining an allegation of sexual abuse
mandates is the Child Interview model
• Professional and legal guidelines • Less widely used for evaluating sexual abuse
allegations is the Parent-Child Interaction
model
The Report • The Comprehensive Evaluation model is best
• Possible conflicts of interest suited for assessment of allegations of in-
• Adequate and inadequate reports trafamilial sexual abuse, where complexity
and multiple victims/offenders may be pres-
ent
Recommended Assessment
Instruments
Interviewer Objectivity and
• Standard assessment battery to assess risk of Allegations of Sexual Abuse
recidivism, treatment needs, and supervision
needs • Gender, profession, and age differences
• Battery also to include (when relevant) mea- • Other factors affecting evaluation objectivity
sures of personality, psychopathology, social • Research on false allegations by children
skills, brain and hormonal dysfunction
• Free drawings by the child as evaluative Number of Child Interviews
measures of sexual abuse
• Interpretation caveats • Repetition of allegations to multiple profes-
• Lack of research on evaluation of very young sionals increases risk of contamination of
children disclosure, trauma to child
• Significant reliance on nonabusing caregiver • Advantages and disadvantages of both too
report few and too many interviews by a single pro-
• Observation of alleged abuser-child interac- fessional
tion as an alternative • Individual differences among children in
• Use of multiple, brief interview sessions disclosing sexual victimization
• Situational and logistical factors affecting
the interview
APSAC STUDY GUIDE, VOLUME 2:
EVALUATING CHILDREN
Documentation
SUSPECTED OF HAVING BEEN
SEXUALLY ABUSED • Advantages and disadvantages of videotaping
• Determining the specifics of videotaping
The APSAC Study Guide, Volume 2, Evaluat- procedure
ing Children Suspected of Having Been Sexu- • Necessity for informed consent of the child,
ally Abused (Faller, 1996), is written to famil- including familiarization with equipment
iarize the health care professional with the ba- and professionals involved
418 part v • child and adolescent treatment

• Assessment of child’s overall functioning Special Considerations for Cases

over and above the sexual abuse through Involving Very Young Children
audio/visual documentation • Chronological age versus developmental age
• Reliance upon caregiver report
Standardized Tests • Observation of alleged abuser-child interac-
tion as an alternative
• Appropriateness of psychological testing for • Need for multiple interviews
differentiating the sexually abused child • Play themes
• Behavior checklists for accessing sympto-
mology in the victim and as third-party re-
port by caregiver Children as Witnesses
• Using projective tests to elicit information • Abundance of analogue studies to assess the
related to the victim’s sexual experience accuracy of sexual abuse experiences
• Ecological validity of child participation
Questioning Techniques • Ecological validity of questioning procedures
• Children’s memory of events varies by age
• Avoiding the use of leading questions— i.e., and context of experience
yes or no questions or multiple choice, as • Children are fairly resistant to suggestive
well as coercive techniques; utilizing open- questioning, but children less than 4 years of
ended questions instead, primarily, or in age are less resistant than their older peers
combination with free narrative • Children more likely to make errors of omis-
sion than commission
Media for Interviewing Children • Use of positive reinforcement appears to
affect the responses of younger children
• Appropriateness of using anatomical dolls to more than older children
elicit sexualized doll play • Children take what adults communicate to
• Sexually abused children more likely to en- them seriously— that is, if an adult commu-
gage in sexual behavior with anatomical nicates certain facts about a situation of which
dolls than nonabused children. a child has no direct knowledge, the child as-
• In general, no significant difference between sumes the adult is telling the truth
uses of anatomical versus nonanatomical • Young children can be programmed to be-
dolls as “props” to elicit responses from sex- lieve they have had experiences which they
ually abused children have not
• Preferability of having experienced profes-
sionals use anatomical dolls
• Seven primary functions of anatomical dolls False Allegations
• Timing and scenarios of presentation of • Determining the difference between a false
anatomical dolls allegation and an unsubstantiated allegation
• Opinions vary as how to use anatomical • Consensually arrived-at criteria are the
dolls — in general, taking cues from the most valid measure to identify false allega-
child and varying techniques circumstan- tions
tially • False allegations generated by adults are
• Anatomical drawings as a substitute for, or more common than false allegations by chil-
prelude to, anatomical dolls dren
• Anatomical drawings are not as controver- • False accusations of sexual abuse by children
sial as anatomical dolls and can become a per- are quite uncommon, but more likely to be
manent part of the case record made by older children, usually adolescents
• Very young children may make fictitious al-
 86 • the apsac study guides 419

legations, primarily to please the evaluator Child Physical Abuse:

or in response to leading questions. Epidemiology, Risk Factors,
• Custody and/or visitation battles between and Evaluation
parents occasionally result in false allega- • Necessity for a complete medical and psy-
tions chosocial history and circumstances leading
• Children also occasionally identify the wrong to the injury in question, including report
abuser— someone less feared or less loved by the child, where appropriate
• Environmental assessment of the abuse site,
Criteria for Deciding Whether an including interviews with neighbors and
Allegation Is Valid others present at the time of the alleged in-
cident
• Review of various professionals’ suggested • Exam should be performed as soon as child is
guidelines for determining sexual abuse stable and should include growth chart mea-
• Child interview is central to any sexual surements and a detailed comprehensive
abuse evaluation, especially documentation head-to-toe physical, including genitalia and
of affect consistent in the abuse description, anus
details of the sexual abuse, and advanced sex- • Siblings should also be interviewed and ex-
ual knowledge amined
• Skeletal X-rays, bone scans, CT scans, and
Forming Conclusions MRIs are recommended, as well as blood
work
• Reaching conclusions regarding the truth- • Findings should be thoroughly documented
fulness of the child in the child’s chart
• Drawing conclusions about whether the
child has been sexually abused
• Utilization of supporting evidence Abdominal Trauma
• Inconclusive evaluations — using an ex- • Small bowel injuries are uncommon. Diag-
tended evaluation nosis can be difficult and symptoms nonspe-
• Protection of the child when the evaluation is cific.
inconclusive • Stomach injuries are also less common, fre-
quently presenting as peritonitis from gas-
tric rupture.
APSAC STUDY GUIDE, VOLUME 3:
• Liver injuries can be very difficult to diag-
MEDICAL EVALUATION OF
nose, especially in the absence of history of
PHYSICALLY AND SEXUALLY
trauma; urinalysis and blood tests are use-
ABUSED CHILDREN
ful.
• Pancreatic injuries, especially pancreatitis,
The APSAC Study Guide, Volume 3, Medical can be diagnosed by CT, ultrasound, or blood
Evaluation of Physically and Sexually Abused work.
Children (Jenny, 1996), has been designed to • Urinary tract injuries are not commonly re-
familiarize the health care professional with ported but can be life-threatening.
the broad range of information contained in the • Adrenal gland and cardiac injuries are un-
medical literature about the physical and sex- common but do occur.
ual abuse of children. It is not intended to be a • Suspected chest and abdominal trauma can
textbook on child abuse, but rather to serve as a be confirmed through computerized tomog-
guide to the best information available and to raphy (CT), ultrasound, or upper GI tract se-
help the professional locate that information. ries.
Also included in the study guide is a glossary
of medical terms in laypersons’ terms.
420 part v • child and adolescent treatment

Burns • Lung, heart, and mediastinal injuries consti-

• Burns, a common form of child abuse, are tute the number of child physical abuse clas-
categorized by burn depth as it relates to the sified as chest injuries.
layer of skin affected.
• First-degree, or epidermal, burns affect the Injuries to the Face, Ears, Mouth,
outermost skin layer, causing only redness. Throat, and Nose
• Second-degree, or partial thickness, burns
involve both the epidermal and dermal lay- • Orofacial trauma is routinely encountered in
ers; they can be superficial or deep. physically abused children.
• Third-degree, or full thickness, burns com- • Facial contusions are the most common ac-
pletely destroy the dermis. cording to recent studies.
• Depth of burn depends on temperature of • Injuries to the lips, tongue, and teeth are fre-
water and length of time in water. quent.
• Hot-liquid burns are often accidental, the re- • Facial fractures are less common, but when
sult of a children pulling a pan of water or present involve the nose, jawbone, temporal
grease from a stove; these burns are espe- bone, and eye socket.
cially damaging. • Other frequent orofacial injuries occur to
• Cigarettes, electric irons, hair dryers, and the palate, pharynx, larynx, nose, and ears.
cigarette lighters result in pattern (contact)
burns; like other burns their severity de- Fractures
pends on temperature of object and length of
exposure. • Certain fractures occur more frequently as a
• Open flame, such as a gas stove, or flamma- result of abuse than by accident.
ble liquids cause flame burns, often accom- • Peritoneal elevation is not often seen in
panied by smoke inhalation. nonabused children.
• Heat stroke frequently occurs when neglect- • Long bone fractures reflect the type of force
ful caregivers leave children in parked cars; applied to the bone, either spiral fractures
heat stroke results in cerebral edema and from rotational force, transverse fractures
bleeding, liver and kidney failure, and circu- from translational forces, or compression
latory collapse. fractures from axial loading.
• Predictive factors associated with child abuse • Metaphysical fractures are rarely seen as the
by burning include delay in seeking medical result of an accidental injury; these fractures
assistance and an injury not consistent with usually occur in children under the age of 2
the report of injury cause. as the result of child abuse.
• Psychological factors in children with abu- • Nine other fracture types are moderately
sive burn injuries include depression, lan- to highly particular to abused children; they
guage deficits, inappropriate affect, with- include posterior rib, scapular, spinous pro-
drawal, attention deficits, and tactile defen- cess, sternal fractures; digital and complex
siveness. skull, multiple fractures, and fractures of
• Social factors associated with abused burn different ages; epiphyseal plate injuries; and
victims include low SES, adolescent parents, vertebral body fractures and subluxations.
premature birth, postnatal illness, physical • Differential diagnosis is important in distin-
or mental handicap. guishing between abuse and nonabuse frac-
tures.
• Specific guidelines are available for imaging
Chest Injuries of suspected child abuse victims.
• Chest injuries, other than rib fractures from • Healing of fractures varies by injury site and
squeezing or shaking an infant’s thorax, are between individual children.
seldom noted as a consequence of child abuse.
 86 • the apsac study guides 421

Head Injuries Child Sexual Abuse: Epidemiology,

Risk Factors, and Evaluation
• The most lethal form of child abuse is head
trauma; often fatal; if not fatal, children are • Recent research indicates sexual abuse to be
left with permanent neurological illnesses a common experience of children —.7 per
such as seizures, cerebral palsy, blindness, or 1,000 children.
deafness. • Many cases of child sexual abuse go unre-
• Infants are more vulnerable to head trauma ported.
because of a softer brain with immature • Reports by adults of sexual abuse as children
neurons, and unmyelinated nerves; also, the vary from 6% to 62% in women and 3% to
presence of more cerebrospinal fluid and pro- 30% in men.
portionately larger heads. • Girls are more likely to be abused than boys
• Types of abusive head injuries include in- and more likely to report abuse.
juries to the scalp, hair loss, bleeding under • Greatest risk is among children 8 to 10 years
the scalp, bleeding under the external perios- old. Also, those from socially isolated fami-
teum of the skull, skull fractures, epidural lies, those with an absent parent or unavail-
and subdural hematomas, dural tears, brain able parents, children growing up in homes
tissue injury, and spinal cord injuries. with a nonbiologically related father or fa-
ther figure.
• Availability of evidence in sexual assault de-
Retinal Hemorrhages and Other
pends on type of assault, age of child, orifices
Eye Injuries
assaulted, and post-assault activities of the
• Retinal hemorrhages are unusual in acciden- victim.
tal head injuries. • Immediate physical exam— within 72 hours
• The chief sign of abusive head traumas, es- of contact— is crucial.
pecially shaken baby syndrome, is retinal • Behavioral reactions in sexually abused chil-
hemorrhage. dren are similar to PTSD.
• Other eye injuries include traumatic reti- • Sexual “acting out” behavior is frequently
noschisis, retinal detachment, retinal folds seen in sexually abused children.
around the macula, bleeding into the optic • A coordinated comprehensive medical and
nerve sheath, and traumatic avulsion of the psychosocial history is essential; when pos-
nerve from the back of the eye. sible, a single interview with all profession-
• Retinal hemorrhage differential diagnosis is als — i.e., physician, law enforcement, social
extensive; retinal hemorrhages from causes worker, and prosecutor — present can mini-
other than trauma are rare. mize further trauma to the child.
• Children’s responses to interviews vary by
their level of cognitive development, emo-
Injuries to the Skin
tional development, behavioral development,
• Injuries to the skin are uncommon in chil- circumstances of the sexual abuse, and re-
dren 9 months old and younger. sponse of those individuals in the child’s im-
• Common skin trauma includes bruises, abra- mediate sphere of contact.
sions, and lacerations. • Physical examination documentation is im-
• Other skin lesions found on abused children portant; equally important is enlisting the
include bite marks, masque ecchymotique, child’s cooperation and participation; allow-
stun-gun injuries, tattoos or other symbolic ing the child to have control of certain ele-
lacerations, lesions caused by folk medicine ments of the exam, as well as advance knowl-
practices, and constriction devices. edge of procedures, can reduce fearfulness.
• Photographs and/or drawings of injury sites
are essential.
422 part v • child and adolescent treatment

• “Re-traumatizing” a child during genital Sexually Transmitted Diseases

exam should be avoided; numerous tech- in Children
niques can be utilized to reduce discomfort • Common nonvenereal pathogens not caused
and embarrassment to the child. by sexually transmitted diseases (STDs) in-
• Examining physician should be familiar with clude vaginitis, vulvitis, and anal infections;
the differences between abnormal and nor- pinworms and foreign bodies also account
mal anatomy, including nonsexual abuse for genital and anal discomfort.
trauma that can be easily mistaken for sex- • STDs in children may differ from those in
ual abuse trauma. adults; most often STDs in children indicate
• Sexual abuse trauma can be documented as sexual abuse.
acute, subacute, or chronic. • Common STDs include syphilis, gonorrhea,
• Photoculposcope usage has both advantages chlamydia, human papilloma virus (HPV),
and disadvantages; it is widely used to eval- herpes, and trichomonas vaginalis.
uate child sexual abuse; it allows for confir- • Guidelines for STD diagnostic tests are rec-
mation of findings and consistency of diag- ommended by the Center for Disease Control.
nosis; colposcopy results can be easily eval-
uated for second opinions, and effectively
presented in court; the major disadvantage is Glossary of Medical Terms in
cost. Physical Abuse
• Detailed, comprehensive documentation, in- • Medical terms frequently used in evaluating
cluding observations of the victims affect physical abuse are defined in easy-to-under-
and language skills, as well as remarks made stand language.
by the child, will go a long way in assisting
the medical professional in being an effective
witness. APSAC Guidelines on Descriptive
Terminology in Child Sexual
Abuse Medical Evaluations
Forensic Examination of the
Sexually Assaulted Child • Descriptive terminology used in medical
evaluations of sexually abused children
• Forensic examinations should be conducted
according to specific protocols.
• Protocols are provided by law enforcement References & Readings
agencies or particular medical facilities. Faller, K. C. (1996). Evaluating children suspected of
• Proper collection, handling, and storage of having been sexually abused. Thousand Oaks,
forensic specimens are crucial to court pre- CA: Sage.
sentation. Jenny, C. (1996). Medical evaluation of physically
• Medical records can be used as evidence in and sexually abused children. Thousand Oaks,
court; accuracy, legibility, and complete doc- CA: Sage.
Quinsey, V. L., & Lalumiere, L. L. (1996). Assess-
umentation will greatly assist the presenta-
ment of sexual offenders against children.
tion. Thousand Oaks, CA: Sage.
• Direct quotes from the child should be used
whenever possible.
• Photographs and/or drawings are also a key Related Topics
element in documentation. Chapter 87, “Interviewing Children When Sexual
Abuse Is Suspected”
Chapter 88, “Treatment of Child Sexual Abuse”
 INTERVIEWING CHILDREN WHEN
87 SEXUAL ABUSE IS SUSPECTED

Karen J. Saywitz & Joyce S. Dorado

Mandated by law to report suspicions of child the occurrence of abuse. At other times, inter-
abuse, practitioners face a dilemma. There is views are conducted to plan treatment, custody
rarely physical evidence or an adult witness to arrangements, home and school placements,
verify a child’s report. Hence, professionals visitation, or family reunification. Sometimes
rely heavily on children’s statements to deter- the goal is formulating a traditional description
mine protection, liability, and treatment. There of functioning and differential diagnosis. How-
is no legally sanctioned interview protocol free ever, the need for questioning can also arise in
of trial ramifications. And despite the rapid ex- the midst of therapy with an unanticipated
pansion of scientific research, researchers have need to assess imminent risk of danger. Before
not produced a gold standard protocol that can the interview begins, it behooves the inter-
be held out as the criterion by which all chil- viewer to clarify the objectives for all parties
dren should be interviewed. In fact, there is and agencies involved. The objectives dictate
little expectation that a single protocol can many of the methodological choices the inter-
emerge as useful for all ages, clinical condi- viewer faces. Procedures that are legitimate for
tions, levels of severity, family functioning, and one purpose can have unintended ramifications
agency needs, given the developmental and in- when used for another.
dividual differences among children, the varia-
tions among circumstances from case to case,
What Is the Interviewer’s
and the varied responsibilities of the agencies
Proper Role?
involved. There is, however, a good deal of con-
sensus on many of the general guidelines for Interviewers must understand the limitations
interviewing children. The discussion and out- of the interview process as a means of proving
line that follow include interviewing sugges- that abuse occurred. Moreover, interviewers
tions that overlap substantially (not com- must be knowledgeable of relevant legal and
pletely) with both clinical consensus and a ethical issues (see Myers, 1998). Interviewers
large body of laboratory findings on child de- must avoid dual relationships. When an inter-
velopment. These suggestions will no doubt re- viewer is both the treating therapist and an
quire revision as the knowledge base grows and evaluator who provides information to the
public policies evolve. court, competing demands often can under-
mine confidentiality and therapeutic alliance,
creating ethical dilemmas. Many professional
QUESTIONS AND ANSWERS organizations recommend that in a given case,
professionals take one role and refer out for the
What Are the Objectives of
other. Interviewers must clearly define their
the Interview?
unique role for themselves, the child, the fam-
In the forensic context, interviewers’ goals ily, and the court. They should carefully con-
vary greatly. Interviews often are conducted to sider invitations to expand and alter their role
determine if the findings are consistent with midstream.

423
424 part v • child and adolescent treatment

Interviewers should be careful to employ Are Children’s Reports Reliable?

methods sufficient to provide the necessary There appears to be interdisciplinary consensus
substantiation for their conclusions. Psycholog- that children are “able to provide reliable and
ical tests can provide useful information but do accurate accounts of events they have wit-
not provide proof of abuse or of a false allega- nessed or experienced. Furthermore, despite
tion. Abuse is an event, not a diagnosis. A reli- frequent claims that children are uniquely sus-
able and valid test to verify its occurrence does ceptible to external influence, it is clear that
not exist. when children are encouraged to describe their
experiences without manipulation by inter-
viewers, their accounts can be extremely infor-
What Do Behavioral Indicators Mean? mative and accurate. Such interviewing is diffi-
cult, however, and is best conducted by well
Often children are referred for an interview trained and experienced interviewers” (Lamb,
because of behavioral changes, for example, 1994, p. 1024).
nightmares or imitations of adult sexual activ- The most reliable information is obtained in
ity. Although many reactions to trauma can response to open-ended questions that elicit
accompany the onset of maltreatment (e.g., free narratives. School-age children can pro-
nightmares, personality change, fearfulness, vide such accounts, and follow-up questions
anxiety), these occur more frequently in a pop- can be used to elaborate, clarify, and justify
ulation of nonabused children who are dis- information provided by the child. However,
tressed for other reasons. No single constella- children under 5 years of age depend on con-
tion of behaviors or symptoms is pathogno- text cues and adult questions to help trigger re-
monic to child abuse, and many genuinely call. They rarely provide more information
abused children, even those with sexually than is asked for. Further information is forth-
transmitted diseases, may show no measur- coming in response to specific questions that
able behavioral problems. Behavior changes help focus children’s attention on the topic at
indicate that further evaluation and investiga- hand, trigger recall of detail, organize retrieval
tion are necessary (Lamb, 1994). Their occur- efforts, and overcome reluctance and anxiety.
rence cannot be used to determine the existence Unfortunately, if such questions are mislead-
of maltreatment, nor can their absence be used ing, they have the potential to distort young
to conclude that a child was not maltreated. children’s reports. When specific questions are
The one indicator that is unique to a history asked, they should be formulated in as nonsug-
of sexual abuse is age-inconsistent sexual be- gestive a manner as possible.
havior and knowledge. Studies suggest that
sexually abused children demonstrate signifi-
cantly higher rates of sexualized behavior than What Do Children Remember?
normative and clinical (nonabused) samples For both adults and children, central actions
(Friedrich et al., 2001). Still, nonabused chil- and events can be recalled for long periods of
dren do engage in sexualized behaviors, albeit time, but peripheral details may be forgotten
at a lower rate. The available research on chil- over long delays. Children may find it more
dren’s knowledge of sexuality suggests that difficult to remember in detail after long delays
preschoolers are rarely aware of adult activi- all that they were able to remember initially.
ties like genital, oral, and anal penetration. However, without coaching or suggestive ques-
However, there is no definitive way to know tions, their errors tend to be a matter of con-
when a child’s age-inconsistent knowledge is a fusing details of similar experiences, especially
function of victimization or of exposure to when the event to be recalled is not very dis-
pornography, crowded living conditions, and tinctive or personally meaningful. Infants and
so forth. toddlers have surprising memories for person-
 87 • interviewing children when sexual abuse is suspected 425

ally experienced events over time; however, 2002). However, when misleading questions
children who are nonverbal at the time of the are used in multiple interviews, they have the
event are unlikely to ever be able to give a nar- potential to distort young children’s state-
rative account of events that occurred prior to ments. Reducing the number of interviews is
the acquisition of language (Fivush, 2002). often advised. Yet disclosure of genuine abuse
Children often perceive different aspects of an is sometimes a process that occurs over time
event to be salient and memorable. They can re- rather than a singular event. When several in-
member details that go unnoticed by adults and terviews are necessary, returning to the same
fail to report information that adults find cru- interviewer is optimal. It is stressful for chil-
cial. Even genuine accounts of abuse from dren to start over repeatedly with unfamiliar
young children will lack detail. This is espe- adults.
cially true when acts of abuse are repeated over
long periods of time. Accurate recounts may
Do Children Readily Disclose
not include unique details placing individual
Abuse to Unfamiliar Interviewers?
incidents in spatiotemporal context. Lack of de-
tail is to be expected and cannot be used as an Many children do report abuse when ques-
indicator of reliability. tioned carefully. Others are reluctant to discuss
Younger children tend to report the actions traumatic events with strangers. In one study,
that occurred. Older children begin to include over half of the children with sexually trans-
descriptions of participants, timing, location, mitted diseases failed to disclose abuse in a
conversations, and affect states. Eventually, clinical interview. Children typically cope with
children develop the ability to ask themselves anxiety-provoking topics via avoidance. Avoid-
the questions necessary to spontaneously in- ing reminders of traumatic events is one hall-
clude the who, when, where, and how of an mark of posttraumatic stress disorder. The in-
event. Older children are likely to notice, make terviewer often has to contend with emotional
sense of, and store more information of rele- reactions, including anxiety, depression, guilt,
vance. They have a greater vocabulary to de- shame, ambivalence, as well as fears of the un-
scribe a memory verbally. Researchers have known, separation, retaliation, and humilia-
begun to develop innovative techniques to help tion. Taking the time to establish rapport and
younger children report additional information providing a supportive, yet unbiased, atmo-
not otherwise produced spontaneously (e.g., sphere may help offset the effects of these emo-
Dorado & Saywitz, 2001). With such tech- tional factors.
niques, more complete and detailed narratives
allow follow-up questions to focus on expand-
Should Anatomically Detailed
ing information provided by children rather
Dolls Be Used?
than adult supposition, lowering the need for
leading questions. Over the last decade, the use of anatomically de-
tailed dolls has declined considerably. There is
little doubt that a child’s manipulation of dolls is
When Should Interviews
not a test of whether abuse occurred (Koocher
Be Conducted?
et al., 1995). Still, sometimes dolls are used in a
In the laboratory, the most detailed and com- limited fashion, as demonstration aids after
plete accounts are found when memory is children make verbal statements suggesting
fresh. Interviews should be conducted as soon abuse or as a body map to facilitate inquiry
as possible. In the field, however, practical, mo- about injuries or anal/genital touch. However,
tivational, and emotional considerations affect studies of 2- to 3-year olds suggest dolls are
the timing of interviews. Repeated interview- contraindicated for this age range. Such young
ing in and of itself is not necessarily detrimen- children have difficulty using dolls to represent
tal to the quality of children’s recall (Fivush, themselves in demonstrations.
426 part v • child and adolescent treatment

Research with older children is confusing distorted. Preschoolers assume adults possess a
because studies rarely distinguish between the superior knowledge base, and they are particu-
impact of dolls alone and the impact of sugges- larly deferential to adult’s beliefs. Adults may
tive techniques used in conjunction with dolls. convey biased views through the questions
The combination of dolls, toy props, and highly they ask. Additionally, preschoolers may con-
suggestive questions can lead to distortion and fuse memories of the event with memories of
error in young children’s recall (Ceci, Cross- false information embedded in adult question-
man, Scullin, Gilstrap, & Huffman, 2002). ing or coaching. This emphasizes the danger of
There is some evidence that in the absence of telling, rather than asking, young children
suggestive, leading, highly specific questioning what occurred. Researchers have found several
the recall of private parts touching by children techniques increase error, including assisting
over 5 years of age can be enhanced by anatom- children to visualize details or pretend after
ical models in comparison to unaided free recall they have stated they cannot remember, pre-
or purely verbal interviews. However, there is senting false physical evidence, and selective
insufficient research to know whether anatom- reinforcement (Ceci et al., 2002).
ical drawings of the fronts and backs of bodies Although recent studies have shown discon-
would be equally beneficial and many issues certing levels of suggestibility in children,
related to forensic practice remain unresolved these effects are primarily found in studies of
(Everson & Boat, 2002). The introduction of very young children, under 5 years of age.
anatomically detailed dolls into a forensic in- These effects are most prevalent when using
terview and the interpretation of children’s sex- presumptive questions rather than mildly lead-
ualized play with such dolls should be under- ing ones. Some of the coercive techniques stud-
taken by those well versed in the literature. ied may not be typical of actual interviews in
the field. Nevertheless, children’s suggestibility
should be of central concern for the inter-
What Factors Contribute to
viewer. Interviewers must minimize conditions
Children’s Suggestibility?
that increase suggestibility and maximize con-
Suggestibility is multiply determined. There ditions that promote resistance, as discussed
is little evidence that suggestibility is a per- below.
sonality trait. Similarly, it is not merely a
function of age, although both developmental
Can We Detect False Allegations?
and individual differences play a role. Very
young children (3 – 4 years of age) are the Thus far, researchers have not produced reli-
most vulnerable to the effects of suggestive able and valid tests to discriminate true from
techniques. By 6 – 7 years of age, children’s re- false cases of abuse. Although there is some on-
sistance to suggestion increases dramatically. going research on checklists of credibility crite-
By 10 –11 years of age, there is another shift ria, many criteria thought to be indicative of
toward adult levels of suggestibility. Still, false cases can also appear in cases of genuine
some 3-year-olds remain resistant in response abuse. For example, consistency is often relied
to the most relentless interviewers, while some upon as an indicator of reliability. However, in-
older children may acquiesce readily under cer- consistency across interviews is frequent, if not
tain conditions. expected, among young children questioned by
Several factors are responsible for children’s different adults, with different questions, in dif-
vulnerability to suggestive interviewing tech- ferent settings, even when memories are largely
niques (Saywitz & Lyon, 2002). Young chil- accurate. In one study, children telling the truth
dren store more information in memory than about being touched were more inconsistent
is reported spontaneously or in response to than children coached to lie about being touched.
open-ended questions. If follow-up questions
are misleading and suggestive, reports can be
 87 • interviewing children when sexual abuse is suspected 427

INTERVIEW OUTLINE • Interviewers may want to consult the grow-

ing literature on pre-interview instructions
Preparation and Gathering of
that can be given to children to enhance re-
Background Information
call and minimize distortion (Saywitz &
• Before questioning, coordinate with other Lyon, 2002).
agencies to reduce multiple interviews. Ver-
ifying information by contacting collaterals
is often necessary. Reports may be reviewed Guidelines for Talking to Children
from schools, law enforcement agencies, pe- • Interviewers must talk to children in lan-
diatric records, child protective services, and guage they can understand. The vocabulary
prior court hearings. and grammar of the question must match
the child’s stage of language development.
Documentation Simplify language by using shorter sen-
tences and words with fewer syllables.
• Questions and responses should be docu- • Interviewers must avoid asking questions
mented verbatim whenever possible. Never that require skills children have not yet
paraphrase children’s statements; use their mastered. Such questions are fertile grounds
words. for misinterpretation. A child who has not
• Documentation of the following is optimal: yet learned to count cannot be asked how
description of abusive acts and alleged of- many times something happened. If he or
fender, age of child at each incident, first and she is, the answer must be weighed accord-
most recent incidents, location(s), entice- ingly within a developmental framework.
ments, threats, elements of secrecy, and evi- Potentially problematic topics include con-
dence of motive to fabricate. Also, document ventional systems of measurement (e.g.,
indicia of reliability associated with the child’s weight in pounds, height in feet, timing in
statement and behavior (e.g., age-appropriate minutes/hours), ethnicity labels, kinship
use of terms, spontaneity, hurried speech, be- terms, and relational terms (e.g., first, al-
lief that disclosure leads to punishment). ways, never, before, ever).
• To conduct a forensically defensible inter- • Interviewers must do everything in their
view, it is important to document precautions power to minimize the potential for distor-
taken to avoid contamination, consultation tion of children’s statements. Interviewers
with colleagues, rationales for special tech- should avoid suggesting answers and should
niques, and alternate hypotheses pursued. maintain an objective, neutral stance in re-
gard to the veracity of the allegations. They
Setting the Context should explore all possible alternative expla-
nations.
• Interview children alone to avoid undue in-
fluence on children’s statements, unless
there is good reason indicating support per- Getting Started
sons are necessary. Support persons if pres-
• Take time to develop rapport in order to pro-
ent should not have an obvious stake in the
mote motivation, cooperation, openness, and
outcome of the case and should sit behind the
honesty with unfamiliar adults in unfamil-
child and refrain from advising the child.
iar settings, especially when secrets, threats,
• Before questioning children about the al-
embarrassments, and loyalties are involved.
leged abuse, interviewers can discuss the
Convey that it is safe for children to tell
limits on confidentiality. Also, children need
what really happened without fear of adult
an outline of the forthcoming interview and
rejection or detachment.
its unique task demands, as well as education
• Make it clear that the interview is a joint ef-
about the flow of information through the
fort in which children are to tell as much as
investigative and judicial process.
428 part v • child and adolescent treatment

possible in their own words. Model an expec- Introducing the Topic of Abuse
tation for independent verbalization (e.g., • One method involves an inventory of body
ask children to explain something unrelated parts from head to toe, asking for each part’s
to the event in question; refrain from filling name, function, and history of being touched
in silence too quickly or asking detailed or hurt by others in ways the child did not
questions.). Model the format you plan to like.
use later (Saywitz & Lyon, 2002). • Ask children to list important people and
• Explain the interviewer’s purpose (e.g., “to events, and to describe household routines,
be sure children stay safe and healthy, to sleeping arrangements, and rules for privacy.
help children with problems, or to help a • Use roundabout, indirect ways of eliciting
judge make the best plan for the whole fam- relevant information without leading ques-
ily”). tions. Ask children who brought them to the
interview and why (e.g., “My social worker
Questioning Children about because I can’t be with my dad.” “Why?”
Child Abuse “Because of the way he touched me.” Oh,
what happened?”). Ask children to describe
• Provide children with an opportunity for an recent changes at home (e.g., “My uncle had
unbiased spontaneous statement (e.g, “Is to leave after my mom got mad at him.”
there anything you want to tell me? . . . “What was she mad about.” “What hap-
think I should know? Why did you come pened to me.” “What happened?”).
here today?”). Start with open-ended ques- • Inquire about most and least favorite experi-
tions (What happened?). ences, reasons the child gets upset, things
• If open-ended questions are successful, in- that make him mad, concerns about privacy
vite children to elaborate on the information and safety, and how she copes with fear.
provided in their own words (“You said Nora • Decisions about raising specific information
was there, what did she do? What happened not yet mentioned by the child are made on a
next?”). case by case basis. Some questions may be
• Follow-up with “Wh” questions (Who? justified when there is corroborating evi-
What? When? Where? How?). dence to suggest a child may be in danger of
• Reserve specific questions until open-ended further abuse and decisions of protection are
ones fail. When they do, start by focusing paramount. The same questions may be con-
children on general topics of relevance (e.g., troversial in cases where alleged perpetrators
“Tell me about school, . . . church . . . have no access to children and there is little
best/worst parts.” evidence other than children’s statements.
• Query information from the child first and
from other sources last.
• For more information there are a number of Precautions to Minimize
interview formats derived from the experi- Suggestion
mental literature to consult, including the • Avoid creating an accusatory atmosphere by
NICHD protocol (Sternberg, Lamb, Esplin, referring to suspects in derogatory or ac-
Orbach, & Hershkowitz, 2002), cognitive cusatory terms (e.g., “Tell me the bad things
interview (Fisher, Brennan, & McCauley, that the bad man did to you.” “He wasn’t
2002), and narrative elaboration procedure supposed to do that, that was bad”).
(Dorado & Saywitz, 2001; Saywitz & Sny- • Avoid suggesting the interviewer is an infal-
der, 1996), as well as professional guidelines lible authority figure with “inside” knowl-
(e.g., American Academy of Child and Ado- edge of what happened gained from other
lescent Psychiatry, 1997; American Profes- sources (e.g., “Well, that’s not what your
sional Society on the Abuse of Children, mom said”). Suggest the child is the expert
1997). on the event in question, not the adults.
 87 • interviewing children when sexual abuse is suspected 429

• Interviewers can be supportive of children’s Ceci, S. J., Crossman, A. M., Scullin, M. H.,
efforts (e.g., “Thanks for listening care- Gilstrap, L., & Huffman, M. A. (2002). Chil-
fully”) but should avoid reinforcing specific dren’s suggestibility research: Implications for
content that might shape children’s responses. the courtroom and the forensic interview. In
Westcott, G. M. Davies, & R. H. Bull (Eds.),
Don’t allow preconceived notions to be rein-
Children’s testimony: A handbook of psycho-
forced while other leads are ignored or de-
logical research and forensic practice (pp. 117 –
valued. 130). West Sussex, England: Wiley.
• Respect children’s denials (Camparo, Wag- Dorado, J., & Saywitz, K. (2001). Interviewing
ner, & Saywitz, 2001). Don’t press children preschoolers from low and middle income com-
to imagine, visualize, or pretend about what munities: A test of the Narrative Elaboration
might have happened (Ceci et al., 2002). recall improvement technique. Journal of Clin-
• Avoid suggestive questions that increase ical Child Psychology, 30, 566 – 578.
children’s errors: Statements followed by re- Everson, M. D., & Boat, B. W. (2002). The utility of
quests for affirmation (“He hurt you, didn’t anatomical dolls and drawings in child forensic
he?”), insertions of negatives (e.g., “Didn’t interviews. In M. L. Eisen, J. A. Quas, & G. S.
Goodman (Eds.), Memory and suggestibility in
he hurt you?”), multiple choice, and suppo-
the forensic interview (pp. 383 – 408). Mah-
sitional questions. In the latter, information
wah, NJ: Erlbaum.
is embedded into the question without giv- Fisher, R. P., Brennan, K. H., & McCauley, M. R.
ing the child the opportunity to affirm or (2002). The cognitive interview method to en-
deny the presumption (e.g., “When John hance eyewitness recall. In M. L. Eisen, J. A.
hurt you, was your mother home? Did he hit Quas, & G. S. Goodman (Eds.), Memory and
you with his hand or a club?”). suggestibility in the forensic interview (pp.
• Turn yes-no questions into “Wh” questions 265 –286). Mahwah, NJ: Erlbaum.
when possible (e.g., “Did he hit you?” be- Fivush, R. (2002). The development of autobio-
comes “What did he do with his hands?”). graphical memory. In G. M. Westcott, F. Davies
& R. H. Bull (Eds.), Children’s testimony: A
handbook of psychological research and foren-
Closure sic practice (pp. 55 – 68). West Sussex, England:
John Wiley & Sons, Ltd.
• Children may need time to regain compo- Friedrich, W. N., Dittner, C. A., Action, R., Berliner,
sure and ask their own questions. They can L., Butler, J., Damon, L., et al. (2001). Child
be praised for their effort and bravery but sexual behavior inventory: Normative, psychi-
not for the content of their statements. Chil- atric and sexual abuse comparisons. Child Mal-
dren need to know what will happen next to treatment, 6, 37 – 49.
dispel misperceptions and reduce fears. Koocher, G. P., Goodman, G. S., White, C. S.,
Friedrich, W. N., Sivan, A. B., & Reynolds, C.
References & Readings R. (1995). Psychological science and the use of
anatomically detailed dolls in child sexual
American Academy of Child and Adolescent Psychi- abuse assessments. Psychological Bulletin, 118,
atry. Practice parameters for the forensic eval- 199 –122.
uation of children and adolescents who may Lamb, M. E. (1994). The investigation of child sex-
have been physically or sexually abused. ual abuse: An interdisciplinary consensus
(1997). Washington, DC: Author. statement. Child Abuse and Neglect, 18, 1021–
American Professional Society on the Abuse of 1028.
Children. Psychosocial evaluation of suspected Myers, J. E. B. (1998). Legal issues in child abuse
sexual abuse in children. (2nd ed.). (1997). and neglect (2nd ed.). Newbury Park, CA:
Chicago, IL: Author. Sage.
Camparo, L. B., Wagner, J. T., & Saywitz, K. J. Saywitz, K. J., & Lyon, T. D. (2002). Coming to grips
(2001). Interviewing children about real and with children’s suggestibility. In M. L. Eisen,
fictitious events: Revisiting the narrative elab- J. A. Quas, & G. S. Goodman (Eds.), Memory
oration procedure. Law and Human Behavior, and suggestibility in the forensic interview,
25(1), 63 –80. (pp. 85 –114). Mahwah, NJ: Erlbaum.
430 part v • child and adolescent treatment

Sternberg, K. J., Lamb, M. E., Esplin, P. W., Orbach, children. Journal of Consulting and Clinical
Y., & Hershkowitz, I. (2002). Using a struc- Psychology, 64, 1347 –1357.
tured interview protocol to improve the quality
of investigative interviews. In M. L. Eisen, J. A.
Quas, & G. S. Goodman (Eds.), Memory and
Related Topics
suggestibility in the forensic interview (pp.
409 – 436). Mahwah, NJ: Erlbaum. Chapter 12, “Interviewing Parents”
Saywitz, K., & Snyder, L. (1996). Narrative elabora- Chapter 88, “Treatment of Child Sexual Abuse”
tion: Test of a new procedure for interviewing

TREATMENT OF CHILD
88 SEXUAL ABUSE

Kathryn Kuehnle

Sexually abused children are a heterogeneous and serious emotional and behavioral difficul-
group. Child sexual abuse is not a discrete clin- ties (Kilpatrick et al., 2003). Sexual behavior
ical syndrome; rather, it is a life event or a se- problems are found in approximately one third
ries of life events. There is no behavior, symp- of sexually abused children (Friedrich, 1993).
tom, or cluster of symptoms that is characteris- Symptoms of posttraumatic stress disorder,
tic of the majority of sexually abused children, depression, fears, affect dysregulation (e.g.,
nor does a child sexual-abuse syndrome exist. poorly controlled states of arousal), poor self-
Sexually abused children exhibit a wide range esteem, cognitive distortions (e.g., self-blame),
of symptoms and behaviors, as well as an ab- social skills deficits, disruptive behavior, ag-
sence of symptoms in some cases (see Kendall- gression, sexualized behaviors, and sexual anx-
Tackett, Williams, & Finkelhor, 1993). Profes- iety are among the problems more frequently
sionals cannot determine whether a child has identified in sexually abused compared to non-
or has not been sexually abused based on the abused children (Beitchman, Zucker, Hood, da
presence or absence of a particular behavior or Costa, & Akman, 1992). However, these symp-
pattern of symptoms and, if a child is identified toms are not specific to sexually abused chil-
as having experienced sexual abuse, treatment dren and are also observed in children experi-
planning must focus on addressing the child’s encing other forms of maltreatment or trau-
unique and varied needs. matic events. Children who experience multiple
Research is robust in showing that child forms of child maltreatment, such as sexual
sexual abuse is a significant risk factor in chil- abuse and physical abuse and/or domestic vio-
dren’s development of mental health disorders lence, are at the greatest risk for long-term
 88 • treatment of child sexual abuse 431

psychopathology (Shipman, Rossman, & West, (Friedrich, 1993). Mediating factors found to
1999; see Family Research Laboratory and Na- be important in the child victim’s psychological
tional Clearinghouse on Child Abuse and Ne- recovery involve the child’s cognitive process-
glect, in References). ing of the event and the family’s response to
Longitudinal studies show that some symp- the abuse. Levels of distress in sexually abused
toms and behaviors displayed by sexually children, psychological symptomatology, and
abused children can diminish without therapy. speed of recovery are related to parental sup-
The majority of children show improvement in port and level of parent distress (Cohen &
adjustment during the 12- to 24-month period Mannarino, 1998a). Differences in how child
following exposure of their abuse, particularly victims make sense of and think about their
with respect to behaviors related to posttrau- abuse experience (e.g., attributions, optimism,
matic stress symptoms and fearfulness. Find- and positive reframing) also mediate the conse-
ings regarding spontaneous improvement of quences of the sexual-abuse experience. Pa-
other symptoms and behaviors such as with- rental response to the abuse, of course, can in-
drawal, acting out, and depression are variable fluence the child victim’s cognitions. Family
(Gomes-Swartz, Horowitz, Cardarelli, & Sau- supportiveness may be a possible alternative
zier, 1990). explanation for some cases in which there is a
Research indicates that one quarter to one positive treatment effect for a sexually abused
third of child sexual abuse victims may show child.
no signs or symptoms that are related to the
abuse (Kendall-Tackett et al., 1993). In compar-
ison to symptomatic sexually abused children, FORMING THE TREATMENT PLAN:
asymptomatic children generally have more SUBSTANTIVE ISSUES
limited histories of abuse; the abuse to which
they were subjected is less likely to have in- The likelihood of effective outcomes is aided
volved force, violence, or penetration; they are when interventions are matched to specific
more likely to have been abused by someone problems through appropriate assessment. In
who is not a father figure; and they typically developing the treatment plan, the first step in
live in more supportive and higher functioning the assessment process is to determine the level
families (Browne & Finkelhor, 1986). Although of risk for harm in the child’s current environ-
empirically derived findings are limited, some ment and to create a safety plan for the child, if
researchers propose the existence of subgroups necessary. The second step requires an “abuse
of asymptomatic children to include those chil- informed” assessment. This assessment re-
dren who are resilient and dealing successfully quires the examiner to identify the direct ef-
with their abuse, those who suppress conflicts fects of the abuse, as well as any pre-existing or
related to the abuse but remain distressed at co-occurring conditions and difficulties. The
another psychological level, and those who third step is to determine family system char-
have a delayed onset of disturbance (Gomes- acteristics (Saunders & Meinig, 2000).
Schwartz et al., 1990). Treatment goals for sexually abused chil-
dren must specify the therapeutic interventions
and what aspects of these interventions (e.g.,
MEDIATING FACTORS IN content of treatment) are specifically targeted
PSYCHOLOGICAL RECOVERY to behavioral symptoms and/or pathological
cognitions. While the content of treatment in-
Sexual-abuse events interact with a complex terventions should ideally be informed by sci-
matrix of factors including the abuse character- ence, research on this aspect of treatment is
istics, family dynamics, co-occurring forms of limited. For example, it is currently unknown
maltreatment, caretaker response to the abuse if expression of abuse memories is beneficial
allegation, involvement in the legal system, for all children, if repression of abuse memo-
and the premorbid personality of the victim ries is beneficial for some children, and whether
432 part v • child and adolescent treatment

the pursuit of traumatic memories prior to the tween group, individual, or play therapies
development of coping strategies and reinforce- (Finkelhor & Berliner, 1995). However, con-
ment of internal resources may be iatrogenic. joint or combined (i.e., separate parent and sep-
Prior to designing and implementing inter- arate child) treatment of the nonoffending par-
ventions with sexually abused children, the ent has been identified as a critical element in
mental health professional must also consider the treatment of sexually abused children (De-
the larger environmental context regarding blinger, Lippman, & Steer, 1996), which is
culture, religious, and racial/ethnic groups to likely since the nonoffending parent’s emo-
which the child and his/her family belong tional support has been found to be associated
(Cohen, Deblinger, Mannarino, & de Arellano, with the child’s post-abuse functioning. For ex-
2001). Values and beliefs about issues such as ample, parents may experience adverse emo-
sexuality, nudity, personal privacy, family roles, tional responses to the sexual abuse of their
and help-seeking are all influenced by a fam- child that may impede their ability to provide
ily’s cultural, religious, and racial/ethnic con- support. Conjoint treatment may decrease pre-
nections, and must be considered in treatment mature termination of treatment and facilitate
planning and intervention. generalization of the child’s treatment gains.
Parent treatment only and parent/child treat-
ment combined are shown to be the most effec-
TREATMENT OF SPECIFIC tive in decreasing externalizing behaviors,
SYMPTOMS while child treatment only and parent/child
treatment combined are the most effective in
Several important conclusions are derived from decreasing internalizing behaviors (Deblinger,
research regarding treatment of specific symp- Steer, & Lippman, 1999).
toms and behavior problems, including that:
(1) children show differential responses to
treatment with some showing greater treat- TREATMENT APPROACHES
ment effects than others; (2) the variables that
distinguish sexually abused children who make There is a growing body of research testing the
significant improvement in treatment from efficacy of mental health interventions with
children who make no improvement have not sexually abused children (Cohen, Berliner, &
been identified; (3) sexual problems and exter- March, 2000; Cohen & Mannarino, 1998b; De-
nalizing behaviors (e.g., aggression, acting out) blinger et al., 1999). However, much of the so-
are less likely to improve with treatment com- cial science literature focuses on treatments,
pared to internalizing behaviors (e.g., depres- developed by individual clinicians, that have
sion, fearfulness); and (4) preschool children’s not been empirically tested. In order to identify
externalizing symptoms may show greater for practitioners effective and appropriate
positive treatment responses when the treat- treatments, a criterion-based classification sys-
ment intervention includes helping parents to tem was designed to categorize treatment ap-
manage the acting out behaviors. proaches. Treatments were categorized as
child, family, child-parent, and parent focused,
and they were rated as follows: 1 = well-
MODALITIES OF TREATMENT supported (i.e., research base) efficacious treat-
ment; 2 = supported and probably efficacious;
Preliminary findings regarding effectiveness of 3 = supported and acceptable treatment; 4 =
interventions with sexually abused children promising and acceptable treatment; 5 = innov-
are, in many ways, consistent with the findings ative or novel treatment; 6 = concerning treat-
from the general literature on child psycho- ment (see Saunders, Berliner, & Hanson, 2003;
therapy indicating an absence of reliable, sig- National Crime Victims Research and Treat-
nificant differences for treatment outcomes be- ment Center).
 88 • treatment of child sexual abuse 433

CHILD-FOCUSED INTERVENTIONS Abuse-specific therapy or elements of this

therapy may be inappropriate with specific
The core child-focused treatment approaches subgroups of victims. For example, some ele-
include (1) cognitive behavioral therapy (CBT); ments of abuse-specific therapy (e.g., encour-
(2) eye movement desensitization and repro- agement of expression of abuse-related feel-
cessing (EMDR); (3) play therapy; (4) pharma- ings) are inappropriate when sexual abuse re-
cotherapy (medication); and (5) psychody- mains a question and cannot be substantiated.
namic psychotherapy. The strongest empirical Additionally, elements of abuse-specific ther-
support exists for behavioral and cognitive- apy that include exposure to other victims’
behavioral interventions (Saunders et al., abuse histories may be inappropriate for pre-
2003). Using the criterion-based categorization school children and children who are mentally
referenced above, the majority of child-focused retarded, diagnosed with pervasive develop-
treatment approaches reviewed were classified mental disorder, or have significant mental ill-
with a level three rating. Trauma-Focused Cog- ness in which perceptions are distorted and
nitive Behavioral Therapy (Deblinger et al., thinking processes are disturbed. Finally, abuse-
1999) was the only approach assigned a level specific therapy, because it is primarily sup-
one rating. portive and educational in nature, may be less
Many of the treatment studies using behav- effective with certain behavioral problems, in-
ioral and cognitive-behavioral interventions cluding sexual behavior problems and exter-
with sexually abused children have relied on nalized problem behaviors that require more
skills training, particularly coping skills, prob- targeted and intensive interventions.
lem-solving skills, and communication skills.
Sexually inappropriate behaviors, regardless of
the reasons for these behaviors, more readily TREATMENT APPROACHES:
respond to behavioral interventions than to FAMILY, PARENT-CHILD, AND
play therapy or psychodynamic treatment. A PARENT-FOCUSED INTERVENTIONS
clear relationship between treatment duration
and effectiveness has not been found with any Similar to the literature on child-focused inter-
of the various approaches. ventions, the clinical literature on family,
A commonly employed technique for treat- parent-child, and parent-focused interventions
ing sexually abused children is “abuse-focused” is extensive, primarily developed by individual
therapy, which uses supportive and psychoedu- clinicians, and lacking an adequate research
cational interventions. Abuse-focused therapy base. Using the criterion-based categorization,
is not associated with any particular theoretical the majority of family and parent-child focused
perspective, nor is it associated with any single treatment approaches reviewed were given a
therapeutic approach. It borrows from a wide level three or four classification (see National
variety of behavioral, cognitive, systemic, and Crime Victims Research and Treatment Cen-
reconstructive or dynamic therapies, and it is ter; Saunders et al., 2003). None of the ap-
most effective with victims who will benefit proaches received a level 1 or 2 rating and one
from supportive and educational interventions, approach, Corrective Attachment Therapy (the
including: (1) the processing of their sexual Evergreen Model), was designated a level 6
abuse memories; (2) exposure to other victims classification. Corrective Attachment Therapy
(e.g., group therapy) to decrease feelings of lacks treatment outcome research, does not
stigmatization and isolation; (3) encourage- provide an acceptable theoretical basis for the
ment of expression of abuse-related feelings treatment, and constitutes a risk of harm to
(e.g., confusion, anger); (4) clarification of those receiving it (American Professional Soci-
pathological beliefs that might lead to negative ety on the Abuse of Children, 1996).
self attributions; and (5) development of skills
to prevent future abuse.
434 part v • child and adolescent treatment

ETHICS AND GUIDELINES sic evaluation of children and adolescents who

may have been physically or sexually abused.
Because of the potential conflict of interest be- Journal of American Academy of Child and
tween the roles of therapist and forensic evalu- Adolescent Psychiatry, 36, 423 – 444. http://
ator (see Greenberg & Shuman, 1997, for a re- www.aacap.org/publications/index.htm
view of this issue more generally), a number of American Professional Society on the Abuse of
Children. (1996). Guidelines for psychosocial
professional organizations have directed that
evaluation of suspected sexual abuse in young
professionals not provide both forensic evalua-
children (2nd ed.). Chicago, IL: American Pro-
tion and therapeutic services engaging the same fessional Society on the Abuse of Children.
case or with the same child. The blurring of http://www.apsac.org/
roles can be a significant problem when work- American Psychological Association. (1998). Guide-
ing with sexually abused children. In order to lines for psychological evaluations in child
avoid role confusion, the therapist should for- protection matters. Washington, DC: American
mally delineate the parameters of his or her Psychological Association. http://www.apa.org/
role to the child’s parent(s). The therapist should divisions/div37/child_maltreatment/child.html
make clear to the parent(s) that the therapist’s American Psychological Association. (2002). Ethics
role is to provide treatment to the sexually code. Retrieved 2004 from http://www.apa.org/
ethics/code2002.html
abused child and is not to provide an evaluation
American Psychological Association. (2003). Profes-
to determine the veracity of a sexual abuse alle-
sional, ethical, and legal issues concerning in-
gation (American Psychological Association, terpersonal violence, maltreatment, and related
2002, 2003). A number of organizations have trauma. Retrieved 2004 from http://www.apa.
promulgated guidelines relevant to the treat- org/pi/pii/professional.html
ment of sexually abused children and, specifi- Beitchman, J. H., Zucker, K. J., Hood, J. E., da Costa,
cally, to role differentiation (American Acad- G. A., & Akman, D. (1992). A review of long-
emy of Child and Adolescent Psychiatry, 1997; term effects of child sexual abuse. Child Abuse
American Professional Society on the Abuse & Neglect, 16, 101–118.
of Children, 1996; American Psychological As- Browne, A., & Finkelhor, D. (1986). The impact of
sociation, 1998; National Center for Post- sexual abuse: A review of the research. Psycho-
logical Bulletin, 99, 66 – 77.
Traumatic Stress Disorder).
Cohen, J. A., Berliner, L., & March, J. S. (2000).
Treatment of children and adolescents. In E. B.
Foa, T. M. Keane, & M. J. Friedman (Eds.), Ef-
SUMMARY fective treatments for PTSD: Practice guide-
lines from the International Society for Trau-
The treatment outcome literature seems to best matic Stress Studies (pp. 106 –138). New York:
support the efficiency of behavioral and cogni- Guilford Press.
tive-behavioral interventions, but because of Cohen, J. A., Deblinger, E., Mannarino, A. P., & de
the paucity of treatment outcome research, the Arellano, M. A. (2001). The importance of cul-
effectiveness of other treatment models cannot ture in treating abused and neglected children:
be ruled out. Treatment providers should fa- An empirical review. Child Maltreatment, 6,
148 –157.
miliarize themselves with the seminal docu-
Cohen, J. A., & Mannarino, A. P. (1998a). Factors
ment Child Physical and Sexual Abuse: Guide-
that mediate the treatment outcome of sexually
lines for Treatment, which has been collabora- abused preschool children: 6 and 12 month fol-
tively prepared by the National Crime Victims low-up. Journal of the Academy of Child and
Research and Treatment Center and the Center Adolescent Psychiatry, 37, 44 – 51.
for Sexual Assault and Traumatic Stress (Saun- Cohen, J. A., & Mannarino, A. P. (1998b). Interven-
ders et al., 2003). tions for sexually abused children: Initial treat-
ment findings. Child Maltreatment, 3, 17 –26.
Deblinger, E., Lippman, J., & Steer, R. (1996). Sexu-
References, Readings, & Internet Sites
ally abused children suffering post-traumatic
American Academy of Child and Adolescent Psychi- stress symptoms: Initial treatment outcome
atry. (1997). Practice parameters for the foren- findings. Child Maltreatment, 1, 310 –321.
 88 • treatment of child sexual abuse 435

Deblinger, E., Steer, R., & Lippman, J. (1999). Two- Results from the National Survey of Adoles-
year follow-up study of cognitive behavior cents. Journal of Consulting and Clinical Psy-
therapy for sexually abused children suffering chology, 71, 692– 700.
post-traumatic stress symptoms. Child Abuse National Center for Post-Traumatic Stress Disorder.
& Neglect, 23, 1371–1378. (n.d.). Home page. Retrieved 2004 from http://
Family Research Laboratory, University of New www.ncptsd.org/
Hampshire. (n.d.). Home page. Retrieved 2004 National Clearinghouse on Child Abuse and Ne-
from http://www.unh.edu/frl/ glect. (n.d.). Home page. Retrieved 2004 from
Finkelhor, D., & Berliner, L. (1995). Research on the http://www.calib.com/nccanch/
treatment of sexually abused children: A re- National Crime Victims Research and Treatment
view and recommendations. Journal of Ameri- Center. (n.d.). Home page. Retrieved 2004 from
can Academy of Child and Adolescent Psychi- http://www.musc.edu/cvc
atry, 34, 1408 –1423. Saunders, B. E., Berliner, L., & Hanson, R. F. (Eds.).
Friedrich, W. N. (1993). Sexual victimization and (2003). Child physical and sexual abuse: Guide-
sexual behavior in children: A review of the re- lines for treatment (final report: January 15,
cent literature. Child Abuse & Neglect, 17, 2003). Charleston, SC: National Crime Victims
59 –66. Research and Treatment Center. http://www.
Gomes-Schwartz, B., Horowitz, J. M., Cardarelli, musc.edu/cvc/
A. P., & Sauzier, M. (1990). The aftermath of Saunders, B. E., & Meinig, M. B. (2000). Immediate
child sexual abuse: 18 months later. In B. issues affecting long term family resolution in
Gomes-Schwartz, J. M. Horowitz, & A. P. Car- cases of parent-child sexual abuse. In R. Reece
darelli (Eds.), Child sexual abuse: The initial (Ed.), Treatment of child abuse: Common ground
effects (pp. 132–152). Newbury Park, CA: for mental health, medical, and legal practi-
Sage. tioners (pp. 36 – 53). Baltimore, MD: Johns
Greenberg, S., & Shuman, D. (1997). Irreconcilable Hopkins University Press.
conflict between therapeutic and forensic roles. Shipman, K. L., Rossman, B. B. R., & West, J. C.
Professional Psychology: Research and Prac- (1999). Co-occurrence of spousal violence and
tice, 28, 50 –57. child abuse: Conceptual implications. Child Mal-
Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, treatment, 4, 93 –102.
D. (1993). Impact of sexual abuse on children:
A review and synthesis of recent empirical
Related Topics
studies. Psychological Bulletin, 113, 164 –180.
Kilpatrick, D. G., Ruggiero, K. J., Acierno, R., Saun- Chapter 86, “The APSAC Study Guides”
ders, B. E., Resnick, H. S., & Best, C. L. (2003). Chapter 87, “Interviewing Children When Sexual
Violence and risk of PTSD, major depression, Abuse Is Suspected”
substance abuse/dependence, and comorbidity:
This page intentionally left blank
PART VI
Biology and Pharmacotherapy
This page intentionally left blank
 NORMAL MEDICAL LABORATORY
89 VALUES AND MEASUREMENT
CONVERSIONS

Gerald P. Koocher & Samuel Z. Goldhaber

Although conversion data provided here are here represent an overview from several sources
standard, note that normal biological and and should not be regarded as absolute. When
chemical values differ across hospitals and lab- interpreting specific results, contact personnel
oratories as a function of the methods, rea- at the lab in question to ascertain their normal
gents, and equipment used. The data presented ranges for the test in question.

table 1. Temperature Conversions: Fahrenheit = table 2. Units of Measurement Conversions

⁄5 (Centigrade) + 32; Centigrade = 5⁄9 (Fahrenheit – 32)
9

1 kg = 2.204 lb
Fahrenheit Centigrade 22 lb = 10 kg
1 lb = 16 oz = 0.454 kg or 454 g
95.0 35.0 1 oz = 29.57 ml
96.8 36.0 1 tsp = 5 ml
98.6 37.0 1 tbsp = 15 ml
100.0 37.8 1 in = 2.54 cm
100.4 38.0 1 cm = 0.394 in
101.0 38.3 1 ft = 30.48 cm
102.0 38.9 1 yd = 91.44 cm
102.2 39.0 1 m = 1.093 yd
103.0 39.4 1 m = 3.28 ft
104.0 40.0 1 mile = 1669.3 m
1 km = 1093.6 yd

439
440 part vi • biology and pharmacotherapy

table 3. Prefixes Denoting Decimal Factors

Prefix Factor Prefix Factor
mega 106 milli 10 – 3
kilo 103 micro 10 – 6
hecto 102 nano 10 – 9
deka 101 pico 10 – 12
deci 10 – 1 femto 10 – 15
centi 10 – 2

table 4. Normal Lab Values

Chemistries Adult Values Pediatric Values

Sodium 134 –146 mEq/L Term, 132–142 mEq/L

Child, 135 –146 mEq/L
Potassium 3.5 –5.1 mEq/L Term, 3.8 –6.1 mEq/L
>1 month, 3.5 –5.1 mEq/L
Chloride 92–109 mEq/L 95 –108 mEq/L
Bicarbonate 24 –31 mEq/L
BUN (blood urea nitrogen) 8 –25 mg/dl 5 –25 mg/dl
Creatinine <1.5 mg/dl 0.7 –1.7 mg/dl
Glucose 55 –115 mg/dl Term, 32–100 mg/dl
>2 weeks, 60 –110 mg/dl
Calcium 8.0 –10.5 mg/dl Term, 7.2–12.0 mg/dl
>1 year, 7.8 –11.0 mg/dl
Phosphorus 2.6 – 4.6 mg/dl
Uric acid 2.4 –7.5 mg/dl 3.0 –7.0 mg/dl
Total protein 5.6 –8.4 g/dl
Albumin 3.4 –5.4 g/dl 3.8 –5.6 g/dl
Total bilirubin 0.2–1.5 mg/dl Total Bilirubin Premature Term
1 day < 8 –9 <6
2 days <12 <9
1 week <15 <10
2– 4 weeks <10 –12 <6
Direct bilirubin 0.0 –0.3 mg/dl <0.2 mg/dl
SGOT, AST (serum glutamic
oxaloacetate, aminotransferase) 0 – 40 U/L Term, 25 –125 U/L
Infant, 20 –60 U/L
Child, 10 – 40 U/L
SGPT, ALT (alanine aminotrans-
ferase, serum glutamic pyruvate
transaminase) 0 – 40 U/L
LDH (lactic dehydrogenase) 50 –240 U/L Term, 150 –600 U/L
<1 year, 140 –350 U/L
Child, 140 –280 U/L
CK (creatine kinase) 5 –200 U/L
CK MB (CK-myocardial band) <3 –5%
Cholesterol <200 mg/dl
LDL cholesterol (low-density
lipoprotein) <130 mg/dl
HDL cholesterol (high-density
lipoprotein) >35 – 40 mg/dl
Triglycerides 30 –135 mg/dl
Amylase 60 –180 U/L
Lipase 4 –25 U/L
Magnesium 1.6 –3.0 mg/dl 1.5 –2.1 mg/dl
GGTP (gamma-glutamyl
transpeptidase) 10 –50 U/L
 89 • normal medical laboratory values and measurement conversions 441

table 4. Normal Lab Values (continued)

Chemistries Adult Values Pediatric Values

PSA (prostate-specific antigen) <4.0 ng/ml

Osmolarity 274 –296 mOsm/kg 274 –296 mOsm/kg
Iron 50 –160 ␮g/dl
TIBC (total iron-binding capacity) 240 – 425 ␮g/dl
Iron % sat 20 –55%
Ferritin 30 –250 ng/ml
Anion gap 8 –12 mEq/L 10 –14 mEq/L
Vitamin B12 200 –1,000 pg/ml
Folate 5 –12 ng/ml
Ammonia <45 ␮g/dl
Lactate 4 –16 mg/dl
Aluminum 4 –10 ␮g/L
Copper 90 –200 ␮g/dl
Zinc 50 –150 ␮g/dl 50 –160 ␮g/dl
APF (alpha-fetoprotein) <25 ng/ml
CEA (carcinoembryonic antigen) <2.5 ng/ml
CEA, smoker <5.0 ng/ml

Hematology

Hgb (hemoglobin) Males, 14 –18 g/dl

Females, 12–16 g/dl
Term, 13 –20 g/dl
1– 4 days, 14 –22 g/dl
2 weeks, 13 –20 g/dl
1 month, 11–18 g/dl
2 months, 10 –15 g/dl
6 months, 10 –14 g/dl
1 year, 10 –13 g/dl
2–8 years, 11–14 g/dl
Hematocrit Males, 40 – 52%
Females, 37 – 47%
Term, 40 –58%
1– 4 days, 45 –60%
2 weeks, 40 –58%
1 month, 32–54%
2 months, 28 – 44%
6 months, 30 – 42%
1 year, 32– 40%
2–8 years, 33 – 40%
RBC (red blood cell [density]) Males, 4.8 –6.0 ⫻ 106/mm3
Females, 4.1–5.5 ⫻ 106/mm3
MCV (mean corpuscular volume) Males, 80 – 90 fl
Females, 80 –100 fl
MCH (mean corpuscular
hemoglobin) 27 –32 pg
MCHC (mean corpuscular
hemoglobin concentration) 32–36%
Hgb A1c (hemoglobin A1c) 3 – 5%
WBC (white blood cells) 5,000 –10,000/␮l Term, 8 –30 (103/mm3)
1–3 days, 9 –32 (103/mm3)
2– 4 weeks, 4 –20 (103/mm3)
2 months, 5 –20 (103/mm3)
6 months, 6 –18 (103/mm3)

(continued)
442 part vi • biology and pharmacotherapy

table 4. Normal Lab Values (continued)

Chemistries Adult Values Pediatric Values

1 year, 5 –18 (103/mm3)

2–8 years, 5 –15 (103/mm3)
Segs 40 –60%
Bands 0 –5%
Lymph 20 – 40%
Mono 4 –8%
Eos 1–3%
Baso 0 –1%
Platelets 150 – 400 ⫻ 103/␮l 150 –357 ⫻ 103/␮l
Haptoglobin 100 –250 mg/dl
ESR (eosinophil sed rate) Males, <10 mm/hr
Females, <20 mm/hr
Retic count 0.5 –2.0% Term, 3 –8%
2 days, 2– 4%
1 month, 0.3 –1.6%
6 years, 0.5 –1.3%
PT (prothrombin time) 11–13 s 11–14 s
PTT (partial prothrombin time) 25 –35 s 21–35 s
Bleeding time <5 –6 min
Thrombin time 10 –14 s
Fibrinogen 200 – 400 mg/dl 150 –375 mg/dl
Lymphocyte (differential)
Total T, CD3 60 –87%
Total T/mm3 630 –3,170
B cell 1–25%
Suppr, CD8 10 – 40%
Suppr/mm3 240 –1,200
Helper, CD4 30 –50%
Helper/mm3 390 –1,770
H:S, CD4/CD8 0.8 –3.0

ABGs (Arterial Blood Gases)

pH 7.35 –7.45 Birth, 7.32–7.45
1 day, 7.27 – 7.44
2 days, 7.36 –7.44
1 month, 7.35 –7.45
PaCO2 35 – 45 mmHg Birth, 25 – 45 mmHg
>2 months, 30 – 45 mmHg
PaO2 80 –100 mmHg Birth, 65 –80 mmHg
Infant, 70 –100 mmHg
Child, 85 –105 mmHg
HCO3 22–28 mEq/L
O2, saturation, artery 95 –98%
O2, saturation, vein 60 –85%

Endocrinology
T4 RIA (thyroxine radioiodine
uptake) 5.0 –12.0 ␮g/dl
T3 uptake (thyrotropin) 22–36%
Free T4 (thyroxine) 0.8 –2.2 ng/dl
T3 (thyrotropin) 75 –200 ng/dl
TSH (thyroid-stimulating hormone) 0.3 –5.0 ␮IU/ml
Aldosterone, supine 3 –12 ng/dl
Aldosterone, upright 5 –25 ng/dl
Calcitonin <75 pg/ml
 89 • normal medical laboratory values and measurement conversions 443

table 4. Normal Lab Values (continued)

Chemistries Adult Values Pediatric Values

Cortisol 6 –24 ␮g/dl, A.M.

2–10 ␮g/dl, P.M.
Gastrin 0 –200 pg/ml
Growth hormone 1–10 ng/ml
Pepsinogen 25 –100 mg/ml
Prolactin Males, 0 –5 ng/ml
Females, 0 –20 ng/ml
PTH (parathyroid homone) 10 –60 pg/ml
BHCG (beta human chorionic
gonadotropin, nonpregnant) <5 mlU/ml
0 –2 weeks 0 –250 mlU/ml
2– 4 weeks 100 –5,000 mlU/ml
1–2 months 4,000 –200,000 mlU/ml
2–3 months 8,000 –100,000 mlU/ml
2nd trimester 4,000 –75,000 mlU/ml
3rd trimester 1,000 –50,000 mlU/ml

Urine
Albumin 20 –100 mg/day
Amylase <20 U/hr
Calcium <300 mg/day
Creatinine 0.75 –1.5 g/day
Creatinine clearance 80 –140 ml/min
Glucose <300 mg/day
Osmolarity 250 –1,000 mOsm/L
Phosphorous 0.5 –1.3 g/day
Potassium 25 –115 mEq/day
Protein 10 –200 mg/day
Sodium 50 –250 mEq/day
Total volume 720 –1,800 ml/day
Urea nitrogen 10 –20 g/day
Uric acid 50 –700 mg/day
Specific gravity 1.002–1.030

Cerebral Spinal Fluid

Protein 10 – 45 mg/dl Preterm, 60 –150 mg/dl
Newborn, 20 –170 mg/dl
>1 year, 5 – 45 mg/dl
Glucose 40 –80 mg/dl Preterm, 24 –75 mg/dl
Newborn, 34 –119 mg/dl
>1 year, 40 –80 mg/dl
Pressure 60 –180 mmH2O Newborn, 70 –120 mmH2O
Child, 70 –180 mmH2O
Leukocytes, total <5/mm3
Leukocites, differential
Lymph 60 –75%
Mono 25 –50%
Neutro 1–3%
Cell count 0 –5 lymphs/HPF Preterm, 0 –25 WBC/mm3; <35% polys
Newborn, 0 –25 WBC/mm3; <35% polys
>2– 4 weeks, 0 –5 WBC/mm3; 0% polys

(continued)
444 part vi • biology and pharmacotherapy

table 4. Normal Lab Values (continued)

Chemistries Adult Values Pediatric Values

Toxicology
Ethanol
Normal <0.005% (5 mg/dl)
Intoxicated 0.1–0.4%
Stuporous 0.4 – 0.5%
Coma >0.5%
Mercury, urine <100 ␮g/24 hr, normal
CoHgb (carbon monoxide hemoglobin)
Nonsmokers 0 –2.5%
Smokers 2–5%
Toxic >20%
Lead 0 – 40 ␮g/dl, normal <10 ug/dl
Lead, urine <100 ␮g/24 hr, normal

table 5. Pediatric Normal Values (Subject to Individual Patient’s Circumstances)

3 6 9 1 1–1.5 2
Values Preterm Term Months Months Months Year Years Years

Weight
in kilograms <3 3–4 5 –6 7 8 –9 10 11 12
Pulse rate 130 –160 120 –150 120 –140 120 –140 120 –140 120 –140 110 –135 110 –130
Blood pressure
(systolic) 45 – 60 60 –70 60 –100 65 –120 70 –120 70 –120 70 –125 75 –125
Respiratory rate 40 – 60 30 –60 30 –50 25 –35 23 –33 20 –30 20 –30 20 –28
Weight
in kilograms 14 –15 16 –17 18 20 24 –25 30 –32 40 45
Pulse rate 100 –120 95 –115 90 –110 90 –110 80 –100 75 –95 70 –90 60 –90
Blood pressure
(systolic) 75 –125 80 –125 80 –125 85 –120 90 –120 90 –125 95 –130 110 –130
Respiratory rate 20 –28 20 –28 20 –25 20 –25 16 –24 16 –24 16 –24 15 –20

References & Readings Hoekelman, R. A., Friedman, S. B., Nelson, N. M.,

Seidel, H. M., & Weitzman, M. D. (Eds.) (1997).
Barkin, R. M. (Ed.). (1992). Pediatric emergency
Primary pediatric care. St. Louis: Mosby.
medicine: Concepts and clinical practice. St.
Lee, G. R., Bithell, T. C., Foerster, J., Athens, J. W., &
Louis: Mosby.
Lukens, J. N. (1993). Wintrobe’s clinical hema-
Bennett, J. C., & Plum, F. (1996). Cecil textbook of
tology. Malverne, PA: Lea and Febiger.
medicine. Philadelphia: Saunders.
Braunwald, E., Fauci, A. S., Kasper, D. L., Hauser
S. L., Longo, D. L., & Jameson, J. L. (Eds.) Related Topics
(2001). Harrison’s principles of internal medi-
cine. New York: McGraw-Hill. Chapter 11, “Medical Evaluation of Children With
Henry, J. B. (1991). Clinical diagnosis and manage- Behavioral or Developmental Disorders”
ment by laboratory methods. Philadelphia: Chapter 139, “Common Clinical Abbreviations and
Saunders. Symbols”
 USE OF HEIGHT AND
90 WEIGHT ASSESSMENT TOOLS

Nancie H. Herbold & Sari Edelstein

In the past, to determine if an individual was INTERPRETATION

over- or underweight, clinicians consulted the
Metropolitan Life Insurance Weight for Height Both BMI, shown in Table 1, and waist circum-
Tables. These tables considered sex and frame ference (WC), shown in Table 2, can be useful
size to determine desirable weight associated measures for determining obesity. According
with greater life expectancy. Today, the pre- to the National Institutes of Health, a high WC
ferred method for assessing body weight is the is associated with an increased risk for Type 2
use of body mass index (BMI). Body mass diabetes, hypertension, and cardiovascular dis-
index is more closely related to body fat con- ease when BMI is between 25 and 34.9. A BMI
tent than the Metropolitan Tables. To deter- greater than 25 is considered overweight, and a
mine BMI for either a man or a woman, body BMI greater than 30 is considered obese. Addi-
weight in kilograms is divided by height in tionally, WC can be useful for those people cat-
meters squared. egorized as normal or overweight in terms of
BMI. For example, an athlete with increased
BMI = Weight (kg) muscle mass may have a BMI greater than 25.
Height (m)2 Changes in WC over time can indicate an in-
crease or decrease in abdominal fat. Increased
BMI = Weight (lbs) ⫻ 703 abdominal fat is associated with an increased
Height (inches)2 risk of heart disease. To use Table 2 for athletic
individuals, convert the weight in pounds by
For ease, Table 1 is provided to make the
dividing by a factor of 2.2 to equal the weight
BMI calculation unnecessary. To use the table,
in kilograms (kg).
find the appropriate height in the left-hand col-
umn. Move across to a given weight; pounds
have been rounded. The number at the top of
WAIST CIRCUMFERENCE
the column is the BMI for that height and
weight, corresponding designations for nor-
To determine your WC, locate your waist and
mal, overweight, obese, and extremely obese
measure the circumference. The tape measure
BMI levels.
should be snug, but should not cause compres-
BMI is a tool for assessing body weight, but
sions on the skin. Table 2 should be helpful in
it is not without its limitations. For example,
determining the possible risks associated with
BMI does not totally differentiate between
your BMI and WC.
weight that is muscle and weight that is fat.
Therefore, an athlete in good physical shape
may have a high BMI but not high body fat.
(Table 2, explained below, can be utilized for
athletic individuals.)

445
table 1. Body Mass Index Table
Normal Overweight Obese Extreme Obesity

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

Height
(inches) Body Weight (pounds)

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258
59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267
60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276
61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285
62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295
63 107 113 118 124 130 135 141 146 152 158 164 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304
64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314
65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324
66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334
67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344
68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354
69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365
70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376
71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386
72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397
73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408
74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420
75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431
76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443

Source: National Institute of Health, 2003. Adapted from Clinical guidelines on identification, evaluation, and treatment of overweight and obesity in adults: The evidence report.
 91 • medical conditions that may present as psychological disorders 447

table 2. Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease
Risks

Disease Riska Relative to Normal Weight and Waist Circumference

BMI Obesity Men 102 cm (40 in) or less Men > 102 cm (40 in)
(kg/m2) Class Women 88 cm (35 in) or less Women > 88 cm (35 in)

Underweight <18.5 — —
Normal 18.5 –24.9 — —
Overweight 25.0 –29.9 Increased High
Obesity 30.0 –34.9 I High Very high
35.0 –39.9 II Very high Very high
Extreme obesity 40.0+b III Extremely high Extremely high

aDiseaserisk for type 2 diabetes, hypertension, and CVD.

bIncreasedwaist circumference can also be a marker for increased risk even in persons of normal weight.
Note: Divide weight in pounds by 2.2 to get kg.
Source: National Institutes of Health, 2003.

References, Readings, & Internet Sources ease Prevention and Health Promotion. Division
of Nutrition and Physical Activity. BMI: Body
National Institutes of Health. National Heart, Lung, Mass Index. See also http://www.cdc.gov/nccd
and Blood Institute. (2003). Clinical guidelines php/dnpa/bmi/bmi-adult-formula.htm; Web
on identification, evaluation, and treatment of site that calculates BMI: http://www.cdc.gov/
overweight and obesity in adults: The evidence nccdphp/dnpa/bmi/calc-bmi.htm
report: Retrieved 2004 from http://www.
nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm
National Research Council. (1989). Diet and health: Related Topic
Implications for reducing chronic disease risk. Chapter 95, “Dietary Supplements and Psychologi-
Washington, DC: National Academy Press. cal Functioning”
United States Department of Health and Human
Services. (2003). Center for Disease Control and
Prevention. National Center for Chronic Dis-

MEDICAL CONDITIONS THAT

91 MAY PRESENT AS
PSYCHOLOGICAL DISORDERS

William J. Reed

Many medical disorders may present with psy- disease process, such as the anxiety and mania
chological symptoms or cognitive disturbances. caused by the overproduction of thyroid hor-
Often the symptoms are the direct result of a mone or the schizophreniform picture of cen-
448 part vi • biology and pharmacotherapy

tral nervous system involvement with sys- school performance (the illicit use of pre-
temic lupus. What may not be as readily appre- scribed medications or the abuse of illicit
ciated is how frequently “psychological” disor- drugs)
ders present with signs or symptoms of physi- • Withdrawal from social or peer activities
ological dysfunction, such as the tachycardia (avoidant behaviors vs. neurological regression)
and increased blood pressure seen with chronic • There is clinical evidence of significant mood
anxiety. Patient amplification of symptoms fre- change and/or disruptive behaviors.
quently produces somatic complaints out of
proportion to the objective medical findings as The combination of a complete medical his-
well as occasional diagnostic confusion (Broom, tory and physical examination coupled with
2000). It is also well documented that the dura- psychological tests and judicious laboratory
tion of physical complaints and medication side testing usually separates the ongoing patholog-
effects may contribute to the presentation of ical processes and those conditions that mimic
physical disease as well as a psychological ill- either psychological or physiological disease.
ness. The following is an attempt to list those entities
A wide variety of medical conditions can seen most often in a pediatric and adolescent
present as psychological disorders in everyday medicine practice.
clinical practice. As many as 10% to 20% of all
pediatric and adolescent medical complaints
may be “psychosomatic” or “somatoform” in
origin (Gold & Friedman, 1995); that is, with- MEDICAL CONDITIONS THAT
out visible alteration in organic function. Both MAY PRESENT AS ANXIETY
terms are probably incorrect descriptions since (AND PANIC ATTACKS)
they suggest that disease cannot exist in the
absence of recognizable pathological change • Akathisia from antipsychotic medications
(Barsky & Burus, 1999). And because of con- • Cardiovascular
ventional medical training, many clinicians and — Angina
psychologists frequently struggle with the no- — Cardiac arrhythmias
tion that a “physiologic” cause must necessar- — Congestive heart failure
ily exist for every symptom. The dualistic — Hypertension
model that created an artificial distinction be- — Mitral valve prolapse (Barlow’s syn-
tween organic (medical) illness and psycholog- drome)
ical (or psychiatric) illness acts an outdated — Myocardial infarction
theoretical constraint. — Pulmonary embolism
At the present time, there is very little evi- — Subclavian steal syndrome
dence to suggest that the mind (psyche) and the
• Chronic illness
body function (soma) differ psycho-neuroim-
• Deficiencies
munologically, endocrinologically, or psy-
— Calcium
chophysiologically (Ryan, 1998). Clinicians
— Magnesium
should recognize the contribution of both the
— Potassium
mind and the body (psychophysiology) as a
— Niacin
continuum, especially when:
— Vitamin B12
• A disease process or disorder persists unex- • Diet effects, caffeine, nicotine, illicit sub-
plained (mullerian duct anomalies present- stance abuse
ing as enuresis) • Drug use or withdrawal (alcohol, ampheta-
• There is poor patient compliance (recurrent mines)
abdominal pain with child neglect) • Endocrine
• There is a drop in academic production or — Carcinoid syndrome
 91 • medical conditions that may present as psychological disorders 449

— Cushing’s disease • Heavy metal toxicity (see above)

— Hyperthyroidism • Landau-Kleffner syndrome
— Hypoglycemia • Mania
— Pheochromocytoma • Medication side effects (see elsewhere)
— Menopause • Neurocysticerosis
• Gastro esophageal reflux
• Hyperhidrosis
MEDICAL CONDITIONS THAT MAY
• Lack of exercise
PRESENT AS DEPRESSION
• Medications and withdrawal
— Anticholinergics
• Acne vulgaris
— Antihistamines
• AIDS
— Barbiturates
• Cancer-pancreatic
— Bronchodilators
• Collagen diseases
— Calcium channel blockers
— Fibromyalgia syndrome
— Corticosteroids
— Juvenile rheumatoid arthritis
— Digitalis
— Mixed connective tissue disease
— Neuroleptics
— Sjogren’s syndrome
— Phenothiazines
— Systemic lupus erythematosis
— Theophylline
• Cystic fibrosis
• Neurological
• Endocrine disorders
— Delirium
— Diabetes mellitus
— Labyrinthitis
— Hyperparathyroidism
— Multiple sclerosis
— Hyperthyroidism
— Partial complex seizures
— Hypopituitarism
— Post concussion
— Hypothyroidism
— Vestibular dysfunction
• Infections
• Nummular eczema (neurodermatitis cir-
— AIDS
cumscripta)
— Encephalitis
• Premenstrual dysphoria syndrome
— Hepatitis
• Recreational drugs
— Influenza
• Respiratory
— Pneumonia
— Asthma
— Syphilis
— Chronic obstructive pulmonary disease
(and emphysema) • Insulin dependent diabetes mellitus
— Hyperventilation syndrome • Leukemia
— Hypoxia • Medications
— Pulmonary embolism — Antihypertensives
— Barbiturates
• Urticaria
— Benzodiazepines
— Clonidine
— Corticosteroids
MEDICAL CONDITIONS THAT MAY
— Digitalis
PRESENT AS ATTENTION-DEFICIT/
— Guanfacine
DISRUPTIVE DISORDERS
— Oral contraceptives
• Absence seizures • Medication induced personality changes
• Complex and simple partial seizures • Migraine headaches
• Frontal lobe disorders
450 part vi • biology and pharmacotherapy

• Neurologic disorders • Gastrointestinal

— Cerebrovascular accidents — Chronic liver disease
— Epilepsy — Inflammatory bowel disease
— Multiple sclerosis
• Genitourinary
— Subarachnoid hemorrhage
— Glomerulonephritis
— Wilson’s disease
— Pregnancy
• Neurosympathetic dystrophy — Pyelonephritis
• Psoriasis
• Hematological disorders
• Substance related, substance dependent and
— Anemia
abusive
— Leukemia
• Verrucae vulgaria
— Lymphoma
— Polycythemia
MEDICAL CONDITIONS THAT MAY • Infections (common)
PRESENT AS FATIGUE AND — AIDS
MALAISE (MODIFIED WITH PER- — Epstein-Barr (infectious mononucleosis)
MISSION FROM CAVANAUGH, — Coccidiomycosis
2002) — Cytomegalovirus
— Histoplasmosis
• Allergic tension fatigue — Lyme disease (chronic)
• Cardiovascular disease — Sarcoidosis
— Arteriovenous fistula — Subclinical hepatitides (B, C)
— Congenital heart disease — Tuberculosis
— Congestive heart failure — Wegener’s granulomatosis
— Hypertrophic cardiomyopathy
• Lymphoid hyperplasia (Down’s syndrome)
— Persistent pulmonary hypertension
• Medications
— Takayasu’s temporal arteritis
— Illicit (e.g., Blue Tuesday from ampheta-
• Collagen diseases mines)
— Dermatomyositis — Over-the-counter
— Mixed connective tissue disorder — Prescription
— Polymyositis
• Myasthenia gravis
— Rheumatoid arthritis
• Muscular dystrophy
— Sjogren’s syndrome
• Narcolepsy
— Systemic lupus erythematosus
• Orthostatic edema
• Chronic fatigue syndrome • Obstructive sleep apnea
• Chronic renal diseases
• Endocrine disorders
— Hyperaldosteronism MEDICAL CONDITIONS THAT MAY
— Hypercortisolism (Cushing’s) PRESENT AS SLEEP DISORDERS
— Hyperthyroidism
— Hypocortisolism (Addison’s) Hypersomnias
— Hypothyroidism • Chronic fatigue syndrome
— Pheochromocytoma • Cranial irradiation
• Ehlers Danlos syndrome • Depression
• Familial hypokalemic periodic paralysis • Drug/medication use
• Fibromyalgia • Inadequate sleep
• Intrathecal chemotherapy
 91 • medical conditions that may present as psychological disorders 451

• Klein Levin syndrome (with hyperphagia in MEDICAL CONDITIONS THAT MAY

males) PRESENT AS CHRONIC PELVIC
• Narcolepsy PAIN IN FEMALES
• Nocturnal hypoventilation
• Poisoning and child abuse • Dysmenorrhea (secondary)
• Postencephalitic sequelae • Dyspareunia (painful intercourse)
• Posttraumatic head injury • Endometriosis
• Sleep reversals • Functional gastrointestinal disorders
• Upper airway resistance and sleep apnea • Mittleschmerz un lust
• Ovarian disorders
• Pregnancy
Developmental Dyssomnias/ • Pseudocyesis
Parasomnias • Sexual abuse or sexual assault
• Arousal disorders (non-REM) • Surgical adhesions, e.g., Ashner’s syndrome
— Bruxism
— Head banging
— Night terrors MEDICAL CONDITIONS THAT MAY
— Paroxysmal nocturnal enuresis PRESENT AS FAILURE TO THRIVE
— Somnambulism OR WEIGHT LOSS

• Benign neonatal sleep myoclonus (Lennox • Achalasia (e.g., Trypanosomiasis)

Gastaut) • Aganglionic megacolon (Hirschsprung’s)
• Bruxism • Anorexia
• Circadian rhythm disorders • Attachment disorders
— Primary latency phase disorder • Bartter syndrome
— Zeitgebers (night shift) • Celiac disease
• Enuresis • Cerebral damage from hypoxia and hemor-
• Head banging rhage
• Nightmares • Child neglect and abuse
• Night terrors • Chronic anemias
• Nighttime body rocking • Chronic hypoxemia
• Narcolepsy • Chronic protein malnutrition
• REM disorders • Congenital anomalies and developmental
— Nightmares feeding problems
— Seizures • Congenital infections
— AIDS
• Obstructive sleep apnea — Cytomegalovirus
• Resistance to sleep — Histoplasmosis
• Restless legs syndrome — Rubella
• Somnambulism — Toxoplasmosis
• Somniloquy — Tuberculosis
• Trained night crying
• Trained night feeding • Cystic fibrosis
• Ultradian disorders • Dwarfing syndromes
— Seasonal affective disorder — Leprechaunism
— LeJeune’s asphyxiating syndrome
• Vulnerable child
• Diencephalic syndromes
• Endocrine disorders
• Fetal alcohol syndrome
452 part vi • biology and pharmacotherapy

• Hypocalorism • Homocysteinuria
• Idiopathic hypercalcemia • Hepatic failure/encephalopathy
• Inborn errors of metabolism • Hyperthyroidism
• Leigh syndrome • Hyperparathyroidism
• Metabolic storage diseases • Hyponatremia
• Newborn narcotic withdrawal • Hyperparathyroidism
• Protein losing enteropathy • Hypothyroidism
• Protein losing nephropathy • Huntington’s disease
• Rumination • Klinefelter’s syndrome
• Schwachman-Diamond syndrome (pancre- • Medication-induced catatonia
atic achylia) • Multiple sclerosis
• Severe gastroesophageal reflux • Pancreatitis
• Porphyria
• Renal failure
MEDICAL CONDITIONS THAT • Systemic lupus erythematosus
MAY PRESENT AS VERTIGO OR • Temporal lobe seizures
DIZZINESS • Traumatic brain injury
• Vitamin B deficiencies
• Acute labyrinthitis • Wilson’s disease
• Acoustic neuroma • Substance-induced (intoxication or with-
• Benign paroxysmal vertigo drawal)
• Benign positional vertigo
• Central vertigo–transient ischemic episodes
• Cerebellar hemorrhage MEDICAL CONDITIONS THAT MAY
• Head trauma PRESENT AS MEMORY LOSS AND
• Meniere’s disease DELIRIUM
• Migraine aura
• Multiple sclerosis • Alcohol dependence
• Perilymph fistula • Alzheimer’s disease
• Peripheral vertigo (damage/dysfunction of • Anoxia
the labyrinth or eighth cranial nerve) • Carbon monoxide poisoning
• Orthostatic hypotension • Carcinoid syndrome
• Postural tachycardia syndrome • Cerebrovascular disorders
• Salicylate, or alcohol toxicity to labyrinth • Date rape drugs
• Toxic damage to labyrinth — Gamma hydroxybutyrate (GHB)
• Vertebrobasilar stroke — Rohypnol
• Viral labyrinthitis
• Electroconvulsive therapy
• Head trauma (post-concussion)
• Heavy metal toxicity
MEDICAL CONDITIONS THAT MAY
• Hypercarbia
PRESENT AS PSYCHOSIS
• Hypoglycemia
• Infections
• Addison’s disease (hypocortisolism)
— Herpes encephalitis
• Cardiovascular disease strokes
— HIV
• Cushing’s disease (hypercortisolism)
— Koru
• Central nervous system infections
— Malaria
• CNS neoplasms
— Neurocysticerosis
• CNS trauma
— Neurosyphilis
• Folate deficiency
— Rabies encephalitis
• HIV and AIDS
 91 • medical conditions that may present as psychological disorders 453

— Subacute sclerosing panencephalitis of Broom, B. C. (2000). Medicine and story: A novel

Dawson clinical panorama arising from a unitary mind/
body approach to physical illness. Advances in
• Keane-Sayres disease Mind-Body Medicine, 16, 161–207.
• Kluver-Bucy disease Cavanaugh, R. M. (2002). Evaluating adolescents
• Medications with fatigue: Ever get tired of it? Pediatric Re-
— Benzodiazepines view, 23, 337 –348.
— Diltiazem Duchowny, M. (1996). Nonepileptic paroxysmal
— Thiopental disorders. In B. O. Berg (Ed.), Principles of
— Others childhood neurology (p. 285). New York: Mc-
Graw Hill.
• Multiple sclerosis Gold, M. A., & Friedman, S. B. (1995). Conversion
• Organic solvents reactions in adolescents. Pediatric Annals, 24,
• Postoperative 296 –306.
• Seizures Hymel, K. P., & Jenny, C. (1986). Child sexual
• Sheehan’s syndrome of postpartum CNS abuse. Pediatric Review, 7, 236 –249.
Levine, M. D., Carey, W. B., & Crocker, A. C. (1999).
hemorrhage
Developmental behavioral pediatrics (3rd ed.).
• Substance abuse
Philadelphia, PA: W. B. Saunders.
• Metabolic Levine, R. L. (1995). Eating disorders in adolescents:
• Postoperative A comprehensive update. International Pedi-
• Substance abuse/withdrawal atrics, 10, 327.
• Vitamin B12, B6 deficiency Morris, M. (1998). Pediatric diagnosis: Interpreta-
tion of symptoms and signs in children and
adolescents (6th ed.). Philadelphia, PA: W. B.
MEDICAL CONDITIONS THAT MAY Saunders.
PRESENT AS DEMENTIA Morrison, J. (1997). When psychological problems
mask medical disorders. New York: Guilford
Press.
• AIDS-associated CNS infections
Netherton, S. D., Holmes, D., & Walker, C. E.
• Alzheimer’s disease
(1999). Child and adolescent psychological dis-
• Creuztfeld-Jakob disease orders. New York: Oxford University Press.
• Head trauma Ryan, N. D. (1998). Psychoneuroendocrinology of
• Hepatolenticular degeneration (Wilson’s children and adolescents. Psychiatry Clinics of
disease) North America, 21, 435 – 441.
• Huntington’s disease Tasman, A., Kay, J., & Lieberman, J. A. (1997). Psy-
• Hydrocephalus ex vacuo chiatry (Vol. 1, chap. 26). Philadelphia, PA: W.
• Neimann Pick disease B. Saunders.
• Neurosyphilis Wood, B. L. (2001). Biobehavioral continuum of psy-
• Parkinson’s disease chologically and physically manifested disease
to explain the false dichotomy of organic v. psy-
• Post anoxia
chological illness. Child and Adolescent Psychi-
• SSPE of Dawson (measles)
atric Clinics of North America, 7, 543 –562.
• Substance abuse Yaylayan, S., Viesselman, J. O., Weller, E. B., et al.
• Vascular thrombosis and embolism (1992). Depressive mood disorders in adoles-
cents. Adolescent Medicine: State of the Art
References & Readings Reviews, 3 – 41.

American Psychiatric Association. (2000). Diagnos-

tic and Statistical Manual (4th ed., rev.). Ar- Related Topic
lington, VA: American Psychiatric Press. Chapter 72, “Psychotherapy With Cognitively Im-
Barsky, A. J., & Burus, J. F. (1999). Functional somatic paired Adults”
syndromes. Annals of Internal Medicine, 130,
910 –921.
 ADULT PSYCHOPHARMACOLOGY 1
92 Common Usage

Joseph K. Belanoff, Charles DeBattista,

& Alan F. Schatzberg

Make the appropriate diagnosis, but especially ticholinergic side effects are desipramine and
identify the target symptoms (see Table 1). Ide- nortriptyline.
ally, one would like to see the patient in a drug- • Selective serotonin reuptake inhibitors
free state for 1–2 weeks, although this is not (SSRIs): The release of fluoxetine in 1988
always possible. Target symptoms are critical. greatly expanded the number of patients with
Past history of medication response is quite major depression treated pharmacologically.
predictive of current response. Family history The SSRIs (fluoxetine, sertraline, paroxetine,
of drug response is often helpful in making a and fluvoxamine) are virtually never lethal
medication choice. in overdose, and their side-effect profiles are
relatively benign.
• Trazodone and nefazodone: Trazodone is an
MAJOR DEPRESSION inhibitor of serotonin reuptake, an agonist
at some serotonin receptors, and an antago-
Major depression is a common debilitating ill- nist at others. It is also an alpha-adrenergic
ness (lifetime prevalence of approximately blocker and an antihistamine, so common
16%). Success rates for psychopharmacological side effects include orthostatic hypotension
interventions are approximately 60 –70%. and sedation. Although the primary indica-
tion for trazodone is major depression, it is
• Monoamine oxidase inhibitors (MAOIs): quite effective in low doses (50 –100 mg) as a
MAOIs are probably underutilized because hypnotic.
of concern about tyramine-induced hyper- Nefazodone has complicated effects on the
tensive crisis (extreme high blood pressure serotonin system. It, too, is a 5-HT2 antago-
brought on by eating certain foods, includ- nist, as well as an inhibitor of serotonin re-
ing aged cheese, aged meat, and red wine, uptake (this combination may lead to sensiti-
while using an MAOI). zation of 5-HT1A receptors).
• Tricyclic antidepressants (TCAs): TCAs have • Venlafaxine: Like the TCAs, venlafaxine is a
demonstrated proven efficacy in major de- nonspecific reuptake inhibitor. Unlike the
pression but can produce side effects, rang- TCAs, venlafaxine does not block choliner-
ing from the annoying (dry mouth) to the gic, histaminergic, or adrenergic receptors,
dangerous (arrhythmia). Least likely to pro- so its side-effect profile is much more be-
duce sedation, postural hypotension, and an- nign.

454
 92 • adult psychopharmacology i 455
table 1. Adult Psychopharmacology
Indication Class Drug Name Dosage Blood Level

Major depression MAOI Phenelzine (Nardil) 45 – 70 mg

MAOI Tranylcypromine (Parnate) 30 – 50 mg
TCA Imipramine (Tofranil) 150 –300 mg 150 –300 ␮g/ml
imipramine &
desipramine
TCA Desipramine (Norpramin) 150 –300 mg 150 –300 ␮g/ml
TCA Amitriptyline (Elavil) 150 –300 mg 100 –250 ␮g/ml
amiltriptyline
& nortrip-
tyline
TCA Nortriptyline (Pamelor) 50 –150 mg 50 –150 ␮g/ml
SSRI Fluoxetine (Prozac) 20 –60 mg
SSRI Sertraline (Zoloft) 50 –200 mg
SSRI Paroxetine (Paxil) 20 – 50 mg
SSRI Fluvoxamine (Luvox) 50 –300 mg
Trazodone (Desyrel) 300 – 600 mg
Nefazodone (Serzone) 300 –600 mg (divided)
Venlafaxine (Effexor) 75 –375 mg (divided)
Bupropion (Wellbutrin) 300 – 450 mg
Mintazapine (Remeron) 15 – 45 mg
Antidepressant
augmentation Lithium 600 –1,800 mg 0.5 –0.8 mEq/L
L-triodothyramine 25 – 50 mcg
Bipolar disorder Lithium 900 –2,000 mg 0.8 –1.2 mEq/L*
Anticonvulsant Carbamazepine (Tegretol) 400 –1,600 mg 6 –10 ␮g/ml
Anticonvulsant Divalproex sodium (Depakote) 750 –2,250 mg (divided) 50 –100 ␮g/ml
Schizophrenia Low-potency
antipsychotic Chlorpromazine (Thorazine) 300 –800 mg
High-potency
antipsychotic Haloperidol (Haldol) 6 –20 mg
Atypical
antipsychotic Risperidone (Risperdal) 2–8 mg
Atypical
antipsychotic Clozapine (Clozaril) 300 –900 mg
Atypical
antipsychotic Olanzapine (Zyprexa) 5 –20 mg
Atypical
antipsychotic Quetiapine (Seroquel) 50 – 400 mg
Atypical
antipsychotic Ziprasidone (Zeldox) 40 –160 mg
Atypical
antipsychotic Aripiprazole (Abilify) 10 –15 mg
Panic disorder Benzodiazepine Alprazolam (Xanax) 1– 6 mg
Generalized
anxiety disorder Buspirone (BuSpar) 15 –30 mg (divided)
Obsessive-
compulsive disorder TCA Clomipramine (Anafranil) 150 –250 mg
SSRI Fluvoxamine (Luvox) 100 –350 mg
Insomnia Trazodone (Desyrel) 50 –100 mg (at bedtime)
Antihistamine Diphenhydramine (Benadryl) 25 –50 mg (at bedtime)
Narcolepsy Psychostimulant Dextroamphetamine (Dexedrine) 10 – 40 mg
TCA Protriptyline (Vivactil) 10 – 40 mg
Schizotypal
personality disorder Antipsychotic Haloperidol (Haldol) 3 mg

(continued)
456 part vi • biology and pharmacotherapy

table 1. Adult Psychopharmacology (continued)

Indication Class Drug Name Dosage Blood Level

Borderline
personality disorder Antipsychotic Loxapine (Loxitane) 5 –25 mg
SSRI Fluoxetine (Prozac) 10 – 40 mg
Avoidant
personality disorder MAOI Phenelzine (Nardil) 60 mg
Alcohol withdrawal Benzodiazepine Chlordiazepoxide (Librium) 25 –100 mg Q 6 h
Benzodiazepine Lorazepam (Ativan) 1 mg Q 1 hr PRN
pulse > 110,
BP > 150/100
Vitamin Thiamine 100 mg 1–3 ⫻ Q D
Vitamin Folic acid 1 mg Q D
Vitamin Multivitamin 1 tablet Q D
Alcohol withdrawal Benzodiazepine Chlordiazepoxide (Librium) 25 –100 mg Q 6 h
Benzodiazepine Lorazepam (Ativan) 1 mg Q 1 hr PRN
pulse > 110,
BP > 150/100
Vitamin Thiamine 100 mg 1–3 ⫻ Q D
Vitamin Folic acid 1 mg Q D
Vitamin Multivitamin 1 tablet Q D
Heroin withdrawal Opioid Methadone 5 mg Q 4 h as needed on
first day then decrease
by 5 mg Q D until 0
Relapse prevention Disulfiram (Antabuse) 500 mg Q D for 2
weeks then 250 Q D
(1st dose at least 12 h
after last E to H use)
Opioid agonist Naltrexone (ReVia) 25 mg Q D for 1–2 days
then 50 mg (1st dose at
least 7 –10 days after last
opioid use)
Bulimia nervosa SSRI Fluoxetine (Prozac) 40 –60 mg
Alzheimer’s
dementia Anticholinesterase Tacrine (Cognex) Start at 40 mg and raise
by 40 mg every 6 weeks
up to 110 mg
Anticholinesterase Donezepil (Aricept) 5 mg

*Levels *1.5 mEq/L may be toxic, and levels *2.5 mEq/L may be fatal.

• Bupropion: Bupropion was to be introduced • Adjunct therapy: If a patient’s depression has

in the United States in 1985 but was delayed been nonresponsive to a 6-week course of
after the occurrence of seizures in patients antidepressants at appropriate dosages, ad-
with bulimia. It was introduced in 1989 and junct therapy with either lithium or thyroid
has proved to be an effective, safe (and un- hormone is an alternative.
derutilized) antidepressant. • Atypical depression (hyperphagia, hyper-
• Mirtazapine: Mirtazapine enhances both no- somnia, leaden paralysis, rejection sensitiv-
radrenergic and serotonergic transmission. ity, mood reactivity): MAOIs have demon-
Side effects include weight gain and sedation strated superior efficacy compared with TCAs
but few sexual side effects. in treating this variation of major depression.
• Electroconvulsive therapy (ECT): When de- • Psychotic (delusional) depression: Antide-
pression is very severe or accompanied by pressant medication alone is usually ineffec-
delusions, ECT is the treatment of choice. tive. The combination of an antidepressant
 92 • adult psychopharmacology i 457

and an antipsychotic is effective in many pa- SCHIZOPHRENIA

tients. ECT is probably the most effective
treatment. Antipsychotic medication is often divided into
• Dysthymia: For many years the prognosis two groups, “typical” and “atypical.” All “typ-
for individuals with dysthymia was poor. ical” antipsychotics are dopamine-2 receptor
There is now increasing evidence that long- blockers. “Atypical” antipsychotics are less
term use of antidepressants, particularly prominent dopamine-2 receptor blockers, and
SSRIs, is quite effective in improving dys- they tend to block many other receptors, partic-
thymia and perhaps in preventing declines ularly serotonin-2 receptors.
into major depression.
• Dopamine receptor antagonists (D2 recep-
tors): All traditional antipsychotic medica-
BIPOLAR DISORDER tion works essentially the same way and has
the same side-effect profile. Medications
The most effective acute treatment for manic with a relatively low affinity for D2 recep-
psychotic agitation (virtually always adminis- tors (“low potency”) require a higher dose,
tered in the emergency room) is an antipsy- and medications with a relatively high affin-
chotic medication (i.e., haloperidol) combined ity for D2 receptors (“high potency”) re-
with a benzodiazepine (i.e., lorazepam). Shortly quire a lower dose.
thereafter, sometimes following a negative tox- • Dopamine/serotonin receptor antagonists:
icology screen, a mood-stabilizing agent must Risperidone, clozapine, olanzapine, quetia-
be started. pine, ziprasidone, and aripiprasole are all less
likely to cause motoric side effects than tra-
• Lithium: Lithium remains the gold standard ditional antipsychotic medication. They may
for the treatment of bipolar disorder. Sev- also be more effective in treating the neg-
enty to eighty percent of acutely manic pa- ative symptoms and cognitive deficits of
tients respond to lithium, but it often takes schizophrenia.
1–3 weeks for a full response.
• Carbamazepine: Primarily used as an anti-
convulsant, carbamazepine also has been ANXIETY DISORDERS
shown to be quite effective in treating bipo-
lar disorder. Biological theories of anxiety disorders have
• Valproic acid: Valproic acid (primarily used pointed to problems in the norepinephrine,
now in divalproex sodium form) has been serotonin, and gamma-aminobutyric acid neu-
granted FDA approval for the treatment of rotransmitter systems. As a consequence, a
bipolar disorder. It appears that valproate wide variety of medications has been tried with
may be especially effective in the treatment varying success.
of rapid-cycling bipolar disorder and mixed
manic-depressive states. Because there are • Panic disorder: Antidepressants should be
many drug-drug interactions with valproic considered the first line of pharmacotherapy
acid, the prescribing physician must be made for patients with panic disorder. Benzodi-
aware of all medication changes (including azepines have also been shown to be effec-
over-the-counter drugs). tive in treating panic disorder but have a
• Other anticonvulsants: Lamotrigine is cur- number of disadvantages over antidepres-
rently being studied for the treatment of bi- sants. They often produce sedation, increase
polar disorder. Other anticonvulsants used the effects of alcohol, produce dyscoordi-
for bipolar disorder include tiagabine, oxcar- nation, and are associated with dependence
bazepine, gabapentin, and levetiracetam, al- and withdrawal. Patients can have severe
though none of these are currently approved panic attacks while withdrawing from benzo-
by the FDA for use in bipolar disorder. diazapines.
458 part vi • biology and pharmacotherapy

• Generalized anxiety disorder (GAD): Ben- PERSONALITY DISORDERS

zodiazepines have been frequently used to
treat patients with GAD. They are effective Despite the fact that pharmacotherapy has in-
in the short run for symptom relief. How- creasingly gained acceptance as a treatment
ever, for all of the reasons listed above, their option for severe personality disorders, there
longer-term use is problematic. Buspirone, a are few well-controlled studies that document
serotonin partial agonist, has been shown to pharmacological efficacy. In addition, many
be as effective as benzodiazepines in patients specific personality disorders have not been
with GAD. studied pharmacologically at all. Those that
• Social phobia: Unfortunately, the pharmaco- have include the following:
logical treatment of social phobia has lagged
behind the treatment of other anxiety disor- • Schizotypal personality disorder: It appears
ders. Alprazolam and phenelzine have been that schizotypal personality disorder has a
reported to produce improvement in symp- genetic association with schizophrenia, so it
toms of social phobia. Beta-blockers have is not surprising that there is some evidence
helped with performance anxiety (in events for improvement with low-dose antipsy-
like public speaking) but not particularly chotic medication.
with social phobia. • Borderline personality disorder (BPD):
• Obsessive-compulsive disorder (OCD): OCD SSRIs seem to help in BPD, particularly with
is both relatively common and quite respon- impulsive aggression and affective insta-
sive to pharmacotherapy. Clomipramine, a bility. Low-dose antipsychotic medication is
nonspecific (but very serotonergically po- often effective in improving hostility and
tent) reuptake inhibitor, has been best stud- cognitive perceptual disturbances. Anticon-
ied and is often effective. All of the SSRIs vulsants, particularly valproic acid, seem to
have been shown to be effective in reducing improve behavioral dyscontrol; benzodi-
the symptoms of OCD. azepines and noradrenergic antidepressants
often seem to make behavioral dyscontrol
worse.
SLEEP DISORDERS • Avoidant personality disorder: There are no
double-blind placebo-controlled studies, but
• Insomnia: Insomnia is a common symptom there is evidence that MAOIs, SSRIs, beta-
in many psychiatric illnesses, particularly adrenergic receptor antagonists, and benzo-
major depression. Insomnia often resolves as diazepines may be useful in combination
the depressive episode resolves. However, with psychotherapy.
when insomnia is particularly distressing to
the patient, low doses of trazodone or diphen-
hydramine are often effective in improving
sleep. PSYCHOACTIVE SUBSTANCE
• Narcolepsy: Psychostimulants (i.e., amphet- ABUSE AND WITHDRAWAL
amines) have long been accepted as valuable
treatment for the daytime sleepiness seen in • Intoxication: Most treatment for serious in-
narcolepsy. Stimulants do not prevent the toxication is focused on physiological sup-
cataplexy that some narcoleptic patients ex- port (controlling blood pressure, heart rate,
perience, but either TCAs or SSRIs in com- respiration, etc.). The psychosis seen in am-
bination with stimulants may be helpful. phetamine and cocaine intoxication may be
Modafinil has proven efficacy in maintaining treated with standard antipsychotics, often
wakefulness in patients with narcolepsy. in combination with benzodiazepines (which
help with agitation).
• Withdrawal: Withdrawal from alcohol, ben-
zodiazepines, and barbiturates is similar and
 92 • adult psychopharmacology i 459

is potentially life-threatening. All of these IMPULSE-CONTROL DISORDERS

withdrawals are best pharmacologically
treated with benzodiazepines. Lorazepam Among the impulse-control disorders, inter-
(Ativan) is recommended for patients with mittent explosive disorder and trichotillomania
significant liver disease because its metabo- are most often treated pharmacologically.
lism is less impaired in advanced liver dis-
ease. Methadone and clonidine are used in • Intermittent explosive disorder: Anticonvul-
opiate withdrawal. sants are used most often, although the re-
• Relapse prevention: The prevalence of sub- sults are mixed. Benzodiazepines often make
stance abuse disorders, particularly alcohol matters worse, with more behavioral dys-
abuse and dependence, has sparked interest control. There is increasing case evidence
in pharmacological methods to help prevent that buspirone (often in higher doses than
relapse. Disulfiram (Antabuse) has been used in generalized anxiety disorder) may be
tried for many years, although its popularity effective.
has certainly declined. Naltrexone, a syn- • Trichotillomania: New pharmacological stud-
thetic opioid antagonist, is used in the treat- ies are taking place with both serotonergic
ment of alcoholism and narcotic dependence. antidepressants and the anticonvulsant val-
Naltrexone aids abstinence by blocking the proic acid.
“high” caused by narcotics.
References & Readings
Albani, F., Riva, R., & Baruzzi, A. (1995). Carbama-
SOMATOFORM DISORDERS zepine clinical pharmacology: A review. Phar-
macopsychiatry, 28(6), 235 –244.
Most of the somatoform disorders are ineffec- Andrews, J. M., & Nemeroff, C. B. (1994). Contem-
tively treated with current medication, and un- porary management of depression. American
fortunately psychoactive medication therapies Journal of Medicine, 97, 245 –325.
are probably overused significantly. The one Callahan, A. M., Fava, M., & Rosenbaum, J. F.
exception is body dysmorphic disorder, where (1993). Drug interactions in psychopharmacol-
the effective use of serotonergic agents (partic- ogy. Psychiatric Clinics of North America, 16,
647 – 671.
ularly SSRIs) has dramatically improved the
Kunovac, J. L., & Stahl, S. M. (1995). Future direc-
prognosis for affected patients.
tion in anxiolytic pharmacotherapy. Psychiatric
Clinics of North America, 18, 895 – 909.
EATING DISORDERS Naranjo, C. A., Herrmann, N., Mittmann, N., &
Bremner, K. E. (1995). Recent advances in geri-
atric psychopharmacology. Drugs and Aging,
• Anorexia nervosa: Unfortunately, there is
7(3), 184 –202.
no shining star of pharmacological treat-
ment for this life-threatening illness. An-
tipsychotic medication has not worked, and Related Topics
cyproheptadine, amitriptyline, and fluoxe- Chapter 93, “Adult Psychopharmacology 2: Side Ef-
tine have had limited success. fects and Warnings”
• Bulimia nervosa: Antidepressants work very Chapter 94, “Pediatric Psychopharmacology”
well in the treatment of bulimia apart from
their ability to elevate mood.
 ADULT
93 PSYCHOPHARMACOLOGY 2
Side Effects and Warnings

Elaine Orabona Mantell

Psychopharmacology is a dynamic field that re- pregnancy/lactation, and menopause. For ex-
quires the practitioner to keep up to date on the ample, Wisner, Perel, and Wheeler (1993)
regularly changing information regarding the found that by the third trimester, women on
pharmacodynamics and pharmacokinetics of average required 1.6 times the nonpregnant
psychoactive medications. Given this caveat, dose of TCA.
several variables do remain constant in the safe • Ethnicity: Populations differ in their expres-
and effective practice of pharmacotherapy. The sion of genes that allow them to metabolize
following is not meant to be exhaustive, but various drugs. The cytochrome P450 en-
rather it highlights information from the aver- zymes responsible for the metabolism of
age clinical assessment that can affect the inter- most psychotropic medications are IAD,
action between drug and patient. IID6, and IIIA3/4. IID6, which is the enzyme
responsible for the hydroxylation of many
• Age: The elderly metabolize drugs at a slower psychiatric medications, has been found to
rate, which is one reason for the axiom, “Start be deficient in 5% to 8% of Caucasians.
low and go slow.” The axiom also holds true Knowledge of genetic differences can help
for children. guide pharmacotherapy when individuals
• Sex: Psychotropic medications can have who are “fast” or “slow” metabolizers show
physical and behavioral teratogenic effects either subtherapeutic response or excessive
on the developing fetus and newborn (e.g., side effects.
lithium has been associated with Ebstein’s • Symptoms: An assessment of symptoms
anomaly, a serious malformation in cardiac will assist with establishing the target symp-
development, when taken during the first toms to be treated and monitored. The as-
trimester). Therefore, the rule of thumb is to sessment must include pertinent negatives
counsel all women of childbearing age about such as the absence of a history of mania
these risks and to avoid all but essential because antidepressants can precipitate a
medications during pregnancy, especially the switch into mania for those with a predispo-
first trimester. When medication is unavoid- sition.
able, serotonin-specific reuptake inhibitors • Past psychiatric history: Look for previous
(SSRIs) have typically been the first-choice psychotropic medication use, including fam-
medications, although this is still controver- ily psychiatric history and use of psycho-
sial because tricyclic antidepressants (TCAs) tropic medications (if a drug worked or did
have a longer track record of use in preg- not work for the patient’s family members
nancy and can be measured through blood before, it is likely to repeat its performance
serum levels. Women also metabolize drugs in the future). Suicide history and current
differently during menstrual cycle phases, profile will suggest whether it is safe to uti-

460
 93 • adult psychopharmacology 2 461

lize medications with narrow versus broad carbamazepine, an anticonvulsant and mood
therapeutic windows. stabilizer, can cause blood dyscrasia and liver
• Past medical history: Medical illness and con- disease, and therefore requires periodic mon-
comitant drug use—even over-the-counter itoring for changes from baseline in CBCs
medication, homeopathic remedies, or folk and LFTs. Similarly, lithium is known to
remedies — can affect the pharmacokinetics cause endocrine effects such as hypothy-
and pharmacodynamics of any psychotropic roidism and renal insufficiency; therefore,
medication. Some combinations can be mon- BUN, creatinine, and thyroid-stimulating
itored with relative safety, while others are hormone (TSH) should be monitored regu-
absolutely contraindicated, such as a mono- larly after baseline levels are obtained.
amine oxidase inhibitor and meperidine or
dextromethorphan.
• Habits: Regular alcohol use can either speed ANTIDEPRESSANTS
up or slow down the metabolism of psycho-
tropic medications, depending on the stage of • TCAs: All the TCAs cause varying degrees
damage to the liver. Also, chronic alcohol of anticholinergic effects (e.g., dry mouth,
withdrawal can lower the seizure threshold, urinary retention, constipation, blurred vi-
which means drugs that lower the seizure sion); antihistaminic effects such as sedation
threshold (e.g., bupropion, high doses of and weight gain; orthostatic hypotension
tricyclics, and low-potency antipsychotics) from alpha-l blockade; sexual dysfunction;
should be avoided in individuals with sei- and the potential for cardiotoxicity because
zure history. Tobacco and caffeine can also of the quinidine-like effects on the heart. In
induce (speed up) the metabolism of various fact, cardiac conduction problems are a sig-
drugs and should be considered when moni- nificant contraindication to treatment with
toring for possible subtherapeutic or interac- TCAs.
tion effects. Illicit drugs can cause a patient • MAOIs: MAOIs are not used as first-line
to appear depressed, psychotic, and/or anx- drugs because of their lethal interaction and
ious. These must always be considered be- overdose effects. A lethal hypertensive crisis
cause of their influence on diagnostic and can occur when these drugs are mixed with
treatment decisions (e.g., whether to with- sympathomimetics or foods containing tyra-
hold, use, or delay the timing of certain psy- mine (a natural by-product of the fermenta-
chotropic medications). tion process), such as cheeses, wines, beers,
• Laboratory studies: The most common lab- chopped liver, fava beans, and chocolate. Be-
oratory studies for psychiatric patients in- sides these agents, L-dopa and TCAs can also
clude complete blood count (CBC) with dif- cause an excessive elevation in blood pressure,
ferential; blood chemistries (typically in- which can result in myocardial infarction and
clude electrolytes, blood urea nitrogen stroke. Other signs and symptoms of hyper-
[BUN], creatinine clearance, liver function tensive crisis include severe headache, exces-
tests [LFTs]); thyroid function tests (TFTs); sive sweating, dilated pupils, and cardiac con-
testing for sexually transmitted disease such duction problems. MAOIs are also contraindi-
as syphilis via RPR or VDRL; urinalysis cated with SSRIs, serotonin precursors, and
with toxicology screen; blood alcohol level; some narcotic analgesics because they can
drug serum levels (for those measurable); cause central serotonin syndrome, character-
and HIV as appropriate. For women of child- ized by rapid heart rate, hypertension, neuro-
bearing age, a pregnancy test such as blood muscular irritability, fever, and even coma,
or urine HCG should also be included. Some convulsions, and death. This is especially im-
of these studies will assist with differential portant when switching from an SSRI such as
diagnoses, but they can also provide base- fluoxetine, which has a relatively long half-
lines for the introduction of new medications life, to an MAOI because this switch requires
that can affect various systems. For example, a longer waiting period (approximately 4
462 part vi • biology and pharmacotherapy

weeks). All these drugs can cause postural hy- laise, abdominal pain, discolored stools, dark
potension, sexual dysfunction, weight gain, urine, jaundice, ascites, nausea, vomiting,
and symptoms similar to those produced by encephalopathy, and hepatic coma should
muscarinic blockage (i.e., anticholinergic side discontinue the drug immediately. Because
effects). Insomnia and restlessness/activation of the concern with hepatotoxicity, Nefa-
are more commonly seen with tranylcypro- zodone should no longer be used as a first-
mine and not phenelzine. line agent, and all patients should be coun-
Of note is the recent introduction of a seled about this risk prior to the initiation of
transdermal form of the MAOI selegiline treatment.
(eldepryl). This parenteral formulation was • Venlafaxine (Effexor): Venlafaxine’s side ef-
designed to eliminate the dietary interac- fects are similar to the SSRI side-effect pro-
tions associated with the oral formulation. file plus sweating, constipation, sedation, and
To date, the only side effect encountered dizziness. This drug is associated with a mild
more often than placebo was skin rash (17% to moderate, transient dose-dependent in-
placebo versus 36% with transdermal se- crease in diastolic blood pressure. Therefore,
legeline). An unexpected but salubrious find- patients with hypertension should be moni-
ing was a more rapid effect on depressive tored closely upon initiation of treatment
symptoms, as early as the first week of treat- and before dose increases.
ment (Bodkin & Amsterdam, 2002). • Bupropion (Wellbutrin, Zyban): Bupropion
• SSRIs: These drugs tend to show a milder shows various advantages over the SSRIs in
side-effect profile than the older antidepres- that it does not have anticholinergic, pos-
sants. Common side effects include acti- tural hypotension, conduction arrhythmias,
vation (sometimes experienced as anxiety), sexual dysfunction, or significant drug inter-
headache, gastrointestinal distress (e.g., action effects. Side effects include activation
nausea, vomiting, and diarrhea), sexual dys- and anorexia. In rare cases, bupropion has
function (mainly delayed ejaculation/or- been associated with psychotic symptoms
gasm), and occasional asthenia. Both activa- and seizure in doses over 450 mg per day. Pa-
tion and sexual dysfunction should be moni- tients with a history of eating disorder,
tored closely as they are the side effects most seizure, and alcohol dependence with signif-
often associated with early discontinuation icant withdrawal symptoms including sei-
and noncompliance with this class of medica- zure, should not take this drug.
tions. An interesting phenomenon is associ- • Mirtazapine (Remeron): A tetracyclic agent
ated with SSRI side effects. SSRIs may cause that has been associated with inverse, dose-
either insomnia or sedation with no apparent dependent sedation (i.e., sedation is reduced
predictability. Therefore, patients who are with doses above 15 mg) and significant
given a morning dosing schedule based on weight gain. Adverse drug effects include
the common side effect of activation and in- neutropenia (1.5% risk) and agranulocytosis
somnia will need to be educated about the (.1%)— avoid in the immunocompromised,
freedom to switch to nighttime dosing and monitor complete blood counts at base-
should they experience sedation. line, annually and with signs/symptoms of
• Trazodone (Desyrel) and Nefazodone (Ser- infection. Other side effects include hyper-
zone): Both of these drugs can cause seda- lipidemia and hypercholesterolemia (over
tion, postural hypotension, nausea, and vomit- 20% above upper normal cholesterol levels).
ing. Trazodone has a greater potential for se-
dation, cardiac arrhythmias, and priapism (a
sustained, painful engorgement of the penis SELECT MOOD STABILIZERS
or clitoris). Nefazodone’s labeling now car-
ries a black box warning concerning hepatox- • Lithium (Eskalith, Lithonate, Lithane): Be-
icity. Patients taking Nefazodone who show cause of its low therapeutic index, lithium can
symptoms such as anorexia, fatigue , ma- easily result in toxicity. Toxic effects can be ex-
 93 • adult psychopharmacology 2 463

pected at serum levels above 1.5 mmol/L, with leads to drug discontinuation. The lamotrigine-
severe adverse effects occurring as low as 2.0 based cutaneous reactions include measle-
mmol/L and above. Signs of toxicity include like rash, hives, and angioedema. But more
sluggishness, impaired gait, slurred speech, serious rashes such as Stevens-Johnson syn-
tinnitus, abdominal distress, tremor, ECG ab- drome, and toxic epidermal necrolysis can
normalities, low blood pressure, seizures, occur. The rate of serious rash requiring hos-
shock, delirium, and coma. Aside from toxic pitalization and discontinuation of treatment
effects lithium’s side-effect profile includes is 3 in 1,000 and usually occurs within 1 to
nausea, vomiting, diarrhea, abdominal pain, 2 months of initiation of treatment. The inci-
sedation, tremor, muscular weakness, in- dence of rash is higher in patients on more
creased thirst and urination, swelling due to than mood stabilizer, and greater with rapid
excessive fluid in body tissues, weight gain, titration. The consensus of clinical opinion is
dry mouth, and dermatological reactions. that, unless an alternative etiology can be
Chronic use can result in leukocytosis, hy- clearly identified, the drug should be discon-
pothyroidism/goiter, acne, and ECG changes. tinued when patients present with rash of
• Carbamazepine (Tegretol): Carbamazepine any kind regardless of severity, since the
is associated with a number of rarely occur- clinician is unable to predict which rashes
ring toxicities, which include hepatitis, blood will become serious.
dyscrasias such as agranulocytosis and aplas- • Topiramate (Topamax): This medication has
tic anemia, and exfoliative dermatitis (Stevens- few drug interactions based on its predomi-
Johnson syndrome). Incidents of leukopenia, nately renal excretion. Side effects in general
thrombocytopenia, elevated liver enzymes, order of occurrence include parasthesias,
and dermatological reactions are typically re- headache, fatigue, somnolence, and weight
versible. Initial signs of toxicity include loss. Because of the weight-loss side effect,
dizziness, blurred and double vision, seda- this medication is often used for patients
tion, and ataxia. Since carbamazepine is a po- who do not comply with treatment on other
tent inducer of hepatic enzymes, it speeds up mood stabilizers because of weight gain.
metabolism and therefore can reduce the lev- This medication may also decrease the serum
els of several other drugs, including antipsy- concentration of oral contraceptives which
chotics, valproate, TCAs, benzodiazepines, can result in pregnancy.
and hormonal contraceptives that may result • Gabapentin (Neurontin): Side effects are
in unintentional pregnancies. Therapeutic mild with this medication, and include seda-
drug monitoring is recommended. tion, dizziness, ataxia, and weight gain. Rapid
• Valproic acid (Depakote): Initial common side loading is well tolerated up to 4800 mg, with
effects include gastrointestinal effects, seda- minimal pharmacokinetics interactions based
tion, tremor, and incoordination of involun- on predominately renal excretion.
tary muscle movements. With chronic use,
there can be mild impairment of cognitive
function, alopecia, and weight gain. Hemato- ANXIOLYTICS
logical effects include those seen commonly
(e.g., thrombocytopenia, platelet dysfunction) • Benzodiazepines: Predictably, the common
and uncommonly (bleeding tendency). He- side effects are sedation and fatigue. In addi-
patic effects include those seen commonly tion, ataxia, slurred speech, and memory
(benign increase of liver enzymes) and un- (usually anterograde amnesia) and cognitive
commonly (hepatitis/hepatic failure). function impairment may occur. Behavioral
• Lamotrigine (Lamictal): In order of decreas- disinhibition can occur in the form of rage,
ing frequency, the most common side effects aggression, impulse dyscontrol, and eupho-
are dizziness, tremor, somnolence, headache, ria. All benzodiazepines can cause depres-
rash, nausea, and insomnia. Rash can be a se- sion. Although these drugs tend to be safe in
rious adverse event and most commonly overdose, this is not the case when mixed
464 part vi • biology and pharmacotherapy

with other CNS depressants, which, in com- quel), Ziprasidone (Geodon)— these agents
bination, can result in respiratory depres- show similar side effect profiles including
sion. Patients should be counseled about this dose-dependent extrapyramidal symptoms
risk, particularly those who drink alcohol. for olanzapine, risperidone, and ziprasidone.
• Buspirone (Buspar): This drug does not tend The risk for tardive dyskinesia (TD) is lower
to produce sedation but can be initially acti- with SGAs, and lowest for Clozapine, but
vating. Side effects can include headache and with all SGAs, monitoring for TD should
gastrointestinal distress (e.g., nausea, diar- occur at baseline and yearly for the duration
rhea, heartburn). It is preferable to benzodi- of treatment. Most SGAs are associated with
azepines in its side-effect profile since it new onset and impairment of glycemic con-
shows virtually no sedation, cognitive and trol (up to 27% with Olanzapine) and hy-
motor impairment, disinhibition, interaction perlipidemia (with the exception of ziprasi-
with alcohol, or potential for dependence. done). Weight gain is also a troublesome side
• First-generation antipsychotics (FGAs): Four effect of both the FGAs and SGAs and can
primary side effects include sedation, ex- interfere with treatment compliance. When
trapyramidal symptoms, anticholinergic prescribing SGAs the following should be
effects, and weight gain. Extrapyramidal routinely monitored. Other common side ef-
symptoms (mostly associated with high- fects for all SGAs include decreased libido,
potency agents) include Parkinsonian symp- sexual dysfunction, prolactin elevations (dose
toms such as rigidity, bradykinesia, and rest- dependent), temperature dysregulation,
ing tremor, akathisia (internal restlessness), photosensitivity, and photoallergic skin reac-
acute dystonias such as muscle contractions tions. Neuroleptic malignant syndrome may
or spasms (e.g., ocular gyric crisis), and tar- also occur with this class of agents.
dive dyskinesia. Some antipsychotics can also
lower the seizure threshold, usually in a
dose-dependent fashion. Hyperprolactinemia OTHER SPECIFIC SIDE EFFECTS
can cause galactorrhea with all of the conven-
tional agents and with the atypical agent, • Clozapine: Because of the risk of agranulocy-
risperidone. Prolonged elevations of pro- tosis, clozapine should only be after treat-
lactin may reduced bone mineral density and ment failure with two or three other antipsy-
thereby increase the risk of fractures. Thior- chotics. Weekly blood monitoring is required
idazine has been associated with an increased for the first six months of treatment, and
risk of sudden death secondary to torsades de then every other week for the duration of
pointes, hypertension, and ischemic heart treatment. However, clozapine has the lowest
disease. Its use is contraindicated with the risk of tardive dyskinesia to date and is even
antidepressant sertraline. Drugs that inhibit used to treat this condition when caused by
the cytochrome P450 enzyme IID6 may raise other antipsychotics. Extrapyramidal symp-
thioridazine levels and therefore the risk for toms are also minimal. Other significant side
sudden death (Reilly, Auis, Ferrrier, Jones, & effects include agranulocytosis, seizures, or-
Thomas, 2002). A recent study found that thostatic hypotension, sedation, hypersaliva-
patients taking FGAs showed a greater than tion, tachycardia, constipation, hyperthermia,
sevenfold increased risk of venous throm- neutropenia, and eosinophilia. Agranulocy-
boembolism — more with low-potency than tosis mortality is high if the drug is not dis-
high-potency drugs. The greatest risk was continued and condition immediately treated.
during the first months of treatment (Zorn- • Olanzapine: Initially touted as the “new
borg & Jick, 2000). Patients on low-potency Clozapine without agranulocytosis.” Olan-
FGAs should be monitored for symptoms of zapine’s major side effects include dose-
phlebitis or embolism. dependent extrapyramidal symptoms, som-
• Second-generation antipsychotics (SGAs): nolence, agitation, insomnia, nervousness,
Clozapine (Clozaril), Olanzapine (Zyprexa), hostility, constipation, and dry mouth.
Risperidone (Risperdal), Quetiapine (Sero- • Risperidone: Although risperidone has a lower
 93 • adult psychopharmacology 2 465

incidence of extrapyramidal symptoms. At References, Readings, & Internet Sites

higher doses, its EPS profile approximates the Bezchilibenyk-Butler, K. Z., & Jefferies, J. J. (Eds.).
traditional neuroleptics. Other side effects (2002). Clinical handbook of psychotropic
include postural hypotension, sedation, cog- drugs. Toronto: Hogrefe & Huber.
nitive impairment, asthenia, constipation, Bodkin, J. A., & Amsterdam, J. (2002). Transdermal
nausea, dyspepsia, tachycardia, headache, fa- selegiline in major depression: A double-blind,
tigue, sexual dysfunction, dizziness, galactor- placebo-contolled study in outpatients. Ameri-
rhea, and “burning sensations.” can Journal of Psychiatry, 159, 1869 –1875.
• Ziprasidone: This drug tends to prolong the Epocrates. (n.d.). Home page. Retrieved 2004 from
QT interval on an electrocardiogram, which http://www.epocrates.com
Hahn, R. K., Albers, L. J., & Reist, C. (1997). Cur-
can potentially result in torsades de pointes,
rent clinical strategies: Psychiatry. Irvine, CA:
a fatal ventricular arrhythmia. The package Current Clinical Strategies Publishing.
insert states that it should be prescribed only Herbmed. (n.d.). Home page. Retrieved 2004 from
after other agents have been tried. Postmar- http://www.herbmed.com
keting data have not supported an increased Hyman, S. E, Arana, G. W., & Rosenbaum, J.
incidence of serious adverse events with re- E. (1995). Handbook of psychiatric drug ther-
gard to cardiac conduction, but conservative apy. Boston: Lippincott Williams & Wilkins.
treatment would suggest routine EKG mon- Janicak, G., Davis, J. M., Preskorn, S. H., & Ayd, E.
itoring for patients treated with ziprasidone. J. (1997). Principles and practice of psy-
Holter monitoring is advisable for patients chopharmacotherapy. Baltimore: Williams &
on ziprasidone who complain of dizziness, Wilkins.
Jensvold, M. E, Halbreich, U., & Hamilton, J. A. (Eds.).
palpitations, or syncope. This drug should
(1996). Psychopharmacology and women.
not be used in combination with medications Washington, DC: American Psychiatric Press.
that prolong the QT interval. The most com- Maxmen, J. S., Dubovsky, S. L., & Ward, N. G.
mon adverse drug effects are somnolence and (2002). Psychotropic drugs fast facts. New
nausea; also rash and orthostatic hypoten- York: Norton.
sion can occur. It is less likely to cause weight Preston, J., & Johnson, J. (2001). Clinical psy-
gain than the other SGAs. chopharmacology made ridiculously simple.
• Quetiapine: The package insert notes that Miami, FL: MedMaster.
with chronic use, this drug may result in Reilly, J. G., Ayis, S. A., Ferrier, I. N., Jones, S. J., &
ocular lens changes. Slit lamp examinations Thomas, S. L. (2002). Thioridazine and sudden
are recommended at baseline and every six unexplained death in psychiatric inpatients.
British Journal of Psychiatry, 180, 515 – 522.
months. This warning was based on studies
Schatzberg, A. E, & Nemeroff, D. B. (1995). Text-
with beagle puppies at four times the recom- book of psychopharmacology. Washington,
mended human dose. Research on monkeys, DC: American Psychiatric Press.
at 5.5 times the recommended human dose, Wisner, K. L., Perel, J. M., & Wheeler, S. M. (1993).
did not increase cataract development. Ocular Tricyclic dose requirements across pregnancy.
assessments may, therefore, be based more on American Journal of Psychiatry, 150, 1541–
malpractice concerns than on empirical phar- 542.
macological science, especially since individu- Zornberg, G. L., & Jick, H. (2000). Antipsychotic
als with schizophrenia often have other risk drug use and risk of first-time idiopathic ve-
factors, such as smoking, and diabetes and nous thromboembolism: A case-control study.
therefore greater risk for ocular lens changes. Lancet, 356, 1219 –1223.
Dose-dependent reductions in total T4 and
Free T4 levels have also been observed. Related Topics
Chapter 92, “Adult Psychopharmacology 1: Com-
Note: The opinions and assertions contained mon Usage”
herein are the private views of the author and are Chapter 94, “Pediatric Psychopharmacology”
not to be construed as the official policy or posi-
tion of the U.S. government, the Department of
Defense, or the Department of the Air Force.
 PEDIATRIC
94 PSYCHOPHARMACOLOGY

Timothy E. Wilens, Thomas J. Spencer,

& Joseph Biederman

There is a growing awareness of psychiatric derman, 1998; Biederman, Faraone, & Mick,
disorders in children and adolescents. Many of 2000). The pharmacological management of
the children who suffer from psychopathology ADHD relies on agents that affect dopaminer-
may benefit from psychopharmacologic treat- gic and noradrenergic neurotransmission —
ment. This chapter reviews potential benefits, namely the stimulants, antidepressants, and
risks, and treatment guidelines for psycho- antihypertensives (Spencer, Biederman, & Wil-
tropic medications used in children and adoles- ens, 1998).
cents (see Table 1).
Stimulants
ATTENTION-DEFICIT/ The most commonly used stimulants are
HYPERACTIVITY DISORDER (ADHD) methylphenidate (Ritalin, Ritalin LA, Con-
certa), amphetamine compounds (Adderall, Ad-
Attention-deficit/hyperactivity disorder (ADHD) derall XR), dextroamphetamine (Dexedrine),
may affect from 5% to 9% of school-age chil- and magnesium pemoline (Cylert). Stimulants
dren and persists into adolescence and adult- have been shown to be effective in approxi-
hood in approximately 50% of cases (Barkley, mately 70% of patients and appear to operate
1998). A child with ADHD is characterized by in a dose-dependent manner in improving cog-
a degree of inattentiveness, impulsivity, and nition and behavior (Greenhill et al., 2002;
often hyperactivity that is inappropriate for the Wilens & Spencer, 2000). The beneficial effects
developmental stage of the affected child of stimulants are of a similar quality and mag-
(Barkley, 1998). ADHD symptoms vary be- nitude in patients of both genders and across
tween children and may adversely influence all different ages to adulthood. Whereas there are
areas of function, including academic perfor- immediate-release preparations of methylphe-
mance, overall behavior, and social/inter- nidate and amphetamine, the extended-release
personal relationships with adults and peers. preparations are preferred and are more fre-
ADHD commonly co-occurs with opposi- quently prescribed. The extended-release prepa-
tional-defiant, conduct, depressive, and anxiety rations of the stimulants have a duration of ac-
disorders (Biederman, Newcorn, & Sprich, tion that starts approximately 30 minutes after
1991) and substance-use disorders in adults dosing lasting from 8 (Ritalin LA, Metadate
(Wilens, Biederman, & Mick, 1998). ADHD CD) to 12 hours (Concerta, Adderall XR). Dos-
has a male preponderance and appears to run in ing starts at the lowest available dose and in-
families. Approximately half of childhood cases creases up to 1.5 (amphetamine) to 2 mg/
will persist into adulthood, with diminuation kg/day (methylphenidate products) of medica-
of hyperactive/impulsive symptoms relative to tion. The typical starting dose of pemoline is
the persistence of attentional dysfunction (Bie- 37.5 mg up to 75 to 150 mg/day. There appears

466
 94 • pediatric psychopharmacology 467

table 1. Pharmacotherapy of Common Disorders

A. Attention-Deficit and Disruptive Behavioral Disorders

Disorder Main Characteristics Pharmacotherapy

Attention-deficit Inattentiveness, impulsivity,

Stimulants (use of extended release preparations; for
hyperactivity disorder hyperactivity uncomplicated ADHD; careful in patients with tics)
(ADHD) 50% may continue to manifest
Atomoxetine (nonstimulant, first line for comorbidity?)
the disorder into adulthood
Tricyclic antidepressants: desipramine, nortriptyline,
Associated with mood, imipramine (second line for nonresponders)
conduct, and anxiety Clonidine (good for preschoolers, severe hyperactivity,
disorders aggression, ADHD + tics; nonresponders): guanfacine (Tenex)—
generally used if clonidine too sedating
Bupropion (second line for nonresponders, useful in mood lability)
Venlafaxine (Effexor)— third line
Combined pharmacotherapy for treatment resistant or comorbid
cases
Conduct disorder (CD)/ Persistent and pervasive No specific pharmacotherapy available for core disorder
Oppositional defiant patterns of aggressive and Behavioral Tx
disorder (ODD) antisocial behaviors For ADHD (see above), complex combinations (i.e., clonidine
Often associated with other and stimulants)
disorders such as ADHD and For agitation and aggression:
depression Clonidine or Tenex
Beta blockers (i.e., propranolol)
Mood stabilizers (i.e., Lithium, Carbamezapine, Valproate)
Atypical antipsychotics (e.g., risperidone)
Other Axis I disorders (i.e., ADHD, MDD, pyschosis, anxiety):
treat the underlying disorder

B. Mood Disorders

Major depressive Sad or irritable mood and Serotonin-specific reuptake inhibitors (SSRIs): fluoxetine,
disorder (MDD) associated vegetative sertraline, fluvoxamine, paroxetine, (es)citalopram
symptoms occurring togetherBupropion, venlafaxine
for a period of time Tricyclic antidepressants
Similar to the adult disorders
Antidepressants and antipsychotics when psychosis develops
with age-specific associatedAdjunct strategies for Tx refractory
features Antidepressants and low dose mood stabilizers, and BZDs, and
thyroid and stimulants
Bipolar disorder Same as depression Mood stabilizers (Lithium, Carbamezapine/Oxcarbazepine,
depressed Valproate-Depakote)
Combined with MDD Tx
Use bupropion, short-acting SSRIs
Bipolar disorder manic Pervasive and/or severely Atypical antipsychotics (for acute mania first line; e.g.,
irritable/angry mood risperidone, quetiapine, olanzapine, ziprasidone, aripiprasole)
Elevated or expansive mood Mood stabilizers (first line)
More frequent psychotic Mood stabilizers and antipsychotics if marked mania or mood
symptoms in juvenile mania lability or psychosis
For Tx refractory: two mood stabilizers (li and valproic acid)
Mood stabilizers and adjunct antipsychotics
Mood stabilizers and high potency benzodiazepine
Mood stabilizer and clonidine

(continued)
468 part vi • biology and pharmacotherapy

table 1. Pharmacotherapy of Common Disorders (continued)

B. Mood Disorders

Disorder Main Characteristics Pharmacotherapy

Bipolar disorder mixed Mixed depressed and manic Mood stabilizers and atypical antipsychotics
symptoms Mood stabilizers/antipsychotics and antidepressants (bupropion)
Chronic course Mood stabilizers and benzodiazepines
Most common presentation of
juvenile bipolar disorder
Usually very severe clinical
picture

C. Anxiety Disorders

Childhood anxiety disorders

Overanxious disorder Excessive or unrealistic worry Serotonin reuptake inhibitors (SSRIs)
Separation anxiety about future events Benzodiazepine (diazepam, clorazepate)
Panic disorder Excessive anxiety on separa- Busipirone (Buspar)
tion from caretakers or For panic, use high potency: e.g., lorazepam
familial surroundings. Tricyclic antidepressants (imipramine, nortriptyline)
Recurrent discrete periods of Combined pharmacotherapy for refractory or comorbid patients
intense fear (panic attacks)
Frequent comorbidity with
MDD
(50%) and ADHD (30%)
Obsessive compulsive Recurrent, severe, and Serotonin-specific reuptake inhibitors (SSRIs)
disorder distressing obsessions and/or Clomipramine
compulsions Venlafaxine
Often associated with Adjunctive: high-potency benzodiazepines, TCAs, Buspirone
Tourette’s disorder, ADHD, Combined pharmacotherapy for Tx refractory or comorbid
mood, anxiety disorders patients (i.e., MDD, ADHD)

D. Other Disorders

Psychotic disorders Delusions and hallucinations Atypical antipsychotics

Loose associations Traditional antipsychotics (risk for tardive dyskinesia)
Paranoia often present High potency BZDs for agitation
Often associated with mood For treatment-resistant cases:
disorders Antipsychotics and mood stabilizers
Antipsychotics and beta blockers
Antipsychotics and benzodiazepines
Clozaril
Tourette’s disorder Multiple motor and one or Clonidine or Tenex
more vocal tic Tricyclic antidepressants (desipramine, imipramine,
Frequently associated with nortriptyline)
OCD and ADHD Atomoxetine (?)
Beta-blockers
Antipsychotics (high potency; Haldol, Orap) or atypical
(risperidone)
Combined pharmacotherapy for treatment resistant or
comorbid cases (+ Klonopin)
Enuresis Bed wetting ddAVP (Vasopressin)
Tricyclic antidepressants (imipramine)

E. Developmental Disorders

Pervasive develop- Qualitative impairment in For repetitive behaviors, serotonin-specific reuptake inhibitors
mental disorders social interactions, acquisition (SSRIs)
of, language, and motor skills Clomipramine (Anafranil)
 94 • pediatric psychopharmacology 469

table 1. Pharmacotherapy of Common Disorders (continued)

E. Developmental Disorders

Disorder Main Characteristics Pharmacotherapy

Autism Stereotypies and self- Cholinesterase inhibitors (investigational) for cognitive

stimulating behaviors often dysfunction (e.g., galantamine, donepezil)
present No specific pharmacotherapy for the core disorder
It can be global, or in specific Pharmacotherapy of complications:
or multiple areas Aggression and self-abuse:
Atypical antipsychotics
Beta blockers (i.e., propranolol)
Clonidine
High potency benzodiazepines
Mood stabilizers (i.e., Lithium, Valproate)
Mixed Opiate antagonist (Naltraxene)
Other Axis I disorders (i.e., ADHD, MDD, psychosis, anxiety):
treat the underlying disorder as in individuals

Abbreviations. ADHD = attention-deficit/hyperactivity disorder; OCD = obsessive-compulsive disorder; MDD = major depressive disorder;
CD = conduct disorder; MR = mental retardation; TCAs = tricyclic antidepressants; MAOIs = monozmine oxidase inhibitors; SSRIs =
serotonin-specific reuptake inhibitors; DDAVP = desmopresin; BZDs = benzodiazepines; Tx = treatment; Dx = diagnosis.

to be a dose response relationship for both be- abuse liability and is unscheduled. Atomoxe-
havioral and cognitive effects of the stimulants tine can be dosed once or twice daily and should
in ADHD individuals (Rapport et al., 1987). be initiated no higher than 0.5 mg/kg/day and
The most commonly reported short-term side increased to 1.2 mg/kg/day in one to two
effects associated with the stimulants are ap- weeks. The peak efficacy of the medication ap-
petite suppression, sleep disturbances, and ab- pears to unfold over two to six weeks.
dominal pain (Greenhill et al., 2002; Wilens & Adverse effects of atomoxetine include seda-
Spencer, 2000). Pemoline has also been associ- tion, appetite suppression, nausea/vomiting,
ated with hepatoxicity, limiting its usefulness. and headaches. Most short-term adverse effects
Long-term side effects remain controversial, can be managed by changing the time of ad-
with mixed literature indicating only a weak ministration of the medication. Data are lim-
association with motor tic development and ited on the long-term adverse effects of the
height/weight decrement (Greenhill et al., stimulants. There do not appear to be drug in-
2002; Wilens & Spencer, 2000). Despite con- teractions with the stimulants — a combination
cerns of long-term effects of stimulants on later that may be very helpful in recalcitrant cases of
substance abuse, recent work indicates that ADHD.
pharmacotherapy of ADHD reduces the risk
for substance abuse in half (Wilens, Faraone,
Antidepressants
Biederman, & Gunawardene, 2003).
Second to the stimulants and atomoxetine, the
antidepressants have been the most studied
Noradrenergic Agents
pharmacological treatment for ADHD (Spencer
Atomoxetine (Straterra) is a recently approved, et al., 1998). The tricyclic antidepressants (TCAs)
nonstimulant agent for children and adults have generally been considered second-line
with ADHD (Michelson et al., 2002; Michelson drugs of choice because of a long duration of ac-
et al., 2001). Atomoxetine is a highly specific tion, greater flexibility in dosage, and minimal
noradrenergic reuptake inhibitor with efficacy risk of abuse or dependence. Electrocardiographic
for ADHD (Michelson et al., 2002; Michelson and serum level monitoring is suggested.
et al., 2001) and perhaps comorbid anxiety, tics, The novel dopaminergic antidepressant bu-
and depression. Atomoxetine demonstrates no propion has been reported to be effective and
470 part vi • biology and pharmacotherapy

well tolerated in the treatment of ADHD chil- ADHD, conduct, and substance-use disorders.
dren (Conners et al., 1996). Bupropion should Juvenile mood disorders are chronic and highly
be started at 37.5 mg and slowly titrated up- recurrent. The antidepressants are the main-
ward with beneficial effects for ADHD gener- stay of treatment.
ally noted at less than 150 mg/day in children.
Bupropion may be particularly useful in youth
Serotonin-Specific Reuptake Inhibitors (SSRIs)
with ADHD and mood lability.
The SSRIs, including fluoxetine (Prozac), parox-
etine (Paxil), sertraline (Zoloft), fluvoxamine
Antihypertensives
(Luvox), and citalopram (Celexa, Lexapro), are
The antihypertensive agent clonidine has been generally considered the first-line drugs of
used increasingly for the treatment of ADHD, choice for juvenile depression (Ambrosini et al.,
particularly in younger children and those 1999; Emslie et al., 1997). These agents vary in
with hyperactivity and aggressivity (Hunt, how long they last and their adverse effects.
Minderaa, & Cohen, 1985). Clonidine is short- Whereas fluoxetine has a long half-life of seven
acting agent with daily dosing ranging 0.05 mg to nine days, paroxetine and sertraline have
to 0.6 mg given in divided doses up to four half-lives of approximately 24 hours. Because of
times daily. Clonidine is used adjunctly with its long half-life, missed doses of fluoxetine
the stimulants and antidepressants. Short-term have less effect on overall clinical stabilization
adverse effects include sedation (which tends to than the other SSRIs. In contrast, for children
subside with continued treatment), dry mouth, who are prone to develop mania, the selection of
depression, confusion, ECG changes, and hy- a shorter acting SSRI may be preferable.
pertension with abrupt withdrawal. A recent The suggested daily doses in pediatric sub-
multisite study demonstrated the usefulness of jects approximate those in adults and varies
clonidine alone and in combination for the among SSRIs. Treatment generally begins
treatment of ADHD in youth with tics (Kur- with 5 –10 mg of fluoxetine or paroxetine, or
lan, 2002). Abrupt withdrawal of clonidine has 25 mg of sertraline or fluvoxamine, and may be
been associated with rebound, thus, slow taper- titrated upward to full adult doses in some
ing is advised. Guanfacine (Tenex) has also cases (i.e., 20 –30 mg of fluoxetine or paroxe-
been used for ADHD. Dosing in school-age tine; 150 –200 mg of sertraline or fluvoxam-
children generally starts at 0.5 mg/day and ine). Common adverse effects of SSRIs include
gradually increased as necessary to a maxi- agitation, gastrointestinal symptoms, irritabil-
mum of 4 mg/day in two or three divided ity, insomnia, and headaches. Fluvoxamine
doses. Guanfacine appears to be longer acting, may cause sedation and is useful in children
less sedating, and more effective for attentional with comorbid sleep difficulties. Most of the
problems than clonidine (Spencer et al., 1998). SSRIs, in particular fluoxetine and paroxetine,
have been found to inhibit various hepatic
(liver) enzymes and thereby increase blood lev-
DEPRESSION els of other medications.

Juvenile depression may occur in up to 5% of

Other Antidepressants
adolescents. Childhood depression presents
with irritability, sad faces, low energy, isola- Venlafaxine (Effexor) possesses both serotoner-
tion, withdrawal, negativism, aggression, and gic and noradrengic properties and may prove to
suicidality (Birmaher, Ryan, Williamson, Brent, be useful in the treatment of juvenile mood dis-
& Kaufman, 1996; Birmaher, Ryan, William- orders with ADHD at typical doses of 50 –150
son, Brent, Kaufman, et al., 1996) Children mg daily. Adverse effects of venlafaxine are
with subsyndromal chronic depressive disor- similar to SSRIs with the addition of nausea,
ders may have dysthymic disorder. Childhood which generally improves within the first week
depression commonly co-occurs with anxiety, of administration, and increased blood pressure.
 94 • pediatric psychopharmacology 471

Bupropion may be helpful in children with children include the anticonvulsants valproic
prominent mood lability, dysthymia, or comor- acid (Depakote, Valproate), carbamazepine (Teg-
bid ADHD. Similar to the management of retol, Carbitrol), oxcarbazepine (Trileptal), and
ADHD (see above), bupropion should be started others (Kowatch et al., 2000). Valproic acid is
at 37.5 mg daily and titrated upward as neces- an anticonvulsant that is often used as a first-
sary with the major side effects including irri- line treatment and is dosed from 250 to 1500
tability, insomnia, tic exacerbation, and seizures. mg daily leading to therapeutic blood levels of
50 –100 mcg/ml. Common short-term side ef-
fects in children include sedation, nausea, and
BIPOLAR DISORDER increased appetite. Carbamazepine is dosed
from 200 mg to 1000 mg leading to therapeu-
In children, mania is commonly manifested by tic blood levels of between 4 to 12 mcg/ml.
an extremely irritable or explosive mood, un- Common side effects include dizziness, drowsi-
modulated high energy such as over talkative- ness, nausea, blurred vision, white blood cell
ness, racing thoughts, poor quality of sleep, or suppression, and serious rashes. Oxcarbazepine
increased goal-directed with associated poor is dosed typically to 1200 –1800 mg/daily (no
functioning (Geller et al., 1995; Geller et al., monitoring required). For valproic acid and car-
2000) Often, youths with bipolar disorder have bamazepine, monitoring of blood counts and
a relative with bipolar disorder. The clinical liver function are warranted during treatment.
course of juvenile mania is frequently chronic
and mixed with manic and depressive features
Atypical Antipsychotics
co-occurring. Bipolar disorder in youths often
onsets with depression with later switching Because of the adverse effects and paucity of ef-
into mania. Juvenile bipolar disorder is highly ficacy of the traditional agents for treating ro-
comorbid with ADHD, anxiety, oppositional bustly the symptoms of bipolar disorder, the
and conduct disorders, and in adolescents, sub- atypical antipsychotics have been increasingly
stance abuse. For juvenile bipolar disorders, the used alone or in combination with mood stabi-
mood stabilizers and atypical antipsychotics are lizers, for youth with bipolar disorder. Risperi-
the treatment of choice. done (Risperidal), quetiapine (Seroquel), olan-
zapine (Zyprexa), ziprasidone (Geodon), and
aripiprasole (Abilify) are the currently avail-
Mood Stabilizers
able atypical antipsychotics that are being used
Lithium is a salt that is considered one of the for mania. The atypical antipsychotics appear
initial agents for labile mood disorders (Alessi, to have both antimanic and antidepressant
Naylor, Ghaziuddin, & Zubieta, 1994) The qualities in youth with bipolar disorder (Fra-
usual lithium starting dosage ranges from 150 zier et al., 1999; Frazier et al., 2001).
to 300 mg in divided doses once or twice a day While generally well tolerated, short-term
and increased based on response, side effects, adverse effects of the atypicals include weight
and serum levels. Suggested serum levels are gain (olanzapine and risperidone), activation
from 0.6 to 1.5 mEq/l for acute episodes and (ziprasidone), and sedation (all). Unlike the
levels of 0.4 to 0.8 for maintenance therapy. traditional antipsychotics, the atypical agents
Common short-term side effects include gas- have a low liability to chronic movement disor-
trointestinal symptoms, frequent urination ders. No laboratory monitoring is required.
and drinking, tremor, somnolence, and rarely
memory impairment. The chronic administra-
tion of lithium may be associated with weight ANXIETY DISORDERS
gain, decreased thyroid functioning, and possi-
ble renal impairment. Children should be fol- The anxiety disorders encompass a wide range
lowed for renal and thyroid function. of clinical conditions in which anxiety is the
Alternative mood-stabilizing agents used in predominant feature (Bernstein & Borchardt,
472 part vi • biology and pharmacotherapy

1991; Reiter, Kutcher, & Gardner, 1992). These idence that therapeutic use predisposes these
include childhood disorders such as separation children to later abuse.
anxiety, generalized anxiety, and social phobia.
Also within the umbrella of anxiety disorders
of childhood is posttraumatic stress disorder, in OBSESSIVE COMPULSIVE
which there is an objective stressor outside the DISORDER
usual human experience along with the recur-
rent experiencing of the event and accompany- Obsessive compulsive disorder (OCD) affects
ing hypervigilence or dissociation. Children 1% to 2% of the population and is character-
may also present with panic disorder and ago- ized by persistent ideas or impulses (obses-
raphobia—a fear of places with limited escape. sions) that are intrusive and senseless, such as
Children with anxiety disorders often have thoughts of becoming contaminated or self-
other coexisting emotional factors such as de- doubting and repetitive, purposeful behaviors
pression as well as behavioral problems such as (compulsions) such as hand washing, counting,
ADHD. or touching in order to neutralize the obsessive
Children and adolescents with anxiety dis- worries (Swedo, Rapoport, Leonard, Lenane, &
orders respond to the same pharmacologic ap- Cheslow, 1989). Trichotillomania, the compul-
proaches as adult patients namely the benzodi- sive pulling out of one’s hair, may be related to
azepines and antidepressants (Bernstein & Bor- OCD. As with other disorders in youth, OCD
chardt, 1991). is often comorbid with other anxiety disorders,
depression, and ADHD. The serotonergic anti-
depressants are the most effective medications
Antidepressants
for OCD.
The initial pharmacological treatment of choice
for the wide umbrella of anxiety disorders in
Serotonin Reuptake Inhibitors
youth is the serotonin reuptake inhibitors (flu-
(SRIs)
voxamine and others) (Walkup et al., 2001). As
described above, these agents are useful in the There is a robust literature and FDA approval
chronic management of anxiety and can be of the efficacy and usefulness of the SSRIs for
combined with other agents for anxiety (ben- juvenile OCD (Geller et al., 2001; March et al.,
zodiazepines-above) or comorbid conditions 1998). Data indicate that relatively higher
(e.g. stimulants). Dosing is similar to that em- doses of the SRIs may be necessary for ade-
ployed for depressive disorders. No laboratory quate treatment of the condition (i.e., fluoxe-
and cardiovascular monitoring is necessary. tine doses of 40 –80 mg daily).
Clomipramine has been shown to be effica-
cious in youth with OCD (Swedo, Leonard, et
Benzodiazepines
al., 1989). Clomipramine is dosed from 50 to
The benzodiazepines remain alternative agents 200 mg daily and has side effects (e.g., dry
for anxiety (Graae, Milner, Rizzotto, & Klein, mouth, constipation) and monitoring require-
1994). Benzodiazepines are chosen based on ments similar to the other tricyclic antidepres-
how long they last and their strength. The sants.
more potent agents clonazepam (Klonopin) and
lorazepam (Ativan) are often used in children
with severe anxiety or panic; whereas the lower TICS AND TOURETTE’S DISORDER
potency agents like diazepam (Valium) can be
helpful in generalized anxiety. Dosing varies Tourette’s disorder is a childhood-onset neu-
between agents and is usually in divided daily ropsychiatric disorder that consists of multiple
doses. Short-term adverse effects are disinhi- motor and phonic tics and other behavioral and
bition and sedation. Although the benzodi- psychological symptoms (Cohen, Friedhoff,
azepines have an abuse liability, there is no ev- Leckman, & Chase, 1992). Affected patients
 94 • pediatric psychopharmacology 473

commonly have spontaneous waxing, waning, ity testing, such as the presence of delusions,
and symptomatic fluctuation. Tourette’s disorder hallucinations, or a thought disorder. Psychosis
is commonly associated with OCD, ADHD, and is present in schizophrenia and related disor-
anxiety disorders. The pharmacotherapy of tic ders, and in some forms of unipolar or bipolar
disorders has changed in recent years and is in- mood disorders. The antipsychotics (also re-
fluenced by the presence of comorbid conditions. ferred to as neuroleptics) are the major treat-
ment for psychosis.
Clonidine
Atypical Antipsychotics
Clonidine has been increasingly utilized as a
first-line drug of choice for tics and Tourette’s Because of the efficacy and tolerability, atypical
disorder (Cohen, Detlor, Young, & Shaywitz, antipsychotics are being increasingly used
1980). The mechanism of action of clonidine’s (Frazier et al., 1997). Risperidone (Risperidal)
effectiveness remains unknown. Dosing for is a high-potency agent that has fewer ex-
tics or Tourette’s disorder appears similar to trapyramidal adverse effects than traditional
those employed for the management of ADHD neuroleptics. Quetiapine (Seroquel), Olanza-
(see above). Recent data indicate that clonidine pine (Zyprexa), ziprasidone (Geodon), and
can be used adjunctly with methylphenidate aripiprasole (Abilify) are lower potency agents
for comorbid ADHD plus tic disorders (Kurlan, that are also very useful for psychosis and se-
2002). vere mood lability. The atypicals appear useful
in treating both positive and negative symp-
toms of psychotic illness. Weight gain, seda-
Antidepressants
tion, and infrequent motor dyskineias and ac-
The TCAs have been used in youth with this tivation are the major adverse effects of the
disorder. TCAs may be particularly helpful in atypical antipsychotics. Clozaril is a low-po-
reducing tic and ADHD symptoms in children tency agent that is infrequently used in treat-
with this comorbidity disorder (Spencer et al., ment refractory individuals, particularly those
2002). Patients with commonly comorbid OCD with negative symptoms or in those who de-
may need additional pharmacotherapy with velop tardive dyskinesia (Kumra et al., 1996).
serotonergic blocking drugs such as clomi- Clozapine has a relatively high incidence of
pramine, or the SRIs. dose-related seizures and bone marrow sup-
pression, making weekly to biweekly white
blood counts mandatory.
Antipsychotics
The antipsychotics remain efficacious agents
Traditional Antipsychotics
for tics in kids who fail to respond to more con-
ventional treatments (Cohen et al., 1992). The There is an extensive array of traditional
high-potency antipsychotics, including risperi- agents that are classified based on their potency
done, pimozide (Orap), and haloperidol (Hal- (strength) and, because of long-term adverse
dol), are generally used in doses of 0.5 to 2 effects, are considered second-line agents for
mg/day. However, antipsychotics have limited the treatment of psychosis. The low-potency
effects on the frequently associated comorbid agents requiring higher dosages include chlor-
disorders (ADHD and OCD) and carry a risk promazine (Thorazine) and thioridazine (Mel-
for substantial adverse effects. laril). The intermediate-potency agents include
trifluoperazine (Stelezine), thiothixene (Na-
vane), and perphenazine (Trilafon). The high-
PSYCHOSIS potency agents requiring lower dosages include
haloperidol (Haldol) and fluphenazine (Pro-
Psychosis is generally used to describe abnor- lixin). The usual daily doses range between 100
mal behaviors of children with impaired real- to 400 mg for the low-potency agents, 5 to 40
474 part vi • biology and pharmacotherapy

mg for the intermediate-potency agents, and Biederman, J. (1998). Attention-deficit/hyperactiv-

from 0.5 to 20 mg for the high-potency com- ity disorder: A life-span perspective. Journal of
pounds. Common short-term adverse effects of Clinical Psychiatry, 59(Suppl. 7), 4 –16.
antipsychotic drugs are motor restlessness or Biederman, J., Faraone, S., & Mick, E. (2000). Age
dependent decline of ADHD symptoms revis-
spasms, Parkinsonism, dry mouth, and signifi-
ited: Impact of remission definition and symp-
cant weight gain. However, whereas the low-
tom subtype. American Journal of Psychiatry,
potency agents are more likely to cause hy- 157, 816 – 817.
potension, tachycardia, and sedation, the high- Biederman, J., Newcorn, J., & Sprich, S. (1991). Co-
potency agents may cause muscle spasms. morbidity of attention deficit hyperactivity dis-
Long-term administration of antipsychotics order with conduct, depressive, anxiety, and
may be associated with abnormal involuntary other disorders. American Journal of Psychia-
motor movements called tardive dyskinesia try, 148, 564 – 577.
(Campbell, Adams, Perry, Spencer, & Overall, Birmaher, B., Ryan, N. D., Williamson, D. E., Brent,
1988). D. A., & Kaufman, J. (1996). Childhood and
adolescent depression: A review of the past 10
years. Part II. Journal of the American Acad-
emy of Child and Adolescent Psychiatry,
CONCLUSIONS
35(12), 1575 –1583.
Birmaher, B., Ryan, N. D., Williamson, D. E., Brent,
The field of pediatric psychopharmacology con- D. A., Kaufman, J., Dahl, R. E., Perel, J., & Nel-
tinues to expand as more agents are used and son, B. (1996). Childhood and adolescent de-
systematically tested for a broad spectrum of pression: A review of the past 10 years. Part I.
child psychopathological conditions. The use of Journal of the American Academy of Child and
combined pharmacotherapy has proved invalu- Adolescent Psychiatry, 35(11), 1427 –1439.
able for resistant and comorbid conditions. Es- Campbell, M., Adams, P., Perry, R., Spencer, E. K., &
sential features in treating child psychopathol- Overall, J. E. (1988). Tardive and withdrawal
ogy are a careful diagnostic assessment, the dyskinesia in autistic children: A prospective
study. Psychopharmacology Bulletin, 24(2),
proper sequencing of psychosocial and pharma-
251–255.
cological interventions, and the integration of
Cohen, D. J., Detlor, J., Young, J. G., & Shaywitz, B.
pharmacotherapy as part of a broader treat- A. (1980). Clonidine ameliorates Gilles de la
ment plan. Tourettes syndrome. Archives of General Psy-
chiatry, 37(12), 1350 –1357.
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Frazier, J. A., Biederman, J., Tohen, M., Feldman, Academy of Child and Adolescent Psychiatry,
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Hunt, R. D., Minderaa, R. B., & Cohen, D. J. (1985). chronic tic disorder and comorbid attention-
Clonidine benefits children with attention deficit/hyperactivity disorder. Archives of Gen-
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Child and Adolescent Psychiatry, 24, 617 – 629. tivity disorder: A life span perspective. In L.
Kowatch, R. A., Suppes, T., Carmody, T. J., Bucci, Dickstein, M. Riba, & J. Oldham (Eds.), Review
J. P., Hume, J. H., Kromelis, M., et al. (2000). of Psychiatry (Vol. 16, pp. IV87 –IV127).
Effect size of lithium, divalproex sodium, and Washington, DC: American Psychiatric Press.
carbamazepine in children and adolescents with Swedo, S. E., Leonard, H. L., Rapoport, J. L., Lenane,
bipolar disorder. Journal of the American M. C., Goldberger, E. L., & Cheslow, D. L.
476 part vi • biology and pharmacotherapy

(1989). A double-blind comparison of clomi- Wilens, T., Faraone, S., Biederman, J., & Gunawar-
pramine and desipramine in the treatment of dene, S. (2003). Does the pharmacotherapy of
trichotillomania (hair pulling). New England ADHD beget later substance abuse: A metana-
Journal of Medicine, 321(8), 496 – 501. lytic review of the literature. Pediatrics, 11(1),
Swedo, S. E., Rapoport, J. L., Leonard, H., Lenane, 179 –185.
M., & Cheslow, D. (1989). Obsessive-compul- Wilens, T., & Spencer, T. (2000). The stimulants re-
sive disorder in children and adolescents. visited. In C. Stubbe (Ed.), Child and adoles-
Archives of General Psychiatry, 46, 335 –341. cent psychiatric clinics of North America (3rd
Walkup, J., Labellarte, M. J., Riddle, M., Pine, D. S., ed., Vol. 9, pp. 573 – 603). Philadelphia: Saun-
Greenhill, L., Klein, R., et al. (2001). Fluvox- ders.
amine for the treatment of anxiety disorders in
children and adolescents. The Research Unit on
Related Topics
Pediatric Psychopharmacology Anxiety Study
Group. New England Journal of Medicine, Chapter 92, “Adult Psychopharmacology 1: Com-
344(17), 1279 –1285. mon Usage”
Wilens, T., Biederman, J., & Mick, E. (1998). Does Chapter 93, “Adult Psychopharmacology 2: Side Ef-
ADHD affect the course of substance abuse? fects and Warnings”
Findings from a sample of adults with and
without ADHD. American Journal on Addic-
tions, 7, 156 –163.

DIETARY SUPPLEMENTS AND

95 PSYCHOLOGICAL
FUNCTIONING

Sari Edelstein and Nancie H. Herbold

Psychological disorders and substance abuse can Dietary Allowance and Adequate Intake levels
be associated with nutritional deficiencies. The set by the National Academy of Sciences. These
origin of these nutritional deficiencies can be levels were intended to be necessary in the daily
due to under eating, overeating, abnormal eat- diet of healthy adults. Some nutrient supple-
ing patterns (Table 1) or as a side effect of alco- mentation may be contraindicated due to other
hol, drugs (Table 2), and medication use (Table chronic illness or medications the patient may
3). This chapter identifies the criteria for nutri- be sustaining. When the practitioner suspects a
ent supplementation, the recommended amount deficiency or toxicity, confirmation laboratory
of supplementation, and the signs of both nutri- values should be made along with consideration
ent deficiency and toxicity. The dosage values of other illness and medication use.
given in the tables represent the Recommended
 95 • dietary supplements and psychological functioning 477

table 1. Dietary Supplements

Nutrient RDA/AI
Deficiency Supplementation Toxicity
Diagnosis Symptoms and Dosagea Symptoms Food Sources

Eating disorders: Osteomalacia, Calcium, 1,000 mg/day Excessive bone Milk, cheese, turnip,
Anorexia nervosa osteoporosis calcification mustard greens, kale,
Bulimia broccoli
Bulimia nervosa Glossitis; Folate, 400 ug/day None known Liver, green leafy
megablastic vegetables, legumes,
anemia broccoli, nuts
Anemia, poor Zinc, 12–15 mg/day None known Meat, liver, eggs, seafood
wound healing
Anxiety Muscle weakness, Thiamin None known Pork, whole grains
poor appetite, Males: 1.2 mg/day
fatigue, Kor- Females: 1.1 mg/day
sakoff’s psychosis
Skin and mouth Niacin Flushing, tingling, Lean meats, poultry, peanuts,
lesions Males: 16 mg/day nausea, dizziness fish, organ meats
Females: 14 mg/day
Oral lesions Vitamin B6, 1.3 mg/day Numbness, ataxia, Red meats, liver, whole
bone pain, muscle grains, potatoes, corn, green
weakness vegetables
Pernicious anemia, Vitamin B12, 2.4 ug/day None known Meats, milk products, egg
possible depression,
anorexia
Glossitis, mega- Folate, 400 ug/day None known Liver, green leafy vegeta-
blastic anemia bles, legumes, broccoli, nuts
Anemia, poor Zinc, 12–15 mg/day None known Meat, liver, eggs, seafood
wound healing
Muscle tremors, Magnesium Increased calcium Whole grains, nuts, dried
irritability, tetany, Males: 420 mg/day secretion beans, peas
hyperhypoflexia Females: 320 mg/day
Myalgia, muscle Selenium Nausea, abdominal Meat, eggs, milk, whole
tenderness, fragile Males: 70 ug/day pain, diarrhea, grains, seafood, garlic
red blood cells Females: 55 ug/day fatigue
Depression Skin and mouth Niacin Flushing, tingling, Lean meats, poultry,
lesions, depessive Males: 16 mg/day nausea, dizziness peanuts, fish, organ meats
psychosis Females: 14 mg/day
Oral lessions Vitamin B6, 1.3 mg/day Numbness, ataxia Red meats, liver, whole
bone pain, muscle grains, potatoes, corn, green
weakness vegetables
Glossitis, mega- Folate, 400 ug/day None known Liver, green leafy vegetables,
blastic anemia legumes, broccoli, nuts
Bleeding gums, Vitamin C GI upset, kidney Citrus fruit, tomatoes,
loose teeth, pin- Males: 90 mg/day stones, excess iron potatoes, brussel sprouts,
point hemorrhages Female: 75 mg/day absorption broccoli, strawberries
Muscle tremors, Magnesium Increased calcium Whole grains, nuts, dried
irritability, tetany, Males: 420 mg/day secretion beans, peas
hyperhypoflexia Females: 320 mg/day
Poor iron absorp- Copper, 2.0 mg/day Wilson’s disease, Liver, kidney, shellfish, nuts,
tion, neutropenia, liver cirrhosis, raisins, chocolate
bone demineral- neurological
ization deterioration
Schizophrenia Skin and mouth Niacin Flushing, tingling, Lean meats, poultry, peanuts,
lesions, depressive Males: 16 mg/day nausea, dizziness fish, organ meats
psychosis Females: 14 mg/day

(continued)
478 part vi • biology and pharmacotherapy

table 1. Dietary Supplements (continued)

Nutrient RDA/AI
Deficiency Supplementation Toxicity
Diagnosis Symptoms and Dosagea Symptoms Food Sources

Muscle tremors, Magnesium Increased calcium Whole grains, nuts, dried

irritability, tetany, Males: 420 mg/day secretion beans, peas
hyperhypoflexia Females: 320 mg/day
Bleeding gums, Vitamin C GI upset, kidney Citrus fruit, tomatoes,
loose teeth, pin- Males: 90 mg/day stones, excess iron potatoes, brussels sprouts,
point hemorrhages Females: 75 mg/day absorption broccoli, strawberries
Organic brain Pernicious anemia, Vitamin B12, 2.4 ug/day None known Meats, milk products, egg
syndromes possible depression,
anorexia
Osteomalcia Vitamin D, 5 ug/day Hypercalcemia Fish, liver, eggs, fortified
nausea, vomiting, milk
polydipsia, polyuria
Myalgia, muscle Selenium Nausea, abdomi- Meat, eggs, milk, whole
tenderness, fragile Males: 70 ug/day nal pain, diarrhea, grains, seafood, garlic
red blood cells Females: 55 ug/day fatigue
Anemia, poor Zinc, 12–15 mg/day None known Meat, liver, eggs, seafood
wound healing

aFood and Nutrition Board, 1989; Food and Nutrition Board, 1998.

table 2. Nutritional Supplementation for Substance Abuse

Nutrient Recommended Dietary
Deficiency Supplementation Toxicity
Diagnosis Symptoms and Dosage Symptoms

Folic acid deficiency Glossitis, megablastic anemia Folate, 400 ug/day None known
Thiamin deficiency Muscle weakness, poor Thiamin None known
appetite, fatigue, depression; Males: 1.2 mg/day
Korsakoff’s psyhosis Females: 1.1 mg/day
Vitamin B-12 deficiency Pernicious anemia, possible Vitamin B12, 2.4 ug/day None known
depression, anorexia
Vitamin B6 deficiency Oral lesions Vitamin B6, 1.3 mg/day Numbness, ataxia, bone pain,
muscle weakness
Vitamin A deficiency Dry eyes, gradual loss of Vitamin A Fatigue, vertigo, night sweats,
vision, hyperkeratosis of Males: 900 mg/day lesions on lips and skin, abdom-
skin Females: 700 mg/day inal pain, vomiting, jaundice
Zinc deficiency Anemia, poor wound healing Zinc, 12–15 mg/day None known
Copper deficiency Poor iron absorption, neutro- Copper, 2.0 mg/day Wilson’s disease, liver cirrhosis,
penia, bone demineralization neurological deterioration

Source: Food and Nutrition Board, 1989; Food and Nutrition Board, 1998.

table 3. Medications and Their Nutritional Effects

Medication Nutritional Effect Recommendation

Alprazolam (Xanax) Increased or decreased appetite, anorexia, Take with food or water, limit caffeine, avoid
increased or decreased weight, increased alcohol, caution with some herbal products
salivation, dry mouth, nausea, vomiting, (kava)
constipation
Amantadine HCL Anorexia, dry mouth, nausea, constipation Avoid alcohol
(Symmetrel)
 95 • dietary supplements and psychological functioning 479

table 3. Medications and Their Nutritional Effects

Medication Nutritional Effect Recommendation

Amitriptyline (Elavil) Dry mouth, nausea, vomiting, anorexia, Take with food, increase fiber may decrease
taste changes, epigastric distress, diarrhea, drug effect. Limit caffeine, avoid alcohol, avoid
constipation, paralytic ileus St. John’s Wort, avoid SAM-e, avoid yohimbe.
Bupropion (Wellbutrin) Anorexia, decreased weight, increased Take with food, avoid alcohol, avoid St. John’s
appetite, increased weight, dry mouth, Wort. Possible anemia.
stomatitis, dyspepsia, nausea, diarrhea,
vomiting, constipation
Benztropine mesylate Dry mouth, nausea, vomiting, epigastric Take with food, avoid alcohol
(Cogentin) distress, constipation
Carbamazepine (Tegretol) Anorexia, dry mouth, decreased appetite, Take with food, avoid alcohol, avoid psyllium
stomatitis, glossitis, nausea, vomiting, seed, aplastic anemia, caution with grapefruit
abdominal pain, constipation, diarrhea juice
Clonazepam (Klonopin) Dry/sore mouth, constipation, abdominal Take with food, limit caffeine, avoid alcohol,
cramps, gastritis, changes in appetite, caution with some herbal products
nausea, anorexia, diarrhea, increased
salivation
Clozapine (Clozaril) Increased appetite, increased weight, Take with food, limit caffeine, avoid alcohol,
anorexia, dry mouth, increased salivation, avoid St. John’s wort. Nutmeg may reduce
nausea, vomiting, dyspepsia, severe effectiveness of drug therapy.
constipation, diarrhea
Diazepam (Valium) Occasional nausea and vomiting, Contraindicated for people with soy protein
diarrhea, constipation sensitivity. Take with food, avoid caffeine,
avoid alcohol, avoid kava.
Fluoxetine (Prozac) Anorexia, decreased weight, dry mouth, Take in A.M. with meals. No tryptophan
taste changes, dyspepsia, nausea, vomiting, supplements. Avoid alcohol, avoid St. John’s
diarrhea, constipation wort. Caution with diabetes—hypoglycemia.
Haloperidol (Haldol) Increase appetite, increase weight, Take with food, avoid alcohol
anorexia, dry mouth, increased salivation,
dyspepsia, nausea, vomiting, constipation,
diarrhea
Lorazepam (Ativan) Occasional dry mouth, nausea, constipation Take with food, avoid caffeine, avoid alcohol
Levodopa (Dopar, Dry mouth, bitter taste, nausea, vomiting, May take with low protein food or juice, not
Larodopa) anorexia, constipation, diarrhea, abdominal with high protein food
pain, excessive salivation, increased or
decreased weight, epigastric distress
Lithium carbonate Decreased appetite, increased thirst, Take with foods, avoid caffeine, avoid alcohol,
metallic taste, dry mouth, nausea, vomit- avoid psyllium seed since it may inhibit
ing, diarrhea, transient hyperglycemia absorption
Nortriptyline (Pamelor) Increased or decreased appetite, dry mouth, Take with food, avoid caffeine, avoid alcohol,
nausea, vomiting, constipation avoid St. John’s Wort
Paroxetine (Paxil) Decreased appetite, increased or decreased Take with food, avoid St. John’s Wort, avoid
weight, dry mouth, taste changes, nausea, SAM-e, avoid yohimbe
dyspepsia, constipation, diarrhea
Phenelzine sulfate (Nardil) Possible B6 deficiency, increased appetite, Avoid foods high in tyramine and tryptophan
increased weight such as cheese, yogurt, pickled, fermented, and
smoked foods. Limit caffeine, avoid tryptophan
supplements, may need B6 supplement, avoid
St. John’s wort, avoid alcohol. Caution with
diabetes as it may decrease serum glucose.
Phenobarbital Nausea, vomiting, constipation Increase Vitamin D and Calcium intake. Limit
(Phenobarbital) xanthine/caffeine, avoid alcohol. May need
Vitamin D, Vitamin B12, and Folate
supple ment with long-term use.

(continued)
480 part vi • biology and pharmacotherapy

table 3. Medications and Their Nutritional Effects (continued)

Medication Nutritional Effect Recommendation

Phenytoin (Dilantin) Taste changes, dysphagia, nausea, Take with food or milk, avoid alcohol, caution
vomiting, constipation with diabetes as it may increase serum glucose.
Folate supplement needed. May need Vitamin
D supplement.
Risperidone (Risperdal) Increased appetite, increased weight, Take with food, avoid alcohol
increased or decreased salivation, nausea,
vomiting, dyspepsia, constipation,
diarrhea, abdominal pain
Sertraline HCL (Zoloft) Increased or decreased appetite, dry Take with food, avoid alcohol, anemia
mouth, nausea, vomiting, diarrhea,
constipation, dyspepsia
Trifluoperazine (Stelazine) Dry mouth, constipation, nausea, Avoid alcohol, avoid kava, avoid St. John’s
increased weight wort, avoid yohimbe
Valproic acid (Depakene) Anorexia, increased or decreased weight, Take with food, avoid alcohol. Do not take with
increased appetite, nausea, vomiting, milk. Do not take syrup in carbonated beverages
indigestion, cramps, gastroenteritis, as it may cause mouth/throat irritation or
diarrhea, constipation unpleasant taste.
Venlafaxine (Effexor) Anorexia, increased or decreased weight, Take with food, avoid St. John’s wort, avoid
increased appetite, dry mouth, taste alcohol
changes, nausea, vomiting, constipation,
diarrhea, dyspepsia

Source: Food and Nutrition Board, 1989; Food and Nutrition Board, 1998.

References & Readings B12, pantothenic acid, biotin, and choline. Wash-
ington, DC: National Academy Press.
Alpert, J. E., Mischoulon, D., Nierenberg, A. A., & Institute of Medicine, National Academy of Sci-
Fava, M. (2000). Nutrition and depression: Focus ences. (2000). Dietary reference intakes for vita-
on folate. Nutrition, 16, 544 – 546. min C, vitamin E, selenium, and carotenoids.
Bottiglieri, T., Laundy, M., Crellin, R., Toone, B. K., Washington, DC: National Academy Press.
Carney, M. W., & Reynolds, E.H. (2000). Homo- Institute of Medicine, National Academy of Sci-
cysteine, folate, methylation, and monoamine ences. (2001). Dietary reference intakes for vita-
metabolism in depression. Journal of Neurology, min A, vitamin K, arsenic, boron, chromium,
Neurosurgery, and Psychiatry, 69, 228 –232. copper, iodine, manganese, molybdenum, nickel,
Food and Nutrition Board. Institute of Medicine– silicon, vanadium and zinc. Washington, DC: Na-
National Academy of Sciences. (1998). Dietary tional Academy Press.
reference intakes (AI). Washington, DC. Penninx, B. W. J. H., Guralnik, J. M., Ferrucci, L.,
Food and Nutrition Board. National Academy of Sci- Fried, L. P., Allen, R. H., & Stabler, S. P. (2000). Vi-
ences–National Research Council. (1989). Recom- tamin B12 deficiency and depression in physically
mended dietary allowances (RDA). Washington, DC. disabled older women: Epidemiologic evidence
Hansen, C. M., Shultz, T. D., Kwak, H., Memon, from the Women’s Health and Aging Study.
H. S., & Leklem, J. E. (2001). Assessment of vita- American Journal of Psychiatry, 157, 715 –721.
min B-6 status in young women consuming a Stewart, J. W., Harrison, W., Quitkin, F., & Baker, H.
controlled diet containing four levels of vitamin (1984). Low B-6 levels in depressed outpatients.
B-6 provides an estimated average requirement Biological Psychiatry, 19, 613 – 616.
and recommended dietary allowance. American
Journal of Clinical Nutrition, 131, 1777 –1786.
Institute of Medicine, National Academy of Sci- Related Topics
ences. (1997). Dietary reference intakes for cal-
cium, phosphorous, magnesium, vitamin D and Chapter 93, “Adult Psychopharmacology 2: Side Ef-
fluoride. Washington, DC: National Academy Press. fects and Warnings”
Institute of Medicine, National Academy of Sci- Chapter 96, “Common Drugs of Abuse”
ences. (1998). Dietary reference intakes for thi- Chapter 102, “Known and Unproven Herbal Treat-
amin, riboflavin, niacin, vitamin B6, vitamin ments for Psychological Disorders”
 96 COMMON DRUGS OF ABUSE

Christopher J. Correia & James G. Murphy

In 2002, the Substance Abuse and Mental Health PREVALENCE OF DRUG USE
Services Administration’s (SAMHSA, 2001) Na-
tional Household Survey on Drug Abuse esti- Table 1 presents SAMHSA prevalence rates for
mated that 28 million Americans aged 12 or the most common drugs of abuse. The 2001
older, or 13% of the population, used an illicit survey included a representative sample of
drug during the previous year. Approximately 17 68,929 Americans above the age of 12. In Table
million (7%) met the DSM-IV diagnostic crite- 1, “binge” alcohol use is defined as drinking
ria for substance abuse or dependence, which are five or more drinks on the same occasion on at
among the most common mental disorders (see least one day in the past 30 days. Heavy alcohol
also Karpiak & Norcross, chap. 1, this volume). use is defined as drinking five or more drinks
Because drug use afflicts individuals from every on the same occasion on five or more days in
demographic group, and because drug-related the past 30 days; all heavy alcohol users are
problems are common in clinical settings, it is also “binge” alcohol users. Illicit drugs include
important for all mental health professionals to prescription-type drugs used nonmedically.
understand the common drugs of abuse. The table provides information for three age

table 1. Prevalence Rates for Common Drugs of Abuse

Serious
Mental
Age 12–17 Age 18 –25 Age 26 and older Illness

Past Past Past Past Past Past Past

Drug Lifetime year month Lifetime year month Lifetime year month year

Alcohol 42.9 33.9 17.3 85.0 75.4 58.8 86.5 65.7 50.8 50.8
Binge alcohol use — — 10.6 — — 38.7 — — 18.8 27.2
Heavy alcohol use — — 2.5 — — 13.6 — — 4.8 8.7
Any tobacco 37.0 23.4 15.1 73.6 53.1 43.9 77.5 33.3 29.0 48.1
Any illicit drug 28.4 20.8 10.8 55.6 31.9 18.8 41.2 8.2 4.5 26.5
Marijuana and hashish 19.7 15.2 8.0 50.0 26.7 16.0 37.0 5.6 3.2 18.8
Cocaine 2.3 1.5 0.4 13.0 5.7 1.9 13.6 1.2 0.6 5.2
Heroin 0.3 0.2 0.0 1.6 0.5 0.2 1.5 0.2 0.0 0.7
Hallucinogens 5.7 4.0 1.2 22.1 9.3 2.7 11.9 0.5 0.1 4.3
Inhalants 8.6 3.5 1.0 13.4 2.5 0.6 7.1 0.2 0.1 1.5
Nonmedical use of:
Pain relievers 9.4 6.4 2.6 18.2 9.6 3.6 8.4 2.3 1.1 10.4
Tranquilizers 2.6 1.7 0.5 8.9 4.2 1.3 6.2 1.2 0.5 6.2
Stimulants 3.7 2.2 0.7 9.5 3.4 1.3 7.1 0.6 0.3 3.5
Sedatives 0.7 0.3 0.1 1.9 0.6 0.2 3.9 0.3 0.1 1.7
Any illicit drug other
than marijuana 18.7 12.0 4.9 35.4 18.4 7.8 24.9 4.4 2.0 17.5

Source: SAMHSA, 2002.

481
482 part vi • biology and pharmacotherapy

groups and for those with a serious mental ill- ASSESSMENT CONSIDERATIONS
ness, defined as having a DSM-IV disorder that
Drug-Use Patterns
results in functional impairment or interferes
with regular life activities. A drug-use assessment should begin with
These data demonstrate that alcohol and questions about lifetime and current use of
marijuana are the most commonly used drugs drugs, with consideration of the base rate for
across all age groups. Individuals under 26 the client’s demographic group (see Table 1).
years old and persons with a serious mental ill- Individuals are most likely to provide accurate
ness are much more likely to use all classes of information when they are asked about use of
illicit drugs. In fact, only 4% of adults (age 26 specific substances, including misuse of pre-
or older) without a serious mental illness re- scription drugs. In some settings, biological
ported using any drug other than marijuana or tests (e.g., breath, hair, saliva, urine) can be
alcohol in the past year. used to detect recent drug use. The validity of
self-reports can be enhanced by asking about
drug use in a nonjudgmental manner and by
DRUGS OF ABUSE providing assurance of confidentiality. In the
absence of legal or other repercussions (e.g.,
Table 2 provides an overview of the common loss of child custody or employment) for re-
drugs abused — specifically, their slang names, porting drug use, self-reports of drug use are
routes of administration, acute effects, adverse generally consistent with collateral reports and
effects, tolerance potential, and how they inter- biological tests (Tucker, Vuchinich, & Murphy,
act with other drugs. To avoid redundancy, the 2002).
adverse effects of drug use on a developing After gathering information about recent
fetus are not mentioned in the table, although drug use, assess quantity and frequency of use
all nonmedical drug use should be discontinued over time. Drug-use patterns are generally
during pregnancy. The table provides only gen- quite variable, and information on contextual
eral information on drug interactions; it is not factors associated with periods of abstinence or
an exhaustive list of potentially hazardous increased use can be useful for treatment plan-
drug interactions. ning. Changes in substance use are often pre-
Although prescription medications are gen- ceded by changes in other life areas, including
erally safe when used as prescribed, when mis- employment, relationships, and physical
used their subjective effects and addiction po- health. Since many abused drugs are not sold
tential are similar to illicit drugs of abuse. For in standard quantities, money spent on drugs
example, medications such as opioid analgesics and hours/days spent under the influence are
(e.g., Oxycodone), methylphenidate (Ritalin), useful proxies for drug amount. It is also cru-
and benzodiazepines (e.g., Valium) can produce cial to gather information on route of adminis-
physiological and subjective effects that are tration, since this has implications for drug po-
similar to heroin, cocaine, and alcohol, respec- tency, abuse potential, and HIV/hepatitis C
tively. Prescription drug misuse is especially risk. In general, snorting, smoking, and inject-
common among young adults, individuals with ing drugs are associated with increased potency
other substance-abuse or mental health prob- and abuse potential relative to oral ingestion.
lems, and individuals who have been treated For example, prescribed drugs such as Oxycon-
with prescription analgesics or sedatives for tin or Ritalin are often crushed and either
long periods (e.g., chronic pain or anxiety pa- snorted or injected for a more potent and ad-
tients). dicting high.

Risks and Negative Consequences

Regular drug use is associated with significant
social, interpersonal, legal, health, and occupa-
table 2. Common Drugs of Abuse: Summary of Routes of Administration, Effects, and Interactions
Drugs, Commercial Routes of Tolerance and Drug
and Slang Name Administration Acute Effects of Intoxication Possible Adverse Effects Dependence Interactions

Cannabinoids—Cannabis products such as marijuana and hashish contain THC, a chemical that produces mild sedative, euphoric, and hallucinogenic effects. Although there is no
risk for overdose, regular use can result in tolerance, functional impairment, and mild withdrawal symptoms.
Hashish Smoked via Increased pulse and appetite, dry Some users experience brief paranoid Tolerance occurs with repeated May interact with heart
boom, hash, cigarette, pipe, or mouth, enhanced sensory reactions and panic. Chronic use of use. Withdrawal symptoms and blood pressure
hash oil, hemp water filtered perception, mild euphoria, smoked THC associated with include restlessness, anxiety, medication, or with other
Marijuana pipe (i.e., bong). relaxation, sedation, and psycho- pulmonary damage. Possible deficits depression, irritability/aggression, drugs that suppress the
Marinol, pot, Can also be motor impairment. Possible in learning, cognition, and motivation. insomnia, tremor, and chills. immune system.
grass, weed, administered dizziness, illusions, and Possible precipitant of psychotic Withdrawal does not pose
reefer, blunt orally. hallucinations episode among those with latent medical risk.
potential. Possible immunosuppressant.

CNS depressants—These include alcohol, barbiturates, benzodiazepines, and other drugs that induce behavioral depression, sedation, and relief from anxiety. At high doses these
drugs produce motor impairment, amnesia, unconsciousness, and potentially fatal respiratory depression. Chronic use of CNS depressants can produce physical dependence, in-
cluding severe withdrawal symptoms.
Alcohol Benzodiazepines Effects of CNS depressants can Dangerous levels of respiratory Tolerance occurs with long-term Can produce potentially
barbiturates and alcohol are be context dependent and depression. Sedation, impaired use. Withdrawal symtoms include lethal respiratory
Amytal, Seconal, orally administered. “biphasic.” Euphoria and dis- judgment and cognitive performance, agitation and increased anxiety, depression when taken in
Phenobarbital, inhibition are common at low anmesia, and psychomotor impair- insomnia, muscle tension, and combination with other
barbs, reds, yellows to moderate doses. High doses ment. These effects can increase risk nausea with vomiting. Severe CNS depressants (e.g.,
Benzodiazepines produce clouded sensorium, for automobile accidents, falls, and withdrawal symptoms include alcohol), or with heroin
Diazepam (Valium) sedation, impaired judgment and high-risk behavior. High doses of tremors and seizures (e.g., or prescription analgesics.
Lorazepam (Ativan), motor ability, amnesia/blackouts, alcohol can lead to asphyxiation from deliriums tremens), hallucinations,
Clonazepam affect lability, aggression, delu- vomiting. Chronic heavy use of and psychotic symptoms. These
(Klonopin), sions, and hallucinations. alcohol can lead to irreversible symptoms can be fatal and often
Alprazolam (Xanax), Benzodiazepines are intended liver damage, dementia, pancreatitis, require medical attention.
candy, downers, for short-term relief of anxiety gastritis, peptic ulcers, and cancers.
sleeping pills and insomnia; higher doses pro-
duce lightheadedness, vertigo,
and muscle incoordination.

(continued)
 table 2. Common Drugs of Abuse: Summary of Routes of Administration, Effects, and Interactions (continued)
Drugs, Commercial Routes of Tolerance and Drug
and Slang Name Administration Acute Effects of Intoxication Possible Adverse Effects Dependence Interactions

Dissociative anesthetics—These drugs are difficult to classify, as they produce a combination of stimulant, depressant, and hallucinogenic effects. They can also cause fatal over-
doses resulting from seizures and coma. Ketamine is also referred to as a “club drug” because of its association with all-night dance parties (raves).

Ketamine Ketamine can be Dream-like disorientation, PCP can cause potentially lethal Tolerance rises quickly, and Dangerous when used with
cat, K, special K, injected, snorted, or euphoria, and analgesia. seizures and coma. Possible acute chronic users will experience other drugs that depress
vitamin K, date smoked. PCP can Impaired motor functioning, and prolonged psychotic states, permanent tolerance after several respiration. Psychological
rape drug also be swallowed. slurred speech, and detachment leading to bizarre or dangerous months of use. These drugs do effects are unpredictable
Phencyclidine from environment. Increased behaviors. Ketamine produces more not appear to produce withdrawal when taken with other
PCP, angel dust, heart rate, blood pressure, and extreme CNS depression, numbness, symptoms or physical addiction. drugs.
boat, hog, love temperature. nausea and vomiting, amnesia and
boat, peace pill, dissociation.
rocket fuel, sherms

Entactogens—Drugs from this class produce both stimulant and mild hallucinogenic effects. They are sometimes referred to as “designer drugs,” or as “club drugs” because of
their association with all-night dance parties (raves).
484

Methylenedioxy- Usually swallowed MDMA produced mild hallu- MDMA can be fatal when combined Tolerance develops, but there Over-the-counter cold
amphetamine in the form of a pill, cinogenic effects, increased with high levels of physical activity, is no evidence of physical remedies and MAO
MDA although pure tactile sensitivity, empathic leading to hyperthermia, hyper- withdrawal. After-effects can inhibitors. MDMA and
Methylenedioxy- powder forms are feelings, mental alertness, and tension, and kidney failure. MDMA include fatigue, depression, and Viagra may cause
ethlylamphetamine sometimes injected, sympathetic nervous system appears to lead to long-term changes anxiety. dangerous changes in heart
MDEA, Eve and tablets can be stimulation. MDEA effects in the serotonergic system, which rate and blood pressure,
Methylenedioxy- inserted into the resemble those of MDMA, but may result in residual anxiety, and prolonged erection
methamphetamine anus. without the empathic qualities. depression, and cognitive impairment. leading to permanent
MDMA, Ecstasy, MDA produces stronger Flashbacks following repeated use anatomical changes.
X, XTC, Adam, hallucinogenic effects have been reported.
lover’s speed, peace,
STP. Trail mix and
sextasy used to
denote combina-
tion of MDMA
and Viagra
(sildenafil citrate).
 table 2. Common Drugs of Abuse: Summary of Routes of Administration, Effects, and Interactions (continued)
Drugs, Commercial Routes of Tolerance and Drug
and Slang Name Administration Acute Effects of Intoxication Possible Adverse Effects Dependence Interactions

Hallucinogens—Hallucinogens produce altered states of perception and intense emotions that vary widely across individuals and occasions. Hallucinogens do not produce depen-
dence, although use of these drugs can result in negative physical and psychological consequences.
Dimethyltrypyamine Oral administration Altered states of perception and Psychological symptoms such as Tolerance builds up rapidly but Mescaline can be
DMT, business is typical. LSD can bodily sensations, intense emotional lability, panic, and fades after a few days. Hallucino- dangerous when used in
man’s trip also be absorbed emotions, detachment from self paranoia can lead to bizarre or gens do not produce withdrawal combination with other
Lysergic acid through mouth and environment, and, for some dangerous behavior. Persisting and are not physically addictive. stimulants. Effects are
diethylamide tissue; DMT and users, feelings of insight with mental disorders, including panic more unpredictable when
LSD, acid, blotter, mescaline can be mystical or religious significance. attacks and psychosis, after use in taken with other drugs.
cubes, microdot smoked Mescaline also has some those with latent potential.
Mescaline amphetamine-like effects. Hallucinogenic persisting
peyote, buttons, perception disorder (flashbacks).
cactus
Psilocybin
485

psychedelic or
magic mushrooms,
shrooms

Inhalants—The drugs in this category have little in common in terms of chemical structure, pharmacology, or behavioral effects. They are all taken by inhalation, however, and
thus are often considered as a group.

Anesthetics Inhalation Rapid onset of sedation, Use of inhalants can lead to lack Tolerance and withdrawal are Interactions with other
nitrous oxide euphoria, and disinhibition. of oxygen, ischemia of heart tissue, possible with prolonged use of drugs with depressant
Solvents Acute effects can include loss of life-threatening cardiac arrhythmias, nitrates. Tolerance to nitrous oxide effects, including cold
paint thinner, consciousness, blackout, muscle cardiac collapse, peripheral nerve is possible but unlikely with medicines, opiates, alcohol,
glue, correction weakness, impaired coordination, damage, liver or kidney damage, recreational use. Little is known barbiturates, and
fluid, marker pens and slurred speech. Nitrates and suffocation. Regular use can about the tolerance and with- benzodiazepines are
Gases dilate blood vessels and produce produce irreversible brain and drawal profile of other especially dangerous.
butane, propane sensation of heat and excitement peripheral nerve damage. inhalants. Nitrates and Viagra can
Aerosols believed to enhance sexual lead to fatal changes in
paint, hair spray pleasure. blood pressure.
Nitrites
“poppers” from
heart medications
 (continued)
table 2. Common Drugs of Abuse: Summary of Routes of Administration, Effects, and Interactions (continued)
Drugs, Commercial Routes of Tolerance and Drug
and Slang Name Administration Acute Effects of Intoxication Possible Adverse Effects Dependence Interactions

Opioid analgesics—These drugs bind to the opioid receptors and block the transmission of pain messages to the brain. They also produce euphoria, drowsiness, and potentially
fatal respiratory depression. Chronic use can produce physical dependence, including severe withdrawal symptoms.
Heroin Heroin is injected, Analgesia, euphoria, sedation, Respiratory depression can be fatal Tolerance occurs with prolonged Interactions with CNS
black tar, smack, smoked, and used reduced anxiety, tranquility, at high doses, or when regular users use. Withdrawal symptoms depressants such as
junk, dope intranasally. Oral respiratory depression, and use in novel environments. Other include craving, sweating, alcohol or benzodiazepines
Prescription medications are cough suppression. side effects include nausea, vomiting, anxiety, depression, irritability, can cause potentially
Analgesics misused by constipation and intestinal cramping, fever, chills, vomiting, diarrhea, fatal respiratory
Morphine, crushing tablet severe itching, and asthma-like and pain. Compulsive use to depression.
Codeine, Demeral, and snorting or symptoms. HIV, Hepatitis C, and avoid withdrawal is common.
Oxycodone injecting. bacterial infections are spread
Oxycontin, through injecting.
Percocet, Vicodin

Stimulants—These drugs produce sympathetic nervous system stimulation, which leads to increased heart rate and blood pressure, and an increase in purposeful movement.
Additional effects include euphoria, increased alertness, and increased energy.

Amphetamines Injected, smoked, Feelings of euphoria, increased Rapid or irregular heart beat, heart Tolerance builds quickly. Users Over-the-counter
Adderall, and snorted. energy, mental alertness, and failure, respiratory failure, strokes, typically experience fatigue and decongestants, MAO
Dexedrine, Stimulant rapid speech. Signs of seizures, headaches, abdominal pain, dysphoria after intoxication. inhibitors, medications
bennies, speed medication can be sympathetic nervous system nausea. With prolonged exposure to Withdrawal symptoms are rarely that raise heart rate or
Cocaine swallowed, or stimulation including high doses, a psychotic state of dangerous but include fatigue, that increase sensitivity
coke, blow, crack crushed and then increased heart rate, blood hostility and paranoia can emerge anxiety, sleeplessness, to seizures.
Methamphetamine snorted or injected. pressure, temperature, and that is similar to acute paranoid irritability, anhedonia, and
crank, crystal fire, both purposeful and schizophrenia. Specific effects of depression.
ice, meth, speed compulsive movements. prolonged exposure to nicotine
Methylphenidate products include chronic lung
Ritalin, vitamin R disease, cardiovascular disease,
Nicotine stroke, and cancer.
Chew, cigars,
cigarettes, smoke-
less tobacco, snuff,
spit tobacco
 96 • common drugs of abuse 487

tional impairment. Substance abusers typically K., Linzer, M., Brody, D., et al. (1995). Psychiatric
present for treatment because of substance- comorbidity, health status, and functional impair-
related impairment, such as marital or health ment associated with alcohol abuse and depen-
problems, rather than substance use itself. dence in primary care patients: Findings of the
PRIME MD-1000 study. Journal of Consulting &
Thus, clinicians need to discuss drug-related
Clinical Psychology, 63, 133 –140.
negative consequences, and query about the
Julien, R. M. (2001). A primer of drug action (9th
presence of symptoms of drug dependence, ed.). New York: Worth.
such as increasing tolerance, withdrawal symp- Kuhn, C., Swartzwelder, S., & Wilson, W. (1998).
toms, and compulsive use. Buzzed: The straight facts about the most used
It is especially important to carefully assess and abused drug from alcohol to ecstasy. New
risk for immediate harm resulting from drug York: Norton.
use. High-risk behaviors such as sharing injec- National Institute on Drug Abuse. (2003). Informa-
tion needles, driving while intoxicated, risky tion on common drugs of abuse. Retrieved 2004
sexual behavior, and taking dangerous drug from http://www.drugabuse.gov/drugpages
combinations should be an immediate treat- Reiger, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z.,
Keith, S. J., Judd, L. L., et al. (1990). Comorbidity
ment priority.
of mental disorders with alcohol and other drug
abuse: Results from the Epidemiological Catch-
Comorbidity ment Area (ECA) study. Journal of the American
Medical Association, 21, 2511–2518.
Substance-use disorders occur among those Substance Abuse and Mental Health Services Ad-
with other DSM-IV disorders at elevated rates, ministration. (2002). Results from the 2001 Na-
relative to the general population. In fact, 37% tional Household Survey on Drug Abuse: Volume
of alcohol abusers and 53% of drug abusers I. Summary of National Findings (Office of Ap-
meet criteria for an additional mental disorder plied Studies, NHSDA Series H-17, DHHS Pub-
(Reiger et al., 1990). Stated differently, 29% of lication No. SMA 02-3758). Rockville, MD.
persons with a mental disorder were comorbid Substance Abuse and Mental Health Services Ad-
ministration. (2003). National clearinghouse for
for a substance-use disorder. Persons with more
alcohol and drug information: PREVLINE. Re-
severe mental illness are the greatest risk; 47%
trieved 2004 from http://www.health.org
of persons with schizophrenia and 56% of per- Tucker, J. A., Vuchinich, R. E., & Murphy, J. G.
sons with bipolar disorder have a lifetime diag- (2002). Assessment, treatment planning, and out-
nosis of substance abuse or dependence. Sub- come evaluation for substance use disorders. In
stance abusers with another psychiatric diag- M. H. Anthony & D. H. Barlow (Eds.), Handbook
nosis tend to experience more psychosocial and of assessment and treatment planning (pp. 415 –
physical health impairment compared to those 452). New York: Guilford Press.
without a comorbid diagnosis (Johnson et al., The Vaults of Erowid. (2003). Psychoactive vaults:
1995). Plant and chemical library. Retrieved 2004 from
http://www.erowid.org/psychoactives

References, Readings, & Internet Sites

Related Topics
Gavin, D. R., Ross, H. E., & Skinner, H. A. (1989).
Diagnostic validity of the drug abuse screening Chapter 93, “Adult Psychopharmacology 2: Side Ef-
test in the assessment of DSM-III drug disorders. fects and Warnings”
British Journal of Addictions, 84, 301–307. Chapter 95, “Dietary Supplements and Psychologi-
Johnson, J. G., Spitzer, R. L., Williams, J. B., Kroenke, cal Functioning”
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PART VII
Self-Help Resources
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 TOP INTERNET SITES
97 FOR PSYCHOLOGISTS AND
THEIR CLIENTS

John M. Grohol

There are millions of Web sites available today, ogy Information Online, About Psychotherapy
and tens of thousands available on psychologi- also provides articles about starting treat-
cal and mental health concerns. Here you will ment and the differences between types of
find a small, select guide to a few of these sites professionals and their degrees. Case studies
that are some of the most reliable and useful, to help clearly illustrate specific examples of
satisfy both your professional needs and the different treatments.
needs of your clients. These sites not only offer • American Psychological Association (http://
a balanced perspective on mental health and www.apa.org/): The American Psychological
psychological issues but also provide unique Association (APA) offers a plethora of re-
resources and content in a user-friendly format sources for all types of psychologists. Up-
to make them worth the effort. dated behavioral healthcare news, research
briefings, access to research databases, and
• About Psychotherapy (http://www.about journal archives are just a few of the many
psychotherapy.com): A down-to-earth in- resources professionals will find at the APA
formation resource that provides detailed site. Consumers will find the APA HelpCen-
descriptions of various types of psychother- ter at http://helping.apa.org/ more oriented
apy by psychologist Bennett Pologe, Ph.D. toward their educational needs.
Dozens of pages describe how psychother- • AtHealth (http://www.athealth.com/): At-
apy works, why a person might consider Health provides a wealth of psychoeduca-
therapy, when to stop, and what legitimate tional materials for the consumer who is in-
therapy consists of. Like Franklin’s Psychol- terested in learning more about a particular

491
492 part vii • self-help resources

disorder or mental health issue. Consumers health service provision and a set of sug-
will also find a practitioner’s directory on the gested ethical principles.
site that allows them to find a local therapist • Mental Health InfoSource (http://www.mh
in their geographic area. For professionals, source.com/): Published by CME, the Men-
AtHealth offers dozens of online continuing tal Health InfoSource has been a strong on-
education accredited courses. line resource for years for both professionals
• DrugDigest (http://www.drugdigest.org/): and their clients. Offering archives of the
DrugDigest is a noncommercial consumer Psychiatric Times and professional resources
health and drug information site that pro- such as classified ads, conference listings, and
vides a searchable drug and herb database. continuing education, the InfoSource also
The results are written in plain English, hosts an “Ask the Expert” area and provides
making it unlike most drug databases avail- educational resources on depression, bipolar
able on the Internet today. For each drug, the disorders, and schizophrenia.
site provides what the medication is used for, • National Institute of Mental Health (http://
how it works, what a person should know www.nimh.nih.gov/): The National Institute
about taking it, common side effects and in- of Mental Health offers information and re-
teractions, how it should be taken, and what sources on mental health information to con-
to do if the person misses a dose. For more sumers, while providing in-depth research
detailed and technical drug information, and grant information to professionals. The
RxList is recommended (http://www.rxlist. site provides access to clinical trial opportu-
com/). nities, funding opportunities, statistics on
• The Foundation Center (http://fdncenter. mental disorders, fact sheets, consumer-
org/): The Foundation Center is an organiza- oriented brochures on common mental dis-
tion that was founded in 1956 to promote orders and their treatments, research re-
philanthropy. Its Web site connects grant ports, national conference and event infor-
seekers with grant makers, but does require mation, and behavioral science news. It also
a fee for access to its database of grants, fel- links to the groundbreaking U.S. Surgeon
lowships, scholarships, and other financial General’s report on mental health.
support. GrantSelect (http://www.grantse- • National Mental Health Association (http://
lect.com/) is another, unrelated fee-based www.nmha.org/): The National Mental
grant research database that provides access Health Association (NMHA) publishes a
to over 10,000 funding opportunities. consumer-oriented site that provides infor-
• Healthfinder (http://www.healthfinder.gov/): mation on mental health disorders. In addi-
This excellent site, maintained by the U.S. tion to updated news headlines, it features
Department of Health and Human Services, information about advocacy, mental health
is a health and wellness directory of govern- parity, a calendar of events, and links to local
ment-backed and other, select Internet re- community affiliates. The NMHA’s online
sources. It is a good, objective source of Fact Sheets cover a broad range of mental
sometimes-dated information that provides disorders, including information about men-
consumers with a way of orienting them- tal illness in older adults, children, and fam-
selves to a particular health or mental health ilies. Much of its information is more con-
topic. sumer-friendly than similar information
• International Society for Mental Health On- published by the National Institute of Men-
line (http://www.ismho.org/): A nonprofit tal Health.
organization founded to promote mental • Psy Broadcasting Corporation (http://www.
health information and services online, it psybc.com/): Professionals who are looking
consists of an international membership of to fulfill their continuing education require-
hundreds of professionals and interested ments can do so easily online through
consumers. The organization has released a PsyBC. Offering both real-time seminars
number of white papers about online mental and ongoing symposia via online discussion
 97 • top internet sites for psychologists and their clients 493

groups, the site provides a variety of means mainstay of the online psychological world,
for obtaining continuing education credits this text is filled with useful articles explor-
while learning something new. ing the psychological underpinnings of vir-
• Psych Central (http://psychcentral.com/): tually every online behavior, from flaming
Focused mainly on consumer’s mental health and the use of emoticons (text or small
needs, this site (which I founded and main- graphics used to denote emotions online) to
tain) is a great resource that has been around online personalities and communities.
longer than the Web itself. Its offerings in- • PubMed (http://www.ncbi.nlm.nih.gov/en
clude daily-updated behavioral healthcare trez/query.fcgi): PubMed is the Internet-
newsfeeds, a guide containing over 2,000 based search portal to MEDLINE, the re-
peer-reviewed Internet resources and sup- nowned public medical research database.
port groups, online self-help support com- Maintained by the National Library of
munity, book reviews, and hundreds of gen- Medicine under the National Institutes of
eral articles about mental disorders, parent- Health, it covers a vast amount of the social
ing, mental health, and relationship issues. science literature and is a good, free alterna-
Psych Central also provides specialized tive to proprietary, costly research databases.
search engines for psychology that integrate Consumers may find the National Library of
Google, MEDLINE, and its own database of Medicine’s MEDLINEPlus (http://www.nlm.
mental health Internet resources. nih.gov/medlineplus/) a great place to start
• Psychological Self-Help (http://www.mental looking for general health and mental health
help.net/psyhelp/): This online self-help information online. This information re-
book, one of the first to be published on the source provides interactive tutorials, a med-
Internet in 1996, delves into some practical ical encyclopedia and dictionary, updated
techniques for individuals to use to try and health news, and a drug database, among
help themselves with many emotional, rela- other offerings.
tionship, and mental health issues. Offering • Social Psychology Network (http://www.social
15 chapters of insight and handy techniques, psychology.org/): The Social Psychology
psychologist Clay Tucker-Ladd, Ph.D., pro- Network is one of the older psychology re-
vides a well-written volume that can be sources online. It remains regularly updated
searched online. by professor Scott Plous, which makes its
• Psychology Information Online (http://www. database of over 5,000 social psychology re-
psychologyinfo.com/): Donald J. Franklin, sources invaluable. Resources are divided
Ph.D., is a New Jersey psychologist who has into psychology and social psychology sub-
put together this resource for consumers ject areas, programs, research groups, jour-
looking for more information about psychol- nals, textbooks, courses, and teaching re-
ogy. The site has articles that provide symp- sources. The site also features professional
toms and descriptions for most psychological discussion forums and makes their whole
problems, as well as descriptions of various database searchable.
types of therapies available used to treat • WebMD (http://www.webmd.com/): The last
them. Articles about selecting a treatment remaining large for-profit health portal from
provider and starting therapy are also avail- the dot.com era, WebMD is a large, rela-
able, as is a directory of psychologists. tively well-balanced, and regularly updated
• The Psychology of Cyberspace (http://www. resource on all health matters, including
rider.edu/suler/psycyber/psycyber.html): So mental health concerns. Although broader in
many professionals operate in an online en- context and nature than most resources
vironment without fully understanding the listed here, it is a critical resource because it
differences between online and real-world reaches millions of people every month who
communications. The Psychology of Cyber- are seeking health information. The site’s
space is an online book authored by psychol- search engine makes finding some psycho-
ogist John Suler of Rider University. A logical information easier. WebMD also in-
494 part vii • self-help resources

cludes Medscape, a professionally oriented searchers, and journalists. New York: Guilford
site that has a high-quality section on psy- Press.
chiatry and mental health. Another large Winkler, M. A., Flanagin, A., Chi-Lum, B., White,
commercial site deserves an honorable men- J., Andrews, K., Kennett, R. L., et al. (2000).
Guidelines for medical and health information
tion here as well, About’s Mental Health Re-
sites on the Internet. Journal of the Americal
sources (http://mentalhealth.about.com/),
Medical Association, 283(12), 1600 –1601. Re-
overseen by psychologist Leonard Holmes, trieved 2004 from http://jama.ama-assn.org/cgi/
Ph.D. content/full/283/12/1600
Wootton, R., Yellowlees, P., & McLaren, P. (Eds.).
References, Readings, & Internet Sites (2003). Telepsychiatry and e-mental health. Lon-
don: Royal Society of Medicine Press.
Gackenbach, J. (1998). Psychology and the Internet:
Intrapersonal, interpersonal, and transpersonal
implications. New York: Academic Press. Related Topics
Grohol, J. M. (2002). The insider’s guide to mental Chapter 100, “Facilitating Client Involvement in
health resources online. New York: Guilford Self-Help Groups”
Press. Chapter 101, “National Self-Help Groups and Orga-
McGuire, M., Stilborne, L., McAdams, M., & Hyatt, nizations”
L. (2002). The Internet handbook for writers, re-

HIGHLY RATED
98 SELF-HELP BOOKS AND
AUTOBIOGRAPHIES

John C. Norcross & Jennifer A. Simansky

Self-help books for mental/behavioral disor- Self-help books and autobiographical ac-
ders and autobiographies by individuals suffer- counts promise similar therapeutic benefits.
ing from such disorders have proliferated in re- Specifically, they can provide phenomenologi-
cent years. Bibliotherapy (the use of self-help cal accounts of behavioral disorders in every-
books with or without formal treatment) and day terms; enhance identification and empathy;
the use of autobiographies as adjuncts to psy- generate hope and insight; offer concrete advice
chotherapy have correspondingly increased. and techniques; explain treatment strategies;
Studies have consistently found that 85% to and summarize research findings (Pardeck &
88% of practicing psychologists prescribe self- Pardeck, 1992).
help books to their patients, and 33% of psy- The early research on bibliotherapy is prom-
chologists recommend autobiographies (Clif- ising. Self-administered treatments are gener-
ford, Norcross, & Sommer, 1999; Marx, Roy- ally cost-effective across a variety of problems
alty, Gyorky, & Stern, 1992; Starker, 1988). with few negative outcomes (Mains & Scogin,
 98 • highly rated self-help books and autobiographies 495

2003; Marrs, 1995; Scogin, Bynum, & Calhoun, 5. What to Expect When You’re Expecting by
1990). At the same time, caution should be ex- Arlene Eisenberg et al. (pregnancy)
ercised because the vast majority of self-help 6. Your Defiant Child by Russell Barkley and
resources have not been empirically evaluated Christine Benton (child management)
and because several disorders, such as severe 7. The 36-Hour Day by Nancy Mace and
alcohol dependence, do not appear to be amen- Peter Rabins (Alzheimer’s)
able to self-help alone (Rosen, 1987; Scogin et 8. The New Our Bodies, Ourselves by Boston
al., 1996). Women’s Collective (women’s health)
We have conducted a series of national stud- 9. The Courage to Heal by Ellen Bass and
ies over the past 10 years to determine the Laura Davis (abuse and recovery)
most highly rated self-help resources. In each 10. Mastery of Your Anxiety and Panic III by
study, we mailed a lengthy survey to clinical Michelle Craske and David Barlow (anxi-
and counseling psychologists residing through- ety)
out the United States. The responding psychol- 11. The Relaxation and Stress Reduction
ogists rated self-help resources with which Workbook by Martha Davis et al. (relax-
they were sufficiently familiar on a 5-point ation)
scale where +2 was “extremely good or out- 12. Feeling Good by David Burns (depression)
standing” and –2 was “extremely bad.” Across 13. The Seven Principles for Making Mar-
the eight studies, nearly 3,500 psychologists riages Work by John Gottman and Nan
contributed their expertise to evaluate self-help Silver (marriage)
books, autobiographies, and movies. 14. What To Expect: The Toddler Years by Ar-
Our Authoritative Guide to Self-Help Re- lene Eisenberg et al. (toddler development
sources in Mental Health (Norcross et al., and care)
2003) features numerical ratings and narrative 15. Infants and Mothers by T. Berry Brazelton
descriptions on more than 800 self-help books (child development and parenting)
and autobiographies for 36 behavioral disor- 16. Wherever You Go, There You Are by Jon
ders and life challenges ranging from abuse to Kabat-Zinn (meditation and relaxation)
violent youth. Presented below are the top- 17. What to Expect the First Year by Arlene
rated 25 self-help books and 25 autobiogra- Eisenberg et al. (infant development and
phies pertaining to mental/behavioral disor- care)
ders. 18. What Every Baby Knows by T. Berry
Brazelton (infant development and parent-
ing)
TOP 25 RATED SELF-HELP BOOKS 19. Dr. Spock’s Baby and Child Care by Ben-
jamin Spock and Steven Parker (infant de-
To be eligible for the top 25 list, a self-help velopment and parenting)
book had to be rated by a minimum of 30 psy- 20. Mind Over Mood by Dennis Greenberger
chologists. Following are the 25 books with the and Christine Padesky (depression)
highest average rating in our national studies, 21. Trauma and Recovery by Judith Herman
beginning with the highest rated. (trauma and PTSD)
22. Reviving Ophelia by Mary Pipher (female
1. Skills Training Manual for Treating Border- adolescent development)
line Personality Disorder by Marsha Line- 23. Dinosaurs Divorce by Laurene Brown and
han (borderline personality disorder) Marc Brown (for children of divorcing
2. Becoming Orgasmic by Julia Heiman and parents)
Joseph Piccolo (sexual dysfunction) 24. Taking Charge of ADHD by Russell Bark-
3. Why Marriages Succeed or Fail by John ley (ADHD)
Gottman (marriage) 25. How to Survive the Loss of a Love by
4. The Anxiety and Phobia Workbook by Ed- Melba Colgrove et al. (grief)
mund Bourne (anxiety)
496 part vii • self-help resources

TOP 25 RATED AUTOBIOGRAPHIES 22. The Virtues of Aging by Jimmy Carter

(aging)
To be eligible for this list, the autobiography 23. Girl, Interrupted by Susanna Kaysen (bor-
had to be rated by a minimum of 10 psycholo- derline personality)
gists. Following are the 25 autobiographies 24. ADHD Handbook for Families by Paul
with the highest professional ratings in our Weingartner (ADHD)
studies, again beginning with the highest 25. Too Much Anger, Too Many Tears by Janet
rated. Gotkin and Paul Gotkin (schizophrenia)

1. Letting Go by Morrie Schwartz (terminal References, Readings, and Internet Sites

illness and dying)
2. Breaking Free From Compulsive Eating by Clifford, J. S., Norcross, J. C., & Sommer, R. (1999).
Geneen Roth (compulsive eating) Autobiographies of mental health clients: Psy-
3. A Grief Observed by C. S. Lewis (grieving) chologists’ uses and recommendations. Profes-
sional Psychology: Research & Practice, 30,
4. Tuesdays With Morrie by Mitch Albom
56 – 59.
(aging and death) Mains, J. A., & Scogin, F. R. (2003). The effective-
5. Elegy for Iris by John Bayley (a spouse’s ness of self-administered treatments: A prac-
Alzheimer’s) tice-friendly review of the research. In Session:
6. Night Falls Fast by Kay Jamison (suicide) Journal of Clinical Psychology, 59(2), 237 –246.
7. Death Be Not Proud by John Gunther (a Marrs, R. W. (1995). A meta-analysis of bibliother-
parent’s loss of an adolescent) apy studies. American Journal of Community
8. A Man Named Dave by Dave Pelzer Psychology, 23, 843 – 870.
(childhood abuse) Marx, J. A., Royalty, G. M., Gyorky, Z. K., & Stern,
9. The Lost Boy by Dave Pelzer (childhood T. E. (1992). Use of self-help books in psy-
abuse) chotherapy. Professional Psychology: Research
and Practice, 23, 300 –305.
10. Broken Cord by Michael Dorris (fetal alco-
Neysmith-Roy, J. M., & Kleisinger, C. L. (1997).
hol syndrome) Using biographies of adults over 65 years of
11. An Unquiet Mind by Kay R. Jamison age to understand life-span developmental psy-
(bipolar disorder) chology. Teaching of Psychology, 24, 116 –118.
12. Heart of a Woman by Maya Angelou Norcross, J. C., Santrock, J. W., Campbell, L. F.,
(women’s issues) Smith, T. P., Sommer, R., & Zuckerman, E .L.
13. The Wheel of Life by Elisabeth Kübler- (2003). Authoritative guide to self-help re-
Ross and Todd Gold (death and dying) sources in mental health (2nd ed.). New York:
14. Darkness Visible by William Styron (de- Guilford Press.
pression) Pardeck, J. T., & Pardeck, J. A. (1992). Bibliotherapy:
15. Motherless Daughter by Hope Edelman A guide to using books in clinical practice. San
Francisco: Mellen Research University Press.
(loss of a parent)
Rosen, G. M. (1987). Self-help treatment books and
16. Feeding the Hungry Heart by Geneen the commercialization of psychotherapy. Amer-
Roth (weight management) ican Psychologist, 42, 46 – 51.
17. I Never Promised You a Rose Garden by Scogin, F., Bynum, J., & Calhoun, S. (1990). Efficacy
Joanne Greenberg (schizophrenia) of self-administered treatment programs: Meta-
18. The Noonday Demon by Andrew Solomon analytic review. Professional Psychology: Re-
(depression) search and Practice, 21, 42– 47.
19. After the Death of a Child by Ann Scogin, F., Floyd, M., Jamison, C., Ackerson, J., Lan-
Finkbeiner (grieving the death of a child) dreville, P., & Bissonnette, L. (1996). Negative
20. Out of the Depths by Anton Boisen (schiz- outcomes: What is the evidence on self-admin-
ophrenia) istered treatments? Journal of Consulting and
Clinical Psychology, 64, 1086 –1089.
21. The Panic Attack Recovery Book by Shir-
Sommer, R., & Osmond, H. (1983). A bibliography of
ley Swede and Seymour Jaffe (anxiety dis- mental patients’ autobiographies, 1969 –1982.
order) American Journal of Psychiatry, 140, 1051–1054.
 99 • popular films portraying mental disorders 497

Starker, S. (1988). Psychologists and self-help books: Related Topics

Attitudes and prescriptive practices of clini-
Chapter 99, “Popular Films Portraying Mental Dis-
cians. American Journal of Psychotherapy, 42,
orders”
448 – 455.
Chapter 100, “Facilitating Client Involvement in
University of California, Davis. Psychology Depart-
Self-Help Groups”
ment. (2002). Autobiographies of mental pa-
Chapter 101, “National Self-Help Groups and Orga-
tients (a compilation of autobiographies). Re-
nizations”
trieved 2004 from http://psychology.ucdavis.edu/
sommerr/

POPULAR FILMS
99 PORTRAYING MENTAL
DISORDERS

Danny Wedding

Numerous popular films illustrate psycho- can. Four examples illustrate this point: Rain
pathology, and any group of mental health pro- Man presented a largely sympathetic portrayal
fessionals can quickly generate a list of films of autism and educated many people who were
that portray alcoholism, drug addiction, per- not familiar with the disorder; As Good As It
sonality disorders, schizophrenia, mood disor- Gets provided a vehicle for Jack Nicholson to
ders, and sexual and gender identity disorders. educate the public about obsessive compulsive
The portrayal of psychopathology in the media disorder; and Shine and A Beautiful Mind both
is a significant factor in shaping and supporting demonstrated that people with serious mental
the stigma associated with mental illness, as disorders like schizophrenia could make impor-
well as the widespread public belief that mental tant societal contributions. In contrast, films
illness is almost inevitably associated with like Me, Myself and Irene perpetuate myths
dangerousness (Wahl, 1995). In addition to and misconceptions about mental illness (e.g.,
shaping the public’s perception of people with that people suffering from schizophrenia have
mental illness, films have a direct effect on the multiple personalities).
public’s image of psychologists, psychiatrists, Films also provide an efficient way for ther-
and other mental health professionals (Gabbard apists to introduce clients to different ways of
& Gabbard, 1999; Hyler, 1988; Wedding & perceiving their situations or problems. Seeing
Boyd, 1999). a recommended film is relatively easy given
the availability of VHS and DVD rental cen-
ters, and compliance with a therapist’s recom-
CLINICAL BENEFITS OF FILMS mendation to view a film is both inexpensive
and convenient. I have had hundreds of clients
Films can sometimes sensitize the public to who never got around to reading the books I
mental health issues in a way few other media would recommend in therapy, but I have never
498 part vii • self-help resources

had a client who would fail to see a film I rec- evident in Tom Cruise’s character (Ron Kovic)
ommended. Films can serves as powerful in Born on the Fourth of July, as well as the al-
metaphors for a client’s personal problems, cohol abuse and dependence and the survivor
they provide rich opportunities for observa- guilt so commonly associated with the disorder.
tional learning, and their discussion can pro- Agoraphobia is illustrated by Elliott Gould’s
vide grist for the therapeutic mill. character in the film Inside Out, and responses
to extreme stress are portrayed in films like
The Pawnbroker, Falling Down, The Deer
INTRODUCING AND ASSIGNING Hunter, Full Metal Jacket, The Killing Fields,
FILMS IN PSYCHOTHERAPY Apocalypse Now, and Glengarry Glen Ross.
The particular film(s) recommended for any
The potential applications of film as homework particular client with an anxiety disorder (such
in psychotherapy are limited only by the imag- at PTSD) will depend on the client’s level of
ination, creativity, and viewing history of the anxiety and his or her comfort levels with in
therapist. A client vacillating about leaving an vivo desensitization.
abusive relationship may benefit from seeing a The classic film illustrating a dissociative
woman and her son extricate themselves from a disorder is Alfred Hitchcock’s Psycho. Al-
pathological environment in This Boy’s Life; though arguably one of the most important
another client concerned about a parent’s de- films ever made, Psycho unfortunately perpet-
mentia may find comfort in watching Iris or uates the widespread belief that people with
On Golden Pond, while someone frustrated mental disorders are dangerous and unpre-
with the headaches associated with dealing dictable. The public’s fear is underscored by the
with a medical bureaucracy might benefit from fact that Norman Bates initially seems harm-
viewing and discussing the protagonist’s expe- less and well intentioned, and at most eccentric.
rience in The Doctor. Other popular films that address dissociative
Another client suffering from the loss of a identity disorder include Sybil, The Three Faces
child might, at an appropriate time, find it ther- of Eve, and Primal Fear. This last film presents
apeutic to watch and discuss In the Bedroom, a scenario in which an altar boy who has mur-
and a young girl with an eating disorder might dered an archbishop feigns a dissociative iden-
learn valuable lessons from The Karen Carpen- tity disorder in order to avoid prosecution for
ter Story. Clinical judgment and experience his crime. Films of this type support the pub-
will help the therapist decide which clients will lic’s misconception that criminals commonly
benefit from viewing films as homework, and pretend to be mentally ill in order to avoid
clinical acumen will guide the decision about punishment for their behavior. Films illustrat-
the optimal time to introduce films in the ther- ing dissociative amnesia include Spellbound;
apeutic journey. Suddenly, Last Summer; Dead Again; Sulli-
van’s Travels; Paris, Texas; The Return of Mar-
tin Guerre; and Sommersby. Other films that
SPECIFIC MOVIE illustrate some form of dissociation but that
RECOMMENDATIONS have characters who may not meet DSM-IV
criteria for the dissociative identity disorder di-
Anxiety disorders are routinely portrayed in agnosis include Raising Cain, Persona, Three
films (especially posttraumatic stress disorder), Women, The Dark Mirror, Sisters, Steppen-
and some of the images of anxiety disorders in wolf, and any of the numerous versions of Dr.
films are almost iconic. Which of us can forget Jekyll and Mr. Hyde.
the scene in Patton in which George C. Scott Mood disorders are common in movies, and
slaps a young soldier suffering from “battle fa- it is not unusual for a character in a film to be
tigue,” or the paralysis Jimmy Stewart experi- suicidal or to actually commit suicide. One of
ences as he copes with his fear of heights in the most compelling recent films to address the
Vertigo? Many of the symptoms of PTSD are linked themes of depression and suicide is The
 99 • popular films portraying mental disorders 499

Hours, in which Nicole Kidman reenacts the may possibly benefit from ECT, and it is help-
depression and eventual suicide by drowning of ful for clinicians to enquire about negative cin-
the gifted novelist Virginia Woolf. (This sim- ematic portrayals these patients may have en-
ple synopsis fails to do justice to a film that is countered.
rich, complex, and variegated.) Al Pacino plays Any group of psychotherapists (or psychol-
a depressed and suicidal retired military officer ogy students) can quickly generate a list of pop-
in Scent of a Woman, and Pacino’s character ular films illustrating the entire panoply of
displays classic risk factors for suicidal (i.e., he personality disorders. The classic example of
is a depressed, older white male, unemployed, this genre is the Alex Forrest character in Fatal
familiar with guns, with a chronic medical con- Attraction (Glenn Close is reported to have
dition [blindness] and a history of alcohol conducted research on borderline personality
abuse and probable alcoholism). The same risk disorder in preparation for her role). Among
factors are present in George C. Scott’s charac- Cluster A disorders, paranoid personality dis-
ter in a slightly older film, The Hospital. Some order is beautifully illustrated by the title
other popular films that address depression and character in Dr. Strangelove and by Humphrey
suicide are Dead Poets Society; ’night Mother; Bogart’s role as Captain Queeg in The Caine
Ordinary People; The Last Picture Show; It’s a Mutiny; the schizoid personality is seen in Five
Wonderful Life; The Deer Hunter; The Field; Easy Pieces, The Accidental Tourist, Taxi Driver,
The Tenant; Mishima; Network; The Last Em- and Sex, Lies, and Videotape; the schizotypal is
peror; Elvira Madigan; The Hairdresser’s Hus- present in The Ruling Class and Pi.
band; and Harold and Maude. The movie Mr. Among Cluster B disorders, the antisocial
Jones stars Richard Gere as a musician with personality is illustrated in any of a hundred
bipolar disorder who presents almost textbook films about violence and murder, including
symptoms of the disorder. Unfortunately, the Henry: Portrait of a Serial Killer, Silence of the
film is marred by his torrid affair with his psy- Lambs, A Clockwork Orange, In Cold Blood,
chiatrist, perpetuating the myth that sexual The Boston Strangler, Cape Fear, Reservoir
misconduct is commonplace among mental Dogs, Peeping Tom, Strangers on a Train, Hel-
health professionals. In About Schmidt, Jack ter Skelter, Natural Born Killers, Widows’
Nicholson plays an older man coping with the Peak, and Blue Velvet. In addition to Fatal At-
depression and anxiety associated with his re- traction, Who’s Afraid of Virginia Woolf illus-
tirement, his wife’s death, and his daughter’s trates borderline personality disorder, as does
determination to marry the wrong man. A re- Mrs. Parker and the Vicious Circle. The histri-
cent release, Love Liza, illustrates the over- onic personality disorder can be seen in the
whelming pain experienced by someone after a roles played by major characters in A Streetcar
spouse’s suicide. I have previously found view- Named Desire, La Cage aux Folles, Long Day’s
ing and discussion of Ordinary People to be Journey Into Night, and Blue Sky. Narcissistic
helpful when working with clients who have personality disorder is convincingly portrayed
lost a child. in the movies Sunset Boulevard, Bugsy, and
Many of the films dealing with mood disor- What Ever Happened to Baby Jane.
ders present dramatic (and almost always neg- Cluster C disorders include avoidant, depen-
ative) demonstrations of electroconvulsive dent, and obsessive-compulsive disorders. The
therapy. Three of the many examples of ECT in avoidant personality is typified in the film adap-
movies include An Angel at My Table, One tation of Tennessee Williams’s play The Glass
Flew Over the Cuckoo’s Nest, and Chatta- Menagerie, and the dependent personality is
hoochee. McDonald and Walter (2001) re- almost perfectly captured by Bill Murray’s
viewed 22 films released between 1948 and character in What About Bob? (Interestingly,
2000 and found that the presentation of ECT in this film ends with an on-screen note that tells
movies was becoming progressively more neg- the audience that the neurotic character Bob
ative. Films such as these almost inevitably went back to graduate school, earned a Ph.D. in
produce considerable anxiety in patients who psychology, and wrote a best-selling self-help
500 part vii • self-help resources

book.) The character of Felix Unger in The Odd Back to the Five and Dime, Jimmy Dean, Jimmy
Couple is a vivid example of someone with an Dean; La Cage aux Folles; To Wong Foo; M.
obsessive-compulsive personality disorder, as is Butterfly; The Ballad of Little Jo; The Crying
Major Frank Burns in M*A*S*H. Game; and Hedwig and the Angry Inch.
Clinicians will want to be judicious in rec- Fetishes are illustrated by films such as Claire’s
ommending films to patients with personality Knee and David Cronenberg’s film Crash.
disorders to avoid potentially insulting the pa- Breaking the Waves is a psychologically pow-
tient (e.g., a histrionic patient would be un- erful Danish film in which a paralyzed man in-
likely to respond positively to the implicit sug- sists that his wife have sex with other men
gestion that her life parallels Gloria Swanson’s while he watches, and Pedro Almodovar’s Tie
portrayal of Norma Desmond in Sunset Boule- Me Up! Tie Me Down! explores the masochis-
vard). tic relationship between a kidnapper and the
Substance-use disorders are also staples in woman he kidnaps. Sexual sadism is brilliantly
popular cinema, and the challenge here is lim- presented in David Lynch’s Blue Velvet; incest
iting the list of films for consideration. Perhaps is a central theme in Angels and Insects, pe-
the classic film in the genre of films addressing dophilia is portrayed by Peter Lorre in “M”
alcoholism is The Lost Weekend; other films and by James Mason (and later Jeremy Irons)
about alcoholism that are almost as compelling in Lolita; and the sexual obsession of a college
include Harvey; Come Back, Little Sheba; professor for a cabaret singer can be seen in a
Days of Wine and Roses; Key Largo; Tender classic film, The Blue Angel. Other popular
Mercies; Arthur; Ironweed; The Verdict; Under films that address sexual and gender identity
the Volcano; and Barfly. More recent films in disorders include Cabaret, Chinatown, The
which alcoholism is the central theme include Collector, Fellini Satyricon, Female Perver-
When a Man Loves a Woman, Leaving Las sions, The Good Mother, Henry & June, Ju
Vegas, 28 Days, Trees Lounge, and Drunks. Dou, Jules and Jim, Kiss of the Spider Woman,
Any of these recent films would provide a Matador, Midnight Cowboy, Murmur of the
meaningful springboard for a discussion of the Heart, Peeping Tom, Pretty Baby, and The Ser-
effects of alcohol on a client’s life and family. geant. Clinicians working with clients con-
Two classic films dealing with drug addic- cerned about homosexuality may find it helpful
tion are Long Day’s Journey Into Night and to assign and discuss both films and TV shows
The Man With the Golden Arm. Opium addic- that portray positive gay role models (e.g., the
tion is portrayed in Indochine and The Last characters of Keith and David on HBO’s Six
Emperor. Drugs also play a central role in Feet Under).
Quentin Tarentino’s Pulp Fiction, and polydrug Childhood psychopathology is brilliantly
addiction is portrayed in Clean and Sober. represented in Neil Jordan’s The Butcher Boy.
Other films that build on drug themes include Some other films that treat childhood disorders
The French Connection, Christiane F., Train- include Forbidden Games, Bergman’s Fanny
spotting, Mona Lisa, Chappaqua, Drugstore and Alexander, and Francois Truffaut’s The 400
Cowboy, Naked Lunch, The Bad Lieutenant, Blows. Other films addressing mental illness in
Goodfellas, Scarface, and Lady Sings the Blues. children include The Best Little Girl in the
The most dramatic recent film illustrating World, Lord of the Flies, and The Tin Drum.
sexual and gender identity disorders is unques- The Wild Child and Every Man for Himself
tionably Boys Don’t Cry, a movie in which and God Against All both explore the effects of
Hilary Swank plays an unforgettable role as deprivation on feral children. The psychologi-
Brandon Teena (Teena Brandon), a Nebraska cal problems associated with childhood poverty
transsexual teen trying to establish her sexual are touchingly portrayed in three foreign
identity in a hostile and ultimately fatal envi- films: El Norte, Pixote, and Salaam Bombay.
ronment. Other films portraying transsexual- The French film Ponette is a remarkable exam-
ism include Myra Breckinridge; Dog Day Af- ination of a child’s attempt to understanding
ternoon; The World According to Garp; Come the meaning of her mother’s death in a world in
 99 • popular films portraying mental disorders 501

which no one will speak honestly with her movies. Hospital and Community Psychiatry,
about what it really means to be dead. I have 42, 1044 –1048.
previously had good success discussing Search- McDonald, A., & Walter, G. (2001). The portrayal of
ing for Bobby Fischer with a demanding, over- ECT in American movies. Journal of ECT, 17,
264 –274.
bearing parent who recognized himself in the
Nicosia, S. Movies and mental illness. (n.d.). Psy-
figure presented by the father in the film.
chology, psychiatry and the movies. Retrieved
Schizophrenia and delusional disorders have 2004 from http://faculty.dwc.edu/nicosia/movies
been illustrated in a number of successful films andmentalillnessfilmography.htm
including Angel Baby, Benny and Joon, Birdy, Psychiatry in the Cinema. (n.d.). Resource page. Re-
Clean Shaven, The Fisher King, Shine, Sweetie, trieved 2004 from http://www.priory.com/
Taxi Driver, and, most recently and most suc- psych/psycinema.htm
cessfully, A Beautiful Mind. In general, I don’t Schulenberg, S. E. (2003). Psychotherapy and movies:
believe films are useful for patients with On using films in clinical practice. Journal of
thought disorders, and they are especially lim- Contemporary Psychotherapy, 33, 35 – 48.
ited with patients with paranoid disorders who Solomon, G. (1995). The motion picture prescrip-
tion: Watch this movie & call me in the morn-
may become confused by the purpose and in-
ing —200 movies to help you heal life’s prob-
tent of the assignment. However, movies like A
lems. Santa Rosa, CA: Aslan.
Beautiful Mind can be very beneficial in help- Solomon, G. (2000). Reel therapy: How movies in-
ing family members understand what their spire you to overcome life’s problems. New
loved one is experiencing. York: Lebhar-Friedman Books.
Teague, R. (2000). Reel spirit: A guide to movies
References, Readings, & Internet Sites that inspire, explore, and empower. Unity Vil-
lage, MO: Unity House.
Berg-Cross, L., Jennings, P., & Baruch, R. (1990). Vaux, S. (1999). Finding meaning at the movies.
Cinematherapy: Theory and application. Psy- Nashville, TN: Abingdon.
chotherapy in Private Practice, 8, 135 –156. Wahl, O. F. (1995). Media madness: Public images of
Eight Major Personality Styles. (n.d.). Disability mental illness. New Brunswick, NJ: Rutgers
Films home page. Retrieved 2004 from http:// University Press.
www.screenplaysystems.com/reel_people/ Wedding, D. (2001). The portrayal of alcohol and al-
personalities coholism in the western genre. Journal of Alco-
Films Involving Disabilities. (n.d.). Web site. Re- hol & Drug Education, 46, 3 –11.
trieved 2004 from http://www.disabilityfilms. Wedding, D. (n.d.). “Movies and Mental Illness” fil-
co.uk/index.html mography. Retrieved 2004 from http://
Gabbard, G., & Gabbard, K. (1999). Psychiatry and www.mimh.edu/Danny_Wedding/
the cinema. Washington, DC: American Psy- Wedding, D., & Boyd, M. A. (1999). Movies & men-
chiatric Press. tal illness: Using films to understand psycho-
Hesley, J. W., & Hesley, J. G. (1998). Rent two films pathology. Boston: McGraw-Hill.
and let’s talk in the morning: Using popular Wedding, D., & Niemiec, R. (2003). The clinical use
movies in psychotherapy. New York: Wiley. of films in psychotherapy. In Session: Journal
Hyler, S. E. (1988). DSM-III at the cinema: Madness of Clinical Psychology, 59, 207 –215.
in the movies. Comprehensive Psychiatry, 29,
195 –206.
Hyler, S. E., Gabbard, G. O., & Schneider, I. (1991). Related Topic
Homicidal maniacs and narcissistic parasites: Chapter 98, “Highly Rated Self-Help Books and
Stigmatization of mentally ill persons in the Autobiographies”
 FACILITATING CLIENT
100 INVOLVEMENT IN
SELF-HELP GROUPS

Elena Klaw & Keith Humphreys

Self-help groups can be invaluable allies to the National data attest to the widespread par-
work of psychologists. Groups are available for ticipation in self-help groups: approximately
virtually every health and social problem, 7% of American adults (about 11 million peo-
making them useful referrals for professionals ple) have participated in a self-help group in
working in a wide range of settings. Further, the past year, and 18% have done so at some
because self-help groups are free of charge and point in their lifetime (Kessler, Mickelson, &
allow unlimited attendance, they can help psy- Zhao, 1997). Indeed, Americans make more
chologists arrange ongoing support for patients visits to self-help groups for addiction and psy-
in a health care system otherwise cramped by chiatric problems than they do to all mental
managed care and financial limitations. To help health professionals combined (Kessler et al.,
psychologists reap these benefits for them- 1997).
selves and their clients, this chapter describes Figure 1 presents information on the self-
what self-help groups are available, how they help groups most commonly attended in the
affect members, and how best to interact with United States. Substance-related groups consti-
them. tute the most popular type, the best known of
which is Alcoholics Anonymous (AA), which
currently has 4 to 6 million members world-
SCOPE AND BENEFITS OF wide (Humphreys, 2003). Yet, two-thirds of
SELF-HELP GROUPS the 1,000 self-help organizations in the United
States developed independently of AA and do
Self-help groups are peer-led organizations of not use AA’s 12 steps. As inspection of the Self-
individuals facing a shared health, social, or Help Sourcebook of the American Self-Help
emotional challenge. Self-help groups are also Clearinghouse will reveal, it is difficult to think
often called “mutual help groups” to reflect the of a problem for which no self-help group ex-
reality that members provide information and ists (White & Madara, 2002).
social support as well as receive it; in this re- Popularity, of course, does not prove effec-
spect, self-help groups differ from other activi- tiveness, so researchers have made substantial
ties that are often called self-help, such as read- efforts in recent years to evaluate whether self-
ing self-help books. Support groups led by help group participation benefits members.
professionals are not typically considered self- Many groups have yet to be studied, but thus
help groups unless the professional personally far evaluation research is encouraging. For ex-
shares the focal problem/concern of the group ample, research supports the conclusions that
(e.g., a psychologist who has AIDS could lead a participation in 12-step addiction-related groups
self-help group focused on living with AIDS) often reduces subsequent use of alcohol and il-
and relates to group members as a peer. licit drugs, participation in weight-loss groups

502
 100 • facilitating client involvement in self-help groups 503

figure 1. Participation in the Most Common Self-Help Groups

promotes healthier weight, joining a group for dara, 2002) and is also available on dozens of
parents of premature newborns enhances Web sites identifiable through a Web search.
parent-infant connectedness, and referral to a The articles are in the public domain and can be
posthospitalization self-help network reduces printed and given to clients or colleagues free
readmission rates for seriously mentally ill in- of charge as a way to make a quick assessment
dividuals (see Kyrouz, Humphreys, & Loomis, of whether self-help groups of a particular type
2002). In addition to helping promote remis- have been studied, and if so, what the outcome
sion of the “presenting problem,” self-help results have been. Psychologists interested in
groups can produce important quality-of-life more detailed and scholarly reviews of the lit-
benefits such as new friendships, recreational erature can find them in a number of recent
opportunities, and deepened sense of spiritual books, including Linda Kurtz’s (1997) Self-
purpose (Humphreys, 1997). As with all out- Help and Support Groups: A Handbook for
come research, practitioners should bear in Practitioners.
mind that the above conclusions are based on
average results, and self-help groups are thus
no more a panacea than is any other psychoso- STRATEGIES TO LINK
cial intervention. With this caution in mind, PROFESSIONAL TREATMENT
practitioners can be confident that many of AND SELF-HELP
their patients could derive at least some benefit
from participating in a self-help group. The following are suggestions for facilitating
Humphreys and colleagues have produced professional linkages to self-help groups and
jargon-free, easy-to-read summaries of the fostering client involvement.
main findings of outcome studies of self-help
groups for a variety of conditions. This “Re- 1. Beware of “professional-centris”: That is,
view of research on the effectiveness of self- be wary of the belief that professional ser-
help mutual aid groups” (updated in 2002 with vices and expertise are the central compo-
Dr. Colleen Loomis) is included in each edition nents of effective mental health care (Salzer,
of the Self-Help Sourcebook (White & Ma- Rappaport, & Segre, 2001). Negative per-
504 part vii • self-help resources

ceptions about self-help groups include un- 5. Invite self-help groups to demonstrate their
substantiated beliefs that groups are harm- potential value to residents of treatment
ful, antiprofessional, foster dependency, and centers: Many addiction and psychiatric
spread misinformation. Such prejudices self-help organizations are willing to hold
may lessen appreciation of self-help groups group meetings in hospitals, treatment pro-
and may be transmitted to clients who grams, and correctional facilities that insti-
might otherwise benefit from group partic- tution residents may attend or observe.
ipation. 6. Build relationships with self-help clearing-
2. Incorporate information about self-help houses and other organizations that support
methods, principles, and group availability self-help: The American Self-help Clearing-
into the curriculum of clinical training pro- house, for example, is particularly well
grams: In a study of future providers, stu- known for its directory of several thousand
dents reported that they would be more self-help organizations, which is available
likely to refer clients to self-help groups if on the World Wide Web as well as in print
they thought that the faculty perceived form (White & Madara, 2002).
them positively (Meissen, Mason, & Glea- 7. In addition to providing self-help brochures
son, 1991). To enhance training about self- in one’s waiting room, participate in using
help, training programs might compare and nontraditional media to disseminate infor-
contrast self-help models with professional mation about self-help: Although newspaper
treatment, simulate self-help meetings, pres- announcements are useful in attracting new
ent examples of professional self-help col- members, participation in more visible public
laborations, and encourage students to join a information campaigns might offer further
self-help group (see Salzer et al., 2001). benefits. For example, one study successfully
3. All professionals should visit at least one increased self-help attendance through a psy-
self-help meeting: Professionals can freely chologist-hosted radio program that featured
attend any “open meetings” of AA and NA, a live self-help group meeting each week
for example. Such visits educate providers (Jason, LaPointe, & Billingham, 1986).
about the nature of self-help groups in gen- 8. Provide information about self-help to re-
eral and local meetings in particular, which ligious leaders: Religious leaders are often
facilitates informed referrals. highly trusted sources of information for
4. Approach self-help groups as respectful col- disadvantaged groups (e.g., low-income in-
laborators (Stewart, 1990): Professionals dividuals, recent immigrants), and are typi-
sometimes have the false impression that cally interested in learning about commu-
the best way to assist self-help groups is to nity self-help strategies (Jason, Goodman,
take control of them in some respect — for Thomas, & Iacono, 1988).
example as a group facilitator — while what
groups usually desire is a collaborative rela-
tionship. RECOMMENDATIONS TO
5. Provide resources to self-help groups: Stud- FACILITATE CLIENT INVOLVEMENT
ies suggest that cooperative relationships IN SELF-HELP GROUPS
between self-help groups and treatment
providers are characterized by frequent con- 1. Frame self-help participation as a process of
tact, staff membership in self-help groups, experimenting with available alternatives so
and cross-volunteering between members that the client can find the route best suited
of the self-help organization and the treat- to recovery. This generates less resistance
ment center (Kurtz, 1984). In terms of re- than pressuring a client to seek help only
source provision, self-help organizations are from a particular group.
often in need of assistance with referrals, 2. Recognize that professional interventions
meeting space, publicity, and Web site de- can increase clients’ level of affiliation with
velopment. self-help groups. Belief that professionals
 100 • facilitating client involvement in self-help groups 505

viewed self-help involvement favorably, for Note: Thanks to Lynzey Baker Baldwin for her
example, has been associated with increased help in preparing this manuscript. Preparation of
goal attainment for individuals with psy- this manuscript was funded in part by the De-
chiatric disabilities (Hodges & Segal, 2002). partment of Veterans Affairs Mental Health
Similarly, greater involvement with 12-step Strategic Healthcare Group and The California
groups has been linked to compatibility be- Wellness Foundation.
tween treatment beliefs and 12-step ideolo-
gies (Mankowski, Humphreys, & Moos, References, Readings, & Internet Sites
2001). Research suggests when treatment
providers encouraged patients to attend meet- Hodges, J. Q., & Segal, S. P. (2002). Goal advance-
ment among mental health self-help agency
ings, work the steps, get a sponsor, and en-
members. Psychiatric Rehabilitation Journal,
gage in other AA/NA-related behaviors, 26, 78 – 85.
substance-abuse patients were more likely Humphreys, K. (1997). Individual and social bene-
to be involved in self-help groups during fits of mutual aid/self-help groups. Social
and after treatment. Policy, 27, 12–19.
3. Employ the approach termed “Twelve Step Humphreys, K. (2003). Circles of recovery: Self-
Facilitation Therapy” as a powerful inter- help organizations for addictions. Cambridge,
vention for wait-list patients, enabling nat- UK: Cambridge University Press.
ural recovery for some individuals and in- Jason, L., Goodman, D., Thomas, N., & Iacono, G.
creasing motivation for those in need of (1988) Clergy’s knowledge of self-help groups
professional care. By conducting 12-step fa- in a large metropolitan area. Journal of
Psychology and Theology, 16, 34 – 40.
cilitation during treatment, providers can
Jason, L. A., LaPointe, P., & Billingham, S. (1986).
increase the likelihood that patients will The media and self-help: A preventive commu-
sustain their recovery after participation in nity intervention. Journal of Primary
professional services has ended. Prevention, 3, 156 –167.
4. Consider sending both religious and nonre- Kessler, R. C., Mickelson, K. D., & Zhao, S. (1997).
ligious clients to 12-step groups. Evidence Patterns and correlates of self-help group
suggests that theists and nontheists are membership in the United States. Social Policy,
equally likely to follow through on and 27, 27 – 46.
benefit from such referrals (Winzelberg & Kurtz, L. F. (1984). Linking treatment centers with
Humphreys, 1999). Alcoholics Anonymous. Social Work in Health
5. Provide significant support when linking Care, 9, 85 – 95.
Kurtz, L. F. (1997). Self-help and support groups: A
clients to self-help groups. One study (Sis-
handbook for practitioners. Thousand Oaks: Sage.
son & Mallams, 1981) demonstrated that Kyrouz, E. M., Humphreys, K., & Loomis, C.
when clinicians allowed clients to call self- (2002). A review of research on the effective-
help organizations from their office and con- ness of self-help mutual aid groups. In B. J.
nected them with to a sponsor who would White & E. J. Madara, The self-help source-
take them to a meeting, 100% of clients at- book: Your guide to community and online
tended at least one self-help meeting. Con- support groups (6th ed., pp. 71– 85). Cedar
versely, when a self-help meeting was sim- Knolls, NJ: American Self-Help Clearinghouse.
ply suggested in the course of treatment, no Mankowski, E. S., Humphreys, K., & Moos, R. H.
clients attended a self-help group. (2001). Individual and contextual predictors of
6. Learn about the specific groups in your involvement in twelve-step self-help groups
after substance abuse treatment. American
community. For example, when referring an
Journal of Community Psychology, 29,
atheist to an AA group, one might choose a 537 –563.
particular AA meeting that places less em- Meissen, G. J., Mason, W. C., & Gleason, D. F.
phasis on spirituality. Similarly, a gay or (1991). Understanding the attitudes and inten-
lesbian client may prefer to attend a spe- tions of future professionals toward self-help.
cialty chapter of a self-help organization American Journal of Community Psychology,
that specifically addresses his or her needs. 19, 699 – 715.
506 part vii • self-help resources

Salzer, M. S., Rappaport, J., & Segre, L. (2001). online support groups (6th ed.). Cedar Knolls, NJ:
Mental health professionals’ support of self- American Self-Help Clearinghouse. http://www.
help groups. Journal of Community & Applied mentalhelp.net/selfhelp/
Social Psychology, 11, 1–10. Winzelberg, A., & Humphreys, K. (1999). Should
Sisson, R. W., & Mallams, J. H. (1981). The use of patients’ religious beliefs and practices influ-
systematic encouragement and community ence clinicians’ referral to 12-step self-help
access procedures to increase attendance at groups? Evidence from a study of 3,018 male
Alcoholics Anonymous and Al-Anon meetings. substance abuse patients. Journal of Consulting
American Journal of Drug and Alcohol Abuse, and Clinical Psychology, 67, 790 – 794.
8, 371–376.
Stewart, J. (1990). Professional interface with mutu-
Related Topic
al-aid self-help groups: A review. Social
Science and Medicine, 31(10), 1143 –1158. Chapter 97, “Top Internet Sites for Psychologists
White, B. J., & Madara, E. J. (2002). The self-help and Their Clients”
sourcebook: Your guide to community and

NATIONAL SELF-HELP
101 GROUPS AND
ORGANIZATIONS

Dennis E. Reidy & John C. Norcross

Self-help groups are supportive, educational patterned after Alcoholics Anonymous (AA)
mutual-aid groups that address a single life that address a wide spectrum of addictive dis-
problem or condition shared by their members orders, such as those to drugs, food, and sex.
(Kurtz, 1997). Participation is voluntary, mem- But self-help groups encompass much more
bers serve as leaders, and professionals rarely than addictions; there are self-help groups for
play an active role in the groups’ activities. All practically all mental and physical disorders, as
forms of self-help groups share one thing: pro- even a casual glance of the blue pages of a tele-
motion of the member’s inner strengths. The phone directory will confirm. In fact, 5% of
groups do so by imparting information, em- American adults attend a self-help group in a
phasizing self-determination, providing mu- given year (Eisenberg et al., 1998).
tual support, and by mobilizing the resources The following list provides the mailing ad-
of the person, the group, and the community dresses, telephone numbers, and Web ad-
(Reissman & Carroll, 1995). dresses of the national chapters of major self-
Millions of Americans have come to rely on help groups and organizations in the United
self-help or support groups for assistance with States. The national listings appear alphabeti-
virtually every human challenge. The most cally by the title of the organization. Our pur-
recognizable of these are the 12-step groups pose is to provide the practitioner with quick
 101 • national self-help groups and organizations 507

access to these self-help groups and organiza- Alcoholics Anonymous

tions. Box 459, Grand Central Station
More exhaustive listings of self-help groups New York, NY 10163
may be obtained from two national self-help Phone: 212-870-3400
clearinghouses. The American Self-Help Clear- http://www.alcoholics-anonymous.org
inghouse’s Self-Help Sourcebook at http:// A 12-step self-help group for those troubled
mentalhelp.net/selfhelp/ serves “as your start- by alcohol consumption.
ing point for exploring real-life support groups
and networks that are available throughout the Alzheimer’s Association
world and in your community.” The similar 919 North Michigan Avenue, Suite 1100
National Mental Health Consumers’ Self-Help Chicago, IL 60611-1676
Clearinghouse at http://www.mhselfhelp.org/ Phone: 800-272-3900, 312-335-8700
(phone: 800-553-4539 or 215-751-1810) is a E-mail: [email protected]
consumer-run association that connects mental http://www.alz.org
health consumers with peer-run groups and of- Provides information, publications, and sup-
fers technical assistance to self-help groups. We port to patients and their caregivers.
strongly recommend that you visit these sites,
particularly if you are searching for a self-help Alzheimer’s Disease Education and Referral
group on a topic or disorder not covered in the Center (ADEAR)
following list. National Institute on Aging
PO Box 8250
Adult Children of Alcoholics World Services Silver Spring, MD 20907-8250
Organization Phone: 800-438-4380
PO Box 3216 E-mail: [email protected]
Torrance, CA 90510 http://www.alzheimers.org
Phone: 310-534-1815 Information, referrals, and publications about
E-mail: [email protected] clinical trials.
http://www.adultchildren.org
A 12-step program for adults raised in alco- Alzheimer’s Disease and Related Disorders
holic families. Association
919 North Michigan Avenue, Suite 1100
Agoraphobics in Motion (AIM) Chicago, IL 60611-8700
1719 Crooks Phone: 312-335-8700
Royal Oak, MI 48067 E-mail: [email protected]
Phone: 248-547-0400 http://www.alz.org
E-mail: [email protected] For caregivers of Alzheimer’s patients.
http://www.aim-hq.org
Offers support, publications, and treatment American Association on Mental Retardation
recommendations on anxiety disorders. 444 North Capitol Street, NW
Washington, DC 20001
Alateen and Al-Anon Family Groups Phone: 800-424-3688
1600 Corporate Landing Parkway http://www.aamr.org
Virginia Beach, VA 23454 Information on mental retardation.
Phone: 800-344-2666
E-mail: [email protected] American Association of Retired Persons
http://www.al-anon.org (AARP)
A fellowship of young persons whose lives 601 E Street NW
have been affected by someone else’s Washington, DC 20049
drinking. Phone: 800-424-3410
E-mail: [email protected]
508 part vii • self-help resources

http://www.aarp.org Phone: 800-223-APDA or 718-981-8001

Multipurpose organization for older adults. E-mail: [email protected]
http://apdaparkinson.com/
American Cancer Society Provides information, referrals, and listings of
Phone: 800-227-2345 local support groups.
http://www.cancer.org
Provides information for cancer sufferers and American Sleep Apnea Association
their family. 1424 K Street NW, Suite 302
Washington, DC 20005
American Council of the Blind Phone: 202-293-3650
1155 15th Street NW, #720 E-mail: [email protected]
Washington, DC 20005 http://www.sleepapnea.org/
Phone: 800-424-8666; 202-467-5081 For persons with sleep apnea and their families.
http://www.acb.org
For blind and visually impaired people and American Social Health Association
their families. PO Box 13827
Research Triangle Park, NC 27709
American Diabetes Association Phone: 919-361-8400
1701 North Beauregard Street E-mail: [email protected]
Alexandria, VA 22311 http://www.ashastd.org
Phone: 800-342-2383 Provides information and education about sex-
E-mail: [email protected] ually transmitted diseases.
http://www.diabetes.org
Provides research, information, and advocacy. American Society on Aging
833 Market Street, Suite 511
American Foundation for Suicide Prevention San Francisco, CA 94103-1824
120 Wall St., 22nd floor Phone: 415-974-9600
New York, NY 10005 E-mail: [email protected]
Phone: 888-333-AFSP or 212-363-3500 http://www.asaging.org/
E-mail: [email protected] Offers educational programming, information
http://www.afsp.org and training resources.
Providing information and education about
suicide. American Society for Deaf Children
PO Box 3355
American Heart Association Gettysburg, PA 17325
7272 Greenville Avenue Phone: 717-334-7922
Dallas, TX 75231 E-mail: [email protected]
Phone: 800-242-8721 http://www.deafchildren.org
http://www.americanheart.org For parents and families with children who are
For cardiac patients and their families. deaf or hard of hearing.

American Lupus Society American Stroke Association

3914 Del Amo Boulevard, Suite 922 7272 Greenville Avenue
Los Angeles, CA 90503 Dallas TX 75231
Phone: 310-390-6888 Phone: 800-787-8984
For lupus patients and their families. http://www.americanheart.org
For stroke victims and their families.
American Parkinson’s Disease Association
1250 Hylan Boulevard, Suite 4B American Suicide Foundation
Staten Island, NY 10305-1946 1045 Park Avenue, Suite 3C
 101 • national self-help groups and organizations 509

New York, NY 10028 Colton, CA 92324

Phone: 800-ASF-4042; 212-210-1111 Phone: 909-355-1100
Provides referrals to national support groups For men who wish to control their anger and
for suicide survivors. eliminate their abusive behavior.

Anxiety Disorders Association of America Brain Injury Association Family Helpline

(ADAA) Phone: 800-444-6443
8730 Georgia Avenue, Suite 100 http://www.bindependent.com/hompg/inter-
Silver Spring, MD 20910 act/com/states.htm
Phone: 240-485-10001 Provides contact information about support
http://www.adaa.org groups in each state.
Promotes the prevention and cure of anxiety
disorders. Cancer Care
275 7th Avenue
ARC New York, NY, 10001
1010 Wayne Ave., Suite 650 Phone: 212-712-8080, 1-800-813-HOPE
Silver Spring, MD 20910 E-mail: [email protected]
Phone: 301-565-3842 http://www.cancercare.org/index.asp
Email: [email protected] For those who have suffered the loss of a loved
http://www.thearc.org one to cancer.
For people with mental retardation or develop-
mental disabilities and their families. Candlelighters Childhood Cancer Foundation
PO Box 498
Association for Repetitive Motion Syndromes Kensington MD 20895-0498
PO Box 471973 Phone: 301-962-3520
Aurora, CO 80047-1973 E-mail: [email protected]
E-mail: [email protected] http://www.candlelighters.org/
http://www.certifiedpst.com/arms/index.html For children with cancer and their families.
For persons with carpal tunnel syndrome and
repetitive motion injuries. CDC National AIDS Clearinghouse
Hotline: 800-458-5231
Attention Deficit Disorder Association http://www.cdcnpin.org/hiv/start.htm
(ADDA) Provides educational materials and referrals to
1788 Second Street, Suite 200 support groups.
Highland Park, IL 60035
Phone: 847-432-ADDA CFIDS Association
E-mail: [email protected] PO Box 220398
http://www.add.org Charlotte, NC 28222-0398
For ADHD patients and their families. Phone: 800-442-3437; 704-365-2343
E-mail: cfids@cfids.org
Autism Society of America http://www.cfids.org
7910 Woodmont Avenue, Suite 300 For people affected by chronic fatigue and im-
Bethesda, Maryland 20814-3067 mune dysfunction syndrome.
Phone: 301-657-0881
http://www.autism-society.org Child Help USA Hotline
For information, referrals, and networking. 15757 North 78th Street
Scottsdale, AZ 85260
Batterers Anonymous Phone: 480-922-8212
1041 South Mt. Vernon Avenue http://www.childhelpusa.org
Suite G-306 Referrals and information on child abuse.
510 part vii • self-help resources

Children and Adults with Attention-Deficit/ Information, support groups, conferences, and
Hyperactivity Disorder (CHADD) newsletters.
8181 Professional Place, Suite 201
Landover, MD 20785 Cult Awareness Network
Phone: 800-233-4050 1680 North Vine Street, Suite 415
E-mail: [email protected] Los Angeles, CA 90028
http://chadd.org/index.htm Phone: 800-556-3055
For ADHD patients and their families. E-mail: [email protected]
http://www.cultawarenessnetwork.org
Cocaine Anonymous Public education about destructive mind-
3740 Overland Avenue, Suite C control cults.
Los Angeles, CA 90034-6337
For local chapters, call 800-347-8998 or Debtors Anonymous
310-559-5833 PO Box 920888
E-mail:[email protected] Needham, MA 02492-0009
http://www.ca.org Phone: 781-453-2743
A 12-step program for individuals afflicted E-mail: [email protected]
with cocaine addiction. http://www.debtorsanonymous.org
A 12-step program for those recovering from
Codependents of Sex Addicts (COSA) compulsive indebtedness.
PO Box 14537
Minneapolis, MN 55414 Domestic Violence Anonymous
Phone: 763-537-6904 DVA, c/o BayLaw
E-mail: [email protected] PO Box 29011
A 12-step program for those in relationships San Francisco, CA 94129
with people who have compulsive sexual Phone: 415-681-4850
behavior. E-mail: [email protected]
http://www.BayLaw.com
Compassionate Friends A 12-step spiritual support for adults recover-
PO Box 3696 ing from domestic violence.
Oak Brook, IL 60522-3696
Phone: 630-990-0010 Emotions Anonymous
E-mail: [email protected] PO Box 4245
http://www.compassionatefriends.org/ St. Paul, MN 55104
For families who have lost a child. Phone: 651-647-9712
http://www.emotionsanonymous.org
Concerned United Birthparents (CUB) Fellowship for people experiencing emotional
PO Box 230457 difficulties.
Encinitas, CA 92023
Phone: 800-822-2777 Epilepsy Foundation
E-mail: [email protected] 4351 Garden City Drive
http://www.cubirthparents.org Landover, MD 20785
For adoption-affected people. Phone: 800-332-1000
http://www.epilepsyfoundation.org
Crohn’s & Colitis Foundation of America Information and referral for people with
386 Park Avenue South, 17th Floor epilepsy and their families.
New York, NY 10016
Phone: 800-932-2423 Family Pride Coalition
E-mail: [email protected] PO Box 65327
http://ccfa.org Washington, DC 200035-5327
 101 • national self-help groups and organizations 511

Phone: 202-331-5015 Schaumburg, IL 60173-4808

E-mail: [email protected] Phone: (847) 519-7730
http://www.familypride.org http://www.lalecheleague.org/
Provides support for gays, lesbians, bisexuals, Support and education for breastfeeding
and their families. mothers.

Food Addicts Anonymous Learning Disabilities Association of America

4623 Forest Hill Boulevard, Suite 109-4 4156 Library Road
West Palm Beach, FL 33415-9120 Pittsburgh, PA 15234
Phone: 561-967-3871 Phone: 412-341-1515 and 412-341-8077
E-mail: [email protected] E-mail: [email protected]
http://www.foodaddictsanonymous.org http://www.ldanatl.org/
A 12-step organization for individuals with For people with learning disabilities and their
food obsessions. families.

Friends for Survival Lupus Foundation of America

PO Box 214463 1300 Piccard Drive, Suite 200
Sacramento, CA 95821 Rockville, MD 20850-3226
Phone: 916-392-0664; 800-646-7322 Phone: 800-558-0121; 301-670-9292
http://www.friendsforsurvival.org/ E-mail: [email protected]
For family, friends, and professionals after a http://www.lupus.org
suicide death. For lupus patients and their families.

Gam-Anon Family Groups Marijuana Anonymous (MA)

PO Box 157 PO Box 2912
Whitestone, NY 11357 Van Nuys, CA 91404
Phone: 718-352-1671 Phone: 800-766-6779
A 12-step program for relatives and friends of E-mail: offi[email protected]
compulsive gamblers. http://www.marijuana-anonymous.org
A 12-step program of recovery from mari-
Gamblers Anonymous juana addiction.
PO Box 17173
Los Angeles, CA 90017 Mothers Against Drunk Driving
Phone: 213-386-8789 PO Box 541688
E-mail: [email protected] Dallas, TX 75354-1688
http://www.gamblersanonymous.org Phone: 800-438-6233
A 12-step program for individuals with a http://www.madd.org
gambling problem. Provides education, political activism, and vic-
tim assistance.
Klinefelter Syndrome and Associates (KSA)
PO Box 119 Multiple Sclerosis Association of America
Roseville, CA 95678-0119 706 Haddonfield Road
Phone: 916-773-2999 Cherry Hill, NJ 08002
E-mail: [email protected] Phone: 800-532-7667
http://www.genetic.org/ks E-mail: [email protected]
Increasing public awareness and providing http://www.msaa.com/
support for those suffering. For multiple sclerosis patients.

La Leche League Muscular Dystrophy Association

1400 North Meacham Road 3300 East Sunrise Drive
512 part vii • self-help resources

Tucson, AZ 85718 2107 Wilson Boulevard, Suite 300

Phone: 602-529-2000 Arlington, VA 2201
E-mail: [email protected] Phone: 703-524-7600 or 800-950-NAMI
http://www.mdausa.org (Hotline)
For fighting 40 neuromuscular diseases. http://www.nami.org
For individuals and their relatives affected by
Nar-Anon World Wide Service mental illness.
302 West 5th Street, Suite 301
San Pedro, CA 90731 National Alliance for Research on Schizophre-
Phone: 310-547-5800 nia and Depression (NARSAD)
A 12-step program of recovery for families 60 Cutter Mill Road, Suite 404
and friends of addicts. Great Neck, NY 11021
Phone: 516-829-0091
Narcolepsy Network E-mail: [email protected]
10921 Reed Hartman Highway http://www.narsad.org
Cincinnati, OH 45242 Supporting scientific research on brain and be-
Phone: 513-891-3522 havior disorders.
E-mail: [email protected]
http://www.websciences.org/narnet/default.html National Alopecia Areata Foundation
For persons with narcolepsy and other sleep PO Box 150760
disorders. San Rafael, CA 94915-0760
Phone: 415-472-3780
Narcotics Anonymous http://www.alopeciaareata.com
PO Box 9999 Support network for people with alopecia
Van Nuys, CA 91409 areata, totalis, and universalis.
Phone: 818-773-9999
E-mail: [email protected] National Association of Anorexia Nervosa and
http://www.na.org Associated Disorders
12-step association of recovering drug addicts. PO Box 7
Highland Park, IL 60035
National Adoption Center Phone: 847-433-4632
1500 Walnut Street, Suite 701 E-mail: [email protected]
Philadelphia, PA 19102 http://www.anad.org
Phone: 800-TO-ADOPT For persons with eating disorders.
E-mail: [email protected]
http://www.adopt.org National Association of the Deaf
Information on adoption agencies and support 814 Thayer Avenue
groups. Silver Springs, MD 20910
Phone: 301-587-1788; 301-587-1789
National AIDS Hotline E-mail: [email protected]
Center For Disease Control http://www.nad.org
PO Box 13827 For people who are deaf and hard of hearing.
Research Triangle Park, NC 27709
Phone: 800-342-AIDS (24 hrs.); Spanish: National Center for Men
800-344 7432 PO Box 555
Offers telephone support, information, and Old Bethpage, NY 11804
referrals. Phone: 516-942-2020; activism/message line:
503-727-3686
National Alliance for the Mentally Ill E-mail: [email protected]
Colonial Place Three Men’s rights, male choice, fathers’ rights.
 101 • national self-help groups and organizations 513

National Chronic Pain Outreach Association Phone: 888-NHF-5552

7979 Old Georgetown Road, #100 http://www.headaches.org
Bethesda, MD 20814 Support for chronic headache sufferers and
Phone: 301-652-4948 their families.
For those suffering with chronic pain.
National Information Center for Children and
National Clearinghouse for Alcohol and Drug Youth with Disabilities
Information PO Box 1492
PO Box 2345 Washington, DC 20013-1492
Rockville, MD 20847-2345 Phone: 800-695-0285
E-mail: [email protected] E-mail: [email protected]
Hotline: 800-788-2800 http://www.nichcy.org
Information on alcohol and drug abuse, pre- Provides information on disabilities and
vention, and treatment. disability-related issues.

National Depressive and Manic Depressive National Mental Health Association (NMHA)
Association 1021 Prince Street
730 North Franklin, Suite 501 Alexandria, VA 22314-2971
Chicago, IL 60610 Phone: 703-684-7722
Phone: 800-826-3632 http://www.nmha.org
E-mail: [email protected] Provides advocacy, education, and research on
http://www.ndmda.org. mental illness.
For persons with depressive and manic-
depressive illness and their families. National Multiple Sclerosis Society
733 Third Avenue
National Domestic Violence Hotline New York, NY 10017-3288
Phone: 800-799-7233; 800-787-3224 Phone: 800-344-4867
http://www.ndvh.org http://www.nationalmssociety.org
Information and referrals for victims of For MS patients and their families.
domestic violence.
National Organization on Fetal Alcohol Syn-
National Down Syndrome Congress drome
1605 Chantilly Drive, #250 216 G Street, NE
Atlanta, GA 30324-3269 Washington, DC 20002
Phone: 800-232-NDSC; 404-653-1555 Phone: 202-785-4585
http://www.ndsccenter.org E-mail: [email protected]
For families affected by Down syndrome. http://www.nofas.org
Provides training workshops, peer education,
National Eating Disorders Association and referrals.
603 Stewart Street, Suite 803
Seattle, WA 98101 National Organization for Men
Phone: 206-382-3587 11 Park Place
E-mail: [email protected] New York, NY 10007-2801
http://nationaleatingdisorders.org Phone: 212-686-MALE; 212-766-4030
For persons with eating disorders, their fami- http://www.tnom.com
lies, and friends. For men seeking equal rights divorce, custody,
property, and visitation laws.
National Headache Foundation
428 West St. James Place, 2nd Floor National Organization for Women (NOW)
Chicago, IL 60614 733 15th Street NW
514 part vii • self-help resources

Washington, DC 20005 Overeaters Anonymous (OA)

Phone: 202-628-8669 PO Box 44020
E-mail: [email protected] Rio Rancho, NM 87174-4020
http://www.now.org Phone: 505-891-2664
Provides advocacy on various women’s rights E-mail: [email protected]
issues. http://www.overeatersanonymous.org
A 12-step self-help fellowship for overeaters.
National Stroke Association
9707 East Easter Lane Parents Anonymous
Englewood, CO 80112 675 West Foothill Boulevard, Suite 220
Phone: 303-771-1700 or 800-STROKES Claremont, CA 91711-3416
http://www.stroke.org Phone: 909-621-6184
For stroke victims and their families. E-mail: parentsanonymous@parentsanonymous.
org
National Parkinson Foundation http:// www.parentsanonymous.org
1501 NW 9th Avenue For parents who want to learn effective ways
Bob Hope Road of raising their children.
Miami, FL 33136-1494
Phone: 305-547-6666 or 800-327-4545 Parents Without Partners
E-mail: [email protected] 1650 South Dixie Highway, Suite 510
http://www.parkinson.org Boca Raton, FL 33432
For individuals and their families afflicted Phone: 561-391-8833
with Parkinson’s disease. E-mail: [email protected]
http://www.parentswithoutpartners.org
Nicotine Anonymous World Service A multiservice organization for single, di-
419 Main Street, PMB# 370 vorced, or widowed parents.
Huntington Beach, CA 92648
Phone: 415-750-0328 Planned Parenthood
E-mail: [email protected] 810 Seventh Avenue
http://nicotine-anonymous.org New York, NY 10019
A 12-step program of recovery from nicotine Phone: 800-230-7526
addiction. E-mail: [email protected]
http://www.plannedparenthood.org
Obsessive-Compulsive Anonymous Referrals to neighborhood Planned Parent-
PO Box 215 hood clinics nationwide.
New Hyde Park, NY 11040
Phone: 516-739-0662 Postpartum Support International
http://hometown.aol.com/west24th/index.html 927 North Kellogg Avenue
A 12-step group for people with obsessive– Santa Barbara, CA 93111
compulsive disorders. Phone: 805-967-736
http://www.postpartum.net/researchpage.htm
Obsessive-Compulsive Foundation For women experiencing emotional changes
337 Notch Hill Road during and after pregnancy.
North Branford, CT 06471
Phone: 203-878-5669 PTSD Support Services
E-mail: [email protected] PO Box 5574
http://www.ocfoundation.org Woodland Park, CO 80866
Sponsors a large Internet site with research, Phone: 719-687-4582
newsletters, and conferences. http://ptsdsupport.net
Helping persons who have been injured emo-
tionally and physically.
 101 • national self-help groups and organizations 515

Rape Abuse and Incest National Network Mentor, Ohio 44060

(RAINN) Phone: 440-951-5357
Phone: 800-656-4673 E-mail: [email protected]
http://www.rainn.org http://www.smartrecovery.org
A national hotline network for victims and An abstinence-based, cognitive-behavioral ap-
survivors of sexual abuse. proach.

Rational Recovery (RR) Sex Addicts Anonymous

PO Box 800 PO Box 70949
Lotus, CA 95651 Houston, TX 77270
Phone: 530-621-2667 or 530-621-4374 Phone: 713-869-4902
http://www.rational.org E-mail: [email protected]
For drug and alcohol addictions. http://www.sexaa.org
A 12-step program of recovery from compul-
Reflex Sympathetic Dystrophy Syndrome sive sexual behavior.
Association
116 Haddon Avenue, Suite D Sexual Compulsives Anonymous
Haddonfield, NJ 08033-2306 PO Box 1585, Old Chelsea Station
Phone: 215-955-5444; 609-795-8845 New York, NY 10011
http://www.rsds.org Phone: 800-977-4325
For those suffering from RSD and their fami- E-mail: [email protected]
lies. http://www.sca-recovery.org
A fellowship for individuals with compulsive
RESOLVE: The National Infertility Associa- sexual behavior.
tion
1310 Broadway Shape Up America!
Somerville MA 02144 4500 Connecticut Avenue, NW, Suite 414
Phone: 888-623-0744 Washington, DC 20008
Email: [email protected] E-mail: [email protected]
Offers support, information, and referrals for http://www.shapeup.org
the infertile. An organization advancing the benefits of
maintaining a healthy weight.
SAFE (Self-Abuse Finally Ends) Alternative
Information Line Stepfamily Association of America
Phone: 800-DONT-CUT 650 J Street, Suite 205
Provides information on self-abuse and treat- Lincoln, NE 68508
ment options. Phone: 800-735-0329
E-mail: [email protected]
Self-Help for Hard of Hearing People (SHHH) http://www.saafamilies.org
7910 Woodmont Avenue, Suite 1200 Information and advocacy for stepfamilies.
Bethesda, MD 20814
Phone: 301-657-2248; 301-657-2249 Sudden Infant Death Syndrome Alliance
Email: [email protected] (SIDS Alliance)
http://www.shhh.org 1314 Bedford Avenue, Suite 210
For hard of hearing people, their families, and Baltimore, MD 21208
friends. Phone: 800-221-SIDS
E-mail: [email protected]
Self Management and Recovery Training http://www.sidsalliance.org/index/default.asp
(SMART) Provides emotional support for families of
7537 Mentor Avenue, Suite 306 SIDS victims.
516 part vii • self-help resources

Survivors of Incest Anonymous (S.I.A.) References, Readings, & Internet Sites

PO Box 190
American Self-Help Clearinghouse. (n.d.). Self-help
Benson, MD 21018-9998 sourcebook. Retrieved 2004 from http://men-
Phone: 410-282-3400 talhelp.net/selfhelp
http://www.siawso.org Barlow, S. W., Burlingame, G. M., Nebeker, R. S., &
A 12-step program for those who have been Anderson, E. (2000). Meta-analysis of medical
victims of child sexual abuse. self-help groups. International Journal of
Group Psychotherapy, 50, 53 – 69.
Tardive Dyskinesia/Tardive Dystonia Na- Eisenberg, D. M., Davis, R. B., Ettner, S. L., Appel, S.,
tional Association Wilkey, S., Rompay, M. V., et al. (1998). Trends
PO Box 45732 in alternative medicine use in the United States,
1990 –1997. Journal of the American Medical
Seattle, WA 98145-0732
Association, 280, 1575 –1589.
Phone: 206-522-3166
Humphreys, K. (1999). Professional interventions
E-mail: [email protected] that facilitate a 12-step self-help group involve-
For those suffering from TD/TD, their fami- ment. Alcohol Research and Health, 23, 93 –
lies, and friends. 98.
Kurtz, L. F. (1997). Self-help and support groups.
Tourette’s Syndrome Association Thousand Oaks, CA: Sage.
42-40 Bell Boulevard, Suite 205 National Mental Health Consumers. (n.d.). Self-
Bayside, NY 11361-2861 Help Clearinghouse. Retrieved 2004 from http://
Phone: 718-224-2999; 800-237-0717 www.mhselfhelp.org
http://www.tsa-usa.org Norcross, J. C., Santrock, J. W., Campbell, L. F.,
Smith T. P., Sommer, R., & Zuckerman, E. L.
Education for patients, professionals, and the
(2003). Authoritative guide to self-help re-
public.
sources in mental health. New York: Guilford
Press.
United Cerebral Palsy Association Powell, T. J. (1987). Self-help organizations and
1660 L Street NW, Suite 700 professional practice. Silver Spring, MD: Na-
Washington, DC 20036 tional Association of Social Workers.
Phone: 800-872-5827 Powell, T. J. (1994). Understanding the self-help or-
E-mail: [email protected] ganization. Beverly Hills, CA: Sage.
http://www.ucpa.org Reissman, F., & Carroll, D. (1995). Redefining self-
Provides programs for individuals with cere- help: Policy and practice. San Francisco: Jossey-
bral palsy and other disabilities. Bass.
Wong, M. M. (1996). The national directory of be-
reavement support groups and services. Forest
Y-ME National Breast Cancer Organization
Hills, NY: ADM Publishing.
212 W. Van Buren Street, Suite 500 Yoder, B. (1990). The recovery resource book. New
Chicago, IL 6067 York: Simon & Schuster.
Phone: 312-986-8338
http://www.y-me.org/
Related Topic
Information and support for breast cancer pa-
tients and their families. Chapter 97, “Top Internet Sites for Psychologists
and Their Clients”
 KNOWN AND UNPROVEN
102 HERBAL TREATMENTS FOR
PSYCHOLOGICAL DISORDERS

Paula J. Biedenharn

Popular in parts of the world for thousands of CAMs to their physicians (Hammerness et al.,
years (Gardner, 2002), herbal medicines have 2003); and even when herbal use is reported, it
grown in use dramatically in the United States is often not recorded on the patients’ medical
over the last decade (Hammerness et al., 2003). charts (Cohen, Ek, & Pan, 2002). Given that
Herbal medicines are the most commonly used herbal medicine use has also increased in the
type of complementary and alternative medi- older adult population — consumers of nearly
cines (CAMs). Also known as botanicals or half of all prescription and over-the-counter
phytomedicines (Fetrow & Avila, 2001), herbal (OTC) medications— their risk for drug inter-
treatments number in the hundreds, with St. actions may be particularly elevated.
John’s wort, ginkgo, and ginseng among the Second, many wonderful medications started
most commonly used (Buchanan & Lemberg, as herbal treatments, including: warfarin (sweet
2001). In the United States, these phytomedi- clover), capsaicin (red pepper), and Taxol (Pa-
cines are used by an estimated 16% to 18% of cific yew tree) (Fetrow & Avila, 2001). There-
adults. In addition to being used for physical fore it seems plausible that some phytomedi-
health problems, these herbs are often used by cines will be found useful for the treatment of
those seeking relief from emotional illnesses. psychological symptoms. However, additional
While many tout the efficacy of these herbal research is needed to confirm both the safety
treatments for psychological disorders such as and the effectiveness of these CAMs. Fonta-
depression, there are several concerns about narosa, Rennie, and DeAngelis (2003) suggest
herbal CAMs that warrant a cautious approach. we should learn from the recent serious prob-
lems discovered about ephedra — a weight-loss
and athletic performance enhancer linked to
CAUTIONS FOR HERBAL CAMS heart attack, stroke, seizure, and death — and
require more rigorous regulation by the FDA
First, many herbal medicines have side effects for these untested CAMs.
and the potential for drug interactions, partic- Third, there are considerable variations in
ularly when taken with certain prescription product strength for herbal medications mak-
medications (McCabe, 2002). Since consumers ing accurate, consistent dosages difficult (Gard-
can purchase these CAMs at grocery stores and ner, 2002; McCabe, 2002). Because herbal
convenience markets, they tend to see herbal CAMs are considered dietary supplements
medicines as safe, natural substances, not as (1994 Dietary Supplement Health and Educa-
drugs. Compounding this problematic percep- tion Act), they are not regulated by the U.S.
tion are vague product labels that typically Food and Drug Administration (FDA) and
offer little warning or advisory information therefore are not standardized. Illustrating this
(Williams, 2003). An added concern is the fact problem, a recent U.S. analysis of St. John’s
that patients typically do not report the use of wort products found variations in hyperforin,

517
518 part vii • self-help resources

believed to be the active ingredient in this herb, wort is definitely not recommended for people
from 0% to 3.26% in samples from various with major or severe depression (Buchanan &
manufacturers (Gardner, 2002). Lemberg, 2001). Despite the uncertainty of its
Perhaps the most significant problem is the efficacy, many people take this herb and report
tremendous lack of scientifically rigorous ex- positive benefits (McCabe, 2002). Additionally,
periments testing the efficacy of CAMs (Mc- St. John’s wort has also been examined for ef-
Cabe, 2002). “Presently, herbal preparations fects on anxiety, obsessive-compulsive disor-
are subject to less stringent safety testing and der, and seasonal affective disorder with very
governmental standards than OTC medica- limited evidence of support (Hammerness et
tions. These medicinal herbs can be marketed al., 2003).
without proof of efficacy and are presumed safe While a popular herb worldwide, St. John’s
until proven harmful” (Buchanan & Lemberg, wort does have side effects and potentially seri-
2001, p. 439). Fortunately, a clearer picture of ous drug interactions, though side effects tend
herbal medicine efficacy is emerging; random- to be lower than those of other antidepressants
ized controlled trials are becoming more com- (Hammerness et al., 2003). Side effects com-
mon and more reliable data is appearing in the monly include gastrointestinal upset, restless-
literature (Gardner, 2002). ness, sedation, dizziness, dry mouth, head-
A working knowledge of these CAMs is be- aches, and skin reactions. Because photosensi-
coming essential for psychologists, as many tivity is common, people taking St. John’s wort
clients are likely to be using these herbal treat- should use sunscreen (McCabe, 2002).
ments or may be interested in trying them Many drug interactions have been identified
(Hammerness et al., 2003). The following is a for this herbal medicine. In particular, St. John’s
brief review of the known and unproven for the wort interferes with the protease inhibitors
herbal medicines mostly commonly used for used to treat HIV (such as indinavir) and with
psychological disorders. the most common antirejection drug used after
transplant surgery (cyclosporine), causing re-
duced blood levels of these crucial medications
ST. JOHN’S WORT FOR DEPRESSION (McCabe, 2002). Acting as a weak monoamine
oxidase inhibitor (MAOI), St. John’s wort adds
The most commonly used and widely known to the effect of prescription MAOIs, SSRIs, and
herb for psychological disorder is St. John’s TCAs — potentially leading to serotonin syn-
wort (Hypericum perforatum). A common drome or a hypertensive crisis. St. John’s wort
roadside weed with yellow flowers, this herb can also cause increased anxiety when taken
has been used for thousands of years to treat a with flagyl. Theoretically, drugs such as war-
wide variety of health problems. Today it is farin (Coumadin) and oral contraceptives,
most commonly used for the treatment of de- statin anticholesterol drugs, and anticonvulsant
pression (Hammerness et al., 2003). drugs may all have decreased blood levels when
There have been more studies of St. John’s St. John’s wort is taken (McCabe, 2002).
wort than most other herbal CAMs, and yet
solid conclusions remain illusive. In Hammer-
ness and colleagues’ (2003) meta-analysis of GINKGO BILOBA FOR MEMORY
previous studies, the authors concluded that St.
John’s wort works better than placebo and Ginkgo biloba is derived from the leaves of a
equal to selective serotonin reuptake inhibitors commonly cultivated, ancient tree. In Europe,
(SSRIs) and tricyclic antidepressants (TCAs) ginkgo is used to treat vascular disorders and
for the short-term (1–3 months) management memory problems in older adults and dementia
of mild to moderate depression. However, two patients (Buchanan & Lemberg, 2001). Five
recent studies found no effect for St. John’s million prescriptions are filled for ginkgo each
wort compared to placebo, thus casting doubt year in Germany alone (Oken, Storzbach, &
on the herb’s efficacy. At this time, St. John’s Kaye, 1998), and it is commonly prescribed in
 102 • known & unproven herbal treatments for psychological disorders 519

France as well (Spinella, 2001). Healthy adults petite, sleep patterns, reaction time, and ab-
take ginkgo to improve short-term memory, stract thinking; however, additional research is
and ginkgo is also used to counteract the sexual needed to confirm this in humans. Ginseng has
dysfunction that often accompanies the use of been found to have vasodilating effects and an-
SSRIs (Buchanan & Lemberg, 2001). tioxidant properties that may impact cognitive
Less is known about ginkgo than about St. and sexual performance (Spinella, 2001).
John’s wort. Oken and colleagues’ (1998) meta- Common side effects for ginseng include in-
analysis of previous studies supports a small somnia, nervousness, headaches, hypertension,
but significant effect on cognitive function in diarrhea, and vaginal bleeding (Fetrow & Avila,
Alzheimer’s patients when 120 to 240 mg is 2001). At normal doses, ginseng has little toxic-
taken for three to six months. It appears to both ity (Spinella, 2001); however, manic symptoms
improve symptoms and delay further deterio- have been reported at high doses (Ernest,
ration in these patients (Ernst, 2001). In ad- 2001). Drug interactions may occur when gin-
dition, healthy adults show some improvement seng is taken with oral contraceptives, steroids,
in memory and other cognitive functions. antidepressants, antipsychotics, and anticoagu-
Ginkgo is believed to work by increasing cere- lants. Also, ginseng is contraindicated for pa-
bral blood flow through small arteries and by tients with diabetes, hypertension, hypoten-
inhibiting platelet aggregation (Buchanan & sion, and cardiovascular disease (Ernst, 2001).
Lemberg, 2001).
Side effects from ginkgo include anxiety, in-
somnia, headache, and GI distress. More seri- KAVA FOR ANXIETY
ously, ginkgo may be a possible teratogen, may
cause mania at high dosage, and may cause se- A native plant of the South Pacific Islands, kava
rious bleeding due to its anticoagulant effect (Piper methysticum) is a derivative of the rhi-
(McCabe, 2002). zome of a pepper plant (Spinella, 2001). Used
ceremonially or recreationally by Micronesian
and Polynesian cultures, kava causes a mild eu-
GINSENG FOR WELL-BEING phoria at normal doses and is known for hav-
ing relaxation, sleep, analgesic, and anticonvul-
There are several types of ginseng, including sant effects. In the West, it is most commonly
Chinese, Korean, Japanese, and American, with used for anxiety and insomnia.
the most studied variety being panax gin- Again, little research is available on this
seng — considered the true ginseng (Spinella, herbal medicine, but some studies suggest that
2001, p. 167). Ginseng may be white or red de- kava is better than placebo if taken for at least
pending on the preparation of the plant’s rhi- two months for the treatment of anxiety. In ad-
zome (which may alter the pharmacological ef- dition, kava appears to work as well as benzodi-
fect) and is expensive to produce and purchase. azepines (Ernst, 2001). Data are limited re-
Nonetheless, it has been used for several thou- garding kava’s effect on sleep, though it is be-
sand years for numerous illnesses. Spinella lieved to have potential for sleep induction.
(2001) characterizes this CAM as an adapto- Improved coordination, mood, and memory
genic agent that “increases one’s biological and have also been identified (McCabe, 2002).
mental resistance to stress.” It is also believed Numbness of the mouth and tongue is a
to be an aphrodisiac and to increase physical common side effect of kava use, as are mild gas-
and mental performance (Fetrow & Avila, trointestinal upset, allergic skin reactions, and
2001). visual disturbances (McCabe, 2002). Anecdotal
While animal studies suggest that ginseng reports suggest kava may add to the depressant
has great potential for learning and memory, effect of alcohol and may aggravate underlying
research on the efficacy of ginseng in humans depressant states in some individuals. Another
is nearly nonexistent (Spinella, 2001). McCabe problem is that the strength of kava extracts
(2002) suggests that ginseng may improve ap- can vary tremendously, as strength is depen-
520 part vii • self-help resources

dent on what part of the plant is processed. The sedative and antianxiety agent. Chamomile,
most serious concern about kava is that fact lavender, and skullcap are also used for their
that it is a drug of abuse in the South Pacific sedative properties. Spinella (2001) suggests
and Australia, undoubtedly for its euphoric ef- that ginger would probably not work as an an-
fects. tidepressant alone, but could augment other
medications and might counteract the negative
side effects of other antidepressant medications.
VALERIAN FOR SLEEP Black cohosh is used to ease menopausal symp-
toms, and its use is likely to increase with
Valerian (Valeriana officinalis) is a small plant growing concerns about pharmaceutical hor-
with pink-white flowers. With use dating back mone replacement therapy. Evening primose
at least a thousand years, the plant’s roots or oil has been tested on hyperactive children
rhizomes are the source of this herbal prepara- with mixed results and with the risk of produc-
tion. Used as a muscle relaxant, digestive aid, ing temporal lope epilepsy (Fetrow & Avila,
and anticonvulsant in Europe (Fetrow & Avila, 2001). Lastly, one methodologically limited
2001), it is most commonly used for the treat- study reported the use of ginseng with ginkgo
ment of anxiety and insomnia (Spinella, 2001). biloba for the treatment of ADHD in children
Empirical research on valerian is limited. with some success (Lyon et al., 2001).
Placebo-controlled studies are particularly dif-
ficult due to the strong, distinctive, unpleasant References, Readings, & Internet Sites
odor of this CAM (McCabe, 2002). Although
results are mixed, valerian does hold potential Buchanan, K., & Lemberg, L. (2001). Herbal or com-
plementary medicine: Fact or fiction? American
as a medication for improving sleep, particu-
Journal of Critical Care, 10, 438 – 443.
larly in poor sleepers. Spinella (2001) also sug-
Cohen, R. J., Ek, K., & Pan, C. X. (2002). Comple-
gests it may have use in treating anxiety or mentary and alternative medicine (CAM) use
other mood disorders due to its pharmacologi- by older adults: A comparison of self-report
cal mechanisms, but studies have not yet been and physician chart documentation. The Jour-
conducted. nals of Gerontology, 57A, M223 –M227.
There seems to be little risk of side effects or Ernest, E. (Ed.). (2001). The desktop guide to com-
drug interactions with valerian. Only overdose plementary and alternative medicine. Edin-
or chronic use produces symptoms such as burgh: Mosby.
nausea, headache, and blurred vision. However, Fetrow, C. W., & Avila, J. R. (2001). Professional’s
use is contraindicated for those with active handbook of complementary and alternative
medicines. Springhouse, PA: Springhouse.
liver disease as anecdotal reports suggest hepa-
Fontanarosa, P. B., Rennie, D., & DeAngelis, C. D.
totoxicity (Fetrow & Avila, 2001) and for those (2003). The need for regulation of dietary sup-
taking other central nervous system depres- plements: Lessons from ephedra. Journal of the
sants (Ernst, 2001). American Medical Association, 289, 1568 –
1570.
Gardner, D. M. (2002). Evidence-based decisions
OTHER HERBS AND APPLICATIONS about herbal products for treating mental dis-
orders. Journal of Psychiatry and Neuroscience,
Far less information is available on most of the 27, 324 –333.
other herbal CAMs used for psychological con- Hammerness, P., Basch, E., Ulbright, C., Barrette, E.,
cerns. Briefly, rauwolfia has been used as an an- Foppa, I., Basch, S., et al. (2003). St. John’s
wort: A systematic review of adverse effects
tipsychotic medication and tranquilizer for
and drug interactions for the consultation psy-
thousands of years; however, adverse side ef- chiatrist. Psychosomatics, 44, 271–282.
fects (primarily depression) and interactions Lyon, J. C., Cline, J. C., Totosy de Zepetnek, J., Jie
have limited its use (Spinella, 2001). Popular in Shan, J., Pang, P., & Benishin, C. (2001). Effect
England, passion flower is a perennial climbing of the herbal extract combination Panax quin-
vine whose colorful flowers are dried for a mild quefolium and Ginkgo biloba on attention-
 102 • known & unproven herbal treatments for psychological disorders 521

deficit hyperactivity disorder: A pilot study. Fugh-Berman, A., Johnson, K., et al. (2003).
Journal of Psychiatry and Neuroscience, 26, Ethnomedicine in the urban environment: Do-
221–228. minican healers in New York City. Human Or-
McCabe, S. (2002). Complementary herbal and al- ganization, 62, 12–26.
ternative drugs in clinical practice. Perspectives Spinella, M. (2001). The psychopharmacology of
in Psychiatric Care, 38, 98 –107. herbal medicine: Plant drugs that alter mind,
National Center for Complementary and Alterna- brain, and behavior. Cambridge, MA: MIT Press.
tive Medicine. (2002). What is complementary Williams, A. (2003). Herbs can cause death or in-
and alternative medicine? Retrieved September jury. Journal of the National Medical Associa-
9, 2003, from http://www.nccam.nih.gov/health/ tion, 95, 108.
whatiscam/
Oken, B. S., Storzbach, D. M., & Kaye, D. M. (1998).
Related Topic
The efficacy of Ginkgo Biloba on cognitive
function in Alzheimer disease. Archives of Chapter 95, “Dietary Supplements and Psychologi-
Neurology, 55, 1409 –1415. cal Functioning”
Reiff, M., O’Connor, B., Kronenberg, F., Balick, M.,
This page intentionally left blank
PART VIII
Ethical and Legal Issues
This page intentionally left blank
 ETHICAL PRINCIPLES OF
103 PSYCHOLOGISTS AND CODE
OF CONDUCT (2002)

American Psychological Association

CONTENTS
INTRODUCTION 2. Competence
PREAMBLE 2.01 Boundaries of Competence
GENERAL PRINCIPLES 2.02 Providing Services in Emergencies
2.03 Maintaining Competence
Principle A: Beneficence and Nonmaleficence
2.04 Bases for Scientific and Professional Judg-
Principle B: Fidelity and Responsibility
ments
Principle C: Integrity
2.05 Delegation of Work to Others
Principle D: Justice
2.06 Personal Problems and Conflicts
Principle E: Respect for People’s Rights and Dignity
ETHICAL STANDARDS 3. Human Relations
1. Resolving Ethical Issues
3.01 Unfair Discrimination
1.01 Misuse of Psychologists’ Work 3.02 Sexual Harassment
1.02 Conflicts Between Ethics and Law, Regula- 3.03 Other Harassment
tions, or Other Governing Legal Authority 3.04 Avoiding Harm
1.03 Conflicts Between Ethics and Organizational 3.05 Multiple Relationships
Demands 3.06 Conflict of Interest
1.04 Informal Resolution of Ethical Violations 3.07 Third-Party Requests for Services
1.05 Reporting Ethical Violations 3.08 Exploitative Relationships
1.06 Cooperating With Ethics Committees 3.09 Cooperation With Other Professionals
1.07 Improper Complaints 3.10 Informed Consent
1.08 Unfair Discrimination Against Complainants 3.11 Psychological Services Delivered To or
and Respondents Through Organizations
3.12 Interruption of Psychological Services

525
526 part viii • ethical and legal issues

4. Privacy and Confidentiality 8.04 Client/Patient, Student, and Subordinate Re-

search Participants
4.01 Maintaining Confidentiality
8.05 Dispensing With Informed Consent for Re-
4.02 Discussing the Limits of Confidentiality
search
4.03 Recording
8.06 Offering Inducements for Research Participa-
4.04 Minimizing Intrusions on Privacy
tion
4.05 Disclosures
8.07 Deception in Research
4.06 Consultations
8.08 Debriefing
4.07 Use of Confidential Information for Didactic
8.09 Humane Care and Use of Animals in Re-
or Other Purposes
search
8.10 Reporting Research Results
5. Advertising and Other Public Statements 8.11 Plagiarism
8.12 Publication Credit
5.01 Avoidance of False or Deceptive Statements 8.13 Duplicate Publication of Data
5.02 Statements by Others 8.14 Sharing Research Data for Verification
5.03 Descriptions of Workshops and Non- 8.15 Reviewers
Degree-Granting Educational Programs
5.04 Media Presentations
5.05 Testimonials 9. Assessment
5.06 In-Person Solicitation
9.01 Bases for Assessments
9.02 Use of Assessments
6. Record Keeping and Fees 9.03 Informed Consent in Assessments
9.04 Release of Test Data
6.01 Documentation of Professional and Scientific 9.05 Test Construction
Work and Maintenance of Records 9.06 Interpreting Assessment Results
6.02 Maintenance, Dissemination, and Disposal of 9.07 Assessment by Unqualified Persons
Confidential Records of Professional and Sci- 9.08 Obsolete Tests and Outdated Test Results
entific Work 9.09 Test Scoring and Interpretation Services
6.03 Withholding Records for Nonpayment 9.10 Explaining Assessment Results
6.04 Fees and Financial Arrangements 9.11 Maintaining Test Security
6.05 Barter With Clients/Patients
6.06 Accuracy in Reports to Payors and Funding
Sources 10. Therapy
6.07 Referrals and Fees
10.01 Informed Consent to Therapy
10.02 Therapy Involving Couples or Families
7. Education and Training 10.03 Group Therapy
10.04 Providing Therapy to Those Served by Oth-
7.01 Design of Education and Training Programs ers
7.02 Descriptions of Education and Training Pro- 10.05 Sexual Intimacies With Current Therapy
grams Clients/Patients
7.03 Accuracy in Teaching 10.06 Sexual Intimacies With Relatives or Signifi-
7.04 Student Disclosure of Personal Information cant Others of Current Therapy Clients/
7.05 Mandatory Individual or Group Therapy Patients
7.06 Assessing Student and Supervisee Perfor- 10.07 Therapy With Former Sexual Partners
mance 10.08 Sexual Intimacies With Former Therapy
7.07 Sexual Relationships With Students and Clients/Patients
Supervisees 10.09 Interruption of Therapy
10.10 Terminating Therapy
8. Research and Publication
8.01 Institutional Approval
8.02 Informed Consent to Research
8.03 Informed Consent for Recording Voices and
Images in Research
 103 • ethical principles of psychologists and code of conduct ( 2002) 527

INTRODUCTION AND APPLICABILITY Standard is not itself a defense to a charge of

unethical conduct.
The American Psychological Association’s (APA’s) The procedures for filing, investigating, and
Ethical Principles of Psychologists and Code of resolving complaints of unethical conduct are
Conduct (hereinafter referred to as the Ethics described in the current Rules and Procedures
Code) consists of an Introduction, a Preamble, of the APA Ethics Committee. APA may im-
five General Principles (A–E), and specific Eth- pose sanctions on its members for violations of
ical Standards. The Introduction discusses the the standards of the Ethics Code, including ter-
intent, organization, procedural considerations, mination of APA membership, and may notify
and scope of application of the Ethics Code. The other bodies and individuals of its actions. Ac-
Preamble and General Principles are aspira- tions that violate the standards of the Ethics
tional goals to guide psychologists toward the Code may also lead to the imposition of sanc-
highest ideals of psychology. Although the Pre- tions on psychologists or students whether or
amble and General Principles are not them- not they are APA members by bodies other
selves enforceable rules, they should be consid- than APA, including state psychological associ-
ered by psychologists in arriving at an ethical ations, other professional groups, psychology
course of action. The Ethical Standards set forth boards, other state or federal agencies, and pay-
enforceable rules for conduct as psychologists. ors for health services. In addition, APA may
Most of the Ethical Standards are written take action against a member after his or her
broadly, in order to apply to psychologists in conviction of a felony, expulsion or suspension
varied roles, although the application of an Eth- from an affiliated state psychological associa-
ical Standard may vary depending on the con- tion, or suspension or loss of licensure. When
text. The Ethical Standards are not exhaustive. the sanction to be imposed by APA is less than
The fact that a given conduct is not specifically expulsion, the 2001 Rules and Procedures do
addressed by an Ethical Standard does not mean not guarantee an opportunity for an in-person
that it is necessarily either ethical or unethical. hearing, but generally provide that complaints
This Ethics Code applies only to psycholo- will be resolved only on the basis of a submit-
gists’ activities that are part of their scientific, ted record.
educational, or professional roles as psycholo- The Ethics Code is intended to provide guid-
gists. Areas covered include but are not limited ance for psychologists and standards of profes-
to the clinical, counseling, and school practice of sional conduct that can be applied by the APA
psychology; research; teaching; supervision of and by other bodies that choose to adopt them.
trainees; public service; policy development; so- The Ethics Code is not intended to be a basis of
cial intervention; development of assessment civil liability. Whether a psychologist has vio-
instruments; conducting assessments; educa- lated the Ethics Code standards does not by it-
tional counseling; organizational consulting; self determine whether the psychologist is
forensic activities; program design and evalua- legally liable in a court action, whether a con-
tion; and administration. This Ethics Code ap- tract is enforceable, or whether other legal con-
plies to these activities across a variety of con- sequences occur.
texts, such as in person, postal, telephone, Inter- The modifiers used in some of the standards
net, and other electronic transmissions. These of this Ethics Code (e.g., reasonably, appropri-
activities shall be distinguished from the purely ate, potentially) are included in the standards
private conduct of psychologists, which is not when they would (1) allow professional judg-
within the purview of the Ethics Code. ment on the part of psychologists, (2) eliminate
Membership in the APA commits members injustice or inequality that would occur with-
and student affiliates to comply with the stan- out the modifier, (3) ensure applicability across
dards of the APA Ethics Code and to the rules the broad range of activities conducted by psy-
and procedures used to enforce them. Lack of chologists, or (4) guard against a set of rigid
awareness or misunderstanding of an Ethical rules that might be quickly outdated. As used
528 part viii • ethical and legal issues

in this Ethics Code, the term reasonable means chologists build their professional and scientific
the prevailing professional judgment of psy- work.
chologists engaged in similar activities in sim- This Ethics Code is intended to provide spe-
ilar circumstances, given the knowledge the cific standards to cover most situations encoun-
psychologist had or should have had at the tered by psychologists. It has as its goals the
time. welfare and protection of the individuals and
In the process of making decisions regarding groups with whom psychologists work and the
their professional behavior, psychologists must education of members, students, and the public
consider this Ethics Code in addition to applic- regarding ethical standards of the discipline.
able laws and psychology board regulations. In The development of a dynamic set of ethical
applying the Ethics Code to their professional standards for psychologists’ work-related con-
work, psychologists may consider other mate- duct requires a personal commitment and life-
rials and guidelines that have been adopted or long effort to act ethically; to encourage ethi-
endorsed by scientific and professional psycho- cal behavior by students, supervisees, employ-
logical organizations and the dictates of their ees, and colleagues; and to consult with others
own conscience, as well as consult with others concerning ethical problems.
within the field. If this Ethics Code establishes
a higher standard of conduct than is required by
law, psychologists must meet the higher ethical GENERAL PRINCIPLES
standard. If psychologists’ ethical responsibili-
ties conflict with law, regulations, or other gov- This section consists of General Principles.
erning legal authority, psychologists make General Principles, as opposed to Ethical Stan-
known their commitment to this Ethics Code dards, are aspirational in nature. Their intent is
and take steps to resolve the conflict in a re- to guide and inspire psychologists toward the
sponsible manner. If the conflict is unresolvable very highest ethical ideals of the profession.
via such means, psychologists may adhere to General Principles, in contrast to Ethical Stan-
the requirements of the law, regulations, or dards, do not represent obligations and should
other governing authority in keeping with ba- not form the basis for imposing sanctions. Re-
sic principles of human rights. lying upon General Principles for either of
these reasons distorts both their meaning and
purpose.
PREAMBLE

Principle A: Beneficence and

Psychologists are committed to increasing sci-
Nonmaleficence
entific and professional knowledge of behavior
and people’s understanding of themselves and Psychologists strive to benefit those with whom
others and to the use of such knowledge to im- they work and take care to do no harm. In their
prove the condition of individuals, organiza- professional actions, psychologists seek to safe-
tions, and society. Psychologists respect and guard the welfare and rights of those with
protect civil and human rights and the central whom they interact professionally and other af-
importance of freedom of inquiry and expres- fected persons, and the welfare of animal sub-
sion in research, teaching, and publication. jects of research. When conflicts occur among
They strive to help the public in developing in- psychologists’ obligations or concerns, they at-
formed judgments and choices concerning hu- tempt to resolve these conflicts in a responsible
man behavior. In doing so, they perform many fashion that avoids or minimizes harm. Be-
roles, such as researcher, educator, diagnosti- cause psychologists’ scientific and professional
cian, therapist, supervisor, consultant, adminis- judgments and actions may affect the lives of
trator, social interventionist, and expert wit- others, they are alert to and guard against per-
ness. This Ethics Code provides a common set sonal, financial, social, organizational, or polit-
of principles and standards upon which psy- ical factors that might lead to misuse of their
 103 • ethical principles of psychologists and code of conduct ( 2002) 529

influence. Psychologists strive to be aware of equal quality in the processes, procedures, and
the possible effect of their own physical and services being conducted by psychologists. Psy-
mental health on their ability to help those with chologists exercise reasonable judgment and
whom they work. take precautions to ensure that their potential
biases, the boundaries of their competence, and
the limitations of their expertise do not lead to
Principle B: Fidelity and
or condone unjust practices.
Responsibility
Psychologists establish relationships of trust
Principle E: Respect for People’s
with those with whom they work. They are
Rights and Dignity
aware of their professional and scientific re-
sponsibilities to society and to the specific com- Psychologists respect the dignity and worth of
munities in which they work. Psychologists all people, and the rights of individuals to pri-
uphold professional standards of conduct, clar- vacy, confidentiality, and self-determination.
ify their professional roles and obligations, ac- Psychologists are aware that special safeguards
cept appropriate responsibility for their behav- may be necessary to protect the rights and wel-
ior, and seek to manage conflicts of interest that fare of persons or communities whose vulner-
could lead to exploitation or harm. Psycholo- abilities impair autonomous decision making.
gists consult with, refer to, or cooperate with Psychologists are aware of and respect cultural,
other professionals and institutions to the ex- individual, and role differences, including those
tent needed to serve the best interests of those based on age, gender, gender identity, race, eth-
with whom they work. They are concerned nicity, culture, national origin, religion, sexual
about the ethical compliance of their colleagues’ orientation, disability, language, and socioeco-
scientific and professional conduct. Psycholo- nomic status and consider these factors when
gists strive to contribute a portion of their pro- working with members of such groups. Psy-
fessional time for little or no compensation or chologists try to eliminate the effect on their
personal advantage. work of biases based on those factors, and they
do not knowingly participate in or condone ac-
tivities of others based upon such prejudices.
Principle C: Integrity
Psychologists seek to promote accuracy, hon-
esty, and truthfulness in the science, teaching, ETHICAL STANDARDS
and practice of psychology. In these activities
psychologists do not steal, cheat, or engage in 1. Resolving Ethical Issues
fraud, subterfuge, or intentional misrepresen-
1.01 Misuse of Psychologists’ Work
tation of fact. Psychologists strive to keep their
promises and to avoid unwise or unclear com- If psychologists learn of misuse or misrepre-
mitments. In situations in which deception may sentation of their work, they take reasonable
be ethically justifiable to maximize benefits and steps to correct or minimize the misuse or mis-
minimize harm, psychologists have a serious representation.
obligation to consider the need for, the possible
consequences of, and their responsibility to cor-
1.02 Conflicts Between Ethics and Law,
rect any resulting mistrust or other harmful ef-
Regulations, or Other Governing
fects that arise from the use of such techniques.
Legal Authority

If psychologists’ ethical responsibilities conflict

Principle D: Justice
with law, regulations, or other governing legal
Psychologists recognize that fairness and jus- authority, psychologists make known their
tice entitle all persons to access to and benefit commitment to the Ethics Code and take steps
from the contributions of psychology and to to resolve the conflict. If the conflict is unre-
530 part viii • ethical and legal issues

solvable via such means, psychologists may ad- 1.06 Cooperating With Ethics Committees
here to the requirements of the law, regula-
Psychologists cooperate in ethics investigations,
tions, or other governing legal authority.
proceedings, and resulting requirements of the
APA or any affiliated state psychological asso-
1.03 Conflicts Between Ethics and ciation to which they belong. In doing so, they
Organizational Demands address any confidentiality issues. Failure to co-
operate is itself an ethics violation. However,
If the demands of an organization with which
making a request for deferment of adjudication
psychologists are affiliated or for whom they
of an ethics complaint pending the outcome of
are working conflict with this Ethics Code, psy-
litigation does not alone constitute noncooper-
chologists clarify the nature of the conflict,
ation.
make known their commitment to the Ethics
Code, and to the extent feasible, resolve the
conflict in a way that permits adherence to the 1.07 Improper Complaints
Ethics Code.
Psychologists do not file or encourage the filing
of ethics complaints that are made with reckless
1.04 Informal Resolution of Ethical Violations disregard for or willful ignorance of facts that
would disprove the allegation.
When psychologists believe that there may
have been an ethical violation by another psy-
chologist, they attempt to resolve the issue by 1.08 Unfair Discrimination Against
bringing it to the attention of that individual, if Complainants and Respondents
an informal resolution appears appropriate and
Psychologists do not deny persons employ-
the intervention does not violate any confiden-
ment, advancement, admissions to academic or
tiality rights that may be involved. (See also
other programs, tenure, or promotion, based
Standards 1.02, Conflicts Between Ethics and
solely upon their having made or their being
Law, Regulations, or Other Governing Legal
the subject of an ethics complaint. This does not
Authority, and 1.03, Conflicts Between Ethics
preclude taking action based upon the outcome
and Organizational Demands.)
of such proceedings or considering other appro-
priate information.
1.05 Reporting Ethical Violations
If an apparent ethical violation has substantially 2. Competence
harmed or is likely to substantially harm a per-
2.01 Boundaries of Competence
son or organization and is not appropriate for
informal resolution under Standard 1.04, Infor- (a) Psychologists provide services, teach, and
mal Resolution of Ethical Violations, or is not conduct research with populations and in areas
resolved properly in that fashion, psychologists only within the boundaries of their compe-
take further action appropriate to the situation. tence, based on their education, training, super-
Such action might include referral to state or vised experience, consultation, study, or profes-
national committees on professional ethics, to sional experience.
state licensing boards, or to the appropriate in- (b) Where scientific or professional knowl-
stitutional authorities. This standard does not edge in the discipline of psychology establishes
apply when an intervention would violate con- that an understanding of factors associated with
fidentiality rights or when psychologists have age, gender, gender identity, race, ethnicity, cul-
been retained to review the work of another ture, national origin, religion, sexual orienta-
psychologist whose professional conduct is in tion, disability, language, or socioeconomic sta-
question. (See also Standard 1.02, Conflicts Be- tus is essential for effective implementation of
tween Ethics and Law, Regulations, or Other their services or research, psychologists have or
Governing Legal Authority.) obtain the training, experience, consultation, or
 103 • ethical principles of psychologists and code of conduct ( 2002) 531

supervision necessary to ensure the competence 2.04 Bases for Scientific and Professional
of their services, or they make appropriate re- Judgments
ferrals, except as provided in Standard 2.02,
Psychologists’ work is based upon established
Providing Services in Emergencies.
scientific and professional knowledge of the dis-
(c) Psychologists planning to provide ser-
cipline. (See also Standards 2.01e, Boundaries
vices, teach, or conduct research involving pop-
of Competence, and 10.01b, Informed Consent
ulations, areas, techniques, or technologies new
to Therapy.)
to them undertake relevant education, training,
supervised experience, consultation, or study.
(d) When psychologists are asked to provide 2.05 Delegation of Work to Others
services to individuals for whom appropriate
Psychologists who delegate work to employees,
mental health services are not available and for
supervisees, or research or teaching assistants
which psychologists have not obtained the
or who use the services of others, such as inter-
competence necessary, psychologists with
preters, take reasonable steps to (1) avoid dele-
closely related prior training or experience may
gating such work to persons who have a multi-
provide such services in order to ensure that
ple relationship with those being served that
services are not denied if they make a reason-
would likely lead to exploitation or loss of
able effort to obtain the competence required by
objectivity; (2) authorize only those responsi-
using relevant research, training, consultation,
bilities that such persons can be expected to
or study.
perform competently on the basis of their edu-
(e) In those emerging areas in which gener-
cation, training, or experience, either indepen-
ally recognized standards for preparatory train-
dently or with the level of supervision being
ing do not yet exist, psychologists nevertheless
provided; and (3) see that such persons perform
take reasonable steps to ensure the competence
these services competently. (See also Standards
of their work and to protect clients/patients,
2.02, Providing Services in Emergencies; 3.05,
students, supervisees, research participants, or-
Multiple Relationships; 4.01, Maintaining Con-
ganizational clients, and others from harm.
fidentiality; 9.01, Bases for Assessments; 9.02,
(f) When assuming forensic roles, psycholo-
Use of Assessments; 9.03, Informed Consent in
gists are or become reasonably familiar with
Assessments; and 9.07, Assessment by Unqual-
the judicial or administrative rules governing
ified Persons.)
their roles.

2.06 Personal Problems and Conflicts

2.02 Providing Services in Emergencies
(a) Psychologists refrain from initiating an
In emergencies, when psychologists provide
activity when they know or should know that
services to individuals for whom other mental
there is a substantial likelihood that their per-
health services are not available and for which
sonal problems will prevent them from per-
psychologists have not obtained the necessary
forming their work-related activities in a com-
training, psychologists may provide such ser-
petent manner.
vices in order to ensure that services are not de-
(b) When psychologists become aware of
nied. The services are discontinued as soon as
personal problems that may interfere with their
the emergency has ended or appropriate ser-
performing work-related duties adequately,
vices are available.
they take appropriate measures, such as obtain-
ing professional consultation or assistance, and
2.03 Maintaining Competence determine whether they should limit, suspend,
or terminate their work-related duties. (See
Psychologists undertake ongoing efforts to de-
also Standard 10.10, Terminating Therapy.)
velop and maintain their competence.
532 part viii • ethical and legal issues

3. Human Relations 3.05 Multiple Relationships

3.01 Unfair Discrimination (a) A multiple relationship occurs when a
psychologist is in a professional role with a per-
In their work-related activities, psychologists
son and (1) at the same time is in another role
do not engage in unfair discrimination based on
with the same person, (2) at the same time is in
age, gender, gender identity, race, ethnicity, cul-
a relationship with a person closely associated
ture, national origin, religion, sexual orienta-
with or related to the person with whom the
tion, disability, socioeconomic status, or any ba-
psychologist has the professional relationship,
sis proscribed by law.
or (3) promises to enter into another relation-
ship in the future with the person or a person
3.02 Sexual Harassment closely associated with or related to the person.
A psychologist refrains from entering into a
Psychologists do not engage in sexual harass-
multiple relationship if the multiple relation-
ment. Sexual harassment is sexual solicitation,
ship could reasonably be expected to impair the
physical advances, or verbal or nonverbal con-
psychologist’s objectivity, competence, or effec-
duct that is sexual in nature, that occurs in con-
tiveness in performing his or her functions as
nection with the psychologist’s activities or
a psychologist, or otherwise risks exploitation
roles as a psychologist, and that either (1) is un-
or harm to the person with whom the profes-
welcome, is offensive, or creates a hostile work-
sional relationship exists.
place or educational environment, and the psy-
Multiple relationships that would not rea-
chologist knows or is told this or (2) is suffi-
sonably be expected to cause impairment or risk
ciently severe or intense to be abusive to a
exploitation or harm are not unethical.
reasonable person in the context. Sexual ha-
(b) If a psychologist finds that, due to un-
rassment can consist of a single intense or
foreseen factors, a potentially harmful multiple
severe act or of multiple persistent or pervasive
relationship has arisen, the psychologist takes
acts. (See also Standard 1.08, Unfair Dis-
reasonable steps to resolve it with due regard
crimination Against Complainants and Re-
for the best interests of the affected person and
spondents.)
maximal compliance with the Ethics Code.
(c) When psychologists are required by law,
3.03 Other Harassment institutional policy, or extraordinary circum-
stances to serve in more than one role in judi-
Psychologists do not knowingly engage in be-
cial or administrative proceedings, at the outset
havior that is harassing or demeaning to per-
they clarify role expectations and the extent of
sons with whom they interact in their work
confidentiality and thereafter as changes occur.
based on factors such as those persons’ age,
(See also Standards 3.04, Avoiding Harm, and
gender, gender identity, race, ethnicity, culture,
3.07, Third-Party Requests for Services.)
national origin, religion, sexual orientation,
disability, language, or socioeconomic status.
3.06 Conflict of Interest
3.04 Avoiding Harm Psychologists refrain from taking on a profes-
sional role when personal, scientific, profes-
Psychologists take reasonable steps to avoid
sional, legal, financial, or other interests or re-
harming their clients/patients, students, super-
lationships could reasonably be expected to (1)
visees, research participants, organizational
impair their objectivity, competence, or effec-
clients, and others with whom they work, and
tiveness in performing their functions as psy-
to minimize harm where it is foreseeable and
chologists or (2) expose the person or organiza-
unavoidable.
tion with whom the professional relationship
exists to harm or exploitation.
 103 • ethical principles of psychologists and code of conduct ( 2002) 533

3.07 Third-Party Requests for Services vidual or individuals using language that is rea-
sonably understandable to that person or per-
When psychologists agree to provide services to
sons except when conducting such activities
a person or entity at the request of a third
without consent is mandated by law or govern-
party, psychologists attempt to clarify at the
mental regulation or as otherwise provided in
outset of the service the nature of the relation-
this Ethics Code. (See also Standards 8.02, In-
ship with all individuals or organizations in-
formed Consent to Research; 9.03, Informed
volved. This clarification includes the role of the
Consent in Assessments; and 10.01, Informed
psychologist (e.g., therapist, consultant, diag-
Consent to Therapy.)
nostician, or expert witness), an identification of
(b) For persons who are legally incapable of
who is the client, the probable uses of the ser-
giving informed consent, psychologists never-
vices provided or the information obtained, and
theless (1) provide an appropriate explanation,
the fact that there may be limits to confiden-
(2) seek the individual’s assent, (3) consider
tiality. (See also Standards 3.05, Multiple Rela-
such persons’ preferences and best interests,
tionships, and 4.02, Discussing the Limits of
and (4) obtain appropriate permission from a
Confidentiality.)
legally authorized person, if such substitute
consent is permitted or required by law. When
3.08 Exploitative Relationships consent by a legally authorized person is not
permitted or required by law, psychologists
Psychologists do not exploit persons over
take reasonable steps to protect the individual’s
whom they have supervisory, evaluative, or
rights and welfare.
other authority such as clients/patients, stu-
(c) When psychological services are court
dents, supervisees, research participants, and
ordered or otherwise mandated, psychologists
employees. (See also Standards 3.05, Multiple
inform the individual of the nature of the an-
Relationships; 6.04, Fees and Financial Ar-
ticipated services, including whether the ser-
rangements; 6.05, Barter With Clients/Patients;
vices are court ordered or mandated and any
7.07, Sexual Relationships With Students and
limits of confidentiality, before proceeding.
Supervisees; 10.05, Sexual Intimacies With
(d) Psychologists appropriately document
Current Therapy Clients/Patients; 10.06, Sex-
written or oral consent, permission, and assent.
ual Intimacies With Relatives or Significant
(See also Standards 8.02, Informed Consent to
Others of Current Therapy Clients/Patients;
Research; 9.03, Informed Consent in Assess-
10.07, Therapy With Former Sexual Partners;
ments; and 10.01, Informed Consent to Ther-
and 10.08, Sexual Intimacies With Former
apy.)
Therapy Clients/Patients.)

3.11 Psychological Services Delivered To or

3.09 Cooperation With Other Professionals
Through Organizations
When indicated and professionally appropriate,
(a) Psychologists delivering services to or
psychologists cooperate with other profession-
through organizations provide information be-
als in order to serve their clients/patients effec-
forehand to clients and when appropriate those
tively and appropriately. (See also Standard
directly affected by the services about (1) the
4.05, Disclosures.)
nature and objectives of the services, (2) the in-
tended recipients, (3) which of the individuals
3.10 Informed Consent are clients, (4) the relationship the psychologist
will have with each person and the organiza-
(a) When psychologists conduct research or
tion, (5) the probable uses of services provided
provide assessment, therapy, counseling, or
and information obtained, (6) who will have ac-
consulting services in person or via electronic
cess to the information, and (7) limits of confi-
transmission or other forms of communication,
dentiality. As soon as feasible, they provide in-
they obtain the informed consent of the indi-
534 part viii • ethical and legal issues

formation about the results and conclusions of (c) Psychologists who offer services, prod-
such services to appropriate persons. ucts, or information via electronic transmission
(b) If psychologists will be precluded by law inform clients/patients of the risks to privacy
or by organizational roles from providing such and limits of confidentiality.
information to particular individuals or groups,
they so inform those individuals or groups at
4.03 Recording
the outset of the service.
Before recording the voices or images of indi-
viduals to whom they provide services, psy-
3.12 Interruption of Psychological Services
chologists obtain permission from all such per-
Unless otherwise covered by contract, psychol- sons or their legal representatives. (See also
ogists make reasonable efforts to plan for facil- Standards 8.03, Informed Consent for Record-
itating services in the event that psychological ing Voices and Images in Research; 8.05, Dis-
services are interrupted by factors such as the pensing With Informed Consent for Research;
psychologist’s illness, death, unavailability, re- and 8.07, Deception in Research.)
location, or retirement or by the client’s/pa-
tient’s relocation or financial limitations. (See
4.04 Minimizing Intrusions on Privacy
also Standard 6.02c, Maintenance, Dissemina-
tion, and Disposal of Confidential Records of (a) Psychologists include in written and oral
Professional and Scientific Work.) reports and consultations only information ger-
mane to the purpose for which the communica-
tion is made.
4. Privacy And Confidentiality
(b) Psychologists discuss confidential infor-
4.01 Maintaining Confidentiality mation obtained in their work only for appro-
priate scientific or professional purposes and
Psychologists have a primary obligation and
only with persons clearly concerned with such
take reasonable precautions to protect confiden-
matters.
tial information obtained through or stored in
any medium, recognizing that the extent and
limits of confidentiality may be regulated by 4.05 Disclosures
law or established by institutional rules or pro-
(a) Psychologists may disclose confidential
fessional or scientific relationship. (See also
information with the appropriate consent of the
Standard 2.05, Delegation of Work to Others.)
organizational client, the individual client/pa-
tient, or another legally authorized person on
4.02 Discussing the Limits of Confidentiality behalf of the client/patient unless prohibited by
law.
(a) Psychologists discuss with persons (in-
(b) Psychologists disclose confidential infor-
cluding, to the extent feasible, persons who are
mation without the consent of the individual
legally incapable of giving informed consent
only as mandated by law, or where permitted
and their legal representatives) and organiza-
by law for a valid purpose such as to (1) provide
tions with whom they establish a scientific or
needed professional services; (2) obtain appro-
professional relationship (1) the relevant limits
priate professional consultations; (3) protect the
of confidentiality and (2) the foreseeable uses of
client/patient, psychologist, or others from
the information generated through their psy-
harm; or (4) obtain payment for services from
chological activities. (See also Standard 3.10,
a client/patient, in which instance disclosure is
Informed Consent.)
limited to the minimum that is necessary to
(b) Unless it is not feasible or is contraindi-
achieve the purpose. (See also Standard 6.04e,
cated, the discussion of confidentiality occurs at
Fees and Financial Arrangements.)
the outset of the relationship and thereafter as
new circumstances may warrant.
 103 • ethical principles of psychologists and code of conduct ( 2002) 535

4.06 Consultations (b) Psychologists do not make false, decep-

tive, or fraudulent statements concerning (1)
When consulting with colleagues, (1) psychol-
their training, experience, or competence;
ogists do not disclose confidential information
(2) their academic degrees; (3) their credentials;
that reasonably could lead to the identification
(4) their institutional or association affiliations;
of a client/patient, research participant, or other
(5) their services; (6) the scientific or clinical ba-
person or organization with whom they have a
sis for, or results or degree of success of, their
confidential relationship unless they have ob-
services; (7) their fees; or (8) their publications
tained the prior consent of the person or orga-
or research findings.
nization or the disclosure cannot be avoided,
(c) Psychologists claim degrees as credentials
and (2) they disclose information only to the
for their health services only if those degrees
extent necessary to achieve the purposes of the
(1) were earned from a regionally accredited
consultation. (See also Standard 4.01, Main-
educational institution or (2) were the basis for
taining Confidentiality.)
psychology licensure by the state in which they
practice.
4.07 Use of Confidential Information for
Didactic or Other Purposes
5.02 Statements by Others
Psychologists do not disclose in their writings,
(a) Psychologists who engage others to cre-
lectures, or other public media, confidential,
ate or place public statements that promote
personally identifiable information concerning
their professional practice, products, or activi-
their clients/patients, students, research partic-
ties retain professional responsibility for such
ipants, organizational clients, or other recipi-
statements.
ents of their services that they obtained during
(b) Psychologists do not compensate em-
the course of their work, unless (1) they take
ployees of press, radio, television, or other com-
reasonable steps to disguise the person or orga-
munication media in return for publicity in a
nization, (2) the person or organization has
news item. (See also Standard 1.01, Misuse of
consented in writing, or (3) there is legal au-
Psychologists’ Work.)
thorization for doing so.
(c) A paid advertisement relating to psychol-
ogists’ activities must be identified or clearly
5. Advertising and Other Public recognizable as such.
Statements

5.01 Avoidance of False or Deceptive 5.03 Descriptions of Workshops and Non-

Statements Degree-Granting Educational Programs
(a) Public statements include but are not To the degree to which they exercise control,
limited to paid or unpaid advertising, product psychologists responsible for announcements,
endorsements, grant applications, licensing catalogs, brochures, or advertisements describ-
applications, other credentialing applications, ing workshops, seminars, or other non-degree-
brochures, printed matter, directory listings, granting educational programs ensure that
personal resumes or curricula vitae, or com- they accurately describe the audience for which
ments for use in media such as print or elec- the program is intended, the educational objec-
tronic transmission, statements in legal pro- tives, the presenters, and the fees involved.
ceedings, lectures and public oral presentations,
and published materials. Psychologists do not
5.04 Media Presentations
knowingly make public statements that are
false, deceptive, or fraudulent concerning their When psychologists provide public advice or
research, practice, or other work activities or comment via print, internet, or other electronic
those of persons or organizations with which transmission, they take precautions to ensure
they are affiliated. that statements (1) are based on their profes-
536 part viii • ethical and legal issues

sional knowledge, training, or experience in ac- 6.02 Maintenance, Dissemination, and

cord with appropriate psychological literature Disposal of Confidential Records of
and practice; (2) are otherwise consistent with Professional and Scientific Work
this Ethics Code; and (3) do not indicate that a
(a) Psychologists maintain confidentiality in
professional relationship has been established
creating, storing, accessing, transferring, and
with the recipient. (See also Standard 2.04,
disposing of records under their control, whether
Bases for Scientific and Professional Judg-
these are written, automated, or in any other
ments.)
medium. (See also Standards 4.01, Maintaining
Confidentiality, and 6.01, Documentation of
5.05 Testimonials Professional and Scientific Work and Mainte-
nance of Records.)
Psychologists do not solicit testimonials from
(b) If confidential information concerning
current therapy clients/patients or other per-
recipients of psychological services is entered
sons who because of their particular circum-
into databases or systems of records available to
stances are vulnerable to undue influence.
persons whose access has not been consented to
by the recipient, psychologists use coding or
5.06 In-Person Solicitation other techniques to avoid the inclusion of per-
sonal identifiers.
Psychologists do not engage, directly or through
(c) Psychologists make plans in advance to
agents, in uninvited in-person solicitation of
facilitate the appropriate transfer and to protect
business from actual or potential therapy clients/
the confidentiality of records and data in the
patients or other persons who because of their
event of psychologists’ withdrawal from posi-
particular circumstances are vulnerable to un-
tions or practice. (See also Standards 3.12, In-
due influence. However, this prohibition does
terruption of Psychological Services, and 10.09,
not preclude (1) attempting to implement ap-
Interruption of Therapy.)
propriate collateral contacts for the purpose of
benefiting an already engaged therapy client/
patient or (2) providing disaster or community 6.03 Withholding Records for Nonpayment
outreach services.
Psychologists may not withhold records under
their control that are requested and needed for
6. Record Keeping and Fees a client’s/patient’s emergency treatment solely
because payment has not been received.
6.01 Documentation of Professional and
Scientific Work and Maintenance
of Records 6.04 Fees and Financial Arrangements

Psychologists create, and to the extent the (a) As early as is feasible in a professional or
records are under their control, maintain, dis- scientific relationship, psychologists and recip-
seminate, store, retain, and dispose of records ients of psychological services reach an agree-
and data relating to their professional and sci- ment specifying compensation and billing ar-
entific work in order to (1) facilitate provision rangements.
of services later by them or by other profes- (b) Psychologists’ fee practices are consistent
sionals, (2) allow for replication of research de- with law.
sign and analyses, (3) meet institutional re- (c) Psychologists do not misrepresent their
quirements, (4) ensure accuracy of billing and fees.
payments, and (5) ensure compliance with law. (d) If limitations to services can be antici-
(See also Standard 4.01, Maintaining Confiden- pated because of limitations in financing, this is
tiality.) discussed with the recipient of services as early
as is feasible. (See also Standards 10.09, Inter-
ruption of Therapy, and 10.10, Terminating
Therapy.)
 103 • ethical principles of psychologists and code of conduct ( 2002) 537

(e) If the recipient of services does not pay 7. Education and Training
for services as agreed, and if psychologists in-
7.01 Design of Education and Training
tend to use collection agencies or legal measures
Programs
to collect the fees, psychologists first inform the
person that such measures will be taken and Psychologists responsible for education and
provide that person an opportunity to make training programs take reasonable steps to en-
prompt payment. (See also Standards 4.05, sure that the programs are designed to provide
Disclosures; 6.03, Withholding Records for the appropriate knowledge and proper experi-
Nonpayment; and 10.01, Informed Consent to ences, and to meet the requirements for licen-
Therapy.) sure, certification, or other goals for which claims
are made by the program. (See also Standard
5.03, Descriptions of Workshops and Non-
6.05 Barter With Clients/Patients
Degree-Granting Educational Programs.)
Barter is the acceptance of goods, services, or
other nonmonetary remuneration from clients/
7.02 Descriptions of Education and Training
patients in return for psychological services.
Programs
Psychologists may barter only if (1) it is not
clinically contraindicated, and (2) the resulting Psychologists responsible for education and
arrangement is not exploitative. (See also Stan- training programs take reasonable steps to en-
dards 3.05, Multiple Relationships, and 6.04, sure that there is a current and accurate de-
Fees and Financial Arrangements.) scription of the program content (including
participation in required course- or program-
related counseling, psychotherapy, experiential
6.06 Accuracy in Reports to Payors and
groups, consulting projects, or community ser-
Funding Sources
vice), training goals and objectives, stipends and
In their reports to payors for services or sources benefits, and requirements that must be met for
of research funding, psychologists take reason- satisfactory completion of the program. This
able steps to ensure the accurate reporting of information must be made readily available to
the nature of the service provided or research all interested parties.
conducted, the fees, charges, or payments, and
where applicable, the identity of the provider,
7.03 Accuracy in Teaching
the findings, and the diagnosis. (See also Stan-
dards 4.01, Maintaining Confidentiality; 4.04, (a) Psychologists take reasonable steps to en-
Minimizing Intrusions on Privacy; and 4.05, sure that course syllabi are accurate regarding
Disclosures.) the subject matter to be covered, bases for eval-
uating progress, and the nature of course expe-
riences. This standard does not preclude an in-
6.07 Referrals and Fees
structor from modifying course content or re-
When psychologists pay, receive payment quirements when the instructor considers it
from, or divide fees with another professional, pedagogically necessary or desirable, so long as
other than in an employer-employee relation- students are made aware of these modifications
ship, the payment to each is based on the ser- in a manner that enables them to fulfill course
vices provided (clinical, consultative, adminis- requirements. (See also Standard 5.01, Avoid-
trative, or other) and is not based on the refer- ance of False or Deceptive Statements.)
ral itself. (See also Standard 3.09, Cooperation (b) When engaged in teaching or training,
With Other Professionals.) psychologists present psychological informa-
tion accurately. (See also Standard 2.03, Main-
taining Competence.)
538 part viii • ethical and legal issues

7.04 Student Disclosure of Personal 7.07 Sexual Relationships With Students and
Information Supervisees
Psychologists do not require students or super- Psychologists do not engage in sexual relation-
visees to disclose personal information in ships with students or supervisees who are in
course- or program-related activities, either their department, agency, or training center or
orally or in writing, regarding sexual history, over whom psychologists have or are likely to
history of abuse and neglect, psychological have evaluative authority. (See also Standard
treatment, and relationships with parents, 3.05, Multiple Relationships.)
peers, and spouses or significant others except if
(1) the program or training facility has clearly
8. Research and Publication
identified this requirement in its admissions
and program materials or (2) the information is 8.01 Institutional Approval
necessary to evaluate or obtain assistance for
When institutional approval is required, psy-
students whose personal problems could rea-
chologists provide accurate information about
sonably be judged to be preventing them from
their research proposals and obtain approval
performing their training- or professionally re-
prior to conducting the research. They conduct
lated activities in a competent manner or posing
the research in accordance with the approved
a threat to the students or others.
research protocol.

7.05 Mandatory Individual or Group Therapy

8.02 Informed Consent to Research
(a) When individual or group therapy is a
(a) When obtaining informed consent as re-
program or course requirement, psychologists
quired in Standard 3.10, Informed Consent,
responsible for that program allow students in
psychologists inform participants about (1) the
undergraduate and graduate programs the op-
purpose of the research, expected duration, and
tion of selecting such therapy from practition-
procedures; (2) their right to decline to partici-
ers unaffiliated with the program. (See also
pate and to withdraw from the research once
Standard 7.02, Descriptions of Education and
participation has begun; (3) the foreseeable
Training Programs.)
consequences of declining or withdrawing; (4)
(b) Faculty who are or are likely to be re-
reasonably foreseeable factors that may be ex-
sponsible for evaluating students’ academic per-
pected to influence their willingness to partici-
formance do not themselves provide that ther-
pate such as potential risks, discomfort, or ad-
apy. (See also Standard 3.05, Multiple Relation-
verse effects; (5) any prospective research ben-
ships.)
efits; (6) limits of confidentiality; (7) incentives
for participation; and (8) whom to contact for
7.06 Assessing Student and Supervisee questions about the research and research par-
Performance ticipants’ rights. They provide opportunity for
the prospective participants to ask questions
(a) In academic and supervisory relation-
and receive answers. (See also Standards 8.03,
ships, psychologists establish a timely and spe-
Informed Consent for Recording Voices and
cific process for providing feedback to students
Images in Research; 8.05, Dispensing With In-
and supervisees. Information regarding the
formed Consent for Research; and 8.07, Decep-
process is provided to the student at the begin-
tion in Research.)
ning of supervision.
(b) Psychologists conducting intervention
(b) Psychologists evaluate students and su-
research involving the use of experimental
pervisees on the basis of their actual perfor-
treatments clarify to participants at the outset
mance on relevant and established program re-
of the research (1) the experimental nature of
quirements.
the treatment; (2) the services that will or will
 103 • ethical principles of psychologists and code of conduct ( 2002) 539

not be available to the control group(s) if ap- methods conducted in educational settings; (b)
propriate; (3) the means by which assignment only anonymous questionnaires, naturalistic
to treatment and control groups will be made; observations, or archival research for which
(4) available treatment alternatives if an indi- disclosure of responses would not place partic-
vidual does not wish to participate in the re- ipants at risk of criminal or civil liability or
search or wishes to withdraw once a study has damage their financial standing, employability,
begun; and (5) compensation for or monetary or reputation, and confidentiality is protected;
costs of participating including, if appropriate, or (c) the study of factors related to job or or-
whether reimbursement from the participant ganization effectiveness conducted in organiza-
or a third-party payor will be sought. (See tional settings for which there is no risk to par-
also Standard 8.02a, Informed Consent to Re- ticipants’ employability, and confidentiality is
search.) protected or (2) where otherwise permitted by
law or federal or institutional regulations.
8.03 Informed Consent for Recording Voices
and Images in Research 8.06 Offering Inducements for Research
Participation
Psychologists obtain informed consent from re-
search participants prior to recording their (a) Psychologists make reasonable efforts to
voices or images for data collection unless (1) avoid offering excessive or inappropriate finan-
the research consists solely of naturalistic ob- cial or other inducements for research partici-
servations in public places, and it is not antici- pation when such inducements are likely to co-
pated that the recording will be used in a man- erce participation.
ner that could cause personal identification or (b) When offering professional services as an
harm, or (2) the research design includes de- inducement for research participation, psychol-
ception, and consent for the use of the recording ogists clarify the nature of the services, as well
is obtained during debriefing. (See also Stan- as the risks, obligations, and limitations. (See
dard 8.07, Deception in Research.) also Standard 6.05, Barter With Clients/Pa-
tients.)
8.04 Client/Patient, Student, and Subordinate
Research Participants 8.07 Deception in Research
(a) When psychologists conduct research (a) Psychologists do not conduct a study in-
with clients/patients, students, or subordinates volving deception unless they have determined
as participants, psychologists take steps to pro- that the use of deceptive techniques is justified
tect the prospective participants from adverse by the study’s significant prospective scientific,
consequences of declining or withdrawing from educational, or applied value and that effective
participation. nondeceptive alternative procedures are not
(b) When research participation is a course feasible.
requirement or an opportunity for extra credit, (b) Psychologists do not deceive prospective
the prospective participant is given the choice of participants about research that is reasonably
equitable alternative activities. expected to cause physical pain or severe emo-
tional distress.
(c) Psychologists explain any deception that
8.05 Dispensing With Informed Consent for
is an integral feature of the design and conduct
Research
of an experiment to participants as early as is
Psychologists may dispense with informed con- feasible, preferably at the conclusion of their
sent only (1) where research would not reason- participation, but no later than at the conclusion
ably be assumed to create distress or harm and of the data collection, and permit participants to
involves (a) the study of normal educational withdraw their data. (See also Standard 8.08,
practices, curricula, or classroom management Debriefing.)
540 part viii • ethical and legal issues

8.08 Debriefing (g) When it is appropriate that an animal’s

life be terminated, psychologists proceed rapidly,
(a) Psychologists provide a prompt opportu-
with an effort to minimize pain and in accor-
nity for participants to obtain appropriate in-
dance with accepted procedures.
formation about the nature, results, and con-
clusions of the research, and they take reason-
able steps to correct any misconceptions that 8.10 Reporting Research Results
participants may have of which the psycholo-
(a) Psychologists do not fabricate data. (See
gists are aware.
also Standard 5.01a, Avoidance of False or De-
(b) If scientific or humane values justify de-
ceptive Statements.)
laying or withholding this information, psy-
(b) If psychologists discover significant er-
chologists take reasonable measures to reduce
rors in their published data, they take reason-
the risk of harm.
able steps to correct such errors in a correction,
(c) When psychologists become aware that
retraction, erratum, or other appropriate publi-
research procedures have harmed a participant,
cation means.
they take reasonable steps to minimize the
harm.
8.11 Plagiarism
8.09 Humane Care and Use of Animals in Psychologists do not present portions of an-
Research other’s work or data as their own, even if the
other work or data source is cited occasionally.
(a) Psychologists acquire, care for, use, and
dispose of animals in compliance with current
federal, state, and local laws and regulations, 8.12 Publication Credit
and with professional standards.
(a) Psychologists take responsibility and
(b) Psychologists trained in research meth-
credit, including authorship credit, only for
ods and experienced in the care of laboratory
work they have actually performed or to which
animals supervise all procedures involving an-
they have substantially contributed. (See also
imals and are responsible for ensuring appro-
Standard 8.12b, Publication Credit.)
priate consideration of their comfort, health,
(b) Principal authorship and other publica-
and humane treatment.
tion credits accurately reflect the relative scien-
(c) Psychologists ensure that all individuals
tific or professional contributions of the indi-
under their supervision who are using animals
viduals involved, regardless of their relative
have received instruction in research methods
status. Mere possession of an institutional posi-
and in the care, maintenance, and handling of
tion, such as department chair, does not justify
the species being used, to the extent appropriate
authorship credit. Minor contributions to the
to their role. (See also Standard 2.05, Delega-
research or to the writing for publications are
tion of Work to Others.)
acknowledged appropriately, such as in foot-
(d) Psychologists make reasonable efforts to
notes or in an introductory statement.
minimize the discomfort, infection, illness, and
(c) Except under exceptional circumstances, a
pain of animal subjects.
student is listed as principal author on any mul-
(e) Psychologists use a procedure subjecting
tiple-authored article that is substantially based
animals to pain, stress, or privation only when
on the student’s doctoral dissertation. Faculty
an alternative procedure is unavailable and the
advisors discuss publication credit with stu-
goal is justified by its prospective scientific, ed-
dents as early as feasible and throughout the re-
ucational, or applied value.
search and publication process as appropriate.
(f) Psychologists perform surgical proce-
(See also Standard 8.12b, Publication Credit.)
dures under appropriate anesthesia and follow
techniques to avoid infection and minimize
pain during and after surgery.
 103 • ethical principles of psychologists and code of conduct ( 2002) 541

8.13 Duplicate Publication of Data ducted an examination of the individuals ade-

quate to support their statements or conclu-
Psychologists do not publish, as original data,
sions. When, despite reasonable efforts, such an
data that have been previously published. This
examination is not practical, psychologists doc-
does not preclude republishing data when they
ument the efforts they made and the result of
are accompanied by proper acknowledgment.
those efforts, clarify the probable impact of
their limited information on the reliability and
8.14 Sharing Research Data for Verification validity of their opinions, and appropriately
limit the nature and extent of their conclusions
(a) After research results are published, psy-
or recommendations. (See also Standards 2.01,
chologists do not withhold the data on which
Boundaries of Competence, and 9.06, Interpret-
their conclusions are based from other compe-
ing Assessment Results.)
tent professionals who seek to verify the sub-
(c) When psychologists conduct a record re-
stantive claims through reanalysis and who in-
view or provide consultation or supervision and
tend to use such data only for that purpose,
an individual examination is not warranted or
provided that the confidentiality of the partici-
necessary for the opinion, psychologists explain
pants can be protected and unless legal rights
this and the sources of information on which
concerning proprietary data preclude their re-
they based their conclusions and recommenda-
lease. This does not preclude psychologists
tions.
from requiring that such individuals or groups
be responsible for costs associated with the pro-
vision of such information. 9.02 Use of Assessments
(b) Psychologists who request data from
(a) Psychologists administer, adapt, score,
other psychologists to verify the substantive
interpret, or use assessment techniques, inter-
claims through reanalysis may use shared data
views, tests, or instruments in a manner and for
only for the declared purpose. Requesting psy-
purposes that are appropriate in light of the re-
chologists obtain prior written agreement for
search on or evidence of the usefulness and
all other uses of the data.
proper application of the techniques.
(b) Psychologists use assessment instru-
8.15 Reviewers ments whose validity and reliability have been
established for use with members of the popu-
Psychologists who review material submitted
lation tested. When such validity or reliability
for presentation, publication, grant, or research
has not been established, psychologists describe
proposal review respect the confidentiality of
the strengths and limitations of test results and
and the proprietary rights in such information
interpretation.
of those who submitted it.
(c) Psychologists use assessment methods
that are appropriate to an individual’s language
9. Assessment preference and competence, unless the use of an
alternative language is relevant to the assess-
9.01 Bases for Assessments
ment issues.
(a) Psychologists base the opinions contained
in their recommendations, reports, and diag-
9.03 Informed Consent in Assessments
nostic or evaluative statements, including for-
ensic testimony, on information and techniques (a) Psychologists obtain informed consent for
sufficient to substantiate their findings. (See assessments, evaluations, or diagnostic services,
also Standard 2.04, Bases for Scientific and Pro- as described in Standard 3.10, Informed Con-
fessional Judgments.) sent, except when (1) testing is mandated by law
(b) Except as noted in 9.01c, psychologists or governmental regulations; (2) informed con-
provide opinions of the psychological charac- sent is implied because testing is conducted as a
teristics of individuals only after they have con- routine educational, institutional, or organiza-
542 part viii • ethical and legal issues

tional activity (e.g., when participants voluntar- (b) In the absence of a client/patient release,
ily agree to assessment when applying for a psychologists provide test data only as required
job); or (3) one purpose of the testing is to eval- by law or court order.
uate decisional capacity. Informed consent in-
cludes an explanation of the nature and purpose
9.05 Test Construction
of the assessment, fees, involvement of third
parties, and limits of confidentiality and suffi- Psychologists who develop tests and other as-
cient opportunity for the client/patient to ask sessment techniques use appropriate psycho-
questions and receive answers. metric procedures and current scientific or pro-
(b) Psychologists inform persons with ques- fessional knowledge for test design, standard-
tionable capacity to consent or for whom testing ization, validation, reduction or elimination of
is mandated by law or governmental regula- bias, and recommendations for use.
tions about the nature and purpose of the pro-
posed assessment services, using language that
9.06 Interpreting Assessment
is reasonably understandable to the person be-
ing assessed. Results When interpreting assessment results,
(c) Psychologists using the services of an in- including automated interpretations, psycholo-
terpreter obtain informed consent from the gists take into account the purpose of the as-
client/patient to use that interpreter, ensure sessment as well as the various test factors,
that confidentiality of test results and test secu- test-taking abilities, and other characteristics of
rity are maintained, and include in their rec- the person being assessed, such as situational,
ommendations, reports, and diagnostic or eval- personal, linguistic, and cultural differences,
uative statements, including forensic testi- that might affect psychologists’ judgments or
mony, discussion of any limitations on the data reduce the accuracy of their interpretations.
obtained. (See also Standards 2.05, Delegation They indicate any significant limitations of
of Work to Others; 4.01, Maintaining Confi- their interpretations. (See also Standards 2.01b
dentiality; 9.01, Bases for Assessments; 9.06, and c, Boundaries of Competence, and 3.01, Un-
Interpreting Assessment Results; and 9.07, As- fair Discrimination.)
sessment by Unqualified Persons.)
9.07 Assessment by Unqualified Persons
9.04 Release of Test Data
Psychologists do not promote the use of psy-
(a) The term test data refers to raw and chological assessment techniques by unquali-
scaled scores, client/patient responses to test fied persons, except when such use is conducted
questions or stimuli, and psychologists’ notes for training purposes with appropriate supervi-
and recordings concerning client/patient state- sion. (See also Standard 2.05, Delegation of
ments and behavior during an examination. Work to Others.)
Those portions of test materials that include
client/patient responses are included in the def-
9.08 Obsolete Tests and Outdated Test Results
inition of test data. Pursuant to a client/patient
release, psychologists provide test data to the (a) Psychologists do not base their assess-
client/patient or other persons identified in the ment or intervention decisions or recommenda-
release. Psychologists may refrain from releas- tions on data or test results that are outdated
ing test data to protect a client/patient or others for the current purpose.
from substantial harm or misuse or misrepre- (b) Psychologists do not base such decisions
sentation of the data or the test, recognizing or recommendations on tests and measures that
that in many instances release of confidential are obsolete and not useful for the current pur-
information under these circumstances is reg- pose.
ulated by law. (See also Standard 9.11, Main-
taining Test Security.)
 103 • ethical principles of psychologists and code of conduct ( 2002) 543

9.09 Test Scoring and Interpretation Services 10. Therapy

(a) Psychologists who offer assessment or 10.01 Informed Consent to Therapy
scoring services to other professionals accu-
(a) When obtaining informed consent to
rately describe the purpose, norms, validity, re-
therapy as required in Standard 3.10, Informed
liability, and applications of the procedures and
Consent, psychologists inform clients/patients
any special qualifications applicable to their use.
as early as is feasible in the therapeutic re-
(b) Psychologists select scoring and inter-
lationship about the nature and anticipated
pretation services (including automated ser-
course of therapy, fees, involvement of third
vices) on the basis of evidence of the validity of
parties, and limits of confidentiality and provide
the program and procedures as well as on other
sufficient opportunity for the client/patient to
appropriate considerations. (See also Standard
ask questions and receive answers. (See also
2.01b and c, Boundaries of Competence.)
Standards 4.02, Discussing the Limits of Con-
(c) Psychologists retain responsibility for
fidentiality, and 6.04, Fees and Financial Ar-
the appropriate application, interpretation, and
rangements.)
use of assessment instruments, whether they
(b) When obtaining informed consent for
score and interpret such tests themselves or use
treatment for which generally recognized tech-
automated or other services.
niques and procedures have not been estab-
lished, psychologists inform their clients/pa-
9.10 Explaining Assessment Results tients of the developing nature of the treat-
ment, the potential risks involved, alternative
Regardless of whether the scoring and interpre-
treatments that may be available, and the vol-
tation are done by psychologists, by employees
untary nature of their participation. (See also
or assistants, or by automated or other outside
Standards 2.01e, Boundaries of Competence,
services, psychologists take reasonable steps to
and 3.10, Informed Consent.)
ensure that explanations of results are given to
(c) When the therapist is a trainee and the
the individual or designated representative un-
legal responsibility for the treatment provided
less the nature of the relationship precludes
resides with the supervisor, the client/patient,
provision of an explanation of results (such as
as part of the informed consent procedure, is in-
in some organizational consulting, preemploy-
formed that the therapist is in training and is
ment or security screenings, and forensic eval-
being supervised and is given the name of the
uations), and this fact has been clearly ex-
supervisor.
plained to the person being assessed in advance.

10.02 Therapy Involving Couples or Families

9.11. Maintaining Test Security
(a) When psychologists agree to provide ser-
The term test materials refers to manuals, in-
vices to several persons who have a relationship
struments, protocols, and test questions or
(such as spouses, significant others, or parents
stimuli and does not include test data as defined
and children), they take reasonable steps to
in Standard 9.04, Release of Test Data. Psychol-
clarify at the outset (1) which of the individuals
ogists make reasonable efforts to maintain the
are clients/patients and (2) the relationship the
integrity and security of test materials and
psychologist will have with each person. This
other assessment techniques consistent with
clarification includes the psychologist’s role and
law and contractual obligations, and in a man-
the probable uses of the services provided or the
ner that permits adherence to this Ethics Code.
information obtained. (See also Standard 4.02,
Discussing the Limits of Confidentiality.)
(b) If it becomes apparent that psychologists
may be called on to perform potentially con-
flicting roles (such as family therapist and then
witness for one party in divorce proceedings),
544 part viii • ethical and legal issues

psychologists take reasonable steps to clarify 10.08 Sexual Intimacies With Former Therapy
and modify, or withdraw from, roles appropri- Clients/Patients
ately. (See also Standard 3.05c, Multiple Rela-
(a) Psychologists do not engage in sexual in-
tionships.)
timacies with former clients/patients for at
least two years after cessation or termination of
10.03 Group Therapy therapy.
(b) Psychologists do not engage in sexual in-
When psychologists provide services to several
timacies with former clients/patients even after
persons in a group setting, they describe at the
a two-year interval except in the most unusual
outset the roles and responsibilities of all par-
circumstances. Psychologists who engage in
ties and the limits of confidentiality.
such activity after the two years following ces-
sation or termination of therapy and of having
10.04 Providing Therapy to Those Served by no sexual contact with the former client/patient
Others bear the burden of demonstrating that there
has been no exploitation, in light of all relevant
In deciding whether to offer or provide services
factors, including (1) the amount of time that
to those already receiving mental health ser-
has passed since therapy terminated; (2) the na-
vices elsewhere, psychologists carefully con-
ture, duration, and intensity of the therapy; (3)
sider the treatment issues and the potential
the circumstances of termination; (4) the client’s/
client’s/patient’s welfare. Psychologists discuss
patient’s personal history; (5) the client’s/
these issues with the client/patient or another
patient’s current mental status; (6) the likeli-
legally authorized person on behalf of the
hood of adverse impact on the client/patient;
client/patient in order to minimize the risk of
and (7) any statements or actions made by the
confusion and conflict, consult with the other
therapist during the course of therapy suggest-
service providers when appropriate, and proceed
ing or inviting the possibility of a posttermina-
with caution and sensitivity to the therapeutic
tion sexual or romantic relationship with the
issues.
client/patient. (See also Standard 3.05, Multiple
Relationships.)
10.05 Sexual Intimacies
With Current Therapy Clients/Patients Psy- 10.09 Interruption of Therapy
chologists do not engage in sexual intimacies
When entering into employment or contractual
with current therapy clients/patients.
relationships, psychologists make reasonable
efforts to provide for orderly and appropriate
10.06 Sexual Intimacies With Relatives or resolution of responsibility for client/patient
Significant Others of Current Therapy care in the event that the employment or con-
Clients/Patients tractual relationship ends, with paramount con-
sideration given to the welfare of the client/pa-
Psychologists do not engage in sexual intima-
tient. (See also Standard 3.12, Interruption of
cies with individuals they know to be close rel-
Psychological Services.)
atives, guardians, or significant others of cur-
rent clients/patients. Psychologists do not ter-
minate therapy to circumvent this standard. 10.10 Terminating Therapy
(a) Psychologists terminate therapy when it
10.07 Therapy With Former Sexual Partners becomes reasonably clear that the client/patient
no longer needs the service, is not likely to ben-
Psychologists do not accept as therapy clients/
efit, or is being harmed by continued service.
patients persons with whom they have engaged
(b) Psychologists may terminate therapy
in sexual intimacies.
when threatened or otherwise endangered by
 104 • privacy, confidentiality, and privilege 545

the client/patient or another person with whom The APA has previously published its Ethics Code as
the client/patient has a relationship. follows:
(c) Except where precluded by the actions of American Psychological Association. (1953). Ethical stan-
clients/patients or third-party payors, prior to dards of psychologists. Washington, DC: Author.
American Psychological Association. (1959). Ethical stan-
termination psychologists provide pretermina-
dards of psychologists. American Psychologist, 14,
tion counseling and suggest alternative service 279 –282.
providers as appropriate. American Psychological Association. (1963). Ethical stan-
dards of psychologists. American Psychologist, 18,
See accompanying Web site for 56 –60.
American Psychological Association. (1968). Ethical stan-
additional materials.
dards of psychologists. American Psychologist, 23,
357 –361.
Source: Copyright 2002 by the American Psycho- American Psychological Association. (1977, March). Ethi-
logical Association. Reprinted with permission. cal standards of psychologists. APA Monitor, 22–23.
American Psychological Association. (1979). Ethical stan-
This version of the APA Ethics Code was adopted by the dards of psychologists. Washington, DC: Author.
American Psychological Association’s Council of Represen- American Psychological Association. (1981). Ethical princi-
tatives during its meeting, August 21, 2002, and became ef- ples of psychologists. American Psychologist, 36,
fective June 1, 2003. Inquiries concerning the substance or 633 –638.
interpretation of the APA Ethics Code should be addressed American Psychological Association. (1990). Ethical princi-
to the Director, Office of Ethics, American Psychological ples of psychologists (Amended June 2, 1989). American
Association, 750 First Street, NE, Washington, DC 20002- Psychologist, 45, 390 –395.
4242. The Ethics Code and information regarding the Code American Psychological Association. (1992). Ethical princi-
can be found on the APA Web site, http://www.apa.org/ ples of psychologists and code of conduct. American Psy-
ethics. The standards in this Ethics Code will be used to ad- chologist, 47, 1597 –1611.
judicate complaints brought concerning alleged conduct oc-
Request copies of the APA’s Ethical Principles of Psy-
curring on or after the effective date. Complaints regarding
chologists and Code of Conduct from the APA Order De-
conduct occurring prior to the effective date will be adju-
partment, 750 First Street, NE, Washington, DC 20002-
dicated on the basis of the version of the Ethics Code that
4242, or phone (202) 336-5510.
was in effect at the time the conduct occurred.

PRIVACY, CONFIDENTIALITY,
104 AND PRIVILEGE

Gerald P. Koocher

The area of confidentiality-related ethical prob- • Privacy (a constitutional guaranty and per-
lems is complicated by common misunderstand- sonal value addressed in the Fourth, Fifth,
ings about three frequently used terms: privacy, and Fourteenth Amendments to the U.S.
confidentiality, and privilege. At least part of Constitution) is basically the right of indi-
the confusion is related to the fact that in par- viduals to decide about how much of their
ticular situations these terms may have narrow thoughts, feelings, or personal data should be
legal meanings that are quite distinct from shared with others. Privacy has often been
broader traditional meanings attached by psy- considered essential to ensure human dignity
chologists or other mental health practitioners. and freedom of self-determination and to
546 part viii • ethical and legal issues

preclude unreasonable governmental intru- BREACHING CONFIDENTIALITY

sions into individuals’ lives.
• Confidentiality refers to a general standard No practitioners can make a convincing case for
of professional conduct that obliges one not absolute confidentiality. That is to say, many
to discuss information about a client with situations might legally or ethically require
anyone else, absent proper authorization. disclosure of otherwise confidential material.
Confidentiality may also be based in statutes
(i.e., laws enacted by legislatures such as • Waivers: The most common situation for
HIPAA), regulations (i.e., rules promulgated disclosure of confidential mental health in-
by the executive branch of government), or formation occurs when a client authorizes
case law (i.e., interpretations of laws by the the release of information to others.
courts). When cited as an ethical principle, • Mandated reporting: All states and Canadian
confidentiality implies an explicit contract or provinces have laws requiring that certain
promise not to reveal anything about a client, professionals who might be expected to en-
except under certain circumstances agreed to counter child abuse (e.g., physicians, nurses,
by both parties. schoolteachers, psychologists, social work-
• Privilege and confidentiality are oft-confused ers) report their “knowledge” or “reasonable
concepts, and the distinction between them is suspicion” to governmental authorities. Some
critical to understanding a variety of ethical jurisdictions also mandate reporting sus-
problems. Privilege (or privileged communi- pected abuse of handicapped, elderly, or “de-
cation) is a legal term describing certain spe- pendent” individuals. Legislatures have en-
cific types of relationships that enjoy protec- acted these statutes because protection of
tion from disclosure in legal proceedings. otherwise vulnerable individuals is deemed
Privilege is granted by law and belongs to the good public policy. Although such mandates
client in the relationship. Normal court rules preempt professional discretion, they also
provide that anything relative and material protect professionals reporting in good faith
to the issue at hand can and should be admit- from suit for defamation. Details of the spe-
ted as evidence. Where privilege exists, how- cific mandates vary by jurisdiction. In some
ever, the client is protected from having the countries there are no reporting mandates.
covered communications revealed without • Danger to self: Clinicians may generally dis-
explicit permission. If the client waives this close confidential data necessary to hospital-
privilege, the psychologist may be compelled ize or otherwise protect clients who are im-
to testify on the nature and specifics of the minently dangerous to themselves (e.g.,
material discussed. The client is usually not client status and risk information).
permitted to waive privilege selectively. In • Danger to others: When clients give clini-
most courts, once a waiver is given, it covers cians reason to believe that they intend to kill
all of the relevant privileged material. or otherwise harm others, disclosure neces-
• Privilege is not automatic. Traditionally, priv- sary to detain or hospitalize the client may be
ilege has been extended to attorney client, appropriate. In addition, if the intended tar-
husband-wife, physician-patient, and priest- gets of violence are identified, the clinician
penitent relationships. Some jurisdictions now may be obligated to take steps to protect the
extend privilege to psychologist-client or psy- victims (e.g., by notifying the authorities,
chotherapist-client relationships, but the ac- the intended victims, or both).
tual laws vary widely, and it is incumbent on • Legal or regulatory actions: If a client sues
each psychologist to know the statutes in force a clinician or files a licensing board or ethics
for his or her practice. (In 1996, the U.S. complaint, the case cannot move forward un-
Supreme Court took up this issue based on less the client releases the practitioner from
conflicting rulings in different federal appel- any confidentiality obligations that might
late court districts in the case of Jaffe v. Red- prevent an adequate defense. In addition, a
mond and upheld privilege between a psy- client who has not paid his or her bill may le-
chotherapist/social worker and her client.) gitimately be taken to court for collection,
 104 • privacy, confidentiality, and privilege 547

even though doing so would make his or her death of a client. Professional Psychology: Re-
status as a client public information. In all of search and Practice, 26, 278 –280.
these circumstances, caution and client noti- Electronic Privacy Information Center. (n.d.). Home
fication of the potential consequences should page. Retrieved 2004 from http://www.epic.org
Federal Trade Commission. (n.d.). Privacy page. Re-
precede any breach of confidence.
trieved 2004 from http://www.ftc.gov/privacy
• Other statutory requirements: In most ju-
Gustafson, K. E., & McNamara, J. R. (1987). Confi-
risdictions, courts can compel disclosure of dentiality with minor clients: Issues and guide-
otherwise confidential information under lines for therapists. Professional Psychology,
various circumstances. For example, parents’ 18, 503 – 508.
mental health records may be open to the Jaffe v. Redmond, 116 S. Ct., 64 L.W 4490 (June 13,
court during child custody disputes in some 1996).
states, but not in others. Kalichman, S. C. (1993). Mandated reporting of
suspected child abuse: Ethics, law, and policy.
Washington, DC: American Psychological As-
KEY BEHAVIORS FOR AVOIDING sociation.
Koocher, C. I., & Keith-Spiegel, P C. (1998). Ethics
PROBLEMS
in psychology: Professional standards and
cases (2nd ed.). New York: Oxford University
• Before disclosing information obtained in the Press.
course of a professional relationship, check Legal Definitions. (n.d.). Online legal dictionary.
the applicable law in your practice jurisdic- Retrieved 2004 from http://www.legal-defini-
tion. tions.com
• Alert clients to limitations on confidentiality Miller, D. J., & Thelan, M. (1986). Knowledge and
at the outset of the professional relationship, beliefs about confidentiality in psychotherapy.
and document delivery of this notice in writ- Professional Psychology, 17, 15 –19.
ing, if possible. If you have initially failed to Muehleman, T., Pickens, B. K., & Robinson, F. (1985).
do so, but realize that the direction a conver- Informing clients about limits in confidential-
ity, risks, and their rights: Is self-disclosure in-
sation is taking may lead to a disclosure ac-
hibited? Professional Psychology, 16, 385 –397.
tion, interrupt the client and warn about lim-
National Institutes of Health. (n.d.). Certificate of
itations of confidentiality at that point. Confidentiality page. Retrieved 2004 from http://
• Document any incidence of clear or ambigu- grants1.nih.gov/grants/policy/coc
ous client risk (e.g., abuse or dangerousness), Pope, K. S. (n.d.). Home page. Retrieved 2004 from
noting whether or not action was taken with http://www.kspope.com
rationales. Pope, K. S., & Vasquez, M. J. T. (1998). Ethics in
psychotherapy and counseling: A practical
References, Readings, & Internet Sites
guide for psychologists (2nd ed.). San Fran-
cisco: Jossey-Bass.
Bennett, B. F., Bryant, B. K., VandenBos, G. R., & Privacy Rights Clearinghouse. (n.d.). Home page. Re-
Greenwood, A. (1990). Professional liability and trieved 2004 from http://www.privacyrights.org
risk management. Washington, DC: American Smith-Bell, M., & Winslade, W. J. (1994). Privacy,
Psychological Association. confidentiality, and privilege in psychothera-
Bersoff, D. N. (Ed.). (2003). Ethical conflicts in psy- peutic relationships. American Journal of Or-
chology (3rd ed.). Washington, DC: American thopsychiatry, 64, 180 –193.
Psychological Association. Taube, D., & Elwork, A. (1990). Researching the ef-
Boruch, R. F., Dennis, M., & Cecil, J. S. (1996). Fifty fects of confidentiality law on patients’ self-dis-
years of empirical research on privacy and con- closures. Professional Psychology, 21, 72– 75.
fidentiality in research settings. In B. H. Stan-
ley, J. E. Sieber, & G. B. Melton (Eds.), Research
Related Topics
ethics: A psychological approach. Lincoln: Uni-
versity of Nebraska Press. Chapter 127, “Basic Elements of Consent”
Burke, C. A. (1995). Until death do us part: An ex- Chapter 128, “Basic Elements of Release Forms”
ploration into confidentiality following the Chapter 129, “Prototype Mental Health Records”
 INVOLUNTARY PSYCHIATRIC
105 HOSPITALIZATION (CIVIL
COMMITMENT)
Adult and Child

Stuart A. Anfang & Paul S. Appelbaum

ADULT mitting the involuntary hospitalization of only

those patients who were dangerous to them-
History
selves or to others. Several court decisions, led
The state’s power to hospitalize involuntarily is by a 1972 federal district court decision in Wis-
based on a combination of two rationales: consin (Lessard v. Schmidt), endorsed danger-
parens patriae (the state caring for those inca- ousness criteria as the proper model for civil
pable of caring for themselves) and “police commitment.
power” (the state’s obligation to protect the A 1977 U.S. Supreme Court decision
public safety). (O’Connor v. Donaldson) appeared to endorse
In 18th- and early 19th-century America, dangerousness-based criteria for commitment,
there was little formal legal regulation of psy- although the Court did not explicitly reject a
chiatric hospitalization. As state hospitals de- need-for-treatment model. By the end of the
veloped in the mid-19th century, legislatures 1970s, every state adopted dangerousness-
began to write statutes that were soon extended based criteria for involuntary hospitalization,
to private institutions. The rationale for com- typically with judicial procedures and protec-
mitment was treatment oriented, hospitalizing tions similar to criminal proceedings.
mentally ill persons who were deemed to be in
need of care. Procedures by the end of the 19th
Criteria
century often included judicial hearings and oc-
casionally jury trials. The dangerousness-based criteria vary across
In the early to mid-20th century, several states, but they typically require (1) the pres-
states moved away from judicial procedures, at- ence of mental illness (in many states this does
tempting to make initial commitment easier not include mental retardation, dementia, or
and quicker, and promoting a model primarily substance abuse, in the absence of other psychi-
of medical decision making. By the 1960s, op- atric illness) and (2) dangerousness.
ponents began to question the legitimacy of Dangerousness typically includes (a) danger
psychiatric diagnosis, the effectiveness of long- to self (physical harm); (b) danger to others
term hospitalization, and the right of the state (physical harm, not usually psychological harm
to force unwanted treatment. By the late 1960s or harm to property); or (c) grave disability (se-
and early 1970s, states moved to dangerous- vere inability to care for one’s minimal survival
ness-based criteria for civil commitment, per- needs in the community). There is variability

548
 105 • involuntary psychiatric hospitalization (civil commitment) 549

across states regarding the definition of danger- “grave disability” standard— or the inability to
ousness — specifically, how imminent or overt provide for one’s basic survival needs in the
the risk of harm must be. Some court decisions community— typically allows for such clinical
and statutes require that involuntary hospital- flexibility.
ization be the “least restrictive alternative” be-
fore allowing a commitment, raising a question
Procedures
of whether the state is obligated to create less
restrictive alternatives, such as community res- In most states, civil commitment procedures in-
idences. The creation of such alternatives may clude many of the protections associated with
be required in some circumstances by the U.S. criminal trials. These often encompass such
Supreme Court’s decision in Olmstead v. L.C. safeguards as timely notice of the allegations
(1999), though such requirements may be lim- that may result in commitment; timely notice
ited by constraints on financial and program- of due process rights, including the right to an
matic resources. attorney; the right to a timely judicial hearing,
In recent years, several states have broad- sometimes including the right to jury trial; the
ened the definition of dangerousness, often ex- right to remain silent when examined by a psy-
panding the “grave disability” standard to in- chiatrist or at trial; and placing on the state the
clude the prospect of severe deterioration lead- burden of proving that the patient meets the
ing to predicted dangerousness. Other states commitment criteria. Jurisdictions differ in
have expanded their commitment criteria to in- the standard of proof required, ranging from an
clude incompetence, disabling illness, or need intermediate “clear and convincing evidence”
for treatment. Future litigation may challenge standard (the minimal constitutionally accept-
the constitutionality of these statutes, which able standard) to the more stringent “beyond a
appear to move away from strict dangerousness reasonable doubt” standard required for crimi-
criteria. Clinicians should be familiar with the nal prosecutions.
statutory criteria in their jurisdiction, as well as Nearly every state allows for emergency
the relevant regulations and court decisions commitment based on a physician’s or other
(case law) regarding civil commitment. mental health professional’s certification of
Critiques of the dangerousness standard mental illness and dangerousness; this commit-
usually include one or more of three basic ar- ment can typically last from 48 hours to 10 –14
guments: (1) the current system makes it diffi- days before requiring the scheduling of a judi-
cult to obtain involuntary treatment for pa- cial hearing for further commitment. Various
tients who are not overtly dangerous but are jurisdictions also allow for emergency commit-
desperately in need of care; (2) dangerousness is ment based on a judge’s order (bench com-
notoriously difficult for clinicians to predict ac- mitment), the certification of a police officer, or
curately; and (3) basing commitment on dan- approval of another designated official. For
gerousness, particularly dangerousness to oth- roughly 40 years, New York State has had a rel-
ers, alters the character of the mental health atively unique statute allowing for commit-
system, shifting its mission from providing ment up to 60 days on the certification of two
treatment to a quasi-police function. physicians, without a required judicial review;
Despite considerable and often impassioned however, on admission every involuntary pa-
debate, the empirical data generally suggest tient is assigned to a mental health attorney
that, in practice, more restrictive commitment who will inform him or her of the right to an
criteria appear to have little impact on the qual- earlier appeal of the commitment and will rep-
itative and quantitative characteristics of the resent him or her if necessary. A 1982 federal
civilly committed population as a whole. The court of appeals decision (Project Release v. Pre-
system appears to allow involuntary hospital- vost) upheld the constitutionality of this proce-
ization for those mentally ill patients in need dure, holding that patients’ interests may be
of treatment, regardless of the precise criteria protected in a variety of acceptable ways.
of the dangerousness-based standards. The All mental health clinicians who work with
550 part viii • ethical and legal issues

potentially dangerous patients should be famil- with needed treatment; and (4) has a reasonable
iar with the commitment procedures and mech- prospect of responding to the proposed treat-
anisms within their jurisdictions. Attorneys ment. Many state legislatures have included
familiar with mental health law can be an in- several of these provisions when writing their
valuable resource, as can forensically trained statutes.
clinicians. Clinicians in all jurisdictions should Outpatient commitment laws generally fol-
be aware of the need to alert the patient to the low one of three basic patterns: (a) conditional
limits of confidentiality — that clinical inter- release for involuntarily hospitalized patients;
view information may be disclosed in the judi- (b) “less restrictive” alternative to hospitaliza-
cial commitment hearing. Some states require tion for patients who meet inpatient com-
such a warning and allow the patient the right mitment criteria; or (c) alternative for patients
to refuse to participate further. not meeting criteria for inpatient commitment,
In addition to describing the appropriate but at risk for severe decompensation without
procedures and criteria, most state commitment treatment. This last pattern, often called pre-
statutes provide immunity to mental health ventive commitment or predicted deteriora-
clinicians who act in good faith when seeking to tion, has generated considerable debate because
hospitalize a patient involuntarily. In all states, it is seen as a move further away from an “im-
if the clinician can document a commitment de- minent dangerousness” standard toward a
cision based on appropriate clinical judgment need-for-treatment approach.
within the professional standard of care, he or Mental health clinicians should be familiar
she can feel reasonably safe from malpractice with the availability of IOC in their jurisdic-
liability for improper commitment (although tions and with the range of possible options and
actual verdicts will be based on the particular resources. Even as state legislatures rush to
facts and circumstances of the situation). As write IOC statutes, considerable debate contin-
with all complex and difficult clinical decisions, ues over the efficacy and utility of these outpa-
consultation with colleagues is often an im- tient commitment programs, with a limited but
portant tool — both for guidance and for risk- growing number of empirical studies.
management purposes.

CHILD
Involuntary Outpatient
Commitment History
Over the past 20 years, involuntary outpatient Constitutional due process rights for children
commitment (IOC) has gained increasing at- in the juvenile justice system were first recog-
tention as a possible alternative to inpatient nized by the U.S. Supreme Court in 1967 (In re
commitment in systems with declining inpa- Gault). Children were held to be entitled to due
tient resources. The majority of states have process protections similar to those of adults in
laws explicitly permitting outpatient commit- criminal proceedings, including the right to
ment, although there is considerable local and counsel, the right to written notice of charges,
regional variation regarding how commonly the right to cross-examine witnesses, and the
the option is used. privilege against self-incrimination. At that
The latest recommendations from the Amer- time, the typical state voluntary psychiatric
ican Psychiatric Association (see Gerbasi, Bon- hospitalization statute allowed a parent or
nie, & Binder, 2000) regarding statutory guide- guardian to admit a minor for psychiatric treat-
lines for IOC include evidence that a person ment (on a physician’s recommendation) with-
(1) suffers from a severe mental illness; (2) is out the minor’s consent and without further ad-
likely, without treatment, to suffer a relapse ministrative or judicial review. Building on
that would render the patient a danger to self or Gault, several cases in North Carolina, Geor-
others or unable to care for self in the foresee- gia, and Pennsylvania challenged the constitu-
able future; (3) is unlikely to seek or comply tionality of those statutes, contending that un-
 105 • involuntary psychiatric hospitalization (civil commitment) 551

wanted or troublesome children were being a mental illness needing treatment, the avail-
“dumped” in mental hospitals. ability of such treatment through the hospital,
In 1979, the U.S. Supreme Court (Parham v. and evidence that the hospital is the least re-
JR) upheld the right of a parent or guardian to strictive setting available. The American Psy-
admit a minor to a psychiatric hospital without chological Association and the American Acad-
a judicial hearing. The Court endorsed the need emy of Child and Adolescent Psychiatry have
for a “neutral factfinder”— typically the ad- issued suggested statutory guidelines.
mitting psychiatrist— to review the admission. Most states have provisions for the minor to
Absent a finding of parental abuse or neglect, appeal the hospitalization, requesting an adver-
the Court assumed that parents act in their sarial judicial hearing. For adolescents between
children’s best interest and doubted that judges 13 and 18, states provide varying procedures,
would be able to make better decisions than allowing minors of a certain age to sign in or
parents acting in collaboration with objective out of a hospital voluntarily, without the ap-
physicians. Many child-rights advocates viewed proval of a parent or guardian. Mental health
the decision as a major defeat, although indi- clinicians should be familiar with the statutory
vidual states were free to enact statutes requir- requirements and case law in their jurisdic-
ing greater protections and judicial oversight. tions. Consultation with an attorney familiar
In the 1980s, many commentators pointed to with child mental health issues or a clinician
alarmingly high admission rates, especially in with forensic expertise is helpful.
private for-profit psychiatric facilities, as evi-
dence of a pattern in which troublesome juve-
niles without clear psychiatric illnesses were GENERAL CLINICAL ISSUES
being hospitalized, often as an alternative to the
juvenile justice system. As managed care trans- • Predicting dangerousness: Clinicians should
formed inpatient mental health care in the be familiar with relevant risk factors, base
1990s, this pattern decreased in frequency. Ex- rates, and both external and internal factors
cept in state facilities for severely ill children that influence the potential for violence.
and adolescents, short-term hospitalization is Risks, resources, and benefits must be bal-
the rule. anced in a clinically sensitive and sophisti-
cated decision process. Consultation and cor-
roborative clinical data are invaluable.
Criteria and Procedures
• Maintaining a therapeutic alliance with a
Given the relatively low constitutional “mini- patient coerced to receive care: Patients
mum” required under Parham, states have di- should be involved in the decision process as
verse approaches to the issue of child hospital- much as possible. As treatment restores the
ization. Involuntary civil commitment without patient’s ability to assess his or her own func-
the consent of a parent or guardian is extremely tioning, the patient and clinician can aim to
rare and typically follows guidelines similar to shape the experience into one that enhances
those for adult civil commitment. More com- the patient’s responsibility, self-respect, and
mon is the “voluntary” hospitalization by a therapeutic rapport.
parent or guardian (including a state social ser- • Resolving conflicts between legal mandates
vice agency) without the consent of the minor. and ethical imperatives in the commitment
States range from the minimum of allowing setting: Whereas legal standards suggest a
a parent to admit a child without any adminis- rigidly defined set of criteria, ethical and
trative or judicial review to requiring a formal clinical imperatives often encourage the clin-
judicial hearing for all admissions with speci- ician to err on the side of caution. Clinicians
fied due process protections. Some states have must be sensitive to both factors and strive
more rigid regulations covering public psychi- for a balanced, thoughtful approach to deci-
atric facilities and minors who are wards of the sion making in cases of involuntary hospital-
state. Typically, states require the presence of ization.
552 part viii • ethical and legal issues

References & Readings Melton, G. B., Petrila, J., Poythress, N. G., & Slobo-
gin, C. (1997). Psychological evaluations for
American Academy of Child and Adolescent Psychi- the courts: A handbook for mental health pro-
atry. (1987). Child and adolescent psychiatric fessionals and lawyers. New York: Guilford
illness: Guidelines for treatment resources, Press.
quality assurances, peer review, and reim- Monahan, J., & Steadman, H. J. (Eds.). (1994). Vio-
bursement. Washington, DC: Author. lence and mental disorder: Developments in
American Psychological Association. (1984). A risk assessment. Chicago: University of Chi-
model act for the mental health treatment of cago Press.
minors. Washington, DC: Author. Monahan, J., Steadman, H., Silver, E., Appelbaum,
Appelbaum, P. S. (1994). Almost a revolution: Men- P. S., Robbins, P. C., Mulvey, E. P., et al. (2001).
tal health law and the limits of change. New Rethinking risk assessment: The MacArthur
York: Oxford University Press. Study of Mental Disorder and Violence. New
Appelbaum, P. S., & Anfang, S. A. (1998). Civil York: Oxford University Press.
commitment. In R. Michels (Ed.), Psychiatry Parry, J. (1994). Survey of standards for extended in-
(Vol. 3, Chapter 32). Philadelphia: Lippincott- voluntary commitment. Mental and Physical
Raven. Disability Law Reporter, 18, 329 –336.
Bagby, R. M., & Atkinson, L. (1988). The effects of Stromberg, C. D., & Stone, A. A. (1983). A model
legislative reform on civil commitment rates: A state law on civil commitment of the mentally
critical analysis. Behavioral Sciences and the ill. Harvard Journal on Legislation, 20, 275 –
Law, 6, 45 – 62. 396.
Brinich, P. M., Amaya, M., & Burlingame, W. V. Warren, C. A. B. (1982). Court of last resort: Men-
(2002). Psychiatric commitment of children tal illness and the law. Chicago: University of
and adolescents. In D. H. Schetky & E. P. Chicago Press.
Benedek (Eds.), Principles and practice of child Weithorn, L. A. (1988). Mental hospitalization of
and adolescent forensic psychiatry (pp. troublesome youth: An analysis of skyrocket-
325 –338). Washington, DC: American Psychi- ing admission rates. Stanford Law Review, 40,
atric Press. 773 – 838.
Gerbasi, J. B., Bonnie, R. J., & Binder, R. L. (2000).
Resource document on mandatory outpatient
treatment. Journal of the American Academy Related Topic
of Psychiatry and the Law, 28, 127 –144. Chapter 106, “Physical Restraint and Seclusion:
Hiday, V. A. (2003). Outpatient commitment: The Regulations and Standards”
state of empirical research on its outcomes.
Psychology, Public Policy, and Law, 9, 8 –32.
 PHYSICAL RESTRAINT AND
106 SECLUSION
Regulations and Standards

Thomas P. Graf

Regulations and practice standards for the use the elderly but also to all mentally ill or devel-
of physical restraint and seclusion have changed opmentally delayed adults in long-term care
since 1998. Federal legislation and standards for that receive Medicare funding. Since then,
hospital and psychiatric facilities have increased freedom from unwarranted restraint has been
patient protection from unnecessary restraint one of the rights monitored in the oversight of
and seclusion, in particular for children and care facilities. However, there was no federal or
adolescents but also for adults. This chapter will state monitoring of serious injury and death as
review essential aspects of those regulations, a result of restraint and seclusion, especially in
the kinds of restraints that require the order of psychiatric inpatient or residential treatment.
a licensed independent medical practitioner, and In 1998, the Hartford Courant released a five-
those that do not. These practice standards, as part investigative report into the alarming
well as the ethical standard to provide effective number of restraint-related deaths that oc-
treatment, should make it important to reduce curred in psychiatric treatment facilities across
the need for restraint and the conditions that the United States (Weiss, Megan, Blint, & Al-
contribute to it. timari, 1998). The newspaper conducted a 50-
state survey in mental health facilities, mental
retardation facilities, and group homes, and it
RECENT REGULATIONS AND documented at least 142 deaths during the pre-
CHANGES OF STANDARDS ceding decade, mostly through asphyxiation.
This contributed to Congress’s passing the
Physical restraint and seclusion have been es- Children’s Health Act in October 1999, which
sential parts in reducing safety risks in violent legislated restrictions in the use of restraint and
and self-harming patients who are in psychi- seclusion in residential treatment and all psy-
atric care. Restraints can be human (such as a chiatric facilities that receive federal or state
therapeutic or protective hold), can involve use funds like Medicaid (Children’s Health Act,
of mechanical devices (e.g., wrist restraint, 2000). For children and adolescents, only per-
jacket vest, or papoose), or can consist of sedat- sonal restraint and seclusion are permitted and
ing psychoactive drugs. Restraint or seclusion only in emergency situations to ensure the im-
has been used not only for reducing imminent mediate physical safety of the resident or oth-
risk for harm to self or others but also for con- ers. The use of both chemical and mechanical
trol, convenience, and retaliation. (For an over- restraints is prohibited. Most other provisions
view of recent changes in laws and regulations in regard to restraint and seclusion have since
in regard to restraint and seclusion, see also been incorporated into other regulations, which
Luna, 2001). In 1987, the Nursing Home Re- will be discussed, as this Act was designed to be
form Act was passed, which applies not only to the minimal floor for further regulations and

553
554 part viii • ethical and legal issues

legislation in this area. Use of restraint and • The restraint and seclusion policy of a facil-
seclusion in correctional and educational set- ity has to be posted. Upon admission to a fa-
tings, including schools, wilderness camps, or cility, the patient’s guardian has to review the
prisons, has not been regulated. Nevertheless, policy and indicate consent by signature.
many school districts now have a restraint and • Restraint and seclusion can be used only to
seclusion policy, which typically stipulates that ensure the patient’s safety or the safety of
physical restraint or seclusion be used only if others during an emergency safety situation.
there is imminent danger to self or others, al- • Restraint and seclusion must end when the
ternative and less restrictive containment has emergency safety situation is over.
been tried but failed, staff has had training in • The least restrictive intervention should be
safe restraint, and there are physician’s orders used. Only a licensed independent practi-
for use of mechanical or chemical restraint tioner (LIP— i.e., physician, nurse practi-
while in seclusion. See Cambridge Public tioner, or physician assistant, consistent with
Schools (2002) for a sample restraint policy. state law) may give the order for carrying
The Joint Commission on Accreditation of out restraint or seclusion.
Healthcare Organizations (JCAHO) issues • A LIP must perform a face-to-face evaluation
practice standards for health and psychiatric of the patient no more than one hour after
care facilities. In 1999, JCAHO issued restric- the restraint or seclusion was initiated.
tive and protective guidelines in regard to re- • Ongoing monitoring of the patient and eval-
straint and seclusion of patients of all ages. JC- uation of physical and psychological condi-
AHO does not investigate individual com- tion are required during seclusion or re-
plaints and its oversight consists mostly of straint and has to be documented.
preannounced visits every three years. Never- • A LIP must conduct an in-person evaluation
theless, implementation and documentation of immediately after the patient is removed
compliance with JCAHO standards are neces- from restraint or seclusion.
sary for all accredited organizations, thus lead- • The patient’s legal guardian must be notified
ing to changes in practice. of the situation that led to the use of restraint
In 2001, the Centers for Medicare & Medic- or seclusion as soon as possible.
aid Services (CMS), formerly called the Health • Two debriefing sessions have to be conducted
Care Financing Administration (HCFA), re- after the use of restraint or seclusion. One of
leased its interim final rule regarding restraint them is between the patient and the staff in-
and seclusion (Health Care Financing Adminis- volved, and one is only for the staff involved.
tration, 2001). This regulation applies to pa- • All deaths have to be reported to the regional
tients under the age of 21 who receive inpatient CMS office.
or residential psychiatric treatment. In con- • All staff must have appropriate training in
trast, JCAHO standards apply to any accredited the use of nonphysical interventions, the safe
medical setting in which emotional or behav- use of restraint and seclusion, identification
ioral problems require use of restraint, and the of factors that lead to emergency situations,
regulations apply to patients of all ages. CMS and CPR. Documentation of each staff mem-
regulations apply only to psychiatric hospital ber’s training must be maintained and avail-
or residential treatment facilities that receive able for review by a state survey agency.
Medicaid funds.
The following holding situations are not re-
garded physical restraint or needing a physi-
CMS Standards
cian order:
What follows is a summary of the CMS stan-
dards in regard to restraint and seclusion • Briefly holding without undue force a patient
(Health Care Financing Administration, 2001); for the purpose of comforting him or her.
exempt conditions of physical containment are • Holding a patient’s hand or arm to safely es-
also discussed. cort him or her.
 106 • physical restraint and seclusion 555

straint or seclusion are: four hours for pa-

JCAHO Definitions and Standards
tients 18 and older, two hours for children 9
The JCAHO’s regulation regarding restraint or to 17, and one hour for children under 9.
seclusion for behavioral health reasons (fur- • Prompt notification of the patient’s family or
thermore, only called restraint or seclusion) ap- guardian when restraint or seclusion is ini-
ply whether the patient is in a behavioral health tiated. Extended episodes of restraint or
care (psychiatric hospital or residential treat- seclusion (more than 12 hours) or multiple
ment) or a general hospital setting. For exam- episodes (two or more in 24 hours) require
ple, if a patient on a postsurgical unit is re- notification of the organization’s clinical lead-
strained because he or she assaults another pa- ership.
tient, the behavioral health standard applies • For adults in long-term care and assisted liv-
(TX.7.1–TX.7.4; Joint Commission on Accred- ing, the right to a restraint-free environ-
itation of Healthcare Organizations [JCAHO], ment. Past deaths in long-term care during
2002). or after restraint were associated with me-
A second set of regulations applies to re- chanical and chemical restraints, used for
straint or seclusion used for medical/surgical long periods of time and without monitoring
care reasons. That restraint aims at directly of the patient’s well-being (U.S. General Ac-
supporting medical healing, such as preventing counting Office, 1999). The restraint stan-
a patient from trying to walk on an injured leg dards aim at increasing dignity and indepen-
or preventing the removal of an IV or feeding dence in the long-term care population but
tube (TX.7.5; JCAHO, 2002). The medical/sur- are not reviewed here.
gical care standards will not be further dis-
cussed here as they are mostly relevant for The JCAHO standards for restraint and
nurses and physicians. Furthermore, there are seclusion (2002) do not apply to the following:
more detailed standards regarding the medical
assessment of patients during the process of re- • The use of restraint associated with acute and
straint that are also not reviewed. See Orhon postoperative medical or surgical care.
(2002) for a review of restraint standards from • Holding or physically redirecting a child,
a nursing perspective. Orhon (2002) also com- without the child’s permission, for 30 min-
pares JCAHO and CMS standards from a gen- utes or less; staff involved in holding has to
eral perspective. be trained in physical restraint and seclusion.
• Time-out, which consists of removing a child
• Restraint is defined as the direct application from the immediate environment and re-
of physical force to a person, with or without stricting him or her to an unlocked quiet
the individual’s permission, with the purpose room for 30 minutes or less in order to re-
of restricting freedom of movement (JC- gain self-control. The child or adolescent
AHO, 2002). may not be physically prevented from leav-
• Seclusion is defined as the involuntary con- ing the time-out area. These restrictions
finement of a person in a locked room. It is have to be consistent with the unit’s rules and
less restrictive than physical restraints be- the patient’s treatment plan.
cause it allows an individual to move about. • Physical escorts.
• Patients in restraint and/or seclusion require • The use of restraint with patients who are se-
continuous personal monitoring through ob- verely developmentally delayed and receive
servation, and have to be assessed every 15 treatment through formal behavior manage-
minutes for injury, health, psychological sta- ment programs that target intractable, se-
tus, and readiness for the restraint or seclu- verely self-injurious, or injurious behaviors.
sion to be discontinued. A patient in a phys- • The use of protective equipment such as hel-
ical hold must have a second staff person ob- mets.
serve the patient. • Forensic restrictions and restrictions imposed
• The time limitations for an order for re- by correction authorities for security pur-
556 part viii • ethical and legal issues

poses. However, restraint or seclusion use re- ple, threatening behavior that may result
lated to the clinical care of a patient under from delirium in fevers or from hypogly-
forensic or correction restrictions is surveyed cemia.
under these standards. • How their own behaviors can affect the be-
haviors of the patients they serve.
• The use of de-escalation, mediation, self-pro-
COMPARING CMS AND JCAHO tection, and techniques, such as time-out.
STANDARDS • Signs of physical distress in patients who are
being held, restrained, or secluded.
CMS requires continuous in-person monitor- • Competence in the safe use of restraint, in-
ing only when patients are concurrently in re- cluding physical holding techniques, take-
straint and seclusion, whereas JCAHO requires down procedures, and the application and re-
continuous monitoring when either restraint or moval of mechanical restraints.
seclusion is used as well. The CMS rule of face-
to-face evaluation by an LIP within one hour of Because direct-care staff need to be able to
initiation of restraint or seclusion is more strin- de-escalate potentially aggressive patients, as
gent than the JCAHO rule of evaluation within well as apply physical control strategies safely,
four hours. However, the JCAHO requires or- both JCAHO and CMS require training docu-
ganizations to comply with the CMS rule be- mentation. The cumulative training costs are
cause organizations must meet federal and state considerable for care institutions — several in-
regulations in order to meet JCAHO’s require- stitutes specialize in training individuals to be-
ments. come trainers in the institution they work in.
Compared to the CMS standards, the JC- Information about these institutes can be found
AHO standards are more specific also in defin- on the Internet.
ing situations exempt from restraint and seclu-
sion standards. This writer is not qualified to
give legal advice about which standards may CLINICAL APPLICATION OF
take precedent, and a qualified lawyer should be RESTRAINT AND SECLUSION
consulted if more clarification is needed. Fur-
thermore, the reviewed CMS and JCAHO stan- The reviewed seclusion and restraint standards
dards were current as of May 2004, but changes have been mandated to protect patient’s physi-
should be monitored as they are announced by cal and mental integrity. However, effective re-
CMS and JCAHO. duction of restraint is also a clinical question
about correct diagnosis and treatment of a pa-
tient’s condition as it contributes to aggression
STAFF TRAINING against self or/and others. Luiselli, Bastien, and
Putnam (1998) identified contextual variables
The JCAHO Standard TX 7.1.2—Staff Training associated with restraint and seclusion on a
and Competence (2002)— outlined require- child and adolescent psychiatric inpatient unit.
ments for competence and training of staff who They found that staff-initiated physical contact
conduct seclusion or restraint. These standards often (34% of instances) precipitated restraint
also comply with CMS standards. Direct care or seclusion and occurred in the context of pa-
staff should be trained in and understand the tients’ refusing to leave or enter the quiet room.
following: They recommended, for that specific situation,
the use of closed-door seclusion time-out to re-
• The underlying causes of threatening behav- duce the avoidance and repeated leaving that
iors exhibited by the patients they serve. precipitated the restraints. Another finding was
• Aggressive behavior that is related to a pa- that mechanical restraints occurred for long pe-
tient’s medical condition and not related to riods of time, in the absence of clear release cri-
his or her emotional condition — for exam- teria. Luiselli et al. point out that “contingent
 106 • physical restraint and seclusion 557

procedures such as time-out and physical hold- straints and restraint fading. Journal of Ap-
ing are most effective when they are of brief plied Behavior Analysis, 30(1), 105 –120.
duration and include a differential release crite- Health Care Financing Administration. Interim
rion. These guidelines ensure that the person Final Rule, Use of Restraint and Seclusion in
Psychiatric Residential Treatment Facilities
who receives time-out learns to end the proce-
Providing Inpatient Psychiatric Services to In-
dure rapidly by ceasing negative behaviors and
dividuals Under Age 21, 42 C.F.R. § 441 and
achieving a more relaxed state” (p. 153). Lui- 483 (2001). Retrieved March 2, 2003, from
selli et al. recommended that occurrence of re- Federal Register, via GPO access: http://www.
straint can be reduced through identification of access.gpo.gov/su_docs/aces/aces140.html, se-
patient-specific triggers. CMS and the JCAHO lect year 2001, 05/22/2001.
recommended that this be part of direct-care Joint Commission on Accreditation of Healthcare
staff competence. However, Luiselli et al. em- Organizations. (2002). Comprehensive accredi-
phasize linking diagnosis to treatment in a for- tation manual for hospitals: The official hand-
mal treatment plan; to assess the nature, con- book. Update 3, Refreshed core on CD-ROM.
texts, and consequences of challenging behav- Oakbrook Terrace, IL: Joint Commission on
Accreditation of Healthcare Organizations.
iors; and to identify how seclusion or restraint
Luiselli, J., Bastien, J., & Putnam, R. (1998). Behav-
can reduce aggression under specific circum-
ioral assessment and analysis of mechanical re-
stances. A behavioral assessment is one way to straint utilization on a psychiatric, child and
determine a patient’s condition as it contributes adolescent inpatient setting. Behavioral Inter-
to injurious behavior, which lends itself well to ventions, 13(3), 147 –155.
determine the effectiveness of restraint proce- Luna, J. (2001). Limiting the use of physical re-
dures. The use of restraints in the treatment of straint and seclusion in psychiatric residential
retractable, self-injurious behaviors in the de- treatment facilities for patients under 21. Re-
velopmentally delayed is exempt from JC- trieved March 1, 2003, from University of
AHO’s restraint and seclusion standards. How- Houston Law Center Web site: http://www.
ever, even there, an individualized treatment law.uh.edu/healthlawperspectives/Mental/
010829Limiting.html
plan is ethically imperative, in that restraints
Orhon, A. J. (2002). Of human bondage: Alterna-
should be used effectively to reduce the future
tives to restraint. Retrieved March 5, 2003,
need for restraints. Fisher, Piazza, Bowman, from Nurses Learning Network Web site:
Hanley, and Adelinis (1997) describe the effec- http://216.155.28.162/nurse/courses/nurse
tive use of restraint fading to control injurious week/nw0187/c1/index.htm
and self-injurious behaviors in such a manner U.S. General Accounting Office. (1999, September).
in three profoundly mentally retarded individ- Mental health: Improper restraint or seclusion
uals. use places people at risk. Retrieved March 9,
2003, from http://www.gao.gov/archive/1999/
he99176.pdf
References, Readings, & Internet Sites
Weiss, E., Megan, K., Blint, D., & Altimari, D.
Cambridge Public Schools. (2002). Cambridge pub- (1998, October 11–15). Deadly restraint: An
lic schools physical restraint policy. Retrieved investigative report. Hartford Courant. Re-
March 1, 2003, from Cambridge Public Schools trieved March 1, 2003, from http://courant.
Web site: http://www.cps.ci.cambridge.ma.us/ ctnow.com/projects/restraint/
pubinfo/PhysicalRestraint062002CSCP.doc
Children’s Health Act, Public Law No. 106-310, Related Topic
§ 3207, 114 Stat. 1178 (2000). Retrieved March
3, 2003, from http://www.access.gpo.gov Chapter 105, “Involuntary Psychiatric Hospitaliza-
Fisher, W. W., Piazza, C. C., Bowman, L., Hanley, G., tion (Civil Commitment): Adult and Child”
et al. (1997). Direct and collateral effects of re-
 BASIC PRINCIPLES FOR
107 DEALING WITH LEGAL
LIABILITY RISK SITUATIONS

Gerald P. Koocher

What should a mental health practitioner do 3. Psychologists have the right to unilaterally
when an “adverse incident” occurs? If no law- terminate services when threatened or oth-
suit has been threatened or filed, but some sig- erwise endangered by the client/patient or
nificant difficulties or adverse events have oc- another person with whom the client/pa-
curred (e.g., a client is not benefiting from tient has a relationship. This includes
treatment, is not adhering to key aspects of a threats of physical harm or threats of law-
treatment program, has become too difficult to suits. Document any such threats in the
work with, commits suicide, or harms a third clinical record.
party), consider the following steps: 4. If a client does not return for a scheduled ap-
pointment, follow up by telephone and in
1. Obtain a consultation from a colleague expe- writing, documenting these steps in your
rienced with such clients and issues. Consider records. Be especially prompt in doing so if
whether you should initiate termination of the client seemed depressed or emotionally
the professional relationship. If you decide to distressed in the previous session.
do so, follow these steps: (a) Notify the pa- 5. If a client complains about something, listen
tient both orally and in writing, specifying carefully and treat the complaint with seri-
the effective date for termination; (b) provide ous concern. Investigate, if necessary, and
a specific professional explanation for termi- respond in as sympathetic and tactful a man-
nating the relationship; (c) agree to continue ner as possible. Apologize, if appropriate.
providing interim services for a reasonable Document all steps taken in your record.
period and recommend other care providers 6. In the event of a client’s death, express sin-
or means of locating them; (d) offer to provide cere compassion and sympathy to surviving
records to new providers upon receipt of relatives, but do not discuss any personal
signed authorization from the client; and (e) feelings of guilt you may be experiencing.
document these steps in your case records. Save such feelings for your personal psy-
2. Avoid initiating a unilateral termination if: chotherapist.
(a) the client is in the midst of a mental
health crisis or emergency situation; (b) sub- If a lawsuit is filed or if you become aware of
stitute services will be difficult for the c1ient the possibility of a suit against you, follow
to obtain (e.g., the client resides in a rural these steps:
area where other practitioners might not he
readily available; or (c) the primary reason 1. Contact your insurance carrier immediately,
for wanting to terminate the client may be both orally and in writing. Retain copies of
regarded as unreasonably discriminatory all correspondence and keep notes of phone
(e.g., terminating psychotherapy with client conversations, including the date and the
after learning of his or her HIV status). representative of the insurer you spoke

558
 107 • basic principles for dealing with legal liability risk situations 559

with. If a suit has actually been filed, your References, Readings, & Internet Sites
insurance carrier should assign local legal
American Psychological Association Committee on
counsel to represent you promptly. If you Professional Practice and Standards. (2003).
retain counsel independently, the insurance Legal issues in the professional practice of psy-
carrier may not be obligated to pay for those chology. Professional Psychology: Research &
services. Failure to notify the insurer in a Practice, 34, 595 – 600.
timely manner may also compromise the de- American Psychological Association Insurance Trust.
fense of your case. (n.d.). Home page. Retrieved 2004 from http://
2. Never interact orally or in writing, “infor- www.apait.org
mally” or otherwise, with a client’s lawyer Appelbaum, P. S. (1993). Legal liability and managed
once a suit is threatened. Once a lawyer rep- care. American Psychologist, 48, 251–277.
Koocher, G. P., & Keith-Spiegel, P. C. (1998). Ethics
resenting your client contacts you in any
in psychology: Professional standards and
dispute involving you and that client, get
cases (2nd ed.). New York: Oxford University
your own attorney involved. Cease all fur- Press.
ther contact with that client until you have National Register of Health Service Providers in
consulted your attorney. Never try to settle Psychology. (n.d.). Home page. Retrieved 2004
matters yourself. from http://www.nationalergister.com/National
3. Do not discuss the case with anyone other RegisterPubs.html
than representatives of the insurance carrier Woody, R. H. (1988). Protecting your mental health
or your lawyer. Do not discuss details of the practice: How to minimize legal and financial
case with colleagues unless directed to do so risk. San Francisco: Jossey-Bass.
by your attorney. Woody, R. H. (1997). Legally safe mental health
practice: Psycholegal questions and answers.
4. Compile and organize all your records, case
Madison, CT: Psychosocial Press.
materials, and chronicles of the event to as-
Woody, R. H. (1999). Domestic violations of confi-
sist in your defense. Do not throw anything dentiality. Professional Psychology: Research
away, and do not show it to anyone except & Practice, 30, 607 – 610.
your attorney. Wright, R. H. (1981a). Psychologists and profes-
5. When asked to provide information or doc- sional liability (malpractice) insurance: A ret-
uments to your insurer or legal counsel, rospective review. American Psychologist, 36,
send copies and safeguard the originals. 1485 –1493.
6. In any malpractice or professional liability Wright, R. H. (1981b). What to do until the malprac-
action where you are asked to agree to a set- tice lawyer comes: A survivor’s manual. Ameri-
tlement, consult a personal attorney (in ad- can Psychologist, 36, 1535 –1541.
dition to the one assigned by the insurance
carrier), especially if sued for damages in ex- Related Topics
cess of the limits of your policy. Chapter 108, “Defending Against Legal Com-
7. Take steps to manage your own anxiety and plaints”
stress level. Such cases can take a severe Chapter 109, “Dealing With Licensing Board and
emotional toll and require several years to Ethics Complaints”
resolve, even though there may be no legit- Chapter 110, “Dealing With Subpoenas”
imate basis for the suit. Although seeking Chapter 124, “Essential Features of Professional Li-
support from friends and colleagues is a nor- ability Insurance”
mal reaction, discussions of specific details
should occur only in contexts where the dis-
cussions are privileged (e.g., with your at-
torney or psychotherapist).
 DEFENDING AGAINST
108 LEGAL COMPLAINTS

Robert H. Woody

Since the mid-1970s, legal complaints have even when a licensing complaint has been dis-
posed an ominous threat to psychologists. By missed, the mere fact that a complaint had been
the early 1980s, the threat of a legal complaint lodged served to lessen their perceived author-
was affecting the profession to the point that ity as an expert witness.
terms such as “litigaphobia” and “litigastress” Even worse, once a legal action has been re-
began to appear in professional publications solved, the potential remains for an additional
(Brodsky, 1983; Turkington, 1987). Today there complaint and investigation by, particularly,
is an even greater risk of a lawsuit against a any other licensing or certification source with
psychologist for alleged malpractice and/or a which the psychologist is or ever becomes affil-
complaint to the state licensing board. Regret- iated. Depending on the jurisdiction and the
tably, the omnipresence of managed care has outcome of the initial legal action, an insurance
created additional liability for psychologists carrier may have to report the matter to a state
(Appelbaum, 1993). regulatory agency, which could trigger another
investigation. Especially problematic is the pos-
sibility that the legal action will be on file in the
A PSYCHOLOGIST CAN BE IRREPARABLY Disciplinary Data System (DDS), a computer-
DAMAGED BY A LEGAL COMPLAINT ized national registry developed and main-
tained by the Association of State and Provin-
While the majority of complaints are for “nui- cial Psychology Boards; this is a new develop-
sance” amounts of money, the negative conse- ment, but it is expanding (Association of State
quences of a complaint are profound. Even if and Provincial Psychology Boards, 1996).
the malpractice carrier pays the settlement or On another plane, psychologists defending
the licensing board imposes a minor (or no) against a legal complaint are prone to suffer
penalty, merely making a settlement for a civil emotional stress. Threats to one’s professional
suit or receiving a finding of probable cause for status cut to the inner core of self-esteem and
discipline from a licensing board creates a life- commonly produce depression, tension, anger,
long blemish on the psychologist’s professional and symptoms of physical illness. Further, mar-
record. The reason is simple: Any negative out- ital and familial relations, career motivation,
come must commonly be reported to any pro- and general satisfaction with life are adversely
fessional association, hospital, or managed care affected (Charles, Wilbert, & Kennedy, 1984).
organization. Several psychologists have re- In my role as a defense attorney for mental
ported that even minor negative outcomes have health professionals, I have witnessed com-
sometimes led to rejection from the foregoing plaints lodged against psychologists with the
types of organizations. Also, whenever the psy- highest of reputations. According to Wright
chologist serves as an expert witness, questions (1981), it appears that “the greater the degree
are likely to be asked about any litigation or of professionalism one demands of oneself, the
regulatory action in which he or she has been more detailed and excruciating is the attendant
a party; several psychologists have said that review and the more intense the accompanying

560
 108 • defending against legal complaints 561

feelings of threat, anxiety, guilt, remorse, and or violation of licensing standards, there are nu-
depression” (p. 1535). merous ways in which the record can be closed
Some psychologists bent on preserving their to public scrutiny (i.e., it will not necessarily be
professional reputation question the value of reported). Just as there is considerable variation
having insurance to cover a malpractice and/or between states in the amount of risk associated
regulatory complaint(s). Often these psycholo- with psychological practice, jurisdictions vary
gists believe that the financial benefit (coverage considerably in how complaints are handled
for any judgment or legal fees) is outweighed prior to a judgment that becomes public record.
by the detriment of the insurance carrier’s con-
trol of settling a legal action. Specifically, an in-
surance policy can reduce the financial outlay A PSYCHOLOGIST IS INADEQUATELY
by the psychologist, but the carrier is able to se- PREPARED TO DEAL WITH
lect the attorney. Numerous psychologists have LEGAL PROBLEMS
expressed the sentiment that the insurance-
selected attorney may be well intentioned and Regardless of the jurisdiction, psychologists
qualified but is under the control of the insur- need to recognize that they are ill advised to
ance company, who pressures the attorney to attempt to “theraperize” a disgruntled client
bring about a prompt settlement (so as to lessen (past or present) who threatens a complaint. As
the defense costs). Various insurance represen- Wright (1981, p. 1535) correctly explained,
tatives generally acknowledge that their goal is “Our training and our personal philosophies
to minimize expenditures on the defense; al- tend to emphasize the importance of the indi-
though they understand the psychologist’s con- vidual and our obligation as a helper/practi-
cern about preserving professional reputation, tioner to evidence humanistic concerns or at-
that concern is beyond the scope of the carrier’s tempt ‘conflict resolution.’ We find it hard to
duty to its investors. Incidentally, this stance believe that our virtue is unappreciated, so we
is maintained even when the lawsuit is clearly attempt to follow our ethical admonitions to re-
frivolous and without legal merit— it is cheaper solve conflict and discover to our subsequent
to pay the litigious client than to teach the dismay that the plaintiff’s attorney made our
client a lesson. This approach may seem short- virtuous and well-meaning efforts appear to be
sighted, but it is the prevailing viewpoint of in- an attempt to ‘cover up’ or ‘cop out’” (p. 1535).
surance carriers. As a result, numerous psy- Well-intentioned efforts that would be quite
chologists find it expeditious and prudent to proper in a therapeutic context become suspect
hire, at their own expense, a personal attorney in the legal context.
to deal with the insurance-paid attorney (e.g., In one case, a male psychologist was accused
to try to persuade against a settlement that un- by a female client of sexual misconduct. With-
justly penalizes the psychologist). out legal counsel, the three partners met with
the client and her husband and offered to refund
the full amount paid over the years for treat-
A PSYCHOLOGIST FACES A HIGH ment, contingent on their not filing a lawsuit
RISK OF A LEGAL COMPLAINT against the allegedly malpracticing psycholo-
gist. The offer was refused, and when a mal-
It is impossible to know the incidence of legal practice action was filed, the proposed refund
actions taken against psychologists. Why? Be- was transformed into a nefarious attempt by
cause many, perhaps most, legal actions initially the psychologists to subvert the couple’s exer-
attempt to accomplish an “out-of-court” settle- cising their legal rights.
ment. That is, the plaintiff’s or complainant’s The foremost problem comes from the fact
attorney contacts the psychologist and offers to that the education and training of psychologists
accept a financial payment to circumvent the are basically antithetical to what leads to excel-
need to file a formal action. Moreover, even if a lence in legal defense work. Dedicated to “ivory
complaint is filed, be it for alleged malpractice tower” notions and often divorced from the re-
562 part viii • ethical and legal issues

ality of modern psychological practice, trainers sional, whether a psychologist or professor, is

are prone to cling to outdated ideas about prac- equipped with considerable knowledge, includ-
titioners. Specifically, they emphasize altruism ing knowledge about human behavior. Unfor-
and subjugating the rights of practitioners to tunately, the knowledge is not assuredly conso-
the preferences and demands of clients. Like- nant with the law and certainly not always in
wise, the curricula remain rooted in the past, accord with the rules that determine what can
with little or no accommodation to the current and should be used in litigation. Second, the
practice environment, namely, the “industrial- knowledge derives from the academy, which
ized” marketplace, which is characterized by has minimal relevance to and is often contra-
commercialism and consumer accountability dictory to legal reality. Suffice it to say that the
and controlled by nonclinical sources, such as legal arena requires expertise foreign to psy-
managed care organizations (Cummings, 1996). chological practice. Wright (1981) explains that
Some faculty members denounce any proposal psychologists facing a legal complaint “enter a
to alter the curriculum to provide course work whole new dimension of experience” (p. 1535)
addressing modern practice issues, such as ac- and that their “training, which tends to em-
quiring business skills, dealing with managed phasize ultimate responsibility of the individ-
care, and being legally safe. As Troy and Schue- ual, may be at variance with both the philo-
man (1996) put it: “Among internal obstacles sophical context of our times and the legal-
one may note the essential stasis and inflexibil- philosophical context in which we operate” (p.
ity of faculty-owned curricula which particu- 1539). Wright’s comments, which were made in
larly resist innovative proposals for instruc- 1981, are even more relevant today.
tional design; criteria for faculty promotion and
tenure; faculty ignorance of the changing im-
peratives of the world of work; competency and A PSYCHOLOGIST PRACTICES
resources shortfall with programs; and the in- UNDER LITIGIOUS CONDITIONS
appropriate expectations of new trainees” (p.
75). For example, when I proposed adding a Modern psychological practice is far different
“real-world” practice course, my colleagues’ from psychological practice in the past, even as
prevailing response was that “they can get that recently as the 1980s. A major change has oc-
kind of learning once they are out in the field.” curred in the tenets of the therapeutic alliance.
Consequently, few psychologists graduate with Prior to psychologists’ seeking and gaining ad-
a pragmatic understanding of how to succeed in mission to the “health care industry” (moti-
psychological practice, not to mention defend- vated by the self-serving goal of increased in-
ing against legal complaints. comes, such as through eligibility for third-
A related problem comes from the fact that party payments), clients tended to treat mental
the psychologist, as a highly intelligent and health practitioners differently from other
well-educated individual, is prone to want to health care providers. There was an unfortu-
serve as “quarterback” in the legal defense. As nate stigma attached to being the recipient of
one attorney told Wright (1981): “Heaven pro- mental health services, and clients tended to
tect me from intelligent, sophisticated clients. consider the therapeutic relationship to be dis-
While they’re ‘helping’ me win my case, they tinctly different from other caregiving rela-
can find ways I never dreamed of to mess things tionships; thus, legal actions against mental
up. The smarter they are the more ways they health practitioners were relatively few, at least
can find to botch it” (p. 1535). This same condi- compared with today. The industrialization or
tion has been found with professors who are commercialization of mental health services led
prone to want to dictate the actions of their at- to, among other things, a reformation of the
torneys, contrary to legal judgment (LaNoue & therapeutic alliance; namely, the dyad of the
Lee, 1987). psychologist and client was joined by a third-
The source of the “quarterback” problem is party payer to create a ménage à trois. With
twofold. First, the intelligent, educated profes- this restructuring, exacerbated by the com-
 108 • defending against legal complaints 563

manding presence of the third-party payer (dic- draining emotionally and financially than de-
tating the terms for the relationship), the unique- fending against a malpractice action. Given that
ness of the therapeutic alliance disappeared and a licensing complaint does involve scrutiny and
litigation increased. judgment by members of the same profession
Government regulation has become all- (as opposed to a judge or jury), it is easy to
powerful in determining the propriety of psy- think that one’s professionalism has been in-
chological practices. When psychologists quested controvertibly impugned.
for state licensure (again, motivated by the self- At the time of the first edition of the Psy-
serving goal of increased incomes), they unex- chologists’ Desk Reference in 1998, it seemed
pectedly surrendered disciplinary control of possible that the threat of legal complaints
professional practice. might have reached its peak. Regrettably, the
Licensing boards, under the watchful eye intervening years reveal, to the contrary, there
(some would say “dictates”) of state prosecuting has been an increase in the number of and rea-
attorneys, became the monitors for possible dis- sons for complaints. Granted, the financial press
ciplinary action. Relatedly, psychologists have on professional associations has led to some
lost their independent determination of clinical ethics committees’ being reluctant to enter into
matters to the micromanagement of practices by adjudication of ethics-based complaints.
the state house. Many psychologists falsely be- In place of collegial reviews and sanctions,
lieve that members of licensing boards are col- the government, through state licensing boards,
leagues who will be understanding and prone to has expanded its commitment to and resources
forgive. They reason that at least some mem- for regulatory actions against mental health
bers of the state board are psychologists; some practitioners, including psychologists. Regret-
may have been colleagues known in the past. In tably, there is reason to believe that some li-
point of fact, the members of the licensing censing boards are, in fact, considering psy-
board, whether psychologist, consumer repre- chologists to be “guilty until proven innocent”
sentative, or state attorney, are appointed (usu- (Peterson, 2001) and depriving psychologists’ of
ally by the governor) to represent politically fair treatment and other legal rights (Williams,
motivated consumer protection. After dealing 2001).
with a licensing complaint, numerous respon- Also, the courts have, if anything, opened
dents have offered comments reflecting their the door of the courthouse further, aided and
surprise. For example: “The members of the abetted by additional liability created by man-
board, especially the psychologists, seemed to aged care (Applebaum, 1993). Now legal ac-
take a ‘guilty until proven innocent’ approach.” tions against mental health professionals in
This is not surprising, since the members are general and psychologists in particular abound.
present as protectors of consumers, certainly not Historically, the advent of legal complaints
as colleagues, and are there by political behest. became pronounced in the mid-1970s, posing
In fact, some psychologist board members have an ominous threat to psychologists. By the
found their roles to be such a heady experience early 1980s, the threat of a legal complaint was
that unprecedented degrees of egotism, narcis- affecting the profession to the point that terms
sism, and self-aggrandizement are revealed. such as “litigaphobia” and “litagress” began to
One psychologist commented, “They seemed to appear in professional publications (Brodsky,
be demanding perfect performance rather than 1983; Turkington, 1987). Today every psycho-
the reasonable standard that I thought deter- logist, regardless of competency, years of expe-
mined malpractice.” Again, this stance is not rience, theory advocated, techniques used, or
surprising, since the degree of proof required types of clients, is at risk of a legal action from
for probable cause for discipline is nebulous and a service user. This chapter explores the issues
usually less strenuous than required for a mal- underlying the threat of legal actions, and offers
practice action. specific suggestions for the practitioner’s main-
Finally, many psychologists find that de- taining effective risk management.
fending against a licensing complaint is more
564 part viii • ethical and legal issues

A PSYCHOLOGIST MUST ACCEPT 10. Formulate a factual and defensible explanation.

BEING DEFENSIVE 11. Trust no one but your attorney.
12. Avoid creating witnesses for the other side.
Clinging to antiquated notions about practices 13. Learn to respond properly to discovery
raises legal liability, and lacking legally related methods and during testimony.
knowledge adds to the risk. Since most psy- 14. Be modest in professional representations.
chologists do not think like lawyers, it is im- 15. Implement a risk management system.
portant to pursue defensive strategies. 16. Define an appropriate standard of care.
Stated simply, there are four essential defen- 17. Buttress your professional credentials.
sive strategies: (1) the psychologist should have 18. Screen clients to eliminate undue risks.
professional liability insurance (including for 19. Guard against a copy-cat complainant.
licensing complaints); (2) the psychologist 20. Develop a healthy personal-professional life.
should rely on a supervisor for protective peer
review (albeit potentially creates liability for The foregoing can be reduced to the follow-
the supervisor as well); (3) the psychologist ing eight detailed recommendations.
should keep detailed records (which are com-
monly weighted heavily for establishing what 1. A psychologist should acquire training to
was or was not involved in the professional ser- view practice operations and client commu-
vices); and (4) in or out of the practice office, the nications with a defensive eye. Since this
psychologist should have prudence govern need is commonly unfilled by graduate
every professional and personal bit of his or her training programs, the psychologist should
conduct. arrange for self-study and seminars.
Relatedly, Smith (2003) recommends that 2. When a potentially litigious client waves a
the psychologist: (1) understand what consti- “red flag,” the psychologist should set aside
tutes a multiple relationship; (2) protect confi- any illogical idea that services must be contin-
dentiality; (3) respect people’s autonomy; (4) ued. Some clients have actually filed legal ac-
know his or her supervisory responsibilities; tions against their psychologists and then ob-
(5) identify the respective roles of the client and jected when services to them were terminated!
the psychologist; (6) document professional If a client threatens or takes legal action against
services carefully; (7) provide only services for the psychologist, the client has sacrificed any
which there is expertise; (8) know the differ- logical claim to the title of “client” and has jus-
ence between abandonment and termination; tified the new title “party opponent.”
(9) stick to the evidence; and (10) be accurate in 3. A psychologist should have a personal at-
billing. torney readily “on call.” As described ear-
Elsewhere (Woody, 2000), this author has lier, an attorney appointed by a malpractice
offered twenty defensive strategies that any insurance carrier enters the conflict after
mental health practitioner should maintain the fact and primarily serves the insurance
when faced with a complaint; the twenty strate- carrier.
gies are: 4. The psychologist should rely on preventive
legal counsel at the first possible “red flag”
1. Maintain a healthy mindset. of litigation. Obtaining the advice of counsel
2. Accept the adversarial nature of the complaint. proactively can reduce the possibility of a
3. Recognize the adversaries. complaint.
4. Become defensive. 5. If a client demonstrates negativism toward
5. Be a warrior. the psychologist that goes beyond “thera-
6. Adopt a long-range perspective. peutic resistance” or “reasonable transfer-
7. Obtain legal counsel. ence,” the psychologist should acknowledge
8. Trust and rely on an attorney. the possibility of a legal complaint. If resis-
9. Do not allow financial considerations to tance or transference moves to the client’s
dominate decision making. mentioning a complaint, the psychologist
 108 • defending against legal complaints 565

should not persevere. In the clinical interests Charles, S. C., Wilbert, J. R., & Kennedy, E. C. (1984).
of the client, a psychologist cannot be ex- Physicians’ self-reports of reactions to malprac-
pected to function effectively under the threat tice litigation. American Journal of Psychiatry,
of litigation, and thus it would be a disser- 141, 563 –565.
Cummings, N. A. (1996). The resocialization of be-
vice to the client to continue.
havioral healthcare practice. In N. A. Cum-
6. A psychologist should not wait until a com-
mings, M. S. Pallak, & J. L. Cummings (Eds.),
plaint seems inevitable or even probable be- Surviving the demise of solo practice: Mental
fore shifting into a defensive posture. The health practitioners prospering in the era of
mere possibility of a complaint justifies ac- managed care (pp. 3 –10). Madison, CT: Psycho-
tion to safeguard the rights of the psychol- social Press (International Universities Press).
ogist, as well as being a service to the client. LaNoue, G. R., & Lee, B. A. (1987). Academics in
7. When legal safeguards are necessary, the court: The consequences of faculty discrimina-
psychologist should assume a defensive pos- tion litigation. Ann Arbor: University of Mich-
ture in all communications with the client or igan Press.
client’s attorney; implement a tactful and Peterson, M. D. (2001). Recognizing concerns about
how some licensing boards are treating psy-
reasonable termination of the clinical service
chologists. Professional Psychology, 32(4),
(such as making a referral to another practi-
339 –340.
tioner); and immediately turn the matter Smith, D. (2003). 10 ways practitioners can avoid
over to his or her personal attorney. frequent ethical pitfalls. APA Monitor, 34(1),
8. When an attorney has become involved, the 50 – 55.
psychologist should accept that the matter is Troy, W. G., & Shueman, S. A. (1996). Program re-
outside of psychological competence and design for graduate training in professional psy-
personal control. The fundamental assump- chology: The road to accountability in a chang-
tion must be that the matter will best be ing professional world. In N. A. Cummings, M.
handled by legal strategies. Consequently, S. Pallak, & J. L. Cummings (Eds.), Surviving
the psychologist must avoid trying to be a the demise of solo practice: Mental health prac-
titioners prospering in the era of managed care
“quarterback” to the legal situation.
(pp. 55 –79). Madison, CT: Psychosocial Press
(International Universities Press).
These eight recommendations pose ideas Turkington, C. (1987). Litigaphobia. Monitor, 17(11),
that may seem foreign to traditional psycho- 1, 8.
logical practice. Some psychologists are reluc- Williams, M. H. (2001). The question of psycholo-
tant to pass clinical conditions through a legal gists’ maltreatment by state licensing boards:
filter and object to the added expense (such as Overcoming denial and seeking remedies. Pro-
paying for a personal attorney). Nonetheless, fessional Psychology, 32(4), 341–344.
modern psychological practice requires a defen- Woody, R. H. (1988a). Fifty ways to avoid malprac-
sive posture and legal protection (with the ex- tice: A guidebook for the mental health practi-
pense being the “cost of doing business” in this tioner. Sarasota, FL: Professional Resource Ex-
change.
litigious era). To do otherwise is to jeopardize
Woody, R. H. (1988b). Protecting your mental health
professional survival and practice success.
practice: How to minimize legal and financial
risk. San Francisco: Jossey-Bass.
References & Readings
Woody, R. H. (1989). Business success in mental health
practice: Modern marketing, management, and
Appelbaum, P. S. (1993). Legal liability and managed
legal strategies. San Francisco: Jossey-Bass.
care. American Psychologist, 48, 251–277.
Woody, R. H. (1991). Quality care in mental health
Association of State and Provincial Psychology
services: Assuring the best clinical services. San
Boards (1996). Disciplinary data system pilot
Francisco: Jossey-Bass.
project kicks off. ASPPD Newsletter, 17(1), 1, 4.
Woody, R. H. (1997). Legally safe mental health
Brodsky, S. L. (1983). Litigaphobia: The profession-
practice: Psycholegal questions and answers.
als’ disease [Review of B. Schutz, Legal liability
Madison, CT: Psychosocial Press (International
in psychotherapy]. Contemporary Psychology,
Universities Press).
28, 204 –205.
566 part viii • ethical and legal issues

Woody, R. H. (2000). What to do upon receiving a Related Topics

complaint. In L. VandeCreek & T. L. Jackson
Chapter 107, “Basic Principles for Dealing With
(Eds.), Innovations in clinical practice: A
Legal Liability Risk Situations”
source book (Vol. 18, pp. 213 –229). Sarasota,
Chapter 109, “Dealing With Licensing Board and
FL: Professional Resource Press.
Ethics Complaints”
Wright, R. H. (1981). What to do until the malprac-
Chapter 110, “Dealing With Subpoenas”
tice lawyer comes: A survivor’s manual. Amer-
ican Psychologist, 36, 1535 –1541.

DEALING WITH LICENSING

109 BOARD AND ETHICS
COMPLAINTS

Gerald P. Koocher & Patricia Keith-Spiegel

Receiving a formal inquiry or complaint letter advantage from this system. Psychologists ini-
from a licensing board or professional associa- tiated the legislation that created our licensing
tion’s ethics committee invariably becomes one boards and professional association ethics com-
of the most stressful events in a psychologist’s mittees. If the profession abandoned an active
career. The actual incidence of actionable com- role in self-regulation, it would ultimately fall
plaints against psychologists is relatively low. under regulation by outsiders with inadequate
In 2002, for example, the APA Ethics Commit- understanding of the history, practices, and sci-
tee received 321 inquiries, but opened only 34 entific foundations of the profession.
cases, and only 16 members were expelled or We have seen a wide range of reactions from
forced to resign of approximately 85,000 mem- respondents to official inquiries and complaints.
bers (APA, 2003). Nonetheless, receiving a no- Some psychologists become so stressed that
tification letter often feels like an attack or a they appear to jeopardize their own health.
personal affront from one’s colleagues. In such Others become hostile or avoidant in ways that
situations it is important to understand the sys- only serve to antagonize those charged with
tem, know one’s rights, and assure oneself of evaluating the complaint. Many seem able to
fair treatment. Keep in mind that “beating the retain a dignified approach to the charge, but all
system” is not the appropriate goal. Psycholo- become anxious to get to the matter as soon as
gists have previously agreed— voluntarily and possible and gain a favorable resolution. Re-
with full informed consent— to enter a profes- ceiving an inquiry or formal notice of charges
sion that has obligated itself to formal peer from any professional monitoring agent will
monitoring. All of us, as well as the public, gain not, of course, improve anyone’s day. However,
 109 • dealing with licensing board and ethics complaints 567

we offer some advice to consider in the event mation, request it and review it care fully to
you ever find yourself in such a situation. determine where you fall in the time line of
First and foremost, know who you are deal- the investigatory process and what rights,
ing with and understand the nature of the com- options, and inquiries you have available be-
plaint and the potential consequences before re- fore responding.
sponding.
Second, do not respond impulsively. Knee-
• Are you dealing with a statutory licensing jerk actions will more likely than not be coun-
authority or a voluntary professional associ- terproductive and complicate the process un-
ation? A professional association’s most se- necessarily.
vere sanction is likely to be expulsion, but a
licensing board has the authority to suspend • Do not contact the complainant directly or
or revoke a professional license. indirectly. The matter is no longer subject to
• Are you dealing with nonclinician investiga- informal resolution. Any contact initiated by
tors or professional colleagues? In some you may be viewed as an attempt at coercion
smaller states or provinces, the staff of the li- or harassment.
censing board may consist of a nonpsychol- • If the complaint involves a current or former
ogist who lacks a fully professional under- client, be sure that the authorities have ob-
standing of the applicable ethics codes and tained and provided you with a waiver signed
regulations. Even when the investigator for a by the client authorizing you to disclose con-
licensing board or ethics committee has fidential information before responding to
training as a psychologist, the degree of ex- the charges. We know of instances where li-
perience and expertise can vary widely. In censing boards initiated complaints based on
many cases additional clarification from oth- third party inquiries without such waivers
ers in authority may be warranted. and then asked the psychologists complained
• Is the contact you received an informal in- about to obtain release of information con-
quiry or a formal charge? Sometimes licens- sent from their own clients. Such requests
ing boards and ethics committees approach are inappropriate, because they put the psy-
less serious allegations by asking the psy- chologist in the uncomfortable and awkward
chologist to respond before they decide to position of asking someone to surrender con-
whether to open a formal complaint. In such fidentiality to serve the needs of another. The
instances, however, “informal” does not mean Federal HIPAA (Health Insurance Portability
“casual.” Rather, such inquiries may be a and Accountability Act) regulations prohibit
sign that the panel has not yet concluded that the release of protected health information
the alleged conduct was serious enough to without such a signed release.
warrant drastic action or meets their defini- • Obtain consultation before responding. A
tion of issuing a formal charge. The correct colleague with prior experience serving on
response should always be thoughtful and ethics panels or licensing boards is an ideal
cautious. choice. Pay for an hour or two of professional
• Have you been given a detailed and compre- time. Doing so establishes a confidential and
hensible rendition of the complaint made possibly privileged relationship (depending
against you? You should not respond sub- on state law) with the consultant. Consulta-
stantively to any complaint without a clear tion with an attorney is also advised, espe-
written explanation of the allegations. In cially if the matter involves an alleged legal
many jurisdictions you may also be entitled offense, if the ethics committee does not ap-
to a written copy of the actual complaint pear to be following the rules and proce-
made against you. dures, or if the case might result in any pub-
• Have you been provided with copies of the lic disciplinary action. Some professional lia-
rules, procedures, or policies under which the bility insurance policies provide coverage for
panel operates? If you do not have this infor- legal consultation in the event of a licensing
568 part viii • ethical and legal issues

board complaint. This insurance does not consult with colleagues or an attorney before
generally apply to professional association responding, but a letter from your attorney
ethics complaints and may not be allowed in alone (i.e., without a response over your sig-
some jurisdictions. We recommend that you nature) is often not sufficient and may also
check your liability policy and secure such be regarded as inappropriate or evasive.
coverage if you do not already have it. • Limit the scope of your response to focus on
• If asked to provide unusual materials during the content areas and issues that directly re-
the investigatory process, do not comply late to the content of the official complaint
without first seeking legal consultation. We letter. Do not ramble or introduce tangential
know of one state licensing authority that issues.
claimed the right to examine “samples of • If you need more time to gather materials
reports” from a psychologist’s work with and respond, ask for it. Be sure to retain
clients other than the ones involved in the copies of everything you send in response to
complaint — a clear violation of the privacy the inquiry.
rights of the affected clients. In another case, • Do not take the position that the best defense
a licensing board insisted that a psychologist is a thundering offense. This will polarize the
provide typed transcripts of substantial files proceedings and reduce the chances for a col-
of handwritten notes at his own expense. legial solution.
• If offered a settlement, “consent decree,” or • If you believe that you have been wrongly or
any resolution short of full dismissal of the erroneously charged, state your case clearly
case against you, obtain additional profes- and provide any appropriate documentation.
sional and legal consultation. Even an appar- • If the complaint accurately represents the
ently mild “reprimand” may result in diffi- events, but does not accurately interpret
culty in renewing liability insurance policies, them, provide your own account and inter-
gaining access to insurance provider panels, pretation with as much documentation as
qualifying for hospital staff privileges, or be- you can.
ing hired for some jobs. Any formal discipli- • If you have committed the offense charged,
nary action, even as mild as a reprimand, document the events and start appropriate
may result in reports to interstate monitor- remediation actions immediately (e.g., seek
ing agencies or professional associations. professional supervision to deal with any ar-
Agreeing to accept an ethics or licensing eas of professional weakness, enter psy-
sanction may also compromise your legal de- chotherapy for any personal problems, or
fense, should the client file suit. If you have take other steps to demonstrate that you do
done something wrong, a penalty may be ap- not intend to allow the error to recur). Pre-
propriate. However, you should be fully sent information regarding any mitigating
aware of the potential consequences before circumstances. It would probably also be wise
simply agreeing to the sanction. to seek legal counsel at this point, if you have
not already done so.
Third, organize your defense and response to • If a charge or complaint is sustained and you
the charges carefully and thoughtfully. are asked to accept disciplinary measures
without a formal hearing, you may want to
• Assess the credibility of the charge. Compile consider reviewing the potential conse-
and organize your records and the relevant quences of the measures with an attorney be-
chronology of events. Respond respectfully fore making a decision.
and fully to the questions or charges within • Know your rights of appeal.
the allotted time frame. Failure to cooperate
with a duly constituted inquiry is, itself, an Fourth, take steps to support yourself emo-
ethical violation. tionally over what is likely to be a stressful
• Psychologists are expected to respond per- process extending over several months.
sonally to the inquiry. It is appropriate to
 109 • dealing with licensing board and ethics complaints 569

• Be patient. It is likely that you will have to of the Ethics Committee, 2002. American Psy-
wait for what will seem like a long while be- chologist, 58, 650 – 657.
fore the matter is resolved. It is perfectly ac- Association of State and Provincial Psychology
ceptable to respectfully inquire regarding the Boards. (n.d.). Home page. Retrieved 2004
from http://www.asppb.org
status of the matter from time to time.
Bass, L. J., DeMers, S. T., Ogloff, J. R., Peterson, C.,
• If appropriate, confide in a colleague or ther-
Pettifor, J. L., Reaves, R. I., et al. (1996). Profes-
apist who will be emotionally supportive sional conduct and discipline in psychology.
through the process. Your relationship with Washington, DC: American Psychological As-
your therapist may be protected by privilege. sociation.
We strongly suggest, however, that you re- Bersoff, D. N. (Ed.). (2003). Ethical conflicts in psy-
frain from discussing the charges against chology (3rd ed.). Washington, DC: American
you with many others. Doing so may in- Psychological Association.
crease your own tension and likely produce Canter, M. B., Bennett, B. E., Jones, S. E., & Nagy,
an adverse impact as more and more individ- T. F. (1994). Ethics for psychologists: A com-
uals become aware of your situation and may mentary on the APA ethics code. Washington,
DC: American Psychological Association.
possibly raise additional problems regarding
Fisher, C. (2003) Decoding the ethics code: A practi-
confidentiality issues. In no instance should
cal guide for psychologists. Thousand Oaks,
you identify the complainant to others, aside CA: Sage.
from the board or committee making the in- Koocher, G. F., & Keith-Spiegel, P. C. (1998). Ethics
quiry (after they produce a signed release) in psychology: Professional standards and
and your attorney. cases (2nd ed.). New York: Oxford University
• Take active, constructive steps to minimize Press.
your own anxiety and stress levels. If this Pope, K. S. (n.d.). Licensing information site. Re-
matter is interfering with your ability to trieved 2004 from http://www.kspope.com/
function, you might benefit from a profes- licensing/index.php
sional counseling relationship in a privileged
context. Related Topics
Chapter 103, “Ethical Principles of Psychologists
References, Readings, & Internet Sites and Code of Conduct (2002)”
Chapter 107, “Basic Principles for Dealing With
American Psychological Association. (2001). Rules
Legal Liability Risk Situations”
and procedures. Washington, DC: Author. http://
Chapter 108, “Defending Against Legal Complaints”
www.apa.org/ethics
American Psychological Association. (2003). Report
 110 DEALING WITH SUBPOENAS

Gerald P. Koocher

Receipt of a legal document commanding that ity, the title of the legal action, and the time and
you appear at a legal proceeding or turn over place of testimony or production of documents.
your records to attorneys, especially when un-
expected, can be a very stressful experience.
How Is a Subpoena Served?
This brief guide can help you understand the
nature of a subpoena and how to respond. How- A subpoena may generally be served by any
ever, law and procedures vary from jurisdiction adult person who is not a party to the litigation.
to jurisdiction; when in doubt, consult with an Usually service is done by a constable or sher-
attorney who is knowledgeable about your lo- iff, who delivers a copy in person or leaves it at
cal jurisdiction. the intended recipient’s residence or place of
business.

QUESTIONS ABOUT SUBPOENAS

Must I Comply With the
What Is a Subpoena? Subpoena?

A subpoena is a document served in a legally Failure to obey a subpoena may lead to being
prescribed manner on a person who is not a held in contempt of court. However, simply be-
party to a case (i.e., not the plaintiff or defen- cause you have been served does not mean that
dant) requiring that person to produce docu- the subpoena is valid or that you must produce
ments, appear and give testimony at a deposi- all materials requested.
tion or trial, or both. In the case of depositions,
seven days’ notice is often required. What Is the Difference Between a
Subpoena and a Court Order?
What Is a Subpoena Duces Tecum? It is important to understand the differences be-
From the Latin meaning “bring it with you,” a tween a subpoena and a court order. A subpoena
subpoena duces tecum requires the person to simply compels a response and in some juris-
bring specified records, reports, tapes, docu- dictions can be issued routinely by an attor-
ments, or other tangible evidence to court or a ney’s request to a clerk of courts. A psycholo-
deposition. For deposition testimony, 30 days’ gist’s response to the subpoena need not be
notice is often required. what is demanded in the actual subpoena doc-
ument. If the papers seek records, documents,
or testimony that may be privileged, the psy-
Who Issues the Subpoena, and chologist should seek clarification from the
What Is in It? client’s attorney or the court. A court order, on
Depending on the jurisdiction, the issuing au- the other hand, generally issues only after a
thority may be a clerk of the court, notary pub- hearing before a judge; it compels a disclosure,
lic, or justice of the peace. The document must unless the order is appealed to a higher court. In
state the name of the court and issuing author- the end, the court must decide what informa-
tion or records are protected and what are not.

570
 110 • dealing with subpoenas 571

Consult your own attorney or the relevant however, it is not unreasonable for the clini-
client’s attorney to assess matters of privilege, cian to personally confirm the client’s wishes,
overbroad requests for documents or materials, especially if the content of the records is sen-
and other specific questions regarding the va- sitive.
lidity of the documents. • If a signed release form is included, but the
clinician believes that the material may be
clinically or legally damaging, discuss these
What If I Cannot Attend on the
issues with the client.
Specified Date?
• Psychologists concerned about releasing ac-
Contact the lawyer who issued the subpoena to tual notes should offer to prepare a prompt
discuss the matter. If the attorney is intransi- report or summary, but they ultimately may
gent, states that the date cannot be rescheduled, have to produce the full record. The original
and the time line is unreasonable (e.g., if you record or notes need not be provided. A no-
are given only 24 hours’ notice and do not have tarized or authenticated copy of the records
time to cancel appointments or provide patient will generally suffice.
coverage), tell the attorney that you plan to • On rare occasion, a subpoena generated by an
contact the judge in the case in order to com- attorney opposing the psychologist’s client or
plain about the inadequate notice. This ap- representing another person may arrive at
proach often stimulates increased flexibility by a clinician’s office in the hands of a person
the attorney. If necessary, do contact the judge seeking immediate access to records. Under
and explain your scheduling problem. Except in such circumstances it is reasonable to inform
unusual or urgent circumstances, the judge is the person: “I cannot disclose whether or not
likely to be accommodating. the person noted in the subpoena is now or
ever was my client. If the person were my
client, I could not provide any information
DEALING WITH SUBPOENAS FOR without a signed release from that individual
PRODUCTION OF DOCUMENTS or a valid court order.” Next, contact your
client, explain the situation, and ask for per-
When a subpoena demanding production of mission to talk with his or her attorney. Ask
documents is served, the psychologist should the patient’s attorney to work out privilege
not provide anything immediately. That is to issues with the opposing attorney or move to
say, nothing should be surrendered to the per- quash the subpoena. These steps will ensure
son serving the subpoena, no matter how ag- that the person to whom you owe prime
gressive the request. The subpoena document obligations (i.e., your client) is protected to
should be accepted, and the psychologist should the full extent allowed by law.
then consult legal counsel regarding applicable • If a valid subpoena seeks raw test data or test
law and resulting obligations. If it is ultimately materials sold only to professionals (e.g., cer-
determined that the call for the records has tain psychological test kits or record forms),
been appropriately issued by a court of compe- one should generally respond by offering to
tent authority, a psychologist may be placed in provide the raw data to a qualified profes-
a very awkward position, especially if the client sional, explaining that laypersons are not
does not wish to have the material disclosed. qualified to interpret the raw data. Test kits
Consider the following actions: whose purchase is restricted by the publisher
to “qualified users” should also generally be
• If a subpoena arrives from a client’s attorney withheld. However, both raw data and test kit
and no release form is included, check with materials would have to be produced in re-
your client, not the attorney, before releasing sponse to a court order. These issues are
the documents. In a technical sense, a request discussed in the 2002 version of the Ameri-
from a client’s attorney is legally the same as can Psychological Association’s Ethical Prin-
a request from the client himself or herself; ciples of Psychologists and Code of Conduct,
572 part viii • ethical and legal issues

reprinted in this volume and available on- Association. (1996). Strategies for private prac-
line. titioners coping with subpoenas or compelled
testimony for client records of test data.
Professional Psychology: Research and
Practice, 27, 245 –251.
GENERAL ADVICE
Committee on Psychological Tests and Assessment.
(1996). Statement on disclosure of test data.
When in doubt, consult your own attorney for American Psychologist, 51, 644 – 668.
advice, but never ignore a subpoena. Koocher, G. P., & Keith-Spiegel, P. C. (1998). Ethics in
psychology: Professional standards and cases
References, Readings, & Internet Sites (2nd ed.). New York: Oxford University Press.
Koocher, G. P., & Rey-Casserly, C. M. (2002).
American Psychological Association. (1993). Record Ethical issues in psychological assessment. In J.
keeping guidelines. American Psychologist, 48, R. Graham & J. A. Naglieri (Eds.), Handbook
984 –986. of assessment psychology. New York: Wiley.
American Psychological Association. (1996). ‘Lectric Law Library. (n.d.). Lexicon on subpoena.
Strategies for private practitioners coping with Retrieved 2004 from http://www.lectlaw.com/
subpoenas or compelled testimony for client def2/s083.htm
records or test data. Professional Psychology: Legal Definitions. (n.d.). Online legal dictionary.
Research and Practice, 27, 245 –251. Retrieved 2004 from http://www.legal-defini
Boruch, R. P., Dennis, M., & Cecil, I. S. (1996). Fifty tions.com
years of empirical research on privacy and con- United States Department of Justice. (n.d.). Kid’s
fidentiality in research settings. In B. H. page glossary. Retrieved 2004 from http://www.
Stanley, J. E. Sieber, & C. B. Melton (Eds.), usdoj.gov/usao/eousa/kidspage/glossary.html
Research ethics: A psychological approach (pp.
129 –173). Lincoln: University of Nebraska
Related Topics
Press.
Burke, C. A. (1995). Until death do us part: An Chapter 104, “Privacy, Confidentiality, and
exploration into confidentiality following the Privilege”
death of a client. Professional Psychology: Chapter 107, “Basic Principles for Dealing With
Research and Practice, 26, 278 –280. Legal Liability Risk Situations”
Committee on Legal Issues, American Psychological Chapter 128, “Basic Elements of Release Forms”

GLOSSARY OF LEGAL TERMS

111 OF SPECIAL INTEREST IN
MENTAL HEALTH PRACTICE

Gerald P. Koocher

Abandonment: Unilateral termination of a psy- chotherapist without the patient’s consent at

chotherapist-patient relationship by the psy- a time when the patient requires continuing
111 • glossary of legal terms of special interest in mental health practice 573

mental health care and without the psycholo- Consent: Voluntary act by which one person
gist’s making arrangements for appropriate agrees to allow another person to do something.
continuation and follow-up care. Express consent is that directly and unequivo-
Affidavit: Sworn statement that is usually cally given, either orally or in writing. Implied
written. consent is that manifested by signs, actions, or
facts or by inaction and silence, which raises a
Agency: Relationship between persons in presumption that the consent has been given. It
which one party authorizes the other to act for may be implied from conduct (implied-in-fact),
or represent that party. for example, when someone rolls up his or her
Allegation: Statement that a party expects to be sleeve and extends an arm for vein puncture, or
able to prove. by the circumstances (implied-in-law), for ex-
ample, in the case of an unconscious person in
Answer: A defendant’s written response to a
an emergency situation.
complaint.
Contributory negligence or comparative negli-
Appeal: The process by which a decision of a
gence: Affirmative defense to a successful action
lower court is brought for review before a court
against a defendant where the plaintiff’s con-
of higher jurisdiction. The party bringing the
current negligence contributed to his or her
appeal is the appellant. The party against whom
own injury, even though the defendant’s actions
the appeal is taken is the appellee.
may also have been responsible for the injury.
Assault: Intentional and unauthorized act of
placing another in apprehension of immediate Damages: Money receivable through judicial
bodily harm. order by a plaintiff sustaining harm, impair-
ment, or loss to his or her person or property as
Battery: Intentional and unauthorized touching the result of the accidental, intentional, or neg-
of a person, directly or indirectly, without con- ligent act of another. Compensatory damages
sent. For example, a surgical procedure per- are intended to compensate the injured party
formed upon a person without express or im- for the injury sustained and nothing more.
plied consent constitutes a battery. Special damages are the actual out-of-pocket
Causation: Existence of a connection between losses incurred by the plaintiff, such as psy-
the act or omission of the defendant and the in- chotherapy expenses and lost earnings, and are
jury suffered by the plaintiff. In a suit for neg- a part of the compensatory damages. Nominal
ligence, the issue of causation usually requires damages are awarded to demonstrate that a
proof that the plaintiff’s harm resulted proxi- legally cognizable wrong has been committed.
mately from the negligence of the defendant. Punitive damages are awarded to punish a de-
Cause of action: Set of facts that give rise to a fendant who has acted maliciously or in reckless
legal right to redress at law. disregard of the plaintiff’s rights. (Some states
Civil action: Action invoking a judicial trial ei- do not allow punitive damages except in actions
ther at law or in equity, which is not criminal in for wrongful death of the plaintiff’s decedent.)
nature. Defamation: Willful and malicious communi-
cation, either written (libel) or spoken (slander),
Common law: Body of rules and principles
that is false; injures the reputation or character
based on Anglo-Saxon law, derived from usage
of another.
and customs, and developed from court deci-
sions based on such law. It is distinguished Defendant: The person against whom a civil or
from statutes enacted by legislatures and all criminal action is brought.
other types of law. Deposition: The testimony of a witness or
Complaint: The initiatory pleading on the part party taken before trial, consisting of an oral,
of the plaintiff in filing a civil lawsuit. Its pur- sworn, out-of-court statement.
pose is to give the defendant notice of the gen- Directed verdict: A verdict for the defendant
eral alleged fact constituting the cause of action. that a jury returns as directed by the judge,
574 part viii • ethical and legal issues

usually based on the inadequacy of the evidence Incompetency: Inability of a person to manage
presented by the plaintiff as a matter of law. his or her own affairs because of mental or
Discovery: Pretrial activities of the parties to physical infirmities. If this status or condition is
litigation to learn of evidence known to the op- legally determined, a guardian will usually be
posing party or various witnesses and therefore appointed to manage the person’s affairs.
to minimize surprises at the time of trial. Indemnity: Agreement whereby a party guar-
Due process: Course of legal proceedings ac- antees reimbursement for possible losses.
cording to those rules and principles that have Independent contractor: Person who agrees
been established in systems of jurisprudence with a party to undertake the performance of a
for the enforcement and protection of private task for which the person is not expected to be
rights. It often means simply a fair hearing. under the direct supervision or control of the
Expert witness: Person who has special train- party. Ordinarily this arrangement and relation-
ing, knowledge, skill, or experience in an area ship shield the party from liability for negli-
relevant to resolution of the legal dispute and gent acts of the independent contractor that oc-
who is allowed to offer an opinion as testimony curred during the performance of the work. For
in court. example, a psychological consultant is an inde-
pendent contractor for whose negligent acts the
Fraud: Intentionally misleading another person
attending psychologist is not liable.
in a manner that causes legal injury to that per-
son. Informed consent: Patient’s voluntary agree-
Guardian: Person appointed by a court to man- ment to accept treatment based on an awareness
age the affairs and protect the interests of an- of the nature of his or her disease, the material
other who is adjudged incompetent by reason of risks and benefits of the proposed treatment,
age, physical status, or mental status and is the alternative treatments and risks, and the
thereby unable to manage his or her own affairs. choice of no treatment at all.
Guardian ad litem: Person appointed as a Injunction: Court order commanding a person or
guardian for a particular purpose, interval, or entity to perform or to refrain from performing
matter. Functioning in this role may involve a certain act or otherwise be found in contempt
undertaking investigations and issuing reports of court.
to the court (e.g., as in child custody matters). Interrogatories: Written questions propounded
The court order appointing the guardian ad by one party to another before trial as part of
litem should specify the nature of the role and the pretrial discovery procedures.
duties.
Intestate: One who dies leaving no valid will.
Hypothetical question: A form of question put
Invasion of privacy: Violation of a person’s
to a witness, usually an expert witness, in
right to be left alone and free from unwar-
which things which counsel claims are or will
ranted publicity and intrusions.
be proved are stated as a factual supposition and
the witness is asked to respond, state, or explain Joint and several liability: Several persons who
the conclusion based on the assumptions and share the liability for the plaintiff’s injury can
questions. be found liable individually or together.
Immunity: In civil law, protection given certain Libel: Defamation of a person’s reputation or
individuals (personal immunity) or groups (in- character by any type of publication, including
stitutional immunity) that may shield them pictures or written word.
from liability for certain acts or legal relation- Malice: The performance of a wrongful act
ships. Ordinarily, the individual may still be without just cause or excuse, with an intent to
sued, because immunity can be raised only as inflict an injury or under such circumstances
an affirmative defense to the complaint, that is, that the law will imply an evil intent.
after a lawsuit has been filed. Malicious prosecution: Countersuit by the orig-
inal defendant to collect damages that have re-
111 • glossary of legal terms of special interest in mental health practice 575

sulted to the original defendant from a civil suit til contradicted and overcome by other evi-
filed maliciously and without probable cause. dence.
Ordinarily, it may not be brought until the ini- Prima facie evidence: Such evidence as is suffi-
tial suit against the original defendant has been cient to establish the fact; if not rebutted, it be-
judicially decided in favor of the defendant. comes conclusive of the fact.
Malpractice: Professional negligence. Failure to Probate court: Court having jurisdiction over
meet a professional standard or care resulting in the estates of deceased persons and persons un-
harm to another. Failure to provide generally der guardianship.
acceptable psychological care and treatment.
Proximate causation: Essential element in a le-
Negligence: Legal cause of action involving the gal cause of action for negligence; that is, it
failure to exercise the degree of diligence and must be shown that the alleged negligent act
care that a reasonably and ordinarily prudent proximately caused the injury for which legal
person would exercise under the same or simi- damages are sought. The dominant and respon-
lar circumstances; the result is the breach of a sible cause necessarily sets other causes in op-
legal duty, which proximately causes an injury eration. It represents a natural and continuous
which the law recognizes as deserving of com- sequence, unbroken by any intervening cause.
pensation. The standard of care of a defendant
Proximate cause: Act of commission or omis-
doctor in a malpractice case is not that of the
sion that through an uninterrupted sequence of
reasonable and ordinarily prudent person (such
events directly results in an injury that other-
as an automobile operator) but that of the av-
wise would not have occurred or else becomes a
erage qualified psychologist practicing in the
substantial factor in causing an injury.
same area of specialization or general practice as
that of the defendant psychologist. Publication: Oral or written act that makes
defamatory material available to persons other
Opinion evidence: Type of evidence that a wit-
than the person defamed.
ness gives based on his or her special training
or background rather than on his or her per- Reasonable medical certainty (or reasonable
sonal knowledge of the facts in issue. Generally, psychological certainty): As used in personal
if the issue involves specialized knowledge, injury lawsuits, a term implying more than
only the opinions of experts are admissible as mere conjecture, possibility, consistency with,
evidence. or speculation; similar to a probability, more
likely than not 50.1%, but an overwhelming
Pain and suffering: Element of “compensa-
likelihood or scientific certainty is not required.
tory” nonpecuniary damages that allows re-
covery for the mental anguish and/or physical Release: Statement signed by a person relin-
pain endured by the plaintiff as a result of in- quishing a right or claim against another per-
jury for which the plaintiff seeks redress. son or persons usually for a payment or other
valuable consideration.
Perjury: Willful giving of false testimony under
oath. Respondeat superior: “Let the master answer.”
A doctrine of vicarious or derivative liability in
Plaintiff: Party who files or initiates a civil law-
which the employer (master) is liable for the le-
suit seeking relief or compensation for damages
gal consequences of the breach of duties by an
or other legal relief.
employee (servant) that the master owes to
Pleadings: The technical means by which par- others, if the breach of duty occurs while the
ties to a dispute frame the issue for the court. servant is engaged in work within the scope of
The plaintiff’s complaint is followed by the de- his or her employment. For example, a hospital
fendant’s answer, and subsequent papers are is liable for the negligent acts of a psychologist
filed as needed. it employs if the acts occurred while the psy-
Prima facie case: A complaint that apparently chologist was working within his or her job de-
contains all the necessary legal elements for a scription.
recognized cause of action and will suffice un-
576 part viii • ethical and legal issues

Settlement: Agreement made between the par- Summons: A process served on a defendant in a
ties to a lawsuit, which resolves their legal dis- civil action to secure his or her appearance in
pute. the action.
Slander: Method of oral defamation in which Tort: Civil wrong in which a person has
the false and malicious words are published by breached a duty to another, which requires
speaking or uttering in the presence of another proof of the following: that a legal duty was
person, other than the person slandered, which owed to the plaintiff by the defendant; that the
prejudices another person’s reputation and char- defendant breached the duty; and that the plain-
acter. tiff was injured as a proximate cause of action,
Standard of care: Measure against which a de- such as negligence.
fendant’s conduct is compared. The required
Vicarious liability: Derivative or secondary lia-
standard in a professional negligence or psy-
bility predicated not upon direct fault but by
chological malpractice case is the standard of the
virtue of the defendant’s relationship to the ac-
average qualified practitioner in the same area
tual wrongdoer, in which the former is pre-
of specialization.
sumed to hold a position of responsibility and
Statute of limitations: Statutes that specify the control over the latter.
permissible time interval between the occur-
Waiver: Intentional and volitional renunciation
rence giving rise to a civil cause of action and
of a known claim or right or a failure to avail
the actual filing of the lawsuit. Thus failure to
oneself of a possible advantage to be derived
file the suit within the prescribed time limits
from another’s act. For example, a waiver might
may become an affirmative defense to the ac-
allow a person to testify to information that
tion. In malpractice actions, a typical statute of
would ordinarily be protected as a privileged
limitations might be 3 years from the date the
communication.
cause of action accrues, but the measuring time
for bringing the suit does not begin to run un- Wanton: Conduct that by its grossly negligent,
til the party claiming injury first discovers or malicious, or reckless nature evinces a disre-
should reasonably have discovered that he or gard for the consequences or for the rights or
she was injured and that the defendant was the safety of others.
one who caused the injury. Further, if the in- Willful: Term descriptive of conduct that en-
jured party is a minor, additional extensions compasses the continuum from intentional to
may be provided. Practitioners should check reckless.
their own state laws for applicable details.
Internet Sites
Stipulations: An agreement entered into be-
tween opposing counsel in a pending action. Legal Definitions. (n.d.). Online legal dictionary.
Subpoena: Court document requiring a person Retrieved 2004 from http://www.legal-defini
tions.com
to appear to give testimony at a deposition or in
‘Lectric Law Library. (n.d.). Legal Lexicon’s Lyceum.
court. Retrieved 2004 from http://www.lectlaw.com/
Subpoena duces tecum: Subpoena that requires def.htm
a person to personally bring to the court pro-
ceeding a specified document or property in his Related Topics
or her possession or under his or her control. Chapter 110, “Dealing With Subpoenas”
Summary judgment: Preverdict judgment ren- Chapter 139, “Common Clinical Abbreviations and
dered by the court in response to a motion by Symbols”
a plaintiff or a defendant, who claims that the
absence of factual dispute on one or more is-
sues eliminates those issues from further con-
siderations.
 FIFTEEN HINTS ON MONEY
112 MATTERS AND RELATED
ETHICAL ISSUES

Gerald P. Koocher & Sam S. Hill III

Money matters raise myriad complex issues in with psychiatrists generally charging more
a psychologist’s practice. One must consider the than psychologists, who charge more than so-
effect of money from the perspectives of busi- cial workers and other master’s-degree-level
ness, ethics, and professional relationships with providers. Some practitioners charge premium
one’s clients. The following items address es- fees for services of a forensic nature that run
sential principles to keep in mind when dealing considerably higher than their fees for psy-
in money matters. chotherapy. One psychiatrist from the North-
1. Inform clients about fees, billing and col- east who testifies in high-profile litigation, for
lection practices, and other financial contingen- example, recently reported charging $150 per
cies as a routine part of initiating the profes- 45-minute psychotherapy session and $400 for
sional relationship. Repeat this information 60 minutes of forensic time.
later, if necessary. From the outset of a rela- 3. Offering sliding fee scales for clients who
tionship with a new client, the psychologist cannot afford their customary charges provides
should take care to explain the nature of ser- an important public service. Some practitioners
vices to be offered, the fees to be charged, the prefer to maintain a high “usual and customary
mode of payment to be used, and other financial rate” while providing an assortment of dis-
arrangements that might reasonably be ex- counts. For example, a client who has been in
pected to influence the potential client’s deci- treatment for an extended period may be pay-
sions. Many practitioners find it useful to put ing a lower rate than a new client. Or an indi-
such information in a pamphlet or handout for vidual who is being seen three hours per week
clients along with other basic information, such may be offered a lower hourly rate than a per-
as confidentiality and emergency coverage no- son seen only once per week. The American
tices. Psychological Association (APA) ethics code
2. What to charge? Many factors contribute specifies the aspirational expectation that psy-
to this decision. Determining the customary chologists render at least some pro bono ser-
charges for one’s services is a complicated task vices (i.e., professional activity undertaken at
that mixes issues of economics, the competitive no charge in the public interest).
business environment, the practitioner’s self- 4. Honoring an estimate is very important.
esteem, and a variety of cultural and profes- Clients may well ask for an estimate regarding
sional taboos. When it comes to mental health the likely cost of services for a neuropsycho-
services, the task is complicated by a host of logical evaluation, a child-custody assessment,
both subtle and obvious psychological and eth- or a course of treatment. If an estimate of
ical values. Fees generally vary as a function of charges is given, it should be honored unless
training and activity. As reported in the sum- unforeseen circumstances arise. In the latter
mary of the current Psychotherapy Finances fee situation, any changes should be discussed with
survey (see chapter 133), fees vary by region, and agreed to by the client. If it seems that fi-

577
578 part viii • ethical and legal issues

nancial difficulties may be an issue, they should complex assessments). This is an unusual prac-
be dealt with directly at the very outset of the tice in psychology, but not unethical so long as
professional relationship. the contingencies are mutually agreed upon.
5. Some practitioners whose clients delay in The most common use of such advance pay-
paying bills occasionally add interest or “billing ments involves relationships in which the prac-
charges” to unpaid invoices. This practice may titioner is asked to hold time available on short
run afoul of the law because state and federal notice for some reasons (as in certain types of
laws generally require special disclosure state- corporate consulting) or when certain types of
ments informing clients about such fees in ad- litigation are involved. For example, practition-
vance and agreed to in writing by the client. ers conducting evaluations for the courts have a
6. The ethical practitioner will attempt to right to be paid for their time, even if the clients
avoid financially triggered abandonment of do not like the recommendations that result. In
clients with two specific strategies. The first is such situations, it is not unusual for the prac-
to never contract for services without first ex- titioner to request a retainer or escrow payment
plaining the costs to the client and mutually de- prior to commencing work.
termining that the costs are affordable. The sec- 9. Payment for missed appointments occa-
ond is to not mislead the client into thinking sionally becomes another source of problems. It
that insurance or other third-party coverage is not unethical to charge a client for an ap-
will bear the full cost of services when it seems pointment that is not kept or that is canceled on
reasonably clear that benefits may expire before short notice, so long as this policy is explained
the need for service ends. When treatment is in and agreed to by the client in advance. Insur-
progress and a client becomes unemployed or ance companies and other third-party payers
otherwise can no longer pay for continued ser- generally do not pay for missed appointments.
vices, the practitioner should be especially sen- 10. Relationships involving kickbacks, fee
sitive to the client’s needs. If a psychologist can- splitting, or payment of commissions for client
not realistically help a client under existing re- referrals may be illegal and unethical. Careful
imbursement restrictions, and the resulting attention to the particular circumstances and
process might be too disruptive, it may be best state laws is important before agreeing to such
to simply explain the problem and not take on arrangements. Clients should be told of any as-
the prospective client. At times it may become pects of the arrangement that might reasonably
necessary to terminate care or transfer the be expected to influence their decision about
client elsewhere over the long term, but this whether to use the practitioner’s services.
should not be done abruptly or in the midst of 11. It is important for psychologists to pay
a crisis period in the client’s life. careful attention to all contractual obligations,
7. Increasing fees in the course of service de- to understand them, and to abide by them. Sim-
livery poses ethical dilemmas. If a commitment ilarly, psychologists should not sign contracts
is made to provide consultation or conduct an with stipulations that might subsequently place
assessment for a set fee, it should be honored. them in ethical jeopardy. When in doubt, ob-
Likewise, a client who enters psychotherapy at taining a legal review of the contract may help.
an agreed-upon rate has a reasonable expecta- 12. Psychologists should not profit unfairly
tion that the charges will not be raised exces- at the expense of clients. Psychologists must ex-
sively. Once service has begun, the provider has ercise great care, and at times suffer potential
an obligation to the client that must be consid- economic disadvantage, so as not to abuse the
ered. Aside from financial hardship issues, the relative position of power and influence they
psychologist may have acquired special influ- have over the clients they serve.
ence with the client that should makes it diffi- 13. Psychologists may be held responsible
cult for the person to object. for financial misrepresentations effected in
8. Some practitioners require clients to pay their name by an employee or agent they have
certain fees in advance of rendering services as designated (including billing and collection
a kind of retainer (e.g., in forensic cases or other agents). They must, therefore, choose their em-
 113 • how to confront an unethical colleague 579

ployees and representatives with care and su- Grossman, M. (1971). Insurance reports as a threat
pervise them closely. to confidentiality. American Journal of Psychia-
14. In all debt collection situations, psychol- try, 128, 96 –100.
ogists must be aware of the laws that apply in Karon, B. P. (1995). Provision of psychotherapy
under managed care: A growing crisis and na-
their jurisdiction and make every effort to be-
tional nightmare. Professional Psychology: Re-
have in a cautious, businesslike fashion. They
search and Practice, 26, 5 – 9.
must avoid using their special position or in- Lovinger, R. J. (1978). Obstacles in psychotherapy:
formation gained through their professional Setting a fee in the initial contact. Professional
role to collect debts. Psychology: Research and Practice, 9, 350 –352.
15. In dealing with managed-care organiza- Myers, W., & BrezIei, M. (1992). Selling or buying
tions, psychologists should adhere to the same a practice. Independent Practitioner, 12, 521.
standards of competence, professionalism, and Pope, K. S. (1988). Fee policies and procedures:
integrity as in other contexts. Heightened sen- Causes of malpractice suits and ethics complaints.
sitivity should be focused on the potential eth- Independent Practitioner, 7, 24 –29.
ical problems inherent in such service delivery Pope, K. S., & Keith-Spiegel, P. (1986, May). Is sell-
ing a practice malpractice? APA Monitor, 4, 40.
systems.
Rodwin, M. (1993). Medicine, money and morals:
Physicians’ conflicts of interest. New York: Ox-
References & Readings ford University Press.
DiBella, C. A. W. (1980). Mastering money issues
that complicate treatment: The last taboo. Ameri- Related Topics
can Journal of Psychotherapy, 24, 510 – 522.
Chapter 107, “Basic Principles for Dealing With
Faustman, W. O. (1982). Legal and ethical issues in
Legal Liability Risk Situations”
debt collection strategies of professional psychol-
Chapter 125, “Sample Psychotherapist-Patient Con-
ogists. Professional Psychology: Research and
tract”
Practice, 13, 208 –214.
Chapter 133, “Psychologists’ Fees and Incomes”

HOW TO CONFRONT AN
113 UNETHICAL COLLEAGUE

Patricia Keith-Spiegel

What action should be taken upon learning of an decide not to get involved. Conflicting feelings
alleged unethical act by a colleague? Either ra- over perceiving a duty to take some action to-
tionalizing away the colleague’s behavior as a ward unethical colleagues and yet maintaining a
minor or a onetime mistake or assuming that loyal and protective stance toward them are
others who know of the behavior will take care common sources of reticence to get involved.
of it is an inadequate excuse for shirking profes- One of the very attractive features of informal
sional responsibility. Yet too many practitioners peer monitoring, however, is that both goals can
580 part viii • ethical and legal issues

be met simultaneously. When you success fully olation by parties who then request assistance
intervene, you will have solved a problem and to deal with the alleged violator, but who insist
possibly protected a colleague from having to that their identities not be revealed. Often these
interact with a more formal (and onerous) cor- people are fearful of reprisal or feel inadequate
rectional forum. to defend themselves.
The American Psychological Association Occasionally, the problem is that yet another
(APA) ethics code (2002) actively deputizes person, critical to the case, is unavailable or un-
psychologists to monitor peer conduct, al- willing to get involved or to be identified. These
though in a somewhat cautious and protective situations pose extremely frustrating predica-
manner. Earlier versions of the ethics code man- ments. Approaching colleagues with charges is-
dated that psychologists deal directly with sued by “unseen accusers” violates the essence
ethics violations committed by colleagues as the of due process. Further, alleged violators often
first line of action. Only if an informal attempt know (or think they know) their accusers’ iden-
proved unsuccessful should an ethics commit- tities anyway. When the alleged unethical be-
tee be contacted. Currently, and partly because haviors are extremely serious, possibly putting
of reported incidents of harassment and intim- yet others in harm’s way, and when the fearful
idation, and the potential for violations of con- but otherwise credible individuals making the
fidentiality, the 2002 code gives psychologists charges are adamant about remaining anony-
the option of deciding the appropriateness of mous, psychologists may not feel comfortable
dealing with the matter directly. If an informal ignoring the situation altogether. However,
solution seems unlikely (for reasons left un- there may be nothing else that can be done.
specified in the code), psychologists are man- Sometimes the option to do nothing may not
dated to take formal action— such as contacting exist, as with state mandatory reporting laws.
a licensing board or ethics committee— so long However, for other nonlegally required report-
as any confidentiality rights or conflicts can be ing situations, the current APA code does not
resolved (Ethical Principles of Psychologists and leave psychologists any options if confidential-
Code of Conduct, Sections 1.04 and 1.05). The ity issues cannot be resolved.
level of seriousness of the alleged behavior is The following list provides guidelines for
not a stated consideration in the 2002 code, al- how to confront a colleague suspected of en-
though Canter, Bennett, Jones, and Nagy (1994) gaging in unethical conduct.
advise against attempting informal resolutions 1. The relevant ethical principle that applies
in cases of complex violations, such as when se- to the suspected breach of professional ethics
rious sexual misconduct has occurred. should first be identified. This may involve an
Peer monitoring often may involve col- overarching moral principle, or it may involve
leagues whose conduct and professional judg- a specific prohibition in an ethics code or policy.
ment are affected by stress, addiction, or phys- If nothing can be linked to the action, and no
ical or mental disability. According to a survey law, relevant policy, or ethics code has been vi-
undertaken by the APA Task Force on Dis- olated, then the matter may not be an ethical
tressed Psychologists, almost 70% of the sam- one. This conclusion is reached most often when
ple personally knew of psychologists who were a colleague has an offensive personal style or
experiencing serious emotional difficulties. holds personal views that are generally unpop-
Moreover, only about a third made substantive ular or widely divergent from your own. You
attempts to help (reported in VandenBos & have the right, of course, to express your per-
Duthie, 1986). From our own experience on sonal feelings to your colleague, but this should
ethics committees, we estimate that almost half not be construed as engaging in a professional
of those psychologists for whom complaints duty.
were made appear to have some personal prob- 2. Assess the strength of the evidence that a
lem that contributed to the alleged ethical vio- violation has been committed. Ethical infrac-
lation. tions, particularly those that are more serious,
It is not uncommon to be told of an ethics vi- are seldom committed openly before a host of
 113 • how to confront an unethical colleague 581

dispassionate witnesses. With few exceptions, 3. Get in close touch with your own motiva-
such as plagiarism or inappropriate advertising tions to engage in (or to avoid) a confrontation
of services, no tangible exhibits corroborate with a colleague. Psychologists who are (or see
that an unethical event ever occurred. A start- themselves as being) directly victimized by the
ing point involves categorizing the source of conduct of a colleague are probably more will-
your information into one of five types: (a) ing to get involved. In addition to any fears,
clear, direct observation of a colleague engaging anger, biases, or other emotional reactions, do
in unethical behavior; (b) knowing or unknow- you perceive that the colleague’s alleged con-
ing disclosure by a colleague that he or she has duct — either as it stands or if it continues —
committed an ethical violation; (c) direct obser- may undermine the integrity of the profession
vation of a colleague’s suspicious but not clearly or harm one or more of the consumers served
interpretable behavior; (d) receipt of a credible by the colleague? If your answer is affirmative,
secondhand report of unethical conduct from then some form of proactive stance is war-
someone seeking out your assistance as a con- ranted. However, if you recognize that your
sultant or intervening party; or (e) casual gos- emotional involvement or vulnerability (e.g.,
sip about a colleague’s unethical behavior. the colleague is your supervisor) creates an ex-
If you did not observe the actions directly, treme hazard that will likely preclude a sat-
how credible is the source of information? Can isfactory outcome, you may wish to consider
you imagine a reason that would not be uneth- passing the intervention task on to another
ical that would explain why the person might party. In such cases, any confidentiality issues
have engaged in this action? That is, can you must first be settled.
think of more than one reason the person might 4. Consultation with a trusted and experi-
have acted that way? If the information came enced colleague who has demonstrated sensi-
by casual gossip, proceed with considerable cau- tivity to ethical issues is strongly recommended
tion. If there is no way to obtain any substan- at this point, even if only to assure yourself
tial, verifiable facts, you may choose to ignore that you are on the right track. Identities
the information or, as a professional courtesy to should not be shared if confidentiality issues
the colleague, inform your colleague of the pertain.
“scuttlebutt.” If the colleague is guilty of what 5. Make your final decision about con-
the idle hearsay suggests, you may have had a fronting the colleague and how to best do it.
salutary effect. However, we recognize that this Even though you are not responsible for recti-
is risky business and may be effective only if fying the unethical behavior of another person,
the colleague is one whose reaction you can rea- the application of a decision-making model
sonably anticipate in advance. may facilitate a positive educative function. You
If the information is secondhand, and you might well find yourself, at this point, tempted
are approached by a credible person who claims to engage in one of two covert activities as al-
firsthand knowledge and is seeking assistance, ternatives to confronting a colleague directly.
we advise being as helpful as you can. Because The first is to pass the information along to
we often advise consulting with colleagues be- other colleagues in an effort to warn them. Al-
fore taking any action, it is only fitting that you though informing others may provide a sense
should be receptive when others approach you that duty has been fulfilled, it is far more likely
for assistance in working through ethical is- that responsibility has only been diffused. Idle
sues. Often you will be able to assist the person talk certainly cannot guarantee that an offend-
with a plan of action that will not include your ing colleague or the public has been affected in
direct involvement or else offer a referral if the any constructive way. Moreover, as noted ear-
dilemma is not one about which you can confi- lier, to the extent that the conduct was mis-
dently comment. If you do agree to be come ac- judged, you could be responsible for an injus-
tively engaged, be sure that you have proper tice to a colleague that is, in itself, unethical.
permission to reveal any relevant identities and The second temptation is to engage in more di-
that you have available all possible information. rect but anonymous action, such as sending an
582 part viii • ethical and legal issues

unsigned note or relevant document (e.g., a ing. I thought we should talk about it.” Things
copy of an ethics code with one or more sections are not always as they seem, and it would be
circled in red). Constructive results, however, wise at the onset to allow for an explanation
are hardly guaranteed. The recipient may not rather than provoke anxiety. For example, it is
understand the intended message. Even if the at least possible that the colleague might learn
information is absorbed, the reaction to an that the young woman was briefly a client
anonymous charge may be counterproductive. years earlier. Such responses may not render
Also, the warning may instill a certain amount the matters moot, but the discussion would
of paranoia that could result in additional neg- likely proceed far differently than with a more
ative consequences, such as adding suspicious- strident opening.
ness to the colleague’s character. Thus, although 8. Set the tone for a constructive and educa-
both of these covert actions seem proactive, we tive session. Your role is not that of accuser,
strongly recommend neither. judge, jury, and penance dispenser. The session
6. If you decide to go ahead with a direct will probably progress best if you see yourself
meeting, schedule it in advance, although not in as having an alliance with the colleague — not
a menacing manner. For example, do not say, in the usual sense of consensus and loyalty, but
“Something has come to my attention about as facing a problem together.
you that causes me grave concern. What are you 9. Describe your ethical obligations, noting
doing a week from next Thursday?” Rather, in- the relevant moral or ethics code principles that
dicate to your colleague that you would like prompted your intervention. Rather than equi-
to speak privately and schedule a face-to-face vocating, state your concerns directly and pre-
meeting at his or her earliest convenience. A sent the evidence on which they are based. Do
business setting would normally be more ap- not attempt to play detective by trying to trap
propriate than a home or restaurant, even if the your colleague through asking leading ques-
colleague is a friend. Handling such matters on tions or by withholding any relevant informa-
the phone is not recommended unless geo- tion that you are authorized to share. Such tac-
graphic barriers preclude a direct meeting. Let- tics lead only to defensiveness and resentment
ters create a record, but they do not allow for and diminish the possibility of a favorable out-
back-and-forth interaction, which we believe to come.
be conducive to a constructive exchange in mat- 10. Allow the colleague ample time to ex-
ters of this sort. We do not recommend e-mail plain and defend in as much detail as required.
for the same reason, as well as the additional The colleague may be flustered and repetitive;
concern that electronic communications can be be patient.
accessed by unauthorized others. 11. What is your relationship with the sus-
7. When entering into the confrontation pected colleague? This will affect both the ap-
phase, remain calm and self-confident. The col- proach taken and how you interpret the situa-
league is likely to display considerable emo- tion. Those who observe or learn of possible un-
tion. Remain as nonthreatening as possible. ethical actions by other psychologists often
Even though it may feel like a safe shield, avoid know the alleged offenders personally. They
adopting a rigidly moralistic demeanor. Most could be good friends or disliked antagonists.
people find righteous indignation obnoxious. They could be subordinates or supervisors. Re-
We suggest noninflammatory language such as actions, depending on the relationships with
expressing confusion and seeking clarification. those suspected of ethics violations, affect both
It might go some thing like this: “The data re- the approach taken to deal with them and the
ported in your article is not quite the same as attributes assigned to colleagues. Fear of re-
what you showed me earlier. I am confused prisal can stifle action and enhance the rational-
about that and wonder if you could help mc un- ization of inaction. If the colleague is disliked,
derstand it. Is there a problem here?” Or, “I met courage to act may come more from the thrill of
a young woman who, upon learning that I was revenge rather than from genuine courage and
a psychologist, told me that she was your client conviction. If the colleague is a friend or ac-
and that the two of you were going to start dat- quaintance with whom there have been no pre-
 113 • how to confront an unethical colleague 583

vious problematic interactions, the meeting such as, “I see you are very upset right now,
usually goes easier. You can express to your and I regret that we cannot explore this matter
friend that your interest and involvement are together in a way that would be satisfactory to
based on caring and concern for his or her pro- both of us. I would like you to think about what
fessional standing. The danger, of course, is that I have presented, and if you would reconsider
you may feel that you are risking an estab- talking more about it, please contact me within
lished, positive relationship. If your friend can a week.” If a return call is not forthcoming,
be educated effectively by you, however, you other forms of action must be considered. This
may well have protected him or her from em- could involve including another appropriate
barrassment or more public forms of censure. person or pressing formal charges to some duly
Moreover, if you have lost respect for your constituted monitoring body. It is probably
friend after observing or learning of possible wise to have another consultation with a trusted
ethical misconduct, the relationship has been colleague at this point. The suspected offender
altered anyway. Discomfort, to the extent that should be informed (in person or in a formal
it ensues, may be temporary. note) of your next step. If you are ever the re-
If the colleague is someone you do not know cipient of a colleague’s inquiry, be grateful for
personally, the confrontation will be, by defini- the warning about how you have been per-
tion, more formal. An expression of concern and ceived and try to openly and honestly work for
a willingness to work through the problem co- the goal of settling the matter in a way that sat-
operatively may still be quite effective. If the isfies all those involved without necessitating a
colleague is someone you do know but dislike, review by outside evaluators.
your dilemma is more pronounced. If the infor-
mation is known to others (or can be appropri- References & Readings
ately shared with others), you might consider
asking someone who has a better relationship American Psychological Association. (2002). Ethical
principles of psychologists and code of conduct.
with this person to intercede or to accompany
Washington, DC: Author.
you. If that is not feasible and a careful assess- Bennett, B. E., Bryant, B. K., VandenBos, G. R., &
ment of your own motivations reveals a conclu- Greenwood, A. (1990). Professional liability and
sion that the possible misconduct clearly re- risk management. Washington, DC: American
quires intervention on its own merits, then you Psychological Association.
should take some form of action. It may still be Canter, M. B., Bennett, B. E., Jones, S. E., & Nagy,
possible to approach this individual yourself, T. F. (1994). Ethics for psychologists: A com-
and if you maintain a professional attitude, it mentary on the APA ethics code. Washington,
may work out. If you are intervening on behalf DC: American Psychological Association.
of another, you will first have to disclose why Koocher, G. P., & Keith-Spiegel, P. C. (1998). Ethics
you are there and offer any other caveats. You in psychology: Professional standards and
cases (2nd ed.). New York: Oxford University
might say something like, “I, myself, have no
Press.
direct knowledge of what I want to discuss, but VandenBos, G. R., & Duthie, R. F. (1986). Con-
I have agreed to speak with you on behalf of two fronting and supporting colleagues in distress.
students.” Your role in such instances may be to In R. R. Kilburg, P. E. Nathan, & R. W. Thoren-
arrange another meeting with all the parties son (Eds.), Professionals in distress. Washing-
present and possibly serve as mediator during ton, DC: American Psychological Association.
such a meeting.
12. If the colleague becomes abusive or Related Topics
threatening, attempt to steer him or her to a
more constructive state. Although many people Chapter 103, “Ethical Principles of Psychologists
need a chance to vent feelings, they often set- and Code of Conduct (2002)”
Chapter 109, “Dealing With Licensing Board and
tle down if the confronting person remains
Ethics Complaints”
steady and refrains from becoming abusive in Chapter 136, “Therapist Self-Care Checklist”
return. If the negative reaction continues, it
may be appropriate to say something calming,
 CONFIDENTIALITY AND THE
114 DUTY TO PROTECT

Tiffany Chenneville

It is generally agreed that information shared the development and maintenance of therapeu-
within the context of a psychotherapy relation- tic relationships. For this reason, and because
ship should be kept confidential. However, the breaches of confidentiality have the potential to
delicate balance between clinicians’ duty to their cause harm to clients, the ethical standard of
clients, on the one hand, and their duty to pro- confidentiality often is upheld through state
tect others, on the other hand, is highlighted laws and regulations.
when threats of violence are made. The com- In an effort to protect the public, provisions
plexity of such matters is discussed in this for confidentiality and the disclosure of confi-
chapter, along with recommendations for ad- dential information are outlined by the Amer-
dressing this dilemma. ican Psychological Association (APA) in its
ethical codes and standards (2002). Ethical Stan-
dard 4.01, which addresses maintaining confi-
CONFIDENTIALITY dentiality, states: “Psychologists have a pri-
mary obligation and take reasonable cautions to
Confidentiality refers to a standard of profes- protect confidential information obtained through
sional conduct between mental health profes- or stored in any medium, recognizing that the
sionals and their clients. It represents an ethical extent and limits of confidentiality may be reg-
principle that can be distinguished from privacy ulated by law or established by institutional
and privilege (see Koocher, chap. 104 in this rules or professional or scientific relationship”
volume). Privacy is a constitutional right, the (APA, 2002, p. 1066).
importance of and limits to which are outlined Confidentiality is one of the most frequent
thoroughly by Gates and Fitzgerald (2000). complaints made to regulatory bodies by mem-
Privilege is a legal term that refers to the right bers of the general public (Josefowitz, 1997).
for communication between individuals within Decisions regarding when it is acceptable to
special relationships to remain private. Special breach client confidentiality weigh heavily on
relationships include those between attorneys the minds of clinicians. The ethical and legal
and their clients, husbands and wives, doctors principles of confidentiality often compete with
and patients, and priests and penitents. In a other equally important principles, sometimes
Supreme Court ruling, the attorney-client resulting in the division of loyalties for clini-
privilege was upheld even after the client’s cians between clients and third parties.
death (Swidler & Berlin and James Hamilton v.
United States, 1997), thus exemplifying the le-
gal system’s acknowledgement of the impor- DUTY TO PROTECT
tance of confidentiality. The values underlying
confidentiality, which include stigma, trust, pri- Duty to protect represents one of the most im-
vacy, and autonomy (Petrila, 2000a) are partic- portant principles competing with confidential-
ularly important within the mental health do- ity. The potentially disastrous consequences of
main. Confidentiality is considered critical to this dilemma are exemplified by the landmark

584
 114 • confidentiality and the duty to protect 585

court case Tarasoff v. Regents of the University no duty to protect exists. In most states, men-
of California (1974, 1976). This case involved a tal health professionals fall under the special re-
university counseling center psychologist who lationship of doctor-client.
was informed by his client of intent to harm From a legal perspective, rules governing
Tatiana Tarasoff. The psychologist reported the third-party liability have become increasingly
situation to campus police, who briefly detained diverse. However, it generally is accepted that
the client. However, the client subsequently in order for a duty to protect to exist, there
was released based on the campus police’s con- must be a serious and imminent risk of harm
clusion that he did not pose a threat to Tarasoff. directed toward an identifiable person (Simon,
Tarasoff, who had been vacationing out of the 2001). It is important to note that the “nam-
county at the time the threat was made, was ing” of a victim is not a necessary component
killed by the client upon her return to the coun- of identification (Walcott et al., 2001). Rather,
try two months later. The psychologist, among the onus is on the mental health professional to
other defendants, was sued by Tarasoff’s par- identify, within reason, potential victims. For
ents for failing to protect their daughter from example, if a client makes a threat against his
harm, either by way of warning or through “wife,” without providing his wife’s name, it
civil commitment of the client. would not be unreasonable to assume the clin-
This case commenced in a ruling by the Su- ician could gain access to the wife’s identifica-
preme Court of California, in which a duty to tion.
warn potential victims of imminent danger was The practitioner’s legal obligations poten-
imposed on psychologists. However, upon ap- tially compete with two ethical principles re-
peal, the “duty to warn” was replaced with a garding avoiding harm and disclosures. Ethical
more general “duty to protect.” Based on this Standard 3.04 states that “psychologists take
ruling, a duty to protect exists when it is deter- reasonable steps to avoid harming their clients/
mined, or should have been determined, that a patients, students, supervisees, research partic-
client poses a serious risk of violence to others. ipants, organizational clients, and others with
Pre-Tarasoff, public protection of a client’s whom they work, and to minimize harm where
potential for violence primarily was limited to it is foreseeable and unavoidable” (APA, 2002,
civil commitment (Felthous, 2001), while psy- p. 1065). With regard to disclosures, Ethical
chological malpractice associated with danger- Standard 4.05b states: “Psychologists disclose
ousness was associated with negligent hospital confidential information without the consent of
release (Walcott, Cerundolo, & Beck, 2001). the individual only as mandated by law, or
Post-Tarasoff, courts initially expanded the role where permitted by law for a valid purpose
of psychologists to protect third parties. Such such as to (1) provide needed professional ser-
expansions included broad interpretations of vi- vices; (2) obtain appropriate professional con-
olence, as evidenced by case law wherein trans- sultations; (3) protect the client/patient, psy-
mission of HIV was considered a violent act un- chologist, or others from harm; or (4) obtain
der Tarasoff principles (Chenneville, 2000). payment for services from a client/patient, in
However, the more recent trend has been to which instance disclosure is limited to the min-
limit the situations in which the duty to protect imum that is necessary to achieve the purpose”
applies and toward permissive or protective dis- (APA, 2002, p. 1066). These professional stan-
closure laws. These laws legally protect clini- dards clearly invoke conflicting duties for clin-
cians who decide that breaching confidentiality icians. Absent of applicable statutory or case
is warranted to protect a third party. When a law, these standards establish an ethical duty
duty does exist, public protection involves “rea- not only to prevent harm to clients but also to
sonable actions,” which include, but may not be prevent others from harm.
limited to, an actual warning, notifying law en- Beyond competing ethical standards, moral
forcement, or civil commitment. Parentheti- issues on the duty to protect are also operating
cally, in the absence of a special relationship (Gutheil, 2001). Among these, the Hippocratic
(e.g., parent-child, doctor-client, priest-penitent), Oath has been referenced in support of main-
586 part viii • ethical and legal issues

taining confidentiality. In support of disclosure, (b) the capacity to carry out the threat, (c)
it has been argued that clinicians acting as the whether or not certain thresholds of violence
“agents” of their clients should breach confi- have been crossed, (d) intent, (e) others’ reac-
dentiality when doing so would be in their tions and responses to threats (i.e., the extent to
clients’ best interest. Similarly, it has been ar- which others are supporting violent behavior in
gued that mental health professionals have a the client and/or the extent to which others are
fiduciary duty. Trusted to put their clients’ best threatened by the client), and (f) compliance
interest before their own, it has been argued with attempts to reduce risk of violence. Al-
that warning may be justified in an attempt to though tools are available to assist clinicians in
spare clients from the potential emotional, so- assessing the risk of violence, it generally is
cial, and legal consequences associated with agreed that clinicians’ ability to accurately pre-
harming others, even if doing so causes the dict violence is limited (Walcott et al., 2001).
clinician distress (Gutheil, 2001). The shift in However, a thorough assessment of violence
the way society views the “victim paradigm” is risk is expected, even if the accuracy of predic-
unclear and further complicates matters. His- tions is not. Following are questions to consider
torically, the client was viewed as the victim, when assessing the foreseeability of harm:
but society frequently now views the potential
target of the client as the victim. Finally, it has • Has the client made a specific threat?
been posited that warning is morally justified • Has the client specified a plan including a
to save a life within the context of an emer- date, time, or place?
gency (Gutheil, 2001). • Does the client have the means to carry
out the threat?
• Does the client have access to weapons?
CLINICAL RECOMMENDATIONS • Does the client possess the physical capa-
bilities required to carry out the threat?
When confronted with the confidentiality ver- • Does the client possess the intellectual ca-
sus duty to protect dilemma, the psychologist pabilities to carry out the threat?
must take several factors into consideration. • Does the client have access to the intended
These factors include professional ethical stan- victim(s)?
dards, the best interest of the client, the major • Does the client believe violence is justi-
premises of Tarasoff, and applicable statutory fied?
and case law. The following recommendations • Does the client believe violence will result
take into account these factors and represent the in positive outcomes?
adaptation of a decision-making model for • Does the client believe his/her needs can
clients whose threat of violence is the transmis- be met without violence?
sion of HIV (Chenneville, 2000). • Is the client being encouraged or sup-
1. Determine whether disclosure is war- ported by others to engage in violent be-
ranted. Foreseeability of harm and identifiabil- havior?
ity of the victim are the two major issues that • What personality characteristics exist that
must be addressed when making a determina- increase the risk for violence?
tion whether disclosure is warranted. In terms • Does the client have a history of violence?
of foreseeability, the extent to which the threat • Does the client have a history of antisocial
of harm is serious and the danger imminent or illegal behavior?
need to be considered. It has been argued that • Does the client have a history of substance
risk appraisal should be “fact based and deduc- abuse?
tive” as opposed to the “more inductive risk as- • Does the client perceive others as hostile?
sessment approach for general violence recidi- • Is the client impulsive?
vism” (Borum & Reddy, 2001, p. 377). This • Does the client typically use good judg-
would include an assessment of the following: ment?
(a) attitudes that support or facilitate violence, • Has the client been diagnosed with an
 114 • confidentiality and the duty to protect 587

Axis I or Axis II disorder? If so, what governing confidentiality and third-party dis-
symptoms are likely to increase the risk of closures vary by state, so it is important for
danger to others? clinicians to investigate the laws and rules set
• Does the client adhere to prescribed treat- forth by the states in which they practice. The
ment? ever-changing legal climate with regard to
• Has the client been prescribed medication Tarasoff has been well documented (Felthous,
and is s/he compliant? 2001; Glancy, Regehr, & Bryant, 1998), and it is
• Does the client possess motivation to pre- the responsibility of clinicians to keep informed
vent or avoid violence? of these changes. State laws and rules often can
be obtained from individual state boards of psy-
Once the foreseeability of harm has been es- chology or by accessing the state statutes and
tablished, the clinician next must determine legislation on the Internet (http://www.prairienet.
whether or not the intended violence is directed org/~scruffy/f.htm). Readers also are referred
toward a specific victim or victims. The follow- to an appendix compiled by Petrila (2000b) that
ing questions can help determine whether an includes the key provisions of state laws per-
identifiable victim exists: taining to confidentiality and mental health.
• Has the client named a specific victim? 4. Implement the least invasive alternative.
• Has the client made reference to an iden- After carefully assessing the situation, the least
tifiable victim whose name was unspeci- invasive alternative should be chosen with pri-
fied, but who could be identified via asso- ority given to clinical and moral reasoning
ciation with the client? (Felthous & Kachigian, 2001). Indeed, predic-
• Has the client made reference to a general tion of dangerousness ultimately is a clinical
class of victims (e.g., colleagues at work)? decision, not a legal one. In cases where threats
are not deemed serious or imminent, or where
2. Refer to the ethical code. An examination victims are not and cannot be identified, main-
of relevant professional ethical guidelines is the taining confidentiality may be the best course
second step of this decision-making model. of action. This may help to preserve the thera-
Members of the American Psychological Asso- peutic alliance, which can then be used to mod-
ciation should refer to Ethical Standards relat- ify the client’s thoughts, feelings, and behavior
ing to confidentiality (4.01), avoiding harm in an attempt to prevent future violence.
(3.04), and disclosures (4.05b). Members of the In situations where warning is not appropri-
APA also should refer to Ethical Standard 1.02, ate or feasible, protective action may include
which addresses conflicts between ethics and notifying law enforcement or civil commit-
law, regulations, or other governing legal au- ment. If disclosure is warranted, it is important
thority and states: “If psychologists’ ethical re- to disclose only the information necessary to
sponsibilities conflict with law, regulations, or protect potential victims. For example, it proba-
other governing legal authority, psychologists bly would not be necessary to include diag-
make known their commitment to the Ethics noses or personal information shared in psy-
Code and take steps to resolve the conflict. If the chotherapy. Rather, the victims or appropriate
conflict is unresolvable via such means, psy- others (e.g., family members or law enforce-
chologists may adhere to the requirements of ment) need only be informed of the potential
the law, regulations, or other governing legal danger of harm by the client. It also is recom-
authority” (APA, 2002, p. 1063). mended that clients not only be informed but
3. Refer to state guidelines. The third step also be included, to the extent feasible, in the
involves referring to statutory and case law, protective action. For example, in some situa-
which typically specifies either mandatory con- tions, assuming no clinical contraindications
fidentiality, required disclosure, or protective exist, it may be appropriate to make disclosures
(i.e., permissive) disclosure whereby clinicians in the presence, or with the assistance, of the
are allowed, but not legally obligated, to dis- client. Finally, given that the best safeguard
close confidential information. Legal mandates against malpractice is documentation, it is cru-
588 part viii • ethical and legal issues

cial for clinicians to document not only their ac- inform. Canadian Journal of Psychiatry, 43,
tions but also the reasons behind their actions. 1001–1005.
In summary, the confidentiality versus duty Gutheil, T. G. (2001). Moral justification for
to protect dilemma entails a clinical assessment Tarasoff-type warnings and breach of confiden-
tiality: A clinician’s perspective. Behavioral
of dangerousness, as opposed to its being a legal
Sciences and the Law, 19, 345 –353.
issue. In many cases, ethical standards are more
Josefowitz, N. (1997). Confidentiality. In D. R.
stringent than legal standards in terms of pro- Evans (Ed.), The law, standards of practice, and
tecting the client. It is the clinician’s responsi- ethics in the practice of psychology (pp. 111–
bility, as outlined in the APA ethical codes, to 134). Toronto: Emond Montgomery Publica-
make known their commitment to the ethical tions.
standards and to attempt to resolve the ethical- Petrila, J. (2000a). Legal and ethical issues in pro-
legal conflict in the most appropriate manner tecting the privacy of behavioral health care
possible. Clinicians may be able to minimize information. In J. J. Gates & B. S. Arons (Eds.),
these difficulties by making clear at the onset of Privacy and confidentiality in mental health
the therapeutic relationship the limits of confi- care (pp. 91–126). Baltimore: Paul H. Brookes.
Petrila, J. (2000b). State mental health confidential-
dentiality and possible procedures to be taken
ity law provisions. In J. J. Gates & B. S. Arons
should a breach be deemed necessary.
(Eds.), Privacy and confidentiality in mental
health care (pp. 219 –232). Baltimore: Paul H.
References, Readings, & Internet Sites Brookes.
Prairienet. (n.d.). Link to full-text state statutes and
American Psychological Association. (2002). Ethical
legislation. Retrieved 2004 from http.//www.
principles of psychologists and code of conduct.
prairienet.org/~scruffy/f.htm
American Psychologist, 57, 1060 –1073.
Simon, R. I. (2001). Duty to foresee, forewarn, and
Borum, R., & Reddy, M. (2001). Assessing violence
protect against violent behavior: A psychiatric
risk in Tarasoff situations: A fact-based model
perspective. In S. Mohammad & S. Lee (Eds.),
of inquiry. Behavioral Sciences and the Law,
School violence: Assessment, management,
19, 375 –385.
and prevention (pp. 201–215). Washington,
Chenneville, T. (2000). HIV, confidentiality, and
DC: American Psychiatric Press.
duty to protect: A decision-making model.
Swidler & Berlin and James Hamilton v. United
Professional Psychology: Research and
States, No. 97-1192 (1997).
Practice, 31, 661–670.
Tarasoff v. Regents of the University of California,
Felthous, A. R. (2001). Introduction to this issue:
118 Cal. Rptr. 129, 529 P.2d 533 (1974).
The clinician’s duty to warn or protect.
Tarasoff v. Regents of the University of California,
Behavioral Sciences and the Law, 19, 321–324.
17 Cal.3d 425, 551 P.2d 334 (1976).
Felthous, A. R., & Kachigian, C. (2001). To warn and
Walcott, D. M., Cerundolo, P., & Beck, J. C. (2001).
to control: Two distinct legal obligations or
Current analysis of the Tarasoff duty: An evo-
variations of a single duty to protect?
lution towards the limitation of the duty to
Behavioral Sciences and the Law, 19, 355 –373.
protect. Behavioral Sciences and the Law, 19,
Gates, J. J., & Fitzgerald, J. (2000). The importance
325 –343.
of privacy and limits to privacy. In J. J. Gates &
B. S. Arons (Eds.), Privacy and confidentiality
in mental health care (pp. 193 –218).
Related Topic
Baltimore: Paul H. Brookes.
Glancy, G. D., Regehr, C., & Bryant, A. G. (1998). Chapter 121, “A Model for Clinical Decision Mak-
Confidentiality in crisis: Part I—The duty to ing With Dangerous Patients”
PART IX
Forensic Matters
This page intentionally left blank
 FORENSIC EVALUATIONS
115 AND TESTIMONY

Stanley L. Brodsky

1. Introducing forensic evaluations: Foren- 4. Keep only one set of records: The occa-
sic clients should be notified that any of their sional practice of securely filing away a second
statements or findings of the evaluation may be- set of “secret and private” notes for one’s own
come part of a public record. Rather than assur- use is wrong. All written notes, observations,
ing the privilege of confidentiality, forensic eval- corroborative information, and reports should
uators fully inform the person that no psychol- be considered to be on the record.
ogist-client privilege exists. Caution individuals 5. Prepare responsibly: Before testifying,
against saying anything they prefer not to be ensure that your knowledge is current in psy-
reported (Greenberg & Moreland, 1993). chological conceptualizations, assessment prac-
2. Detailed reporting and documentation: tices, and relevant professional issues (Brodsky,
Record and maintain detailed information re- 1994).
garding times, dates, and durations of appoint- 6. Depositions: Besides the stated purpose
ments, phone calls, interviews, reviews of records, of discovery by opposing counsel of facts and
consultations, and examination of possible cor- findings, depositions serve two additional and
roborating information. Vagueness about such sometimes nonobvious purposes. They inform
information may become a source of vulnera- both sides so that evidence may be weighed that
bility on the witness stand. would influence settlement discussions. Depo-
3. Never change records: Some evaluators sitions also allow witnesses to learn the lines of
revise their notes when further information is inquiry that may be pursued in the trial. The
received. Avoid this practice. Add and date any following is a piece of specific advice for deposi-
supplementary information to notes and rec- tions: If you don’t know, don’t discuss. Much
ords, but do not change already recorded ob- more than in live trials, witnesses in deposi-
servations or notes. tions sometimes babble on and speculate far be-

591
592 part ix • forensic matters

yond their knowledge, competence, and find- 13. Credibility: An implicit goal of wit-
ings. nesses is to be credible and believed. People be-
7. Meet before the direct examination: Some lieve witnesses who are likable and confident.
attorneys are unavailable or reluctant to meet To the extent possible, given the nature of the
with their witnesses before trials. It is worth- setting, allow the likable aspects of who you are
while to pursue such meetings so you will to be visible, and confidently present your find-
know what questions will be asked (Brodsky, ings and conclusions.
1991). Attorneys who have not met with their 14. Data that do not support your conclu-
experts often miss essential parts of psycholog- sions: Excessively partisan witnesses attempt to
ical findings during direct examinations. deny existing information they have gathered
8. Understand the legal context: The legal that contradicts their conclusions. Conscien-
rules of evidence and procedure profoundly af- tious and responsible witnesses freely and
fect acceptability of testimony (Committee on without defensiveness acknowledge and discuss
Ethical Guidelines for Forensic Psychologists, contradicting information.
1991). Read one of the psychology and law 15. Admitting ignorance: Some expert wit-
texts on this subject. I recommend the book by nesses present themselves as omniscient and
Melton, Petrila, Poythress, and Slobogin (1987). infallible in their fields. Don’t. Instead, state “I
9. Testify only within the scope of reason- don’t know” in response to queries when you
able and accepted scientific knowledge: Experts truly do not know the answer.
are bound to this standard by the U.S. Supreme 16. Use evaluations and testimony as stim-
Court Daubert decision. These research results uli to learn: Evaluators and witnesses are typi-
should be used in an impartial manner in the cally so caught up in “doing” that they are not
face of adversarial pulls of attorneys. It is not open to conceptualizing cases and testimony as
unethical to disagree with other experts about learning experiences. I suggest asking, “What
readings or applications of knowledge. It is un- additional validated measures might I adminis-
ethical to relinquish the role of neutral expert ter that are directly related to these forensic is-
in favor of highly selective gleaning of knowl- sues? What else should I read or what short
edge (Sales & Shuman, 1993; Sales & Simon, courses should I take to be better prepared?
1993). What have I learned about my own needs for
10. Stay clearly within the boundaries of professional and scholarly growth?”
your own professional expertise: This mandate
from the APA Code of Ethics (American Psy-
chological Association, 1992) means that prac- References & Readings
titioners with expertise only in psychology of
American Psychological Association. (1992). Ethical
adults do not assess children or testify about principles of psychologists and code of conduct.
child psychology. In the same sense, one should American Psychologist, 47, 1597–1611.
not consider observation of other witnesses’ be- Brodsky, S. L. (1991). Testifying in court: Guidelines
havior on the stand to be remotely equivalent to and maxims for the expert witness. Washing-
findings from conventional psychological as- ton, DC: American Psychological Association.
sessments. Brodsky, S. L. (1994). Are there sufficient founda-
11. Credentials: Skilled opposing counsel tions for mental health experts to testify in
can always find something you have not ac- court? Yes. In S. A. Kirk & S. D. Einbinder
complished, written, or mastered. Admit all (Eds.), Controversial issues in mental health
(pp. 189 –196). Needham Heights, MA: Allyn
nonaccomplishments in a matter-of-fact way.
and Bacon.
12. Experience: The legal system uses
Committee on Ethical Guidelines for Forensic Psy-
breadth, depth, and duration of experience as chologists. (1991). Speciality guidelines for
part of credentialing expert witnesses. Clini- forensic psychologists. Law and Human Be-
cians should be aware that, by itself, clinical ex- havior, 15, 655 – 665.
perience is unrelated to accuracy of diagnostic Faust, D. (1994). Are there sufficient foundations for
judgments (Faust, 1994; Garb, 1989, 1992). mental health experts to testify in court? No. In
 116 • forensic evaluation outline 593

S. A. Kirk & S. D. Einbinder (Eds.), Controver- C. (1987). Psychological evaluation for the
sial issues in mental health. Needham Heights, courts: A handbook for mental health profes-
MA: Allyn and Bacon. sionals and lawyers. New York: Guilford Press.
Garb, H. N. (1989). Clinical judgment, clinical train- Sales, B. D., & Shuman, D. W. (1993). Reclaiming
ing, and professional experience. Psychological the integrity of science in expert witnessing.
Bulletin, 105, 387 –396. Ethics and Behavior, 3, 223 –229.
Garb, H. N. (1992). The trained psychologist as ex- Sales, B. D., & Simon, L. (1993). Institutional con-
pert witness. Clinical Psychology Review, 12, straints on the ethics of expert testimony.
451– 467. Ethics and Behavior, 3, 231–249.
Greenberg, S. A., & Moreland, K. L. (1993, October
16 –17). Forensic evaluations and forensic ap-
Related Topics
plications of the MMPI and MMPI-2. Paper
presented at continuing education workshop Chapter 116, “Forensic Evaluation Outline”
sponsored by the University of Minnesota in Chapter 117, “Forensic Referrals Checklist”
cooperation with the Alabama Psychological Chapter 119, “Forensic Assessment Instruments”
Association, Montgomery, AL. Chapter 120, “Evaluation of Competency to Stand
Melton, G., Petrila, J., Poythress, N. G., & Slobogin, Trial”

FORENSIC EVALUATION
116 OUTLINE

David L. Shapiro

I. Identifying data (include name, date of related by family or friends, relevant

birth, age, place of birth, birth order, reli- history leading to offense)
gious background, present living arrange- VII. Behavior in jail (include patient’s state-
ment, marital status, occupation, race) ments and interviews of correctional
II. Charges against defendant personnel)
III. Documents reviewed and people inter- VIII. Jail psychiatric records (include discus-
viewed sions of consultations, medications, di-
IV. Confidentiality waiver (state under- agnoses, consistency or inconsistency
standing in client’s own words) with above self-described behavior)
V. Statement of facts (obtain from police IX. Mental status examination (include ap-
reports, witnesses’ statements, inter- pearance, behavior, orientation, atten-
views of police officers and witnesses, tion, perception, memory, affect, speech,
results of drug and alcohol screening if delusions, hallucinations, suicidal
available) ideation, judgment, indications of toxic-
VI. Patient’s version of offense (include pa- ity, estimated intelligence and insight)
tient’s perceptions, drug or alcohol usage X. Social history (obtain from patient and
at time, symptoms indicative of mental include history obtained from family
disorder, behavior at time of offense as and/or friends)
594 part ix • forensic matters

A. Early childhood (include family composi- M. Hallucinations unrelated to functional

tion, nature of interactions, family intact- mental disorder
ness, major events, illnesses or injuries) N. Fugue states
B. Latency age (include school performance, O. Déjà vu phenomena
attitude toward studies, outside interests, P. Jamais vu phenomena
nature of peer interaction) Q. Depersonalization or derealization
C. Adolescence (include sexual development, R. Double vision or blurriness
identity issues, drugs, alcohol, nature of S. History of delirium tremens
peer interaction, occupations) T. Memory disturbances
D. Young adulthood (include nature of in- U. Difficulty understanding what is read
terpersonal relationships, quality of job V. Difficulty following conversations
history) W. Contact with chemicals
E. Adulthood X. History of venereal disease (syphilis)
F. Sexual and marital (include dating, num- XIV. Chronological review of psychiatric
ber of marriages, personality of spouse, records
reasons for separation if any) XV. Interview with treating therapists
G. Education (include types of schools, XVI. Review of general medical records
grades, extracurricular activities)
(check especially for head trauma, an-
H. Vocational (include number of jobs,
length of jobs)
tianxiety or antidepressant medica-
I. Military (include branch, dates, rank ob- tion)
tained, disciplinary actions if any) XVII. Review of school records
J. Religious history XVIII. Review of occupational records
K. Drug and alcohol abuse (include history, XIX. Review and critique of prior evalua-
kinds, extent, effects on behavior) tions in current case
L. History of physical or sexual abuse XX. Referrals to other consultants and re-
XI. Criminal history (include for each sults of their examinations
charge, date of charge, place, and dispo- XXI. Test results (include test-taking atti-
sition) tude, behavior, degree of defensive-
ness, validity, motivation, reaction
XII. Psychiatric history (include nature of
time, evidence of perseveration)
admissions, whether voluntary or invol-
A. WAIS-III or WISC-III
untary, willingness to sign releases, B. Projectives
type of treatment rendered) C. Objective personality tests
A. Family psychiatric history D. Neuropsychological screening
B. Patient’s psychiatric history E. Neuropsychological battery
XIII. Neurological history F. Assessment of malingering
A. Head injuries and sequelae (include hos- G. Summary of testing
pitals, where treatment rendered) XXII. Opinion on criminal responsibility (or
B. Blackouts (unrelated to drugs or alcohol) competence) (specify how mental disor-
C. Dizzy spells der may affect each functional capacity)
D. Seizures A. Competence
E. Stupor or staring 1. Factual understanding
F. Repetitive stereotype movements 2. Rational understanding
G. Perceptual distortions 3. Relation to attorney
H. Pathological intoxication 4. Knowledge of roles of various people
I. Spatial disorientation 5. Knowledge of pleas and outcomes
J. Learning disabilities B. Criminal responsibility
K. Explosive behavioral outbursts with 1. Mental disorder: In what way does
minimal provocation (note especially it affect
amnesia, aura, peculiar tastes or a. Ability to appreciate wrongful-
smells) ness of behavior
L. Confusional episodes and/or slurred b. Ability to conform to law (if ap-
speech unrelated to drugs or alcohol plicable)
 117 • forensic referrals checklist 595

c. Other forensic issues (e.g., Shapiro, D. L. (1990). Forensic psychological assess-

ability to waive Miranda rights, ment: An integrated approach. Boston: Allyn
competence to confess, whether and Bacon.
or not the mental disorder re- Shapiro, D. L. (2000). Criminal responsibility eval-
sulted in an inability to form uations. Sarasota, FL: Professional Resource
specific intent) (for each issue, Press.
how does mental disorder Smith, S., & Meyer, R. (1987). Law, behavior, and
relate to each of the functional mental health: Policy and practice. New York:
capacities?) New York University Press.
XXIII. Recommendations for disposition Weiner, I., & Hess, A. (1998). Handbook of forensic
psychology (2nd ed.). New York: Wiley.
References & Readings
Related Topics
Curran, W., McGarry, A. L., Shah, S. (1986). Foren-
sic psychiatry and psychology. Philadelphia: Chapter 115, “Forensic Evaluations and Testimony”
F. A. Davis. Chapter 117, “Forensic Referrals Checklist”
Melton, G., Petrila, J., Poythress, N., Slobogin, C. Chapter 119, “Forensic Assessment Instruments”
(1997). Psychological evaluations for the courts Chapter 122, “Principles for Conducting a Compre-
(2nd ed.). New York: Guilford Press. hensive Child Custody Evaluation”

117 FORENSIC REFERRALS CHECKLIST

Geoffrey R. McKee

Forensic psychology is the application of the based on the psychologist’s research, which the
theories, methods, and research of psychology jury then applies to the facts of the case. This
to questions of law. Attorneys seek the assis- chapter also offers questions you should ask to
tance of psychologists to develop expert opinion help you decide whether the attorney is seeking
to support their arguments before or during professional consultation or a “hired gun.”
trials or hearings involving clients they repre- 1. What is (are) the legal issue(s) in the
sent. The purpose of this chapter is to highlight case? This question clarifies the type of case
questions you can employ to decide whether to (civil, criminal, domestic, administrative) being
accept such cases and to specify the scope and referred, the issues the attorney considers to be
content of your consultation to the attorney. most important, and what general area(s) of ex-
The competent attorney always anticipates that pertise are being sought. Any legal case may
the case will go to trial. Thus he or she seeks a have a host of issues to be litigated (e.g., compe-
psychologist who will qualify as an expert wit- tence to confess, competence to stand trial, crim-
ness to provide either “opinion testimony” inal responsibility, and capital mitigation in a
based on direct contact with the attorney’s cli- murder case). An early stage in the legal process
ent or “dissertation testimony” (Myers, 1992) is negotiation of the issues to be argued. For ex-
596 part ix • forensic matters

ample, in a personal injury case, the plaintiff tance to the court’s and/or jury’s decision mak-
files a complaint of facts or allegations to which ing by providing information about the parties
the defendant agrees or denies in an answer. in litigation, many issues may exceed the com-
The resulting items of disagreement, some of petence of our methods and practice. The ad-
which may require the expertise of a psycholo- missibility requirements of Daubert v. Merrell
gist, become the issues for litigation. Dow Pharmaceuticals, Inc. (1993; see especially
2. What case facts support your side? The Marlowe, 1995) now mandate methods with
adverse side? A competent attorney will pre- higher reliability and validity than the “general
sent the case succinctly and understand both acceptance” standards of Frye v. United States
sides of the litigation. This question identifies (1923). The current American Psychological
ill-prepared lawyers seeking only a “hired gun” Association’s “Ethical Principles of Psycholo-
and also illuminates potential biases or preju- gists and Code of Conduct” (2002) specify that
dices the attorney may have (e.g., that all plain- psychologists have an ethical responsibility to
tiffs malinger illness for disability). For exam- base their work on “established scientific and
ple, an attorney representing a documented professional knowledge of the discipline” (2.04),
alcoholic and domestically abusive husband including diagnostic statements and forensic
might request consultation regarding child cus- testimony (9.01a). In certain jurisdictions, it is
tody. Knowing these facts, you might decline now not uncommon for the clinician to testify
the case, despite the attorney’s protestations in a pretrial “Daubert hearing” about the sci-
that the client’s problems are “irrelevant” to his entific validity and reliability of his or her pro-
capacity as a parent. posed evaluation procedures to assist the judge’s
3. What specific questions would you like admissibility of evidence decisions.
me to answer? This inquiry identifies the para- 5. Am I competent on the basis of my train-
meters of your “contract” with the attorney, af- ing, experience, and licensure to qualify as an
firms the basis for his or her client’s informed expert witness in court to answer the referral
consent to your services, clarifies the founda- questions? Numerous legal decisions (e.g., Ibn-
tion (sources of data) necessary for the forma- Tamas v. United States, 1979) have affirmed
tion of your professional opinion(s), and de- that a judge’s determination of a witness’s qual-
limits the scope of your expert testimony, if ification as an expert is not dependent solely
subpoenaed. For example, if you have completed on professional title (e.g., psychologist, psychi-
an evaluation only of a client’s competence to atrist). Rather, the relevance of the witness’s
stand trial, it would be unethical, beyond the training and work experience to the issues liti-
scope of your agreement with the attorney, and gated is of paramount importance. Both the
beyond the client’s consent to employ the same American Psychological Association’s “Ethical
set of data to testify about the client’s parent- Principles of Psychologists and Code of Con-
ing capacity or his or her mental state at the duct” (2.01; 2002) and the “Specialty Guide-
time of the alleged offense. lines for Forensic Psychologists” (III; 1991)
Once you have a basic understanding of the suggest the parameters for competence when
facts and issues of the case, you should ask engaging in clinical or forensic practice. The
Questions 4 and 5 of yourself. Because public clinician should also be familiar with the pro-
testimony might occur in any legal case, thus fessional discussions and controversies in the
placing the attorney’s client in jeopardy, you current professional literature relevant to the
should be conservative when answering these case’s psycholegal issues, such as psychometric
questions and realize the adverse side may have “profiles” (Murphy & Peters, 1992), forensic
retained a psychologist to assist with cross- use of projective measures (Grove, Barden,
examination of your credentials to impeach Garb, & Lilienfield, 2002), violence prediction
your testimony. (Monahan et al., 2001), or battered woman
4. Can the attorney’s questions be answered syndrome (Follingstad, 2003). Beyond clinical
by current psychological knowledge and re- competence, in forensic cases, psychologists
search? While psychology can be of great assis- have an ethical responsibility to “become rea-
 117 • forensic referrals checklist 597

sonably familiar with the judicial or adminis- tortion by clients in criminal, civil, domestic,
trative rules governing their roles” and ensure and administrative litigation, the psychologist
that those to whom the psychologist delegates cannot rely solely on the statements of the
services have relevant competence (American plaintiff or defendant. The “Guidelines” (VI.B)
Psychological Association Standards 2.01(f) and mandate corroboration by other sources as fun-
2.05.2, 2002). damental to the formation of your expert opin-
If you answered “Yes” to Questions 4 and 5, ions. Ask what records the attorney has for
proceed to the items below. your review; at this point, the attorney’s de-
6. Will my consultation (evaluation, etc.) be scription of the case should suggest other doc-
privileged as your work product? Work product uments needed to complete your consultation.
is any evidence a lawyer develops that is pro- Place the burden of obtaining the documents on
hibited from disclosure under attorney-client the lawyer — subpoenas short-circuit institu-
privilege, a more protective standard than pro- tional resistance to disclosure of records and
fessional confidentiality. This question clarifies also allow the attorney to overcome any dis-
the conditions under which your service to the covery rules that you, as a nonlawyer, would
attorney (and his or her client) might be shared not necessarily know.
with the adverse attorney or the court and the 9. Who will be responsible for payment of
client’s informed consent regarding release of my time? How shall we arrange my retainer?
information (including your courtroom testi- Financial matters need to be resolved prior to
mony). Each state has its own set of criminal your acceptance of the case. You should clearly
procedure and civil procedure rules governing describe your fee structure (per hour, per day,
discovery. This question addresses a funda- etc.) and what will constitute billable hours of
mental legal issue that requires an answer from your work (e.g., travel time, different fees for
the referring attorney. records review or courtroom testimony). Early
7. When is this case likely to go to trial or confirmation of fee arrangements is an ethical
hearing? The well-prepared attorney antici- obligation (American Psychological Association
pates the use of experts well in advance of trial Standards 6.04(a), 2002). Many experienced
and realizes that thorough psychological con- forensic psychologists have clearly written con-
sultation requires time to review documents, tracts that are signed by all relevant parties
evaluate the client over more than one session, prior to formal case acceptance (for examples,
conduct collateral interviews, and suggest addi- see Pope, Butcher, & Seelen, 2000). Agreements
tional consultations beyond the expertise of the for retainers, if requested, should also be made
retained psychologist. Accepting last-minute at this point and precede actual work on the
consultations may leave you vulnerable to case. Avoid cases where contingency fees are of-
cross-examination questions of practicing “curb- fered, since this practice is patently unethical
side psychology,” the accusation of superficial (“Guidelines,” IV.B). If courtroom testimony
preparation of expert opinions. In cases where or deposition is anticipated, request that pay-
notice is short, you may wish to accept the case ment for your time be held in the attorney’s es-
on the condition that the attorney will seek a crow account prior to your court appearance so
continuance for time to complete a full examina- that the content of your testimony will not be
tion. Midtrial consultations should be avoided influenced by the anticipation of fee payment.
unless your testimony will be of “dissertation” 10. In what form would you like my re-
form, explaining published research for the port? The task of the forensic psychologist is to
court’s consideration of a particular issue (e.g., form expert opinion(s), using professionally
eyewitness memory, relationship violence; see accepted methods, about case-relevant psycho-
generally Goldstein, 2003). legal issue(s) as defined by legal standards from
8. What documents do you have pertinent statutory or case law. When retained by coun-
to your client? What records does the other sel, the forensic psychologist is not necessarily
side have, and when will they be disclosed? Be- required to prepare a written report; indeed,
cause of the high rates of malingering and dis- the psychologist is encouraged to limit unnec-
598 part ix • forensic matters

essary disclosure of material about the client References & Readings

(“Guidelines,” V.C: APA Standards 4.04(a),
American Psychological Association. (2002). Ethical
4.06, 2002). Elsewhere (McKee, 1995), I have principles of psychologists and code of conduct.
suggested ways to avoid misuse of reports in American Psychologist, 57, 1060 –1073.
legal contexts. Report content may be influ- Committee on Ethical Guidelines for Forensic Psy-
enced by discovery rules, which may vary chologists. (1991). Specialty guidelines for for-
among criminal, civil, domestic, and adminis- ensic psychologists. Law and Human Behavior,
trative procedures, as well as from jurisdiction 15, 655 – 665.
to jurisdiction. Excellent examples of forensic Daubert v. Merrell Dow Pharmaceuticals, Inc., 727 F.
report formats for a variety of psycholegal is- Supp. 570 (S.D. Cal. 1989), remanded 113 S.Ct.
sues may be found in Heilbrun, Marczyk, and 2786 (1993).
Follingstad, D. R. (2003). Battered woman syndrome
DeMatteo (2002). Because the attorney is your
in the courts. In A. M. Goldstein (Ed.), Hand-
client, he or she has the right to decide the for-
book of psychology. Forensic psychology (Vol.
mat of your report and is also more familiar 11, pp. 485 – 507). Hoboken, NJ: Wiley.
with the discovery rules governing work prod- Frye v. United States, 293 F. 1013 (D.C. Cir. 1923).
uct (see Question 6). Although the attorney Goldstein, A. M. (Ed.). (2003). Handbook of psy-
may govern the form of report, he or she does chology. Forensic psychology (Vol. 11). Hobo-
not control the content; thus, when a report is ken, NJ: Wiley.
drafted, the attorney should be forewarned Grove, W. M., Barden, C., Garb, W. N. & Lilienfield, S. O.
that both supportive and adverse data will be (2002). Failure of Rorschach-Comprehensive-
included. Avoid attorneys who wish to control System-based testimony to be admissible under
the content of your opinions or want you to al- the Daubert-Joiner-Kumho standard. Psychol-
ogy, Public Policy, and Law, 8(2), 216 –234.
ter your opinions to support their argument.
Heilbrun, K., Marczyk, G. R., & DeMatteo, D. (Eds.).
11. What if my opinion does not support
(2002). Forensic mental health assessment: A
your side? This is the acid test for the attorney’s casebook. New York: Oxford University Press.
integrity in seeking your consultation. Lawyers Ibn-Tamas v. United States, 407 A.2d 606 (1979).
have a duty to explore mental health issues, if Marlowe, D. B. (1995). A hybrid decision frame-
such facts are known or available, in the course work for evaluating psychometric evidence.
of case preparation. Attorneys have been cited Behavioral Sciences and the Law, 13, 207 –228.
for ineffective assistance of counsel for failing McKee, G. R. (1995). Insanity and adultery: Forensic
to explore mental health issues. Resolution of implications of a divorce case. Psychological Re-
this issue at this point will minimize conflict ports, 76, 427 – 434.
later if your data suggest an opinion other than Monahan, J., et al. (2001). Rethinking risk assess-
ment. New York: Oxford University Press.
what the attorney wished. Remember that
Murphy, W. D., & Peters, J. M. (1992). Profiling
when you are retained, you have a duty to ad-
child sexual abusers. Criminal Justice and Be-
vocate your opinion, not the attorney’s posi- havior, 19, 24 –37.
tion. If an attorney decides not to retain you af- Myers, J. E. B. (1992). Legal issues in child abuse
ter this question, that is the attorney’s choice and neglect. Newbury Park, CA: Sage.
and may likely increase his or her estimation of Pope, K. S., Butcher, J. N., & Seelen, J. (2000). The
you. Having a reputation as a psychologist who MMPI, MMPI-2, and MMPI-A in court (2nd ed.).
“calls ‘em as you see ‘em” will significantly en- Washington, DC: American Psychological As-
hance your credibility during testimony and sociation.
also deflect cross-examination aspersions that
you are a “hired gun.” Indeed, balanced opin- Related Topics
ions are not reflected in the number of times
Chapter 111, “Glossary of Legal Terms of Special
you testify for one side or the other but rather
Interest in Mental Health Practice”
in the percentage of cases in which you do not Chapter 115, “Forensic Evaluations and Testimony”
testify because your opinion is adverse to the Chapter 116, “Forensic Evaluation Outline”
attorney who retained you. Chapter 118, “Expert Testimony in Depositions”
Chapter 134, “Establishing a Consultation Agreement”
 EXPERT TESTIMONY IN
118 DEPOSITIONS

Geoffrey R. McKee

The psychologist as expert witness has received ever, many states have simply adopted the Fed-
considerable attention and discussion over the eral Rules of Civil Procedure (1995) and/or the
past 20 years (Blau, 1984; Brodsky, this volume, Federal Rules of Criminal Procedure (1995).
chap. 115; Brodsky & Robey, 1973; Pope, The remainder of this chapter discusses depo-
Butcher, & Seelen, 2000; Ziskin, 1981). Most of sitions in terms of context and issues relevant
the literature focuses on courtroom testimony to the deposing (adverse) attorney and non-
during criminal trials or domestic court hear- deposing (retaining) attorney.
ings. Little, however, has been written about the
psychologist giving depositions, the most com-
mon form of expert testimony in civil proceed- CONTEXT
ings. Depositions are considered by many ex-
perts to be the “most grueling, intense, and The purpose of a deposition is to discover (and
anxiety-producing aspect of litigation” (Sacks, preserve for future use at trial) evidence pos-
1995, p. 18). The purpose of this chapter is to sessed by competing parties in litigation. In a
highlight the differences between expert testi- case involving mental health issues, both attor-
mony during depositions versus courtroom neys will often depose the other side’s experts
(Table 1) to facilitate psychologists’ effective in an attempt to find out the expert’s credentials
participation in this stage of litigation. and the foundation (database), methods, con-
The Federal Rules of Civil Procedure Rule tent, and reasoning of the expert’s opinions. Be-
26(b)(4)(A) (1995) and Federal Rules of Crimi- cause depositions are a pretrial procedure, the
nal Procedure Rule 15 (1995) provide that any deposition typically occurs in a private setting,
party (plaintiff or defendant; prosecution or de- such as the psychologist’s office or, for strategic
fense) may take the deposition of any expert purposes (e.g., to unsettle the expert), in the of-
who will testify at trial regarding his or her fice of the deposing attorney. Neither a judge
already disclosed report. A deposition is a nor a jury is present; however, the questions
statement from a witness (deponent) under and answers are preserved by a court stenog-
oath taken in question-and-answer form (Blau, rapher and, increasingly, by videotape. Prior
1984). Depositions are one of several methods to the deponent psychologist’s testimony, the
of pretrial discovery in which an attorney at- attorneys will resolve any variations from the
tempts to uncover evidence from the opposing “usual stipulations” governing depositions such
attorney. Depositions may be given orally in as the method of taking the deposition, the use
face-to-face contact with the attorneys, or they of the deposition (e.g., for impeachment of the
may be given in written form through inter- expert’s testimony at trial), the waiver of the
rogatories (Horowitz & Willging, 1984). Such nondeposing attorney’s objections to his or her
procedures are governed by specific rules, which psychologist being deposed, and the documen-
may vary from jurisdiction to jurisdiction; how- tation of either attorney’s objections to deposi-

599
600 part ix • forensic matters

table 1. Differences Between Expert Testimony in Deposition and Courtroom

Issue Deposition Courtroom

Context
Purpose Discover evidence Resolve dispute
Setting Private office Public courtroom
Scope of inquiry Extensive (civil) Limited (prejudice to jury)
Authority Deposition rules Rules of court; statutes
Procedure Deposing attorney first Retaining attorney first
Fees Paid by deposing attorney Paid by retaining attorney
Objections’ resolution Delayed until trial Immediate by judge
Posttestimony issues Never waive reading/signing transcript Leave; credibility decreases if you stay at
attorneys’ table and consult through trial

Deposing (Adverse) Attorney

Intent Investigative Adversarial
Demeanor Deliberate Theatrical
Pace Leisurely Expedited
General questions Highly technical Laymanlike for jury
Vita questions Extensive Limited; stipulated if better than adverse
attorney’s expert
Opinion questions Extensive Selective to minimize impact
Error questions Delayed until trial Immediate: embarrassment

Nondeposing (Retaining) Attorney

Intent Resistance to disclosure Instructive to judge, jury
Demeanor Passive to minimize exposure of strategy Active to influence juror decision making
Questions None or limited to selected issues Extensive on direct; active on redirect as
necessary
Consultation with expert Limited or prohibited during testimony Collaborative prior/during trial (though
not during testimony)

tion questions that will be reserved for the fore the judge; despite the objection, the expert
judge’s ruling. In contrast to courtroom testi- is typically requested to answer the question.
mony, wherein the retaining attorney begins After testifying, but before the deposition is
the questioning of his or her expert, followed formally concluded, the psychologist should al-
by cross-examination by the adverse attorney, ways request his or her right to read and sign
in a deposition the deposing (adverse) attorney the transcript of the deposition to correct any
initiates questioning of the deponent. Typically typographical, form, or substance mistakes
the deposing attorney’s scope of inquiry is ex- made by the stenographer (Sacks, 1995). The
tensive because a deposition is a discovery pro- transcript will be the document against which
cedure and concerns regarding prejudice of the the psychologist’s trial testimony will be com-
jury are minimal. Similar to the sequences in pared; any differences may be employed by the
courtroom testimony, the deponent psycholo- deposing attorney to discredit the psycholo-
gist is first questioned regarding his or her gist’s conclusions and opinions. If the psycholo-
qualifications (credentials), followed by inves- gist and retaining attorney have not discussed
tigation of the content of his or her opinions the review and signing of the transcript, the at-
relevant to the case’s psycholegal issues. If, dur- torney may unwittingly agree to waive this
ing questioning, the retaining attorney objects “usual stipulation,” with disastrous results for
to the deposing attorney’s question, resolution the psychologist at trial.
of the objection is delayed until a hearing be-
 118 • expert testimony in depositions 601

DEPOSING (ADVERSE) ATTORNEY with the expert’s qualifications. Rather than a

few superficial questions or stipulations at trial
Because the deposing attorney has requested (especially with highly qualified experts), the
the deposition and is paying the deponent psy- deposing attorney may spend hours in a case-
chologist’s fees, he or she is the central figure of by-case review of the psychologist’s experience,
the proceedings. The deposing attorney’s intent course-by-course review of the psychologist’s
is to be investigative and, at times, confronta- training, article-by-article review of the psy-
tional. He or she hopes to learn as much as pos- chologist’s publications, and/or transcript-by-
sible about the expert’s credentials, foundation, transcript review of the psychologist’s prior tes-
methods, and content of opinion(s), as well as timony. The intent is part factual and part
the psychologist’s demeanor, persuasiveness, strategic: The attorney wants to find anything
and credibility as a witness. In contrast to court- that might be used to impeach the expert’s cred-
room theatrics to influence jury perceptions, ibility while also exhausting the psychologist
the deposing attorney will likely be subdued, so that he or she might make errors during di-
deliberate, and methodical in questioning to en- rect questioning that could subsequently be
sure that he or she has a full understanding of used at trial to diminish the influence of his or
the basis for the expert’s opinions. The deposing her testimony. For example, suppose that the
attorney will likely have retained a psycholo- psychologist inadvertently scored the MMPI
gist to review the deponent psychologist’s re- results for the male plaintiff using the female
port prior to deposition and to assist in his or norms. If the attorney (or his or her retained
her questioning. Without the judge’s implied psychologist) detects the error, he or she may
pressure to avoid wasting the court’s time with wish to highlight the error immediately to
exploratory inquiries of dubious relevance, the challenge the competence of the deponent psy-
attorney’s pace can be leisurely during a depo- chologist’s opinions as a prelude to settlement
sition, with frequent consultations with the at- or wait until trial to embarrass the expert in
torney’s colleagues and long pauses between front of the jury. Error detection might also
questions — delays that are rarely tolerated by force the retaining attorney to “rehabilitate”
trial judges. the psychologist’s testimony through addi-
In general, the deposing attorney’s questions tional questioning, causing unexpected disclo-
will be highly technical rather than simplistic sure of that attorney’s case strategy and fur-
for juror influence because he or she wishes to ther inquiry by the deposing attorney in re-
obtain a full and complete exposition of the ex- sponse to the deponent’s additional testimony.
pert’s qualifications, methods, and reasoning in Typically, the majority of the deposing at-
forming his or her opinions. Many of the depo- torney’s questions will focus on the deponent
sition questions may have been developed by psychologist’s opinions of the psycholegal issues
the deposing attorney’s retained psychologist, of the case. During trial, the deposing (adverse)
who will subsequently review the deponent attorney would be seeking to minimize the
psychologist’s testimony for errors of founda- impact of the expert’s testimony on the judge
tion, method, and/or reasoning and may sug- and/or jury by often dramatic, theatrical, and/or
gest further inquiries during trial. The depos- dismissive interrogation. During deposition, the
ing attorney’s retained psychologist may also attorney’s inquiry will be broad and deep, pa-
provide an opinion about the overall compe- tiently probing for any weaknesses in the psy-
tence of the deponent psychologist’s opinions to chologist’s foundation, methods, or reasoning.
assist the attorney in deciding whether to pro- The attorney may use a variety of methods, in-
ceed to trial or seek settlement. The quality of cluding the “learned treatise” (Poythress, 1980)
the expert’s consultation is dependent on the or “hypothetical question” (Myers, 1992); de-
quality of the attorney’s questions; thus, the scriptions and responses to such gambits may
deponent psychologist is likely to face very spe- be found in Brodsky (this volume, chap. 115) and
cific, highly technical inquiries. other sources (Appelbaum & Gutheil, 1991;
The extensiveness of inquiry may begin Brodsky & Robey, 1973; Pope et al., 2000). The
602 part ix • forensic matters

more deliberate, unhurried climate of the depo- tion, or cross-examination: To be forewarned is

sition allows for extensive inquiry of the psy- to be forearmed.
chologist’s methods based on Daubert v. Mer-
rell Dow Pharmaceuticals, Inc. (1993; see espe- References & Readings
cially the Daubert questions proposed by
Marlowe, 1995). If the psychologist is unable to Appelbaum, P. S., & Gutheil, T. G. (1991). Clinical
handbook of psychiatry and the law (2nd ed.).
rebut such challenges to the testimony, his or
Baltimore: Williams & Wilkins.
her opinions may be deemed inadmissible at Blau, T. H. (1984). The psychologist as expert wit-
trial, negating the psychologist’s contribution ness. New York: Wiley.
to the retaining attorney’s case and forcing the Brodsky, S. L. (2000). The expert expert witness.
attorney into either dropping the case or reach- Washington, DC: American Psychological As-
ing a significantly diminished settlement (or, if sociation.
a criminal defense attorney, an unfavorable Brodsky, S. L., & Robey, A. (1973). On becoming an
conviction). expert witness: Issues of orientation and ef-
fectiveness. Professional Psychology, 3, 173 –
176.
NONDEPOSING (RETAINING) ATTORNEY
Daubert v. Merrell Dow Pharmaceuticals, Inc., 727 F.
Supp. 570 (S.D. Cal. 1989), remanded 113 S.Ct.
2786 (1993).
Generally, the intent of the nondeposing attor- Federal Rules of Civil Procedure, Fed. R. Civ. P. Rule
ney during the deposition of his or her expert is 26(b)(4)(A) (1995).
to minimize discovery of his or her case facts and Federal Rules of Criminal Procedure, Fed. R. Crim. P.
strategy by the opposing attorney. In contrast to Rule 15 (1995).
active, instructive, persuasive direct inquiry of Hall v. Clifton Precision, Civ. A. No. 92-5947 (E.D.
his or her psychologist at trial to maximize the Pa., 1993).
impact of the expert’s testimony on the jury’s de- Horowitz, I. A., & Willging, T. E. (1984). The psy-
cision making, during deposition the nondepos- chology of law: Integrations and applications.
ing attorney is frequently very passive, object- Boston: Little, Brown.
ing only when absolutely necessary. Often, fol- Marlowe, D. B. (1995). A hybrid decision frame-
work for evaluating psychometric evidence.
lowing the psychologist’s deposition testimony,
Behavioral Sciences and the Law, 13, 207 –228.
the attorney will not ask questions. The nonde- Myers, J. E. B. (1992). Legal issues in child abuse
posing attorney may ask the deponent psychol- and neglect. Newbury Park, CA: Sage.
ogist to reiterate the opinions of his or her report Pope, K. S., Butcher, J. N., & Seelen, J. (2000). The
“for the record,” especially if the deposing at- MMPI, MMPI-2, & MMPI-A in court (2nd
torney has avoided the psychologist’s conclu- ed.). Washington, DC: American Psychological
sions and focused only on the expert’s suspected Association.
weaknesses. Finally, the retaining attorney is Poythress, N. G. (1980). Coping on the witness stand:
typically prohibited from conferring with his or Learned responses to “learned treatises.” Pro-
her psychologist during deposition testimony to fessional Psychology, 11, 169 –179.
allow the deposing attorney to question the wit- Sacks, M. E. (1995). An overview of the law: A guide
for testifying and consulting experts. Hor-
ness without obstruction or coaching (Hall v.
sham, PA: LRP Publications.
Clifton Precision, 1993). Ziskin, J. (1981). Coping with psychiatric and psy-
chological testimony (3rd ed.). Venice, CA:
The purpose of this chapter has been to describe Law and Psychology Press.
the basic elements and issues pertaining to the
psychologist’s participation in pretrial deposi-
tions. Brodsky’s (this volume, chap. 115) outline Related Topics
is an excellent guide for preparation of forensic
Chapter 115, “Forensic Evaluations and Testimony”
psychological consultation services and expert
Chapter 117, “Forensic Referrals Checklist”
testimony. The reader is referred to Pope et al.
(1993) for specific questions attorneys might
employ during qualification, direct examina-
 FORENSIC ASSESSMENT
119 INSTRUMENTS

Randy Borum

Psychologists often rely on standardized tests ments of legal insanity/criminal responsibility

and measures for assistance in diagnosis and is described below.
treatment planning. Most of these instruments Rogers Criminal Responsibility Assessment
are designed to assess the presence, nature, and Scales (R-CRAS; Rogers, 1984): The R-CRAS
degree of mental disorders and their symp- is designed to structure and quantify the
toms— issues that are the focus of most clinical decision-making process in clinical-forensic as-
psychological assessments. However, in a for- sessments of insanity. After the examiner con-
ensic evaluation, information concerning one’s ducts a thorough evaluation, including relevant
mental disorder is only one component of the interviews and reviews of pertinent records, the
answer to a psycholegal question. Typically, the R-CRAS presents 30 items, called Psychologi-
psychologist must also assess and address some cal and Situational Variables, which must be as-
specific functional ability such as competence to signed a numerical rating. The Psychological
stand trial or capacity to function as a parent. and Situational Variables cover the following
Provided below are brief descriptions of several domains: Patient’s Reliability; Organicity; Psy-
forensic assessment instruments (FAIs) de- chopathology; Cognitive Control; and Behav-
signed to assess functional capacities relevant to ioral Control. The examiner uses these ratings
a given forensic issue. For a comprehensive re- and the assessment information in a decision
view of FAIs, Thomas Grisso’s Evaluating tree analysis, which leads to a conclusion that
Competencies: Forensic Assessments and In- the defendant is either “sane” or “insane,” ac-
struments (1986) is an excellent reference. A cording to the relevant legal standard. Interrater
second edition of this text is currently being reliability coefficients for the R-CRAS aver-
written. Topic-specific review articles are listed aged .58 for the clinical variables and .81 for the
beneath the appropriate topic heading. decision variables (malingering and compo-
nents of the legal insanity standard). In a sam-
ple of 93 defendants, the R-CRAS decision con-
CRIMINAL FORENSIC EVALUATIONS curred with the court’s decision in 88% of the
(Review articles: Grisso, 1986; cases where the court was not given informa-
Rogers & Ewing, 1992) tion concerning R-CRAS results.

The two most frequent evaluation issues for

forensic psychologists in the criminal justice CHILD CUSTODY AND
system relate to competency to stand trial and
PARENTAL CAPACITY
insanity/criminal responsibility. In chapter (Review article: Heinze & Grisso, 1996)
120, Paul D. Lipsitt has reviewed the primary
FAIs used for assessing competency to stand trial Ackerman-Schoendorf Scales for Parent Eval-
(the Competency Screening Test, the Compe- uation of Custody (ASPECT; Ackerman &
tence to Stand Trial Assessment Inventory, and Schoendorf, 1992): “The ASPECT is not a test
the Interdisciplinary Fitness Interview; Borum but rather a system combining the results of
& Grisso, 1995). An FAI developed for assess- psychological testing, interviews, and observa-
603
604 part ix • forensic matters

tions of each parent and child to provide data erally being more consistent than those of
regarding the suitability of the parent for cus- younger children (aged 12–14). Concerning
tody” (Heinze & Grisso, 1996). Each parent potential validity, Bricklin reports a high level
must complete an extensive Parent Question- of concurrence between the BPS and other in-
naire, and each parent as well as each child struments he has developed, but it is unclear if
must complete a specified battery of psycholog- any other validity data exist for the measure at
ical tests. The clinician uses these data to com- this time.
plete a series of 56 dichotomous questions Parenting Stress Index (PSI; Abidin, 1990):
(yes/no) for each parent. The results of this The PSI is a 101-item self-report inventory
form yield three subscale scores (Observa- designed to assess the type and severity of
tional, Social, and Cognitive-Emotional) and a stresses associated with the child-rearing role.
Parenting Custody Index (PCI). The PCI is con- A 36-item short form also exists. Parent-
sidered to be the global measure of parenting respondents rate their agreement with an item
effectiveness. The scores for each parent are using a 5-point Likert-type scale. Response
presented in color graphs, with suggestions style is assessed with a Defensive Responding
concerning the comparative parenting effec- Scale. In the Child Domain, the PSI measures
tiveness and identification of the “preferred child characteristics associated with stress in
parent.” The ASPECT was normed on a sample parenting (subscales relating to child adapt-
of 200 parents. When two independent raters ability, acceptability, demandingness, mood,
reviewed a sample of 88 records, the interrater hyperactivity/distractibility, and reinforcing
reliability coefficient for the PCI was .96, with of parent); in the Parent Domain, it assesses
other subscales falling in the low to mid-.90s. stress resulting from the parenting role (sub-
The primary validity study shows that AS- scales relating to depression, attachment, re-
PECT results agreed with the judges’ custody striction of role, sense of competence, social
decision in 75% of 118 cases. However, it ap- isolation, relationship with spouse, and pa-
pears that the ASPECT results were presented rental health). A Total Stress Score is derived
as part of the evidence in these cases. by summing the two Domain scores. The nor-
Bricklin Perceptual Scales (BPS; Bricklin, mative sample is composed of 2,633 parents.
1984): The BPS is a 64-item instrument de- Alpha coefficients for domain scores, subscales,
signed for children over 6 years of age; 32 and total scores range between .70 and .95.
items relate to each parent. The BPS is admin- Test-retest coefficients across numerous stud-
istered by presenting the child with an item ies with varying time frames have yielded es-
and asking him or her to indicate how well the timates from .55 to .96. The PSI has shown sig-
item describes the parent. For each question, nificant correlations, in the expected directions,
the child is given an 8-inch card with a black with other similar measures and with abusive
line labeled with “not so well” at one end and parental behaviors, parental roles, marital satis-
“very well” at the other. The child responds to faction, and social support. To date, there have
the item by punching a hole at the appropriate been approximately 200 studies involving the
point along the line. On the back of the card PSI.
the line is divided evenly into 60 segments, Parent-Child Relationship Inventory (PCRI;
each of which has a corresponding point value. Gerard, 1994): The PCRI is a 78-item self-re-
The parent who has the highest score for a port inventory comprising seven content scales:
given item “wins” that item. According to the Parental Support; Satisfaction with Parenting;
BPS, the “parent of choice” is indicated by the Involvement; Communication; Limit Setting;
parent who “wins” the greatest number of Autonomy; and Role Orientation. There are
items. There are currently no normative data also two validity scales to measure social desir-
available for this instrument. A preliminary ability and inconsistent responding. Parent-
study of test-retest showed coefficients for in- respondents rate their agreement with an item
dividual items ranging from .61 to .94, with using a 4-point Likert-type scale. Normative
the scores of older children (aged 15 –17) gen- data are provided for a sample of 1,139 parents.
 119 • forensic assessment instruments 605

Alpha coefficients for the subscales range from an 85-item instrument with seven sections
.70 to .88, with 1-week test-retest reliabilities (time orientation, communication, transporta-
from .68 to .93. Concurrent validation studies tion, financial, shopping, grooming, and eating)
have shown significant correlations between and a total administration time of approxi-
the PCRI and the Personality Inventory for mately 30 minutes. Each item requires the ex-
Children; parental discipline style; and parents’ aminee to demonstrate knowledge or perform a
sense of social support, competence, and self- task relevant to daily independent living — for
esteem. example, using a telephone, identifying and
counting currency, working with a grocery list,
and using eating utensils. Interrater reliabilities
for composite and subscale scores are in the
GUARDIANSHIP
.90s. Test-retest coefficients over several weeks
(Review article: Grisso, 1994)
ranged between .55 and .92 in a sample of im-
Independent Living Scales (ILS; Loeb, 1996): paired patients and were even higher in normal
The ILS is a 70-item instrument designed to controls. The DAFS also correlated significantly
evaluate an individual’s capacity to care for with an independent dementia rating scale and
himself or herself and manage his or her own with independent chart reports of specific func-
affairs. The ILS is administered as a perfor- tional impairments.
mance-based structured interview with items
that relate to a range of situations and tasks en-
countered in daily living. It takes approxi-
VIOLENCE RISK ASSESSMENT
mately 45 minutes to administer and 10 min-
(Review article: Borum, 1996)
utes to score. The administration can be adapted
to accommodate an examinee’s physical/vi- Violence Prediction Scheme (VPS; Webster,
sual/literacy limitations. Extra materials (e.g., Harris, Rice, Cormier, & Quinsey, 1994): The
telephone, telephone book, envelope, pencil and VPS combines clinical and actuarial factors in
paper, and money) are required to administer a comprehensive scheme for assessing danger-
some tasks. The ILS yields five subscale scores ousness and risk. The actuarial component is
(Memory/Orientation; Managing Money; Man- based on the Violence Risk Assessment Guide
aging Home and Transportation; Health and (VRAG), a 12-item tool that showed a classifi-
Safety; and Social Adjustment); two factor cation accuracy rate of about 75% in a sample
scores (Performance/Information and Problem of patients from a maximum security psychi-
Solving); and a Full Scale standard score, which atric hospital. Preliminary efforts at cross-
provides a global index of the examinee’s level validation with sex offenders in the community
of functioning (low, moderate, or high). Inter- and maximum security inmates in prison have
nal consistency for the ILS scores ranges from been promising. In the VPS scheme, the actu-
.72 to .92, with test-retest coefficients between arial and VRAG data are combined with an as-
.81 and .94. Interrater reliabilities range be- sessment of current status and clinical informa-
tween .95 and .99. Although the ILS was de- tion, including a 10-item clinical scheme called
signed primarily for use with older adults the ASSESS-LIST, an acronym that stands for
(65+), normative data are also available for Antecedent history, Self-presentation, Social
adults with dementia, severe mental illness, and psychosocial adjustment, Expectations and
mild mental retardation, and mild brain injury. plans, Symptoms, Supervision, Life factors, In-
In validation studies, the ILS has shown appro- stitutional management, Sexual adjustment,
priate correlations with measures of intellectual and Treatment progress. The examiner scores
and cognitive functioning and with other in- each of these items as either “favorable” or
struments measuring Activities of Daily Living “unfavorable.” Currently no psychometric data
(ADLs). are available for the ASSESS-LIST items.
Direct Assessment of Functional Status HCR-20 (Webster, Douglas, Eaves, & Hart,
(DAFS; Lowenstein et al., 1989): The DAFS is 1997): The HCR-20 is an instrument/guide
606 part ix • forensic matters

“designed for use in the assessment of risk for terrater reliability for the sum of items was .92,
future violent behavior in criminal and psychi- and reliability for the SARA-informed risk rat-
atric populations. Briefly, the first 10 items of ing was .80. The SARA-informed summary
the HCR-20 pertain to the historical, or static, risk ratings were also strongly related to reof-
variables of the individual being assessed (H fending, with those rated as “high” risk being
Scale), the next five items reflect the current 5.5 times more likely to reoffend than those
clinical status and personality characteristics of with ratings of “low” or “moderate” risk.
the individual (C Scale), and the remaining five
pertain to future risk of violent behavior (R References & Readings
Scale)” (Webster et al., 1997, emphasis added).
The historical and risk variables can primarily Abidin, R. (1990). Parenting Stress Index (3rd ed.).
Odessa, FL: Psychological Assessment Re-
be coded from records or secondary informa-
sources.
tion sources, although the clinical factors need Ackerman, M., & Schoendorf, K. (1992). ASPECT:
to be evaluated and rated by a qualified mental Ackerman-Schoendorf Scales for Parent Eval-
health professional based on interviews, prog- uation of Custody. Los Angeles: Western Psy-
ress notes, psychological assessments, or simi- chological Services.
lar sources. The HCR-20 has a defined three- Borum, R. (1996). Improving the clinical practice of
level scoring system for each item, similar to violence risk assessment: Technology, guide-
that of the Psychopathy Checklist-Revised lines, and training. American Psychologist, 51,
(PCL-R). Preliminary data have shown signif- 945 – 956.
icant correlations between the H Scale and C Borum, R., & Grisso, T. (1995). A survey of psycho-
Scale and scores on the VRAG (see above), logical test use in criminal forensic evaluations.
Professional Psychology: Research and Prac-
PCL-R, and number of previous charges for vi-
tice, 26, 465 – 473.
olent offenses. It also appears likely that the Bricklin, B. (1984). The Bricklin Perceptual Scales:
items can be reliably coded with average inter- Child-perception-of-parents-series. Furlong, PA:
rater reliability coefficients of about .80. The Village.
HCR-20 cannot currently be considered a test Gerard, A. (1994). Parent-Child Relationship In-
in the formal sense, but it may be useful as a ventory (PCRI): Manual. Los Angeles: West-
checklist to prompt the examiner to cover or ern Psychological Services.
consider the major relevant areas of inquiry. Grisso, T. (1986). Evaluating competencies: Forensic
Several new studies involving the HCR-20 are assessments and instruments. New York: Ple-
currently under way. num Press.
Spousal Assault Risk Assessment Guide Grisso, T. (1994). Clinical assessments of legal compe-
tence of older adults. In M. Storandt & G. Van-
(SARA; Kropp, Hart, Webster, and Eaves,
denBos (Eds.), Neuropsychological assessment
1995): The SARA is a 20-item clinical checklist of dementia and depression in older adults: A
of risk factors for spousal assault. It has an op- clinician’s guide (pp. 119 –139). Washington,
erationally defined three-level scoring scheme DC: American Psychological Association.
but is constructed to be used as a clinical guide Heinze, M., & Grisso, T. (1996). Review of instru-
— rather than a test — for assessing the risk of ments assessing parenting competencies used
future violence in men arrested for spousal as- in child custody evaluations. Behavioral Sci-
sault. The SARA has four main sections: the ences and the Law, 14, 293 –313.
Criminal History section; Psychosocial Adjust- Kropp, P. R., Hart, S. D., Webster, C. D., & Eaves, D.
ment section; Spousal Assault History section; (1995). Manual for the Spousal Assault Risk
and a final section relating to the Alleged (Cur- Assessment Guide (2nd ed.). Vancouver: British
Columbia Institute on Family Violence.
rent) Offense. After all four sections are com-
Loeb, P. (1996). Independent Living Scales. San An-
pleted, the clinician makes a “summary risk tonio, TX: Psychological Corporation.
rating” (low, moderate, or high) of imminent Lowenstein, D., Amigo, E., Duara, R., Guterman,
risk of violence toward a partner and imminent A., Hurwitz, D., Berkowitz, N., et al. (1989).
risk of violence toward others. Preliminary data A new scale for the assessment of functional
from one retrospective study showed that in- status in Alzheimer’s disease and related dis-
 120 • evaluation of competency to stand trial 607

orders. Journal of Gerontology: Psychological diction Scheme: Assessing dangerousness in

Sciences, 44, 114 –121. high risk men. Toronto, Ontario: Centre of
Rogers, R. (1984). Rogers Criminal Responsibility Criminology, University of Toronto.
Assessment Scales. Odessa, FL: Psychological
Assessment Resources.
Related Topics
Rogers, R., & Ewing, C. (1992). The measurement
of insanity: Debating the merits of the R-CRAS Chapter 86, “The APSAC Study Guides”
and its alternatives. International Journal of Chapter 87, “Interviewing Children When Sexual
Law and Psychiatry, 15, 113 –123. Abuse Is Suspected”
Webster, C. D., Douglas, K. S., Eaves, D., & Hart, Chapter 120, “Evaluation of Competency to Stand
S. D. (1997). HCR-20: Assessing risk for vio- Trial”
lence, Version 2. Burnaby: Mental Health Law Chapter 122, “Principles for Conducting a Compre-
and Policy Institute, Simon Fraser University. hensive Child Custody Evaluation”
Webster, C. D., Harris, G. T., Rice, M. E., Cormier,
C., & Quinsey, V. L. (1994). The Violence Pre-

EVALUATION OF COMPETENCY
120 TO STAND TRIAL

Paul D. Lipsitt

Competency for trial evaluation has been the The defendant who has permanent incapac-
object of psychological research for several ity may not be tried. The temporarily incapable
decades. Forensic psychologists and other men- defendant is entitled to a postponement of trial
tal health professionals have aided the courts in until competency has been restored. Any per-
developing objective measures to determine son charged with a criminal offense must be
whether defendants meet the criteria for the le- able to muster a sufficient level of cognitive and
gal standard for competency. An individual who affective resources to effect an adequate defense
suffers from impairment due to mental illness to the charges with the aid of an attorney. To
or mental defect may not possess sufficient psy- avoid indefinite commitment, the U.S. Supreme
chological presence to contribute to an adequate Court has held that those unlikely to ever gain
defense to the charges and, therefore, may be competency may be detained for only a reason-
deprived of a fair trial. The basic assumption able period for competency observation and
enunciated in Kinloch’s Case (1764) is that one treatment (Jackson v. Indiana, 1972). Long-
accused of a crime is entitled to psychological as term hospitalization must meet the same stan-
well as physical presence in court to defend one- dards required for a civil involuntary commit-
self against one’s accuser. Derived from English ment (Lipsitt, 1970).
Common Law, competency for trial is a neces- The issue of competency is usually raised
sity in order to meet the Constitutional re- prior to trial but may be raised at any time dur-
quirement of due process. ing the procedures. While usually initiated as
608 part ix • forensic matters

a request for evaluation by the defense, the pro- The forensic examiner may take into consider-
secution or the judge may raise the question of ation impaired reasoning or other psychologi-
competency. cal aberrations that may prevent a defendant
Competency for trial is based on legal crite- from serving as his own counsel, but legal skills
ria rather than psychological diagnosis of men- are not a relevant issue.
tal illness or mental defect. Defendants who are Most state statutes do not define compe-
mentally disabled, even to a serious degree, tency, nor do they offer guidelines for its as-
such as those with psychosis or moderate men- sessment. In order to mitigate the subjectivity
tal retardation, may be functionally competent of the competency assessment and to provide a
for trial. However, psychological factors may guide for its determination, various tests and
impact on the ability to perform the task of ad- procedures have been developed by research so-
equately participating in one’s criminal trial. If cial scientists.
the results of an initial evaluation indicate that During the 1960s, in conjunction with an in-
the requirements for competency are suffi- creasing concern for the civil rights and liber-
ciently compromised, the court would order ties of the mentally ill, involuntary commit-
treatment with the goal of restoration of com- ment procedures were challenged through the
petency, to be followed by proceedings in court legal system, many reaching the U.S. Supreme
to face the criminal charges. In the event that Court. Persons charged with offenses, but never
the incompetency is determined to be perma- found guilty, were frequently hospitalized in-
nent or unlikely to be restored in the foresee- voluntarily, often for life. A federally funded
able future, other steps are taken to protect the study at Harvard Medical School (Laboratory
rights of a defendant who has been charged but of Community Psychiatry, 1973) was initiated
has yet to be adjudicated. to address the absence of standards for assessing
The general criteria that determine compe- competency in the criminal justice system. The
tency for trial include (a) an ability to commu- Competency Screening Test (CST) and the
nicate and cooperate with one’s attorney in de- Competency Assessment Instrument (CAI)
fending oneself in court, (b) an awareness of the were developed as a part of this project. About
nature and object of the legal proceedings, and 10 years after the first use of the CAI, the In-
(c) an understanding of the possible conse- terdisciplinary Fitness Interview (IFI) was de-
quences of a trial. These elements provide a veloped (Golding, Roesch, & Schreiber, 1984).
framework for the psychologist to assess the Later revised (Golding, 1993), the IFI-R focuses
defendant’s ability to function on a task that on 11 competence categories, such as “appreci-
will require some level of understanding and ac- ation of the charges” and “relationship to coun-
tive participation. The assessment and evalua- sel,” and 9 clinical symptom categories, such as
tion data are generated by the psychologist or “impaired reasoning” and “thought disorder.”
other forensic mental health professional, but More recently, as part of research funded by the
the conclusion of competency or incompetency MacArthur Foundation, John Monahan and col-
is the prerogative of the judge. leagues have developed a test of competency,
In 1960, the U.S. Supreme Court stated that based on three parameters: understanding, rea-
competency should be determined by assessing soning and appreciation (Hoge, Bonnie, Poy-
whether the defendant has “sufficient present thress, & Monahan, 1999; Otto et al., 1998).
ability to consult with his attorney with a rea- These three parameters have been incorporated
sonable degree of rational understanding and a into a 22-item instrument.
rational as well as a factual understanding of The CST was developed as a screening in-
the proceedings against him” (Dusky v. United strument to reduce the need for pretrial com-
States, p. 402). In 1993, the United States mitment of those who can be declared clearly
Supreme Court held that a defendant’s decision competent. Using the CST, many individuals
to plead guilty or waive the right to counsel for whom the competency issue has been raised
need not be measured by a higher or different can be tested in the court or place of detention.
standard than Dusky (Godinez v. Moran, 1993). Those receiving a score within the competent
 120 • evaluation of competency to stand trial 609

table 1. The Competency Screening Test

1. The lawyer told Bill that . . .
2. When I go to court the lawyer will . . .
3. Jack felt that the judge . . .
4. When Phil was accused of the crime, he . . .
5. When I prepare to go to court with my lawyer . . .
6. If the jury finds me guilty, I . . .
7. The way a court trial is decided . . .
8. When the evidence in George’s case was presented to the jury . . .
9. When the lawyer questioned his client in court, the client said . . .
10. If Jack has to try his own case, he . . .
11. Each time the D.A. asked me a question, I . . .
12. While listening to the witnesses testify against me, I . . .
13. When the witness testifying against Harry gave incorrect evidence, he . . .
14. When Bob disagreed with his lawyer on his defense, he . . .
15. When I was formally accused of the crime, I thought to myself . . .
16. If Ed’s lawyer suggests that he plead guilty, he . . .
17. What concerns Fred most about his lawyer . . .
18. When they say a man is innocent until proven guilty . . .
19. When I think of being sent to prison, I . . .
20. When Phil thinks of what he is accused of, he . . .
21. When the jury hears my case, they will . . .
22. If I had a chance to speak to the judge, I . . .

range can proceed directly to trial, avoiding un- self-administered, for individuals with inade-
necessary hospitalized observation for compe- quate reading skills the stems may be read and
tency evaluation. responses recorded by the administrator. On
The CST, which has been the subject of sev- average, the CST can be administered in about
eral validation studies (Nicholson, Robertson, 25 minutes and scored in 15 to 20 minutes with
Johnson, & Jensen, 1988; Nottingham, & Mat- the aid of the scoring manual.
son, 1981; Randolph, Hicks, Mason, & Cuneo, The scoring system uses a 3-point scale from
1982), consists of 22 sentence-completion stems, 0 to 2. The scoring manual serves as a guide,
each of which focuses on a legal as well as a with examples of prototypical responses at the
psychological aspect of competency for trial three levels of scoring. In general, characteris-
(Table 1). A factor analysis of the CST reveals tics that would merit a score of 0 involve sub-
six factors, all closely related to the established stantial disorganization in content, inability to
legal criteria for competency for trial. These are relate or to trust, defining the lawyer’s role as
(a) relationship of the defendant to his or her punitive or rejecting, extreme concreteness, or
attorney in developing a defense; (b) defendant’s self-defeating behavior. A 1-point score is given
understanding and awareness of the nature of when the response can be characterized as pas-
the court proceedings; (c) defendant’s affective sive, acquiescent, avoidant, or impoverished,
response to the court process in dealing with ac- though not clearly inappropriate. Reference to
cusations and feelings of guilt; (d) judgmental the scoring manual provides specific guidelines
qualities in engaging in the strategy and eval- for each item. For example, a 2-point response
uation of the trial; (e) defendant’s trust and con- to Item 2, “When I go to court, the lawyer will
fidence in his or her attorney; and (f) defen- . . . ,” is “defend me.” In contrast, a sentence
dant’s recognition of the seriousness of his or completion of “put me away” would merit a 0.
her position. The legal criterion relates to the defendant’s un-
The CST is administered as a paper-and- derstanding of the lawyer’s role in aiding in his
pencil test, with a brief instruction regarding or her defense. The psychological referent is the
the completion of each sentence as it relates to ability to trust and accept the attorney.
the law and going to court. Although typically The CST can be used when the competency
610 part ix • forensic matters

issue is raised before the trial or at any time function and cope with a trial. Thirteen variables
during the trial proceedings. Defendants who guide the interviewer in conducting the compe-
score in the competent range on the CST are tency assessment (Table 2). The 13 items are
unlikely to present as false negatives, that is, rated from a grade of 0 (least competent) to 5
incompetent after further assessment (Lipsitt, (most competent). A clinical opinion based on
Lelos, & McGarry, 1971). A low score on the each function offers information to help the
CST places the defendant in the questionable court determine the ultimate issue of compe-
category for competency and in need of more tency in the case. The weight the court assigns to
extensive assessment. The semistructured for- one function may differ from another, since each
mat of the CAI or the IFI can elicit more de- function is considered independently, and the
tailed clinical information for evaluating com- various ratings are not cumulative. The judge
petency when the CST score is in the question- must assess the various scales to determine
able range. whether the defendant’s overall competency is at
The CAI designates the parameters for in- an adequate level to proceed to trial. While there
quiry into competency in language familiar are no objective standards for making the rat-
to lawyers and judges. The guidelines aid the ings, sample interview questions and responses
mental health professional in translating psy- are provided in the manual to aid in assessing the
chological factors into an assessment of ability to level of competency. If a substantial number of

table 2. Competency to Stand Trial Assessment Instrument

Degree of Incapacity

Total Severe Moderate Mild None Unratable

1. Appraisal of available legal defenses 1 2 3 4 5 6

2. Unmanageable behavior 1 2 3 4 5 6
3. Quality of relating to attorney 1 2 3 4 5 6
4. Planning of legal strategy, including guilty 1 2 3 4 5 6
plea to lesser charges where pertinent
5. Appraisal of role of:
a. Defense counsel 1 2 3 4 5 6
b. Prosecuting attorney 1 2 3 4 5 6
c. Judge 1 2 3 4 5 6
d. Jury 1 2 3 4 5 6
e. Defendant 1 2 3 4 5 6
f. Witnesses 1 2 3 4 5 6
6. Understanding of court procedure 1 2 3 4 5 6
7. Appreciation of charges 1 2 3 4 5 6
8. Appreciation of range and nature of possible 1 2 3 4 5 6
penalties
9. Appraisal of likely outcome 1 2 3 4 5 6
10. Capacity to disclose to attorney available 1 2 3 4 5 6
pertinent facts surrounding the offense
including the defendant’s movements, timing,
mental state, actions at the time of the offense
11. Capacity to realistically challenge prosecution 1 2 3 4 5 6
witnesses
12. Capacity to testify relevantly 1 2 3 4 5 6
13. Self-defeating vs. self-serving motivation 1 2 3 4 5 6
(legal sense)

Examinee——— Examiner———
Date———
 120 • evaluation of competency to stand trial 611

ratings are 3 or lower, the assumption of compe- Golding, S., Roesch, R., & Schreiber, J. (1984). As-
tency should be strongly questioned. sessment and conceptualization of competency
When ordering a competency evaluation, the to stand trial: Preliminary data on the Interdis-
judge often includes a request for an evaluation ciplinary Fitness Interview. Law and Human
Behavior, 9, 321–334.
to determine criminal responsibility. The ex-
Golding, S. L. (1993). Interdisciplinary Fitness In-
aminer must clearly separate the issues of com-
terview-Revised: Training manual. Unpub-
petency for trial from criminal responsibility lished manuscript.
and develop separate reports. Competency for Hoge, S. K., Bonnie, R. J., Poythress, N. G., & Mona-
trial is a description of current status, whereas han, J. (1999). The MacArthur Competence As-
criminal responsibility refers to “legal sanity” sessment Tool—Criminal Adjudication (Mac-
at the time of the offense. CAT-CA). Odessa, FL: Psychological Assess-
In cases in which a finding of legal incompe- ment Resources.
tency may be likely, it is generally recom- Jackson v. Indiana, 406 U.S. 715 (1972).
mended that information regarding remedia- Kinloch’s Case, 18 How. St. Tr. (Eng.) 395 (1746).
tion be provided to the court (Lipsitt, 1986). Laboratory of Community Psychiatry, Harvard
Medical School. (1973). Competency to stand
Courts usually rely on the forensic examiner’s
trial and mental illness (DHEW Publication
information and judgment with regard to the
No. HSM 73-9105).
defendant’s deficits and on the opinion regard- Lipsitt, P. D. (1970). The dilemma of competency for
ing treatment options and recommendations re- trial and mental illness. New England Journal
lating to appropriate interventions for the of Medicine, 228, 797 – 798.
restoration of competency within a reasonable Lipsitt, P. D. (1986). Beyond competency to stand
period of time. trial. In L. Everstine & D. S. Everstine (Eds.),
Psychotherapy and the law (pp. 131–141). Or-
lando: Grune & Stratton.
SUMMARY Lipsitt, P. D., Lelos, D., & McGarry, A. L. (1971). Com-
petency for trial: A screening instrument. Amer-
ican Journal of Psychiatry, 128(1), 105 –109.
Competency is a legal concept, not a psycholog-
Nicholson, R. A., Robertson, H. C., Johnson, W. G.,
ical diagnosis. It refers to the capacity or ability
& Jensen, G. (1988). A comparison of instru-
to perform the task of adequately participating ments for assessing competency to stand trial.
in one’s criminal trial. Criteria have been estab- Law and Human Behavior, 12, 313 –322.
lished to evaluate the affective and cognitive fac- Nottingham, E. J., IV, & Mattson, R. E. (1981). A
tors that contribute to defending oneself in validation study of the Competency Screening
court with the aid of an attorney. The compe- Test. Law and Human Behavior, 5, 329 –335.
tency issue usually arises at the pretrial stage Otto, R. K, Poythress, N. G., Nicholson, R. A.,
when a defendant is charged or indicted, but it Edens, J. F., Monahan, J., Bonnie, R. J., et al.
may be raised at any time during the trial pro- (1998). Psychometric properties of the Mac-
cedures. The issue may be raised by the defense Arthur Competence Tool—Criminal Adjudica-
tion. Psychological Assessment 10, 435 – 443.
attorney, the prosecutor, or the judge. Compe-
Randolph, J. J., Hicks, T., Mason, D., & Cuneo, D. J.
tency is an evaluation of current functioning
(1982). The Competency Screening Test: A val-
and is clearly distinguished in concept and focus idation study in Cook County, Illinois. Crimi-
of evaluation from criminal responsibility or the nal Justice and Behavior, 9, 495 – 500.
insanity defense. Instruments described here
have been developed as aids for the forensic
mental health professional in assisting the court Related Topics
in the determination of competency for trial.
Chapter 115, “Forensic Evaluations and Testimony”
Chapter 116, “Forensic Evaluation Outline”
References & Readings Chapter 117, “Forensic Referrals Checklist”
Chapter 119, “Forensic Assessment Instruments”
Dusky v. U.S., 362 U.S. 402 (1960).
Godinez v. Moran, 509 U.S. 389; 113 S. Ct. 268
(1993).
 A MODEL FOR CLINICAL
121 DECISION MAKING WITH
DANGEROUS PATIENTS

Leon VandeCreek

Dangerous patients pose a special challenge to legislation that followed the lead of Tarasoff,
psychotherapists. If, on the one hand, the ther- however, has created a “duty to protect” doc-
apist underestimates the patient’s threats and trine that therapists are often advised to follow
harm comes to a third party, the therapist may even if their states have not formally endorsed
feel that more should have been done to protect the doctrine through legislation or court deci-
the innocent victim, and the victim, or sur- sions (VandeCreek & Knapp, 1993). Conse-
vivors, may initiate a lawsuit. On the other quently, therapists must now consider clinical
hand, if the therapist incorrectly believes that issues in the context of both ethical and legal
harm is imminent and acts to warn a potential constraints. Fortunately, courts recognize that
victim, the patient may feel betrayed and the psychotherapists cannot predict dangerousness
therapeutic relationship may be threatened. with complete accuracy. Instead, the courts con-
Even worse, the patient may drop out of ther- sider whether the psychotherapist used accept-
apy and lose faith in therapists, thereby ending able professional judgment in completing an as-
any preventive role that therapy may have had sessment of dangerousness and in developing
in preventing violence. and implementing the treatment plan (Vande-
The American Psychological Association’s Creek & Knapp, 2000).
(APA) “Ethical Principles of Psychologists and One of the difficulties that therapists face,
Code of Conduct” (2002) permits psychologists however, when managing dangerous patients is
to breach confidentiality if it is necessary to that no standard of care has been established.
protect the patient or others from harm. The The recent practice of specifying empirically
option of breaching confidentiality, permitted supported treatments for a variety of mental
by the ethics code, may protect the psychologist health conditions has not yet been applied to
from charges of ethical violations, but the psy- the diagnosis and treatment of patients who
chologist must still exercise judgment about pose a danger to others (VandeCreek & Knapp,
when to breach confidentiality or when to en- 2000). Botkin and Nietzel (1987) surveyed psy-
gage in other strategies that may reduce the po- chologists about their use of interventions with
tential for violence. dangerous patients. They found that hospital-
Decision making with dangerous patients is izing, strengthening the therapeutic alliance,
made more precarious by the increased possi- managing the patient’s environment, and break-
bility of legal liability. Prior to the 1976 Cali- ing confidentiality were the most frequently
fornia Supreme Court decision of Tarasoff v. employed interventions. Similarly, Monahan
Regents of the University of California, psy- (1993) recommended three broad areas of in-
chotherapists did not have to contend with legal tervention for patients who pose a high risk of
repercussions surrounding confidentiality in violence: hospitalizing patients, intensifying
their management of dangerous patients. The treatment, and warning potential victims. More
Tarasoff ruling, and that of other courts and recently, Truscott, Evans, and Mansell (1995)

612
 121 • a model for clinical decision making with dangerous patients 613

Break Confidentiality

Build Rapport
and/or Involve Intensify Therapy
High Significant Others and
and/or Hospitalize
Manage Environment
Violence Risk

Shift Focus
Low Build Rapport to Violence
Management

Weak Strong

Therapeutic Alliance

figure 1. Model for Decision Making with Dangerous Clients (reprinted with per-
mission from Truscott, Evans, & Mansell, 1995)

presented a model for decision making when consider hospitalization. Breaking confidential-
working with dangerous patients. Their model ity, then, should occur only in the context of a
is presented here. weak alliance and high violence potential.
The model proposes that patients who pose a To implement this model, or any other deci-
threat of violence be thought of as occupying sion making model, when working with poten-
one of four cells in a 2 ⫻ 2, Violence Risk ⫻ tially dangerous patients, psychologists must
Therapeutic Alliance Strength table. Interven- make assessments of violence potential. The le-
tions can be selected to strengthen the alliance gal test in predicting violence is one of “reason-
and reduce the violence risk as suggested by able foreseeability.” That is, would other psy-
Botkin and Nietzel (1987) and Monahan chologists with a similar patient make a similar
(1993). The model is presented in Figure 1. assessment and draw a similar conclusion? Li-
The authors suggest that whenever possible, ability is more likely to be imposed if the psy-
psychologists should work to strengthen and chologist failed to follow appropriate proce-
maintain the therapeutic alliance because the dures in reaching a decision and in implement-
alliance is the backbone of most interventions. ing the decision than if an incorrect prediction
If the alliance is weak, the psychologist has a was made. Thorough records are imperative to
reduced chance of effectiveness with the pa- document decision making about dangerous pa-
tient, especially when risk of violence is high. tients.
The model suggests that when the alliance is The following variables should be considered
strong, the psychologist can focus on violence when reviewing a patient’s potential for vio-
management, and if the risk of violence in- lence (Borum, 1996; Litwack, Kirschner, &
creases, therapy should be intensified and the Wack, 1993; Meloy, 1987; Monahan & Stead-
patient’s environment more carefully managed. man, 1994; Otto, 2000). Truscott et al. (1995)
On the other hand, if the alliance is weak and provide several case examples that use these
the risk of violence is high, the psychologist risk factors within the context of the decision-
should attempt to strengthen the alliance and/ making model. Individual characteristics in-
or involve significant others in treatment and clude the following:
614 part ix • forensic matters

• History of violence: This is the single best creasing the frequency of sessions, address-
predictor of violent behavior. The age at ing anger in psychotherapy, incorporating
which the first offense occurred is also an im- other parties into treatment, asking the
portant variable. Individuals who commit patient to release weapons, and reviewing
their first violent offense prior to adolescence requirements of relevant duty-to-protect
are more likely to engage in violent behav- statutes?
iors throughout their lifetime. 4. Have I consulted with a knowledgeable col-
• Clinical risk factors: A diagnosis of substance league?
abuse or dependence is probably the second 5. Have I carefully documented my clinical
most important factor. Persons with mental judgment and treatment and my consulta-
illness who believe that they are being tions?
threatened by others are also more likely to
resort to violence.
• Demographic variables: Non-White persons References & Readings
in their late teens and early 20s with low IQ
and education are most likely to engage in vi- American Psychological Association. (2002). Ethical
principles of psychologists and code of conduct.
olent behaviors. Unstable residential and
American Psychologist, 57, 1060 –1073.
work histories increase the risk. Until re- Borum, R. (1996). Improving the clinical practice of
cently, men were believed to pose more risks violence risk assessment. American Psycholo-
of violence than women, but research now gist, 51, 945 – 956.
suggests that clinicians, at least those work- Botkin, D. J., & Nietzel, M. T. (1987). How thera-
ing with more disturbed patient populations, pists manage potentially dangerous clients: To-
should not consider patient sex to be a base- ward a standard of care for psychotherapists.
line risk factor (Otto, 2000). Professional Psychology: Research and Prac-
tice, 18, 84 – 86.
Situational characteristics include the fol- Lidz, C., Mulvey, E., & Gardner, W. (1993). The
lowing: accuracy of predictions of violence to others.
Journal of the American Medical Association,
269, 1007 –1011.
• Availability of potential victim(s): Most vi- Litwack, T. R., Kirschner, S. M., & Wack, R. C. (1993).
olent crimes occur between people who know The assessment of dangerousness and predictions
each other. of violence: Recent research and future prospects.
• Access to weapons: Persons with martial arts Psychiatric Quarterly, 64, 245 –273.
training or combat experience, and those who Meloy, J. R. (1987). The prediction of violence in
possess great physical strength are capable of outpatient psychotherapy. American Journal
inflicting greater harm. of Psychotherapy, 41, 38 – 45.
• Stressors: Daily stressors such as relation- Monahan, J. (1993). Limiting therapist exposure to
ship and financial problems can reduce a per- Tarasoff liability: Guidelines for risk contain-
son’s frustration tolerance. ment. American Psychologist, 48, 242–250.
Monahan, J., & Steadman, H. J. (Eds.). (1994).
Violence and mental disorder: Developments
Psychotherapists can assess the quality of in risk assessment. Chicago: University of Chi-
their management of dangerous patients by cago Press.
asking the following questions: Mossman, D. (1994). Assessing predictions of vio-
lence: Being accurate about accuracy. Journal of
1. Am I aware of state and federal laws and Consulting and Clinical Psychology, 62, 783 –
agency policies? 792.
2. Have I done a thorough evaluation of the Otto, R. K. (2000). Assessing and managing violence
dangerousness of the patient and have I up- risk in outpatient settings. Journal of Clinical
dated it recently? Psychology, 56, 1239 –1262.
3. When patients have presented a threat of Stromberg, C., Schneider, J., & Joondeph, B. (1993).
Dealing with potentially dangerous patients:
harm, have I modified my treatment plan to
The psychologist’s legal update. Washington,
address the increased risk, such as by in-
 122 • principles for conductinng a comprehensive child custody evaluation 615

DC: National Register of Health Service Pro- the treatment of life-endangering patients.
viders in Psychology. Sarasota, FL: Professional Resource Press.
Tarasoff v. Regents of the University of California, VandeCreek, L., & Knapp, S. (2000). Risk manage-
17 Cal. 3d 425, 551 P.2d 334 (1976). ment and life-threatening patient behavior.
Truscott, D. (1993). The psychotherapist’s duty to Journal of Clinical Psychology, 56, 1335 –1351.
protect: An annotated bibliography. Journal of
Psychiatry & Law, 21, 221–244.
Related Topics
Truscott, D., Evans, J., & Mansell, S. (1995).
Outpatient psychotherapy with dangerous Chapter 114, “Confidentiality and the Duty to Protect”
clients: A model for clinical decision making. Chapter 115, “Forensic Evaluations and Testimony”
Professional Psychology: Research and Chapter 116, “Forensic Evaluation Outline”
Practice, 26, 484 – 490. Chapter 117, “Forensic Referrals Checklist”
VandeCreek, L., & Knapp, S. (1993). Tarasoff and Chapter 119, “Forensic Assessment Instruments”
beyond: Legal and clinical considerations in

PRINCIPLES FOR CONDUCTING

122 A COMPREHENSIVE CHILD
CUSTODY EVALUATION

Barry Bricklin

STEPS IN STRUCTURING AND should or should not notify the other par-
CONDUCTING A COMPREHENSIVE ent may arise. Following a written court
CUSTODY EVALUATION order, one must be aware of the controver-
sies and widespread misunderstandings
1. Seek to be a neutral, bilateral evaluator, ap- about the implications of what different le-
pointed to this role by a court order that gal custody dispositions allow a parent to
details the participants. If you cannot ob- do on behalf of a child should the other
tain a court order, seek a stipulation signed parent not be asked to share in the deci-
by both sides. If you lack access to both sion-making and/or object. For example,
sides, inspect any existing divorce and/or some psycholegal experts interpret shared
custody order to make certain the person legal custody as indicating that either par-
seeking your services has a legal right to ent can seek psychological services, and
waive confidentiality and give consent that others as indicating the agreement of both
the evaluation take place for the child in the parents is required. The latter is a safer po-
possible absence of agreement by the other sition. (Members of the legal community
parent. Prior to a written order, either par- are also divided on the implications of
ent can seek the services of a psychologist, shared legal custody.) The main arguments
albeit the issue of whether an evaluator against notifying and/or inviting the other
616 part ix • forensic matters

parent to participate, is that it may result in Have the main participants send appropri-
either alienation pressures directed at a ate consent-to-share information forms to
child, or physical intimidation of the per- relevant parties.
son seeking the services. If the written or- 8. Mail out self-report questionnaire forms or
der is unclear, which is often the case, re- use them as in-person interview guides
quest that the judge who wrote it clarify with all main participants. (See Bricklin &
the matter. Elliot, 1995, and Bricklin, 1995, for the
2. When you cannot secure the cooperation of tremendously extensive data needed for a
all critical participants, document efforts to comprehensive evaluation.)
do so. Remember to limit conclusions to 9. Arrange to have both parents bring in the
those made possible by available clinical child for any initial psychological testing.
and/or published databases and to detail in Arrange for the current noncustodial par-
any written report and/or courtroom tes- ent to spend several hours with the child on
timony what remains to be done to bring the two days prior to the initial visit. If you
the evaluation to the level of a bilateral, choose to interview the child at this initial
comprehensive one. session, be aware that each parent may
3. Make certain there is an explicit (or im- subtly or openly question the child regard-
plicit) database in terms of which the refer- ing what he or she said, and alienating
ral question can be addressed. Many par- pressures on the child may needlessly in-
ents want custody evaluators to help over- crease. Conduct an observation session in-
turn an existing plan on the basis of some volving the child and both parents together
highly subjective complaint (e.g., “He lets on this initial day. Make sure the parents
them go to bed dirty”). There are no data- put aside expressing their hostilities during
bases available by means of which an eval- this session.
uator can address such issues. 10. Arrange observation schedules that are fair
4. Have the involved attorneys clarify whether and balanced. Make sure the child spends
the change-of-circumstances issue must be an equal amount of time with each parent
addressed; that is, if there is an existing prior to one-on-one observation sessions.
custody order, it can be modified only un- (The existing visitation schedule may have
der certain conditions. to be modified.) Each child should be seen
5. Have the attorneys clarify all the legal with both parents together and with each
issues involved. This would include the alone. One may desire to observe other
“must assess” aspects demanded in a given family subsystems (e.g., all the children
jurisdiction (e.g., whether joint custody is together with each parent). It is exceed-
presumed to be the best choice unless ingly important to see the parents together
proven not to be). Make sure you under- if you are considering true joint (physical
stand both statutory and case-law legal cri- as well as legal) custody; one should docu-
teria. See Bricklin and Elliot (1995) for a ment their capacity for cooperative com-
sample model contract that covers many of munication. Set up scenarios in which you
the points mentioned here. can observe how a parent guides, sets lim-
6. Obtain signed consent forms to waive con- its, teaches, and so forth. In regard to all ob-
fidentiality requirements (to reveal as well servations, pay special attention to how
as seek relevant information, as when you a child utilizes parental communications,
need to obtain parent B’s reactions to alle- not simply to what parents are doing and/
gations made by parent A) and to adminis- or saying. A formal, quantified observation
ter tests and gather interview, observation, format designed to measure a caretaker’s
and document data in regard to all partici- impact on a child is presented in Bricklin
pants. and Elliot (2002a, 2002b) and Bricklin and
7. Mail out requests for pertinent documents Halbert (2004).
from schools, pediatricians, and so forth. 11. Test and further interview the parents.
 122 • principles for conducting a comprehensive child custody evaluation 617

12. Test and interview significant others (e.g., (the right and responsibility to make educa-
grandparents, live-in companions). tional, interpersonal and elective medical/psy-
13. Distinguish collateral sources of informa- chological decisions for a child) and physical
tion (e.g., neighbors, pediatricians) that re- custody (a time-share plan). Either parent can
quire in-person contact from those that do make emergency decisions. There is contro-
not. versy regarding what constitutes a psycholog-
14. Interview the child. ical emergency. Judges usually prefer to award
15. Use the gathered data to address the critical shared rather than sole legal custody (it keeps
assessment targets listed later. both parents involved) unless there are blatant
16. While various legal criteria of custody dis- reasons not to (bad logistics, serious psycho-
pute resolution detail what to evaluate pathology, the parents never agree about any-
(e.g., the Uniform Marriage and Divorce thing).
Act, Section 402, 1979), none specify how An orientational target is one of such major
to prioritize the huge amount of informa- importance that it must be addressed immedi-
tion collected, especially in terms of what it ately and/or kept in mind at all times. For ex-
means to an involved child. As of the time ample, a severe physical impairment on the part
this was written (February 2003), there of a child may make parental time availability a
were only two published systems offering controlling factor in a given case.
formal models to aggregate the data gath-
ered. Our model, A Comprehensive Cus- 1. The probability that the parents can reach an
tody Evaluation Standard System (AC- agreement on their own. (If high, one might
CESS; Bricklin & Elliot, 1995), uses data- recommend mediation instead of evalua-
based tests designed to illuminate the range tion.)
of impacts each parent is having on an in- 2. Information gleaned from prior legal pro-
volved child to prioritize the information ceedings: isolate what has already been es-
gathered and a modified Bayesian decision tablished and what remains to be done.
model to consider evidence for which no 3. Pertinent legal issues: jurisdictional criteria
“relevance” databases exist (e.g., a parent’s of dispute resolution (e.g., joint custody pre-
health, finances, time availability). Relia- sumption); need to address potential change
bility, validity and normative data now of circumstances; and so forth.
exist on 3,880 cases (Bricklin & Elliot, 4. Child’s psychological, physical, developmen-
2002a). Another model is by Ackerman and tal, educational, and cultural status. Seek to
Schoendorf (1992). identify a child’s unique needs so that the
Without a database, the evaluator must visitation plan suggested addresses them.
seek convergent and independent lines of
information. Assessment Targets
There is controversy as to whether a
psychologist in the role of an expert wit- Assessment targets are custody-relevant areas
ness in a courtroom setting should address that are assessed by a wide variety of clinical
an “ultimate issue,” which in a custody case techniques, generating data from psychological
might be who should be the primary cus- tests, observations, interviews, medical and ed-
todial parent. If in doubt, seek clarification ucational documents, and home visits.
from the presiding judge. Specific assessment targets are the degree to
which

CRITICAL ASSESSMENT AREAS 1. The child seems really “wanted” by each

disputant (e.g., does a parent pick up a child
Orientational Targets only to drop him or her off immediately at
A comprehensive custody evaluation seeks to a grandparent’s home?).
generate information relevant to legal custody 2. Each parent congruently offers (and mod-
618 part ix • forensic matters

els) communications to the child so as to 12. Each parent can provide continuity in all
engender signs of positive affective re- important phases of a child’s life (e.g., ex-
sponses in the child (e.g., happiness, good tended family, school, friendships, reli-
self-feeling). gious affiliations).
3. Each parent congruently offers (and mod- 13. Each parent can enhance the child’s rela-
els) communications to the child so as to tionship with each sibling.
engender signs of behavioral self-sufficiency 14. Each parent is available to be with the child.
(e.g., responses mirroring competency, in- 15. Each parent can provide adequate babysit-
dependence in thought and action). ting, day care, and so forth.
4. Each parent has demonstrated caretaking 16. Each parent can provide for the child’s ma-
skills in prior relationships. terial needs, including on-time meals, ap-
5. Each parent can avoid episodes of neglect propriate sleeping arrangements and home-
and physical or sexual abuse; the degree to work space, and so forth.
which each parent and person to whom the 17. Each parent is able to maintain good phys-
child might be exposed under competing ical health.
visitation arrangements can avoid episodes 18. A child’s consciously stated wishes (if ver-
of any criminal behavior. balized) may be taken into account. Our
6. Each parent can avoid episodes of alcohol or data indicate that children’s consciously
drug use that could impair child care re- sourced opinions about custody, even those
sponsibilities. of older children, have only a 50% agree-
7. Each parent can avoid episodes of dis- ment rate with those of mental health ex-
tractibility and/or irritability that could perts.
impair child care responsibilities.
8. Each parent is aware of the child’s daily
Data-Based Assessment Targets
routine, interpersonal relationships, health
needs, developmental history, school his- A data-based assessment target refers to a tar-
tory, fears, personal hygiene, communica- get that can be addressed by tests or procedures
tion patterns. in which the interpretations of the information
9. Each parent is able to recognize the critical yielded by the latter have been developed from
issues involved in child care situations; the a population representative of the cases to
necessity of selecting adequate solutions in which this target is to be applied. The degree to
child care situations; the importance of com- which
municating to the child in words and actions
understandable to the child; the desirabil- 1. Each parent teaches and models the skills of
ity of acknowledging the feelings aroused competency.
in a child by various situations; the desir- 2. Each parent offers and models warmth, em-
ability of considering a child’s unique past pathy, and support.
history in deciding how to respond to child 3. Each parent appropriately insists on (and
care situations; the importance of consider- models) consistency.
ing feedback data in responding to a child. 4. Each parent teaches and models admirable
10. Each parent is aware of his or her own traits (e.g., trustworthiness, altruism).
weak spots and vulnerabilities in dealing 5. Each parent is a source of psychological as-
with children, and the degree to which each sets and/or liabilities.
parent has developed strategies to cope 6. Each child seeks to be psychologically “close”
with these weaknesses. to each parent (Bricklin & Elliot, 1995).
11. Each parent shows flexibility, honesty, and
supportiveness in dealing with the child’s Note: A more comprehensive version of these
other parent and members of his or her materials can be found in Barry Bricklin, The
family and takes care introducing new par- Custody Evaluation Handbook: Research-Based
ent-companions into a child’s life. Solutions and Applications (New York: Brunner/
 122 • principles for conducting a comprehensive child custody evaluation 619

Mazel, 1995) and a summary of normative, reli- tody data be generated scientifically? Part I.
ability, and validity data can be found in Bricklin American Journal of Family Therapy, 32, 189 –
and Elliot (2002a and 2002b). 203.
Brodzinsky, D. (1993). On the use and misuse of
psychological testing in child custody evalua-
References & Readings tions. Professional Psychology: Research and
Practice, 24, 213 –219.
Ackerman, M. J., & Schoendorf, K. (1992). Acker- Gordon, R., & Peek, L. A. (1988). The custody quo-
man-Schoendorf scales for parent evaluation tient. Dallas, TX: Wilmington Institute.
of custody. Los Angeles: Western Psychological Halon, R. L. (1990). The comprehensive child cus-
Services. tody evaluation. American Journal of Forensic
Bricklin, B. (1995). The custody evaluation hand- Psychology, 8(3), 19 – 46.
book: Research-based solutions and applica- Sales, B., Manber, R., & Rohman, L. (1992). Social
tions. New York: Brunner/Mazel. science research and child-custody decision
Bricklin, B., & Elliot, G. (1995). ACCESS: A com- making. Applied and Preventive Psychology, 1,
prehensive custody evaluation standard sys- 23 – 40.
tem. Furlong, PA: Village Publishing. Schutz, B. M., Dixon, E. B., Lindenberger, J. C., &
Bricklin, B., & Elliot, G. (2000). Qualifications of Ruther, N. J. (1989). Solomon’s sword: A prac-
and techniques to be used by judges, attorneys tical guide to conducting child custody evalua-
and mental health professionals who deal with tions. San Francisco: Jossey-Bass.
children in high conflict divorce cases. Univer- Stahl, P. M. (1994). Conducting child custody evalu-
sity of Arkansas at Little Rock Law Review, ations: A comprehensive guide. Thousand Oaks,
122(3), 501–528. CA: Sage.
Bricklin, B., & Elliot, G. (2002a, April). What can Uniform Marriage and Divorce Act. (1979). In Uni-
empirical data on 4,500 child custody cases tell form Laws Annotated, 9A.
us? Paper presented at the American College of
Forensic Psychology, San Francisco, CA.
Bricklin, B., & Elliot, G. (2002b). The Perception-of- Related Topics
Relationships Test (PORT) and Bricklin Percep-
Chapter 12, “Interviewing Parents”
tual Scales (BPS): Current and new empirical
Chapter 115, “Forensic Evaluations and Testimony”
data on 3,880 cases, 1961–2002. Furlong, PA:
Chapter 116, “Forensic Evaluation Outline”
Village Publishing.
Chapter 119, “Forensic Assessment Instruments”
Bricklin, B., & Halbert, M. (2004). Can child cus-
 RECOGNIZING, ASSISTING,
123 AND REPORTING THE
IMPAIRED PSYCHOLOGIST

Gary R. Schoener

DEFINITIONS AND HISTORY tions in Psychology (Kilburn, Nathan, & Thore-

son, 1986). This was followed by the Advisory
The term impaired, when applied to a psycholo- Committee on the Distressed Psychologist,
gist or other health care professional, has histor- which reported to the Board of Professional Af-
ically been considered almost synonymous with fairs of the American Psychological Association
the notions of alcoholism or substance abuse. (APA), which soon changed the name to the Ad-
This reflects the fact that one of the most com- visory Committee on Impaired Psychologists
mon sources of impairment in health profession- and then produced the book Assisting Impaired
als is drug or alcohol addiction. Most “impaired Psychologists: Program Development for State
practitioner” programs in health professions, and Psychological Associations (Schwebel, Skorina,
even in the legal profession, focus on alcoholism & Schoener, 1988). A revised edition was pub-
and other substance abuse. Each of these pro- lished in 1994. The committee’s current name
grams also deals with other problems—for ex- uses “Colleague Assistance” in place of “Im-
ample, depression, marital difficulties, anxiety paired Psychologists” in order to underline a
disorders, and sexual compulsivity—but today broader focus, including prevention, and to
the focus remains on chemical abuse or depen- stress the need to help colleagues who are dis-
dency problems. tressed or impaired.
As defined in psychology, The topic of sexual misconduct by profes-
sionals has generated literally thousands of
impairment refers to objective change in a person’s books and articles (e.g., Lerman, 1990), with
professional functioning. An impaired psychologist some focused on prevention (e.g., Pope, Sonne,
is one whose work-related performance has dimin- & Holroyd, 1993) and others examining treat-
ished in quality. This may be manifested in one or ment of the offending professional (e.g., Gab-
more of the following ways: work assignments are bard, 1995; Gonsiorek, 1995; Schoener, Mil-
typically late or incomplete; conflict with colleagues grom, Gonsiorek, Luepker, & Conroe, 1989).
has noticeably increased; clients, students, or fami- For psychology, sexual misconduct is probably
lies have registered complaints; or the amount of ab- the most visible outcome of impairment, as well
senteeism and tardiness has markedly increased. as the most expensive in terms of the genera-
(Schwebel, Skorina, & Schoener, 1994, p. 2) tion of ethics complaints and licensure board ac-
tions, and it accounted for at least half of the
Organized psychology’s first major thrust at cost of defense and awards to plaintiffs in mal-
identifying and dealing with impairment in- practice actions. Sexual misconduct has typi-
volved a task force and then a book, Profession- cally not been dealt with by committees on im-
als in Distress: Issues, Syndromes, and Solu- paired practitioners in other professions, and in

620
 123 • recognizing, assisting, and reporting the impaired psychologist 621

psychology there has been debate over whether 2. Any reporting to a state board required by
it should be dealt with differently. Some have licensure statutes (e.g., Minnesota requires
questioned whether rehabilitation should be at- reporting of certain offenses unless they are
tempted in such cases (e.g., Pope et al., 1993), communicated by the psychologist who is
whereas others provide assessment and/or re- seeking help)
habilitation (e.g., Abel, Osborn, & Warberg, 3. Any reporting duties based on your knowl-
1995; Gabbard, 1995; Gonsiorek, 1995; Schoener, edge of dangers to others, such as potential
1995). dangers to clients
A relatively new factor in the handling of 4. Duties to report impaired functioning of a
impairment is the Americans With Disabilities staff member who works in the same facility
Act (cf. Bruyere & O’Keeffe, 1994). While pro- as you do
hibiting discrimination against individuals
with disabilities, both mental and physical, the In some states, colleague assistance or im-
act requires employers to “make reasonable ac- paired practitioner programs have selected ex-
commodation” to employees’ disabilities. This emptions from reporting duties. It is important
affects the handling of the impaired profes- that you determine whether such an exemption
sional in two ways. First, it provides an incen- might apply to your activities. They are typi-
tive to acknowledge disability rather than hide cally limited to work by professional review
it; second, it directs the psychologist in the role committees or impaired practitioner programs.
of employer to make reasonable efforts to help Those involved in subsequent treatment or re-
someone dealing with a disability function on habilitation should also note their responsibili-
the job. Thus, the impaired or potentially im- ties (cf. Jorgenson, 1995).
paired psychologist has reason to present his or
her difficulties to an employer or supervisor in
hopes of negotiating a helpful accommodation. GUIDELINES FOR INTERVENTION

The APA Code of Ethics and general standards

RESPONSIBILITY TO REPORT in professional practice, education, and research
require that psychologists consult with col-
Psychologists often have professional responsi- leagues who are at risk to engage in unethical
bilities with regard to clients, students, and practice. The practical issue of how and when to
others who may be affected by the practitioner’s intervene depends on the following factors:
impairment. Where such individuals are at
risk, there may be a duty to act quickly. In ad- 1. Your relationship with the colleague who is,
dition, reporting duties need to be carried out if or may be, impaired
you learn of possible child abuse or neglect or 2. Your professional status vis-à-vis the col-
of anything that must be reported to a state league — for example, a supervisor, profes-
board or other regulatory authority. sor, administrator
First and foremost, never agree to keep some- 3. Whether or not the colleague has come to
thing confidential until you know what the im- you for assistance
paired professional has to say and whether you 4. The organizational or institutional setting in
can keep it confidential. As with clients, anyone which you work and what policies, proce-
with whom you consult about impairment dures, and departments exist to help with
needs to know the limits of the privacy of your the situation
discussions with them. All of the following re-
porting duties would be based on state laws or The 2002 revision of APA Ethical Principles
guidelines: of Psychologists and Code of Conduct contains
a new section relating to students that cautions
1. Reporting of abuse or neglect of a minor or those who might begin inquiring about a stu-
of a vulnerable adult dent’s personal adjustment. Section 7.04 reads:
622 part ix • forensic matters

Student Disclosure of Personal Information. Psy- convention, can be contacted for resources
chologists do not require students or supervisees to through its Web site.
disclose personal information in course- or program- Several videotapes that focus on practitioner
related activities, either orally or in writing, regard- impairments may be quite useful for staff ori-
ing sexual history, history of abuse and neglect, psy- entation in an organization for assisting an
chological treatment, and relationships with parents, individual professional. The Journey Back, pro-
peers, and spouses or significant others except if (1) duced by a public television station in Los An-
the program or training facility has clearly identified geles, is available from Video Finder (800-343-
this requirement in its admissions and program ma- 4727). Michael F. Myers, M.D., has produced
terials or (2) the information is necessary to evaluate two films. Physicians Living With Depression,
or obtain assistance for students whose personal done under the auspices of the Committee on
problems could reasonably be judged to be prevent- Physician Health, Illness, and Impairment, is
ing them from performing their training- or profes- part of the American Psychiatric Association
sionally related activities in a competent manner or Videotape Series and can be purchased from
posing a threat to the students or others. American Psychiatric Press. Another tape con-
sists of Dr. Myers interviewing a physician who
Before acting, examine any organizational became impaired and had sexual contact with a
policies or guidelines concerning impaired staff. patient. Crossing the Boundary: Sexual Issues
In larger organizations, human resources de- in the Doctor-Patient Relationship can be or-
partments often play a role in such interven- dered from Dr. Michael Myers (604-732-8013
tion. They may be consulted for advice or for or 604-631-5498).
direct assistance. Employee assistance programs One of the fundamental questions in this
also provide guidance that may be of help. area is the manner of intervention. Some cir-
There also may be experts in your local com- cumstances permit a private talk with an im-
munity who can be of assistance. A number of paired practitioner to start things moving,
state psychological associations have colleague whereas in other cases a more active interven-
assistance committees. The Practice Directorate tion is necessary. Whenever several profession-
at the APA has such information through staff als confront an impaired psychologist jointly,
for the Advisory Committee on Colleague As- or involve others, such as family members,
sistance. The APA effort, in fact, is focused on there is the potential for greater anger and de-
the creation of state committees to provide as- fensiveness. However, in some circumstances,
sistance to those seeking to intervene or obtain little else works. Four intervention options
help for colleagues. If there are no readily iden- (Schwebel et al., 1994) are presented below.
tifiable local experts and there is no state com-
mittee, it is also possible to arrange for help
Voluntary Intervention
with substance-abusing or alcoholic colleagues
through Psychologists Helping Psychologists In some situations, an impaired psychologist
(PHP), a national organization founded in 1980. calls for help or approaches a colleague. It is es-
It can be contacted through Ann Stone at 703- sential to remember the importance of follow-
578-1644 (e-mail: [email protected]). Its Web through. The fact that a colleague comes in for
site can also be contacted for referrals. help does not mean that he or she will take the
Another possible resource is the colleague as- next step. Sometimes receiving support reduces
sistance committee of another health profession, the person’s motivation. Furthermore, it is im-
such as medicine. These committees can be most portant to have a competent diagnostician de-
easily located by contacting the state professional termine what sort of treatment is needed. Pro-
organization. In addition, PHP is connected to fessionals often look healthier than they are,
International Doctors in Alcoholics Anonymous, and as a result inadequate treatment may be
which consists of professionals in many fields planned. In the case of professional misconduct,
who are involved in Alcoholics Anonymous. such as sex with clients, it is critical that some-
This 53-year-old organization, which has a yearly one with specialized experience do the assess-
 123 • recognizing, assisting, and reporting the impaired psychologist 623

ment and treatment planning to avoid common with the psychologist’s spouse or significant
pitfalls in such cases (Gabbard, 1995). other, and an intervention team is organized
that includes a number of key people in the
psychologist’s life. Prior to the intervention,
The “12-Step” Intervention
this group meets and plans the intervention, in-
The 12-step intervention is aimed at someone cluding some role playing of possible scenarios.
who appears to be alcoholic or to have a sub- The eventual intervention is thus scripted be-
stance abuse problem. Psychologists or other forehand. The psychologist is then told that if he
health professionals who are in recovery from or she does not enter and complete treatment,
substance abuse and who have experience in specific negative consequences will occur. This
this type of intervention arrange a meeting can involve job suspension, a report to a licens-
with the impaired psychologist; they share ing body, or a spouse filing for divorce. This ap-
their own experiences and encourage the person proach is coercive and intrusive, and it may bring
to join Alcoholics Anonymous or Psychologists about an angry response from the psychologist.
Helping Psychologists or to seek help in an- It should be done with the aid of persons experi-
other way. Although such an intervention is in- enced in such work.
trusive, it is not intended to be confrontive. The
goal is to provide a model for recovery and to
SUPPORT AND MONITORING
convey the relief that a psychologist can be al-
coholic and benefit from help.
A major factor in the success of colleague assis-
tance is the degree to which you can help the
Confrontive Intervention psychologist start the treatment process. Help-
ing to arrange for work coverage, an appropri-
In confrontive intervention, an employer or a
ate medical leave, and identification of afford-
colleague assistance committee receives a report
able treatment covered by insurance is very im-
that a psychologist has a significant problem
portant. Many such practical problems can
and has not responded to suggestions that he or
sabotage treatment efforts. When someone is in
she seek help. An investigation is conducted to
treatment for impairment, maintaining contact
determine if such a problem can be documented
in a supportive fashion can be quite helpful. It
behaviorally, and then a small team of profes-
is also important to monitor compliance, to the
sionals (or, in some instances, a work super-
degree possible, in order to be able to confront
visor) confronts the psychologist with the
those who attempt to quit before completion.
evidence that has been gathered. A treatment
referral has previously been identified, the psy-
chologist is offered a plan of action, and peer WORK REENTRY
pressure is used to try to bring about an agree-
ment to receive help and follow through. This The main goal of any intervention should be to
approach is more confrontive than the 12-step facilitate a professional assessment and treat-
intervention in that considerable peer pressure ment planning of the psychologist. After that,
is applied. it is important to consult with the assessor con-
cerning job or practice limitations. When it
seems that the treatment is completed, there
Comprehensive Intervention
should be an assessment of the situation, in-
Comprehensive intervention is reserved for sit- cluding a “return to work” assessment, which
uations in which the psychologist’s problem is specifies things that would help prevent a re-
severe, or at least getting worse, and he or she currence and also reduce the risk of any mis-
has not responded to input or suggestions that conduct or relapse.
he or she seek help. It goes beyond the con- With alcoholism there may be a require-
frontive intervention in that the information- ment that the psychologist attend support
gathering process usually involves discussions groups and also a warning that the smell of al-
624 part ix • forensic matters

cohol on his or her breath may be sufficient nerability to depression. Northvale, NJ: Jason
cause for suspension. In the case of substance Aronson.
abuse, random urine testing may be required. It International Doctors in Alcoholics Anonymous.
is also likely that more frequent supervisory (n.d.). Home page. Retrieved 2004 from http://
www.ida.org
meetings will be required at first in order to en-
Jorgenson, L. (1995). Rehabilitating sexually ex-
sure that workload and duties are realistic given
ploitative therapists: A risk management per-
the recovery process. spective. Psychiatric Annals, 25, 118 –122.
Kilburn, R., Nathan, P., & Thoreson, R. (1986). Pro-
fessionals in distress: Issues, syndromes, and
REDUCING LEGAL RISKS solutions in psychology. Washington, DC: Amer-
ican Psychological Association.
Some of the legal risks connected with various Koocher, G. P., & Keith-Spiegel, P. (1998). Ethics in
types of intervention are discussed in Schwebel psychology: Professional standards and cases
et al. (1994). The more confrontive the interven- (2nd ed.). New York: Oxford University Press.
tion, the riskier it is. However, despite fears of re- Lerman, H. (1990). Sexual intimacies between psy-
chotherapists and patients: An annotated bibli-
taliation for invasion of privacy, such cases ap-
ography of mental health, legal, and public
pear to be quite rare. The most common mis-
media literature and relevent legal cases (2nd
takes with legal consequences are failures: to ed.). Washington, DC: Division of Psychother-
consult with human resources personnel; to plan apy, American Psychological Association.
the intervention within the personnel guidelines Pope, K. S., Sonne, J. L., & Holroyd, J. (1993). Sexual
of a facility; and to review the Americans With feelings in psychotherapy: Explorations for
Disabilities Act for its applicability to the situa- therapists and therapists-in-training. Washing-
tion. Psychologists need to be aware that when ton, DC: American Psychological Association.
disputes arise within the family, especially in Psychologists Helping Psychologists. (n.d.). http://
cases of family dissolution or divorce, well- www.crml.uab.edu/~jah/php.html
intentioned helpers can find themselves pawns in Schoener, G. R. (1995). Assessment of professionals
who have engaged in boundary violations. Psy-
intrafamilial power struggles. Thus, it is impor-
chiatric Annals, 25, 95 – 99.
tant to carefully gather background data and to
Schoener, G. R., Milgrom, J. H., Gonsiorek, J. C.,
be clear on what basis you believe the psycholo- Luepker, E. T., & Conroe, R. (1989). Psycho-
gist has a problem. therapists’ sexual involvement with clients: In-
tervention and prevention. Minneapolis, MN:
References, Readings, & Internet Sites Walk-In Counseling Center.
Schwebel, M., Skorina, J., & Schoener, G. (1994).
Abel, G., Osborn, C., & Warberg, B. (1995). Cogni- Assisting impaired psychologists: Program de-
tive-behavioral treatment for professional sexual velopment for state psychological associations
misconduct. Psychiatric Annals, 25, 106 –112. (Rev. ed.). Washington, DC: American Psycho-
Bruyere, S., & O’Keeffe, J. (1994). Implications of logical Association.
the Americans With Disabilities Act for psy- Skorina, J. K., Bissell, L. C., & De Soto, C. B. (1990).
chology. Washington, DC: American Psycho- The alcoholic psychologist: Routes to recovery.
logical Association. Professional Psychology: Research and Prac-
Gabbard, G. (1995). Transference and counter- tice, 21, 248 –251.
transference in the psychotherapy of therapists
charged with sexual misconduct. Psychiatric
Annals, 25, 100 –105.
Related Topics
Gonsiorek, J. (1995). Assessment and treatment of
health care professionals and clergy who sex- Chapter 65, “Refusal Skills Training”
ually exploit patients. In J. Gonsiorek (Ed.), Chapter 66, “Sexual Feelings, Actions, and Dilem-
Breach of trust: Sexual exploitation by health mas in Psychotherapy”
care professionals and clergy (pp. 225 –234). Chapter 113, “How to Confront an Unethical Col-
Thousand Oaks, CA: Sage. league”
Health, S. (1991). Dealing with the therapist’s vul- Chapter 136, “Therapist Self-Care Checklist”
 ESSENTIAL FEATURES OF
124 PROFESSIONAL LIABILITY
INSURANCE

Bruce E. Bennett

THE RELATIONSHIP BETWEEN • The risk of real or perceived damage or harm

RISK AND INSURANCE is not limited to psychologists who deliver
health care services.
Risk management essentially involves the trans- • Psychologists working for or consulting with
fer of financial obligations from one party to business or governmental agencies, indus-
another. trial organizational psychologists, academic
and research psychologists, and school psy-
• A significant feature of managed care ar- chologists also are vulnerable to litigation for
rangements is that some of the risk for pay- any harm or injury that may result from
ment of claims is shifted from the payer to their services. For example, a psychologist
the provider. who uses psychological tests for employee
• In clinical practice, a missed diagnosis or im- selection, retention, or promotion may be
proper treatment that damages a patient sued for any negative outcome based on the
may result in a malpractice suit against the evaluation. A student who feels harassed or
practitioner. is dissatisfied with a grade or evaluation may
• Fortunately, the psychologist can shift the risk sue his or her psychology professor or super-
for the potential financial loss to another party visor.
by purchasing professional liability insurance. • The delivery of psychological services is
never without risk.
• Any psychologist who provides professional
WHO NEEDS PROFESSIONAL services without adequate professional liabil-
LIABILITY COVERAGE? ity insurance has assumed the entire risk for
any financial losses, including legal expenses
Ideally, risk management would lead to the total to defend the practitioner and any damages
elimination or avoidance of activities that could awarded.
lead to harm, damage, or other negative conse-
quences. In practice the risk of damage or harm
to a client or other entity receiving professional POLICY TYPE
services can only be minimized. Even the most
ethical and skilled practitioners have been sub- Insurance is a written contract between the in-
ject to malpractice suits. It is important that sured and the insurance carrier. For the pre-
psychologists recognize there is always the pos- mium received, the insurance carrier agrees to
sibility of a negative outcome associated with both defend the psychologist (i.e., pay the legal
the delivery of professional services. expenses associated with defending a claim) and

625
626 part ix • forensic matters

indemnify the psychologist (i.e., pay for any • The premium for an occurrence policy is
cash settlements or damages awarded by a jury, higher than the premium for a claims-made
subject to any policy limitations). Two basic policy because coverage in an occurrence policy
types of professional liability coverage are is provided for all future claims that resulted
available: occurrence coverage and claims-made from alleged malpractice during the policy pe-
coverage. riod. Occurrence premiums remain relatively
stable over time, changing primarily as a func-
• Occurrence coverage: An occurrence policy tion of losses in the program, increases in legal
covers any incident that happens while expenses, and general inflation.
the policy is in force—regardless of when the • Premiums for a claims-made policy are lower
claim is filed. In an occurrence policy, the during the first few years because coverage is
claim will be covered according to the terms provided only for claims filed during the cov-
and conditions of the policy in force at the erage period. For example, first-year premi-
time the alleged malpractice occurred. A psy- ums need only cover the claims filed during
chologist who terminates an occurrence pol- the first year. As the policy matures, how-
icy (e.g., due to retirement, leave of absence, ever, the premiums will increase.
or changing to another policy type or another • The differential in cost between an occurrence
carrier) would be covered for any claim filed and a claims-made policy will generally ex-
in the future based on any alleged malpractice ceed the price of the tail coverage necessary
during the policy period. There would be no to terminate the claims-made policy. The psy-
need to purchase additional insurance. chologist can save considerable money by
• Claims-made coverage: A claims-made pol- purchasing claims-made coverage.
icy covers any incident that happens after • Independent of policy type, premiums will
the policy is in force. The claim, however, increase as the policy limits increase, as the
must be reported while the policy is in force. scope of coverage increases, and as benefits
All claims-made policies have a retroactive and enhancements are added to the policy.
date— the day that continuous coverage un- • Premiums for practitioners are higher in
der the claims-made policy begins. In order some states than in others.
to be covered under a claims-made policy, the • Premiums are generally lower in policies
incident must have occurred after the retro- that exclude certain types of activities, ser-
active date and the claim filed before the pol- vices, or service settings (e.g., custody evalu-
icy is terminated. Claims filed after coverage ations, certain types of forensic activities, and
ends will be covered only if the practitioner working in a correctional setting).
has purchased an extended reporting period, • Some policies include the cost of defending a
commonly referred to as “tail coverage.” In a malpractice suit within the policy limits,
claims-made policy, the claim will be covered thus reducing the amount available for pay-
according to the terms and conditions of the ment of damages by the amount of the legal
policy in force at the time the claim is filed. expenses. When the policy limits are reduced
by defense cost, the policy price should be
lower. Because of the high cost of defense,
FACTORS AFFECTING POLICY PRICE however, psychologists are encouraged to
avoid this restriction.
The majority of psychologists today purchase
claims-made insurance with coverage levels at
$1 million/$3 million (i.e., a maximum of $1 READ YOUR POLICY AND
million in coverage for a single incident and up UNDERSTAND HOW IT WORKS
to $3 million aggregate coverage for all claims
filed in the year). The range of coverage avail- It is important that psychologists be familiar
able extends from $200,000/$200,000 up to $2 with the terms, conditions, and exclusions in
million/$4 million. their professional liability policy.
 124 • essential features of professional liability insurance 627

Policy Conditions • A malpractice suit may allege that the psy-

Insurance policies contain a number of condi- chologist’s services and conduct were intended
tions that the insured must meet in order to to injure the plaintiff. Intentional and willful
keep the policy in force. acts are generally excluded from coverage.
• If a claim alleges acts or services that are ex-
• The policy may require that the insured co- cluded from coverage, the carrier will issue a
operate with the carrier in the defense of a “reservation of rights” letter to the defendant.
claim against the insured and that the in- This letter generally provides that the carrier
sured immediately report a suit or threat of will defend the case but may not have re-
suit to the carrier. sponsibility to pay for any damages awarded
• The policy may prohibit the insured from as- for the noncovered acts.
suming any obligations, incurring any costs,
or settling any claims without the company’s Special Provisions Related to
written consent. These and other conditions Sexual Misconduct Claims
are included in the policy to protect the car-
rier from additional unnecessary losses that Approximately half of the losses in the psychol-
may result from the practitioner’s inappro- ogists’ professional liability program are due to
priate actions. sexual misconduct claims. Small wonder, then,
• If the psychologist violates policy provisions, that many insurance carriers have imposed spe-
the insurance company may attempt to re- cific limitations on such claims. The carriers,
strict or deny coverage for a specific claim. In noting that sexual misconduct is unethical and
the extreme, the carrier may sue the psy- that an increasing number of states have crimi-
chologist to rescind the policy, thus avoiding nalized sexual relations between therapist and
all coverage for any claim. patient, are not willing to assume the liability
• If the carrier determines that the psycholo- for associated losses. Put differently, the com-
gist is a bad risk for coverage, the policy may pany shifts the risks associated with such be-
be terminated or not renewed. haviors to the practitioner, keeping the premi-
ums charged to ethical practitioners lower.

Policy Limitations or Exclusions • Some carriers cap the amount the policy will
pay for damages.
In addition to specific conditions regarding cov- • Other carriers will fully defend a sexual mis-
erage, professional liability insurance policies conduct claim but exclude any payments for
place limitations on, or exclude, coverage for damages.
specific activities.

• Psychologists’ professional liability insur- An insurance carrier may control for po-
ance generally will not cover claims against tential future losses by terminating or not re-
the insured for business relationships with newing the policy of a psychologist who has
current or former clients or as an owner or been found guilty of sexual misconduct by a li-
operator of a hospital or other overnight fa- censing board or ethics committee, even if no
cility. These functions involve business and malpractice suit has been filed. Psychologists
managerial decisions rather than the delivery dropped by one carrier will have difficulty find-
of professional services. Facilities such as hos- ing another carrier willing to offer coverage.
pitals will need “directors and officers” and Ethical practitioners should be concerned
“errors and omissions” coverage. with how the policy will respond to a frivolous
• The policy may exclude claims of dishonest, claim alleging sexual misconduct.
criminal, or fraudulent acts by the psychol-
ogist. Insurance is not sold to protect dishon- • A policy that contains a blanket exclusion for
est or criminal behavior. therapist-patient sex may not even provide a
628 part ix • forensic matters

legal defense. It is important that the policy the insured is advised to purchase the longest
defend claims alleging malpractice, regard- tail coverage possible. The cost for indefinite
less of the claim’s merit. tail coverage is usually 175% of the final
• Some policies cap the carrier’s liability for year’s premium.
damages in sexual misconduct cases at a fixed • Occurrence coverage to occurrence coverage
dollar amount. Under these terms, if a friv- by a different carrier: In order to avoid any
olous case is settled, the psychologist may be gap in coverage when moving from an oc-
required to pay that part of the settlement currence policy to an occurrence policy from
that is in excess of the capped amount. another carrier, the policy date of the new
• A policy that will not pay damages but will coverage should be the same as or earlier
defend multiple claims for sexual misconduct than the termination date of the terminated
may, in fact, provide the best protection for policy.
a frivolous claim. The legal costs of going • Claims-made coverage to claims-made cov-
to trial can be very high, for both plaintiff erage by a different carrier: The psychologist
and defendant. If the case is frivolous or who desires to change claims-made carriers
weak, the plaintiff, or plaintiff’s attorney, has two choices. (a) Purchase the tail cover-
may wish to negotiate a settlement. Gener- age on the old claims-made policy and pur-
ally, insurance carriers will attempt to settle chase the first-year step rates on the new
a case for an amount that is less than the cost claims-made policy using the same renewal
of defense. If such a settlement is reached, date as the old policy. If tail coverage is pur-
the carrier will make the payment. chased on the old policy, the previous carrier
will cover all claims generated under the ter-
minated policy. The new carrier will cover
CHANGING POLICY TYPES OR claims resulting from alleged malpractice oc-
INSURANCE CARRIERS
curring after the effective date of the new
policy. (b) Drop the old claims-made policy
When changing policy types or changing carri- and purchase the new claims-made policy us-
ers, be careful to avoid gaps in coverage. ing the same retroactive date as the old policy.
If the practitioner drops the old policy and
• Occurrence coverage to claims-made cover- purchases the new policy at the next step rate
age: In order to avoid any gap in coverage (e.g., if the current policy is at the fourth-
when moving from an occurrence policy to a year step rate, the new policy will be at the
claims-made policy, the retroactive date of fifth-year step rate), all claims will then be
the claims-made policy must be the same as covered by the new carrier. Purchasing the
or earlier than the termination date of the oc- new claims-made policy at the next step rate
currence policy. will generally be more cost-effective in the
• Claims-made coverage to occurrence cover- short run. In addition, if the new carrier has
age: In order to avoid any gap in coverage a better reputation for handling claims, the
when moving from a claims-made policy to practitioner should follow this latter strategy.
an occurrence policy, the psychologist must
(a) purchase the extended reporting period
or the “tail coverage” for the terminated COVERAGE FOR PSYCHOLOGISTS
claims-made policy and (b) purchase occur- EMPLOYED IN GROUP SETTINGS
rence coverage with a date that is the same or
earlier than the termination date of the Psychologists employed in group or corporate
claims-made policy. If the tail coverage is not practices, in schools or academic settings, or in
purchased, any claims filed after the claims- agency settings (e.g., mental health centers,
made policy is terminated will not be cov- hospitals, or other government agencies) need
ered. Because of the general long reporting to determine if they are adequately covered for
period for psychological malpractice claims, the services they perform in that setting. If not,
 124 • essential features of professional liability insurance 629

they should purchase their own personal liabil- but they will not cover the independent con-
ity insurance. The following issues should be tractor.
considered: • If a group is uninsured, it is possible that the
group may refuse to defend or indemnify a
• Does the employer/group (e.g., group or cor- psychologist-employee named in a malprac-
porate practice, mental health center, hospital, tice suit. The group may attempt to defend it-
corporation, government agency, school, aca- self by asserting that the psychologist-
demic institution) have professional liability employee acted outside the scope of the em-
insurance? ployment contract and that the group has no
• Does the insurance list both the group and duty to defend the alleged wrongdoing. In ef-
the employee as a named insured under the fect, the group might join the plaintiff against
policy? the psychologist-employee.
• Are the levels of coverage adequate to cover • Whereas an uninsured agency or organiza-
any losses against the group and its em- tion may have resources to defend a claim, it
ployees? may be unable to pay damages. Uninsured
• Do all members in the group share the ag- psychologists employed by such agencies
gregate limit of coverage, or does each mem- who are named as codefendants in the case
ber have his or her own aggregate limit? Al- may have to contribute to any damages
though managed care companies may prefer awarded.
to contract with group practices, many are • If a group or agency does not have profes-
hesitant to deal with groups in which all sional liability coverage, or if a psychologist-
members share the aggregate limit of cover- employee determines that the coverage avail-
age. able is not adequate, serious consideration
• Does the policy require the carrier to defend should be given to purchasing individual
and indemnify an employee who is sued for coverage.
malpractice if the employee is not a named
insured under the policy?
• Will the group policy cover an employee for SETTLEMENT VERSUS TRIAL
services rendered outside the group setting?
• Do local, state, or federal statutes provide Very few malpractice suits go to trial. Insurance
good-faith immunity for employees working carriers know that the most cost-effective reso-
in certain government settings? If a jury lution of this type of litigation is to settle the
determines that the psychologist actually case. On the other hand, psychologists who do
acted in bad faith (e.g., acted in a way to in- not believe they are guilty of malpractice usu-
tentionally harm the plaintiff), the immu- ally want to go to trial, even if an appeal to the
nity statute may be voided, and the psychol- U.S. Supreme Court is necessary.
ogist would then be responsible for payment
of the damages. • Regardless of the “innocence” of the practi-
• Regardless of the workplace setting, psychol- tioner, there is always the possibility that a
ogists should avoid an uninsured risk. If the jury will award large damages. The psychol-
practitioner renders professional services out- ogist would be personally responsible for any
side the group setting (e.g., part-time con- damages that exceed the policy limits.
sulting, supervision, teaching, or private • No one can predict how a jury will respond,
practice), it is always recommended that in- even to a claim that has no merit.
dividual coverage be in place. • The plaintiff may want to settle the case if
• Psychologists serving as independent con- the allegations of malpractice will be difficult
tractors for a group should have individual to prove, if the evidence indicates that the
coverage. Group policies will cover a suit case is not clear-cut, or if the damages are not
brought against the group as a result of the significant.
wrongdoing of an independent contractor, • The defendant may wish to settle to avoid
630 part ix • forensic matters

painful depositions, prolonged litigation, po- PROFESSIONAL LIABILITY INSURANCE

tential embarrassment in the public arena, IS FOR THE LONG TERM
and the loss of income due to time away from
the practice. Over time, the insurance industry tends to go
• The net effect is that both the plaintiff and through market cycles, fluctuating between
the defendant may have strong incentives to “soft” and “hard” markets. Competition is a
seek a settlement rather than go to trial. key factor in a soft market: the return on in-
• Most frivolous cases are dismissed or settled vestments is high, and insurance carriers at-
for small amounts. Fortunately, frivolous cases tempt to increase their cash flow by offering
are generally transparent; if so, they may not new products or by decreasing premiums on
have a significant impact on the psycholo- current products to capture competitors’ busi-
gist’s insurability. ness. In a hard market, when the economy is
• On the other hand, a large settlement is often not doing well, rates usually increase dramati-
interpreted as an indication of the serious- cally, and some companies may go out of busi-
ness of the charges and resulting damages. ness.
Malpractice suits against psychologists
tend to be filed long after the alleged negli-
PSYCHOLOGIST’S ROLE IN gence or misconduct occurred. The premiums
CASE SETTLEMENT collected today must provide coverage for a
possible claim against the psychologist in the
Most insurance policies (e.g., auto or home- future, sometimes years later. If current rates
owner’s insurance) permit the insurance com- are too low, the carrier may not be able to pro-
pany to settle a claim without the consent of the vide the protection when needed. Moving
insured. One professional liability policy con- from a soft to a hard market when premiums
tained a provision that required the written have been artificially low could result in large
consent of the insured to settle a claim; if an in- rate increases, modifications in the scope of
sured refused to settle, the carrier was forced to coverage, or a decision by the carrier to drop
take the case to trial. Although this provision this line of coverage. Psychologists are advised
may seem beneficial to the insured individual, to view the purchase of professional liability
the result is that almost all cases go to trial, at insurance as an investment in the future. Put
great expense to all practitioners insured under differently, a cheap policy may come with a
the program. high price.
The major psychologists’ professional lia-
bility policies provide a compromise between
these two extreme positions. In the course of ADMITTED VERSUS SURPLUS
litigation, the attorneys for the plaintiff and de- LINES CARRIERS
fendant may discuss settlement as an option to
trial. Even if the attorneys representing the Most insurance carriers are “admitted,” that is,
plaintiff and defendant reach agreement on a approved by the state insurance commissioner
proposed settlement, the carrier cannot settle to do business in that state. Admitted carriers
the case without the written consent of the in- are required to participate in consumer protec-
sured. However, if the insured refuses to accept tion programs in the state. If an admitted car-
the settlement proposal, the carrier’s ultimate rier cannot meet its obligations to cover losses,
liability will be capped at the amount of the state insurance funds may be available to pro-
proposed settlement. If a jury awards damages tect the insureds. Some carriers, however, offer
in excess of the capped amount, the psycholo- policies on a nonadmitted basis, commonly re-
gist, not the carrier, will have to pay the differ- ferred to as “surplus lines coverage.” Such pol-
ence. icies will clearly state that insured psycholo-
gists are not protected by state-authorized con-
sumer protection programs.
 124 • essential features of professional liability insurance 631

• Surplus lines coverage may be available for endorsed or sponsored comprehensive and cost-
practitioners who are otherwise uninsurable effective professional liability insurance for
because of a history of previous claims. Such more than 30 years, during both soft and hard
policies are usually very expensive and may markets, including times when some carriers
restrict available limits of liability. dropped psychology as a line of coverage. The
• Other carriers may offer surplus lines cover- Trust-sponsored professional liability insur-
age in markets where coverage is not readily ance program was developed by psychologists
available (e.g., in hard markets when carriers for psychologists. The Trust serves as an om-
fail or stop offering this type of coverage). budsperson for practitioners, representing their
interests on all aspects of coverage and price.

WHERE TO PURCHASE PROFESSIONAL References & Readings

LIABILITY INSURANCE
Koocher, G. P., & Keith-Spiegel, P. C. (1998). Ethics
in psychology: Professional standards and
The diligent psychologist will approach the cases (2nd ed.). New York: Oxford University
subject of professional liability insurance as an Press.
important business decision, both to protect the Woody, R. H. (1988). Protecting your mental health
psychologist’s assets and to provide the comfort practice: How to minimize legal and financial
and security needed to function in a profes- risk. San Francisco: Jossey-Bass.
sional capacity. Wright, R. H. (1981). Psychologists and professional
Policy features, strength and stability of the liability (malpractice) insurance: A retrospec-
carrier, price, special enhancements, and repre- tive review. American Psychologist, 36, 1485 –
sentation of the psychologist’s interests with 1493.
the carrier are important aspects of any pur-
chasing decision. The majority of practitioners Related Topics
purchase professional liability insurance from Chapter 107, “Basic Principles for Dealing With
programs endorsed or sponsored by their na- Legal Liability Risk Situations”
tional professional association. The American Chapter 108, “Defending Against Legal Com-
Psychological Association Insurance Trust has plaints”
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PART X
Practice Management
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 SAMPLE PSYCHOTHERAPIST-
125 PATIENT CONTRACT

Eric A. Harris & Bruce E. Bennett

This draft psychotherapist-patient contract has than adjusting your practices to fit the contract.
been prepared for two reasons. First, it allows More importantly, you should make sure that
one to comply with the requirement that prac- the provisions of this contract are in compliance
titioners have the informed consent of their pa- with the requirements of the HIPAA Privacy
tients (American Psychological Association, Rule (Standards for Privacy of Individually
2002, Standards 3.01 and 10.01). Second, it al- Identifiable Health Information). In addition,
lows a therapist to establish a legally enforce- since regulations and laws governing certain in-
able business relationship with the patient and stitutions are somewhat different than those
avoids risks that such business issues will be- governing private practitioners, these forms
come the basis of a malpractice suit or an ethics may also need to be modified before they can be
or licensing board complaint. Most commenta- used in hospitals, clinics, or other institutional
tors suggest that full informed consent is both settings.
ethically necessary and a good risk manage- This document includes some basic, general
ment strategy. language about the risks and benefits of psy-
This draft was designed for psychotherapy chotherapy; these should be supplemented, ei-
practices. It can and should be modified to in- ther in writing or orally, by the therapist on a
clude other practice areas such as psychological case-by-case basis. This approach was selected
evaluations, testing, neuropsychological assess- because the risks and benefits of therapy can
ment, family therapy, and group psychotherapy vary considerably from case to case. Therefore,
if these are part of a practitioner’s work. it is hard to design a single draft that is appro-
There is a great variety of business practices priate for all situations. For example, it is prob-
among psychologists. You should redraft the ably important to have a much more thorough
contract to fit your business practices, rather discussion of risks and benefits with those pa-

635
636 part x • practice management

tients considered to be either most difficult or you might have so that we can discuss them at
most risky. If one is a group or family therapist, our next meeting. Once you sign this, it will
additional issues may need to be included. The constitute a binding agreement between us.
psychologist may orally provide whatever addi-
tional information is required and make a note
in the record about what was said. Of course, Psychological Services
this will not be as protective as a signed agree- Psychotherapy is not easily described in gen-
ment, but in most cases it makes the most sense eral statements. It varies depending on the per-
clinically. sonality of both the therapist and the patient
Although this model contract was originally and the particular problems which the patient
developed for Massachusetts psychologists, most brings. There are a number of different ap-
of it can be used anywhere. There are two ex- proaches which can be utilized to deal with the
ceptions: (a) patients’ access to their own records problems you hope to address. It is not like vis-
and (b) the laws and regulations governing ther- iting a medical doctor, in that psychotherapy
apeutic confidentiality and testimonial privilege, requires a very active effort on your part. In or-
as well as exceptions to these protections of the der to be most successful, you will have to work
psychotherapist-patient relationship. The model on things we talk about both during our ses-
provides sufficient alternative sections to cover sions and at home.
almost all variations regarding record access. Psychotherapy has both benefits and risks.
However, there is much variation from state to Risks sometimes include experiencing uncom-
state in laws governing privilege, confidential- fortable feelings such as sadness, guilt, anxiety,
ity, and exceptions to both, so an adaptation anger and frustration, loneliness, and helpless-
should be made for each state in which a psy- ness. Psychotherapy often requires discussing
chologist practices. unpleasant aspects of your life. Psychotherapy
The reader is strongly advised to have his or has also been shown to have benefits for people
her personal attorney review the informed con- who undertake it. Therapy often leads to a sig-
sent document prior to implementation. The nificant reduction in feelings of distress, better
document should be in compliance with local relationships, and resolutions of specific prob-
and state statutes regulating the practice of psy- lems. But there are no guarantees about what
chology. It should also avoid language that will happen.
could be interpreted as a guarantee or implied Our first few sessions will involve an evalu-
warranty regarding the services rendered. ation of your needs. By the end of the evalua-
This consent form is the property of the tion, I will be able to offer you some initial im-
American Psychological Association Insurance pressions of what our work will include and an
Trust (APAIT), and copyright to the form is initial treatment plan to follow, if you decide to
owned by the APAIT, © 1997 American Psy- continue. You should evaluate this information
chological Association Insurance Trust. This along with your own assessment about whether
form is used with permission. you feel comfortable working with me. Ther-
What follows is a specific draft text that you apy involves a large commitment of time,
may adapt for your practice or agency. Sections money, and energy, so you should be very care-
of the draft where you should insert numbers ful about the therapist you select. If you have
are designated XX, and sections you may want questions about my procedures, we should dis-
to specially modify are bracketed [thus]. cuss them whenever they arise. If your doubts
persist, I will be happy to help you to secure an
appropriate consultation with another mental
Outpatient Services Contract health professional.

Welcome to my practice. This document con-

Meetings
tains important information about my profes-
sional services and business policies. Please read My normal practice is to conduct an evaluation
it carefully and jot down any questions that which will last from two to four sessions. Dur-
 125 • sample psychotherapist-patient contract 637

ing this time, we can both decide whether I am rears and suitable arrangements for payment
the best person to provide the services that you have not been agreed to, I have the option of us-
need in order to meet your treatment objec- ing legal means to secure payment, including
tives. If psychotherapy is initiated, I will usu- collection agencies or small claims court. [If
ally schedule one 50-minute session (one ap- such legal action is necessary, the costs of
pointment hour of 50 minutes’ duration) per bringing that proceeding will be included in the
week at a mutually agreed time, although claim.] In most cases, the only information I re-
sometimes sessions will be longer or more fre- lease about a client’s treatment would be the
quent. Once this appointment hour is sched- client’s name, the nature of the services pro-
uled, you will be expected to pay for it unless vided, and the amount due.
you provide XXX hours/days advance notice of
cancellation [or unless we both agree that you
Insurance Reimbursement
were unable to attend due to circumstances
which were beyond your control]. [If it is pos- In order for us to set realistic treatment goals
sible, I will try to find another time to resched- and priorities, it is important to evaluate what
ule the appointment.] resources are available to pay for your treat-
ment. If you have a health insurance policy, it
will usually provide some coverage for mental
Professional Fees health treatment. I will provide you with what-
ever assistance I can in facilitating your receipt
My hourly fee is $XXX. In addition to weekly
of the benefits to which you are entitled includ-
appointments, it is my practice to charge this
ing filling out forms as appropriate. However,
amount on a prorated basis for other profes-
you, and not your insurance company, are re-
sional services you may require such as report
sponsible for full payment of the fee that we
writing, telephone conversations that last
have agreed to. Therefore, it is very important
longer than XX minutes, attendance at meet-
that you find out exactly what mental health
ings or consultations with other professionals
services your insurance policy covers.
that you have authorized, preparation of re-
You should carefully read the section in your
cords or treatment summaries, or the time re-
insurance coverage booklet that describes men-
quired to perform any other service that you
tal health services. If you have questions, you
may request of me. If you become involved in
should call your plan administrator and inquire.
litigation that requires my participation, you
Of course, I will provide you with whatever in-
will be expected to pay for the professional time
formation I can based on my experience and
required even if I am compelled to testify by
will be happy to try to assist you in deciphering
another party. [Because of the complexity and
the information you receive from your carrier.
difficulty of legal involvement, I charge $XXX
If necessary to resolve confusion, I am willing
per hour for preparation for and attendance at
to call the carrier on your behalf.
any legal proceeding.]
The escalation of the cost of health care has
resulted in an increasing level of complexity
about insurance benefits which sometimes
Billing and Payments
makes it difficult to determine exactly how
You will be expected to pay for each session at much mental health coverage is available.
the time it is held, unless we agree otherwise or “Managed Health Care Plans” such as HMOs
unless you have insurance coverage that re- and PPOs often require advance authorization
quires another arrangement. Payment sched- before they will provide reimbursement for
ules for other professional services will be agreed mental health services. These plans are often
to at the time these services are requested. [In oriented toward a short-term treatment ap-
circumstances of unusual financial hardship, I proach designed to resolve specific problems
may be willing to negotiate a fee adjustment or that are interfering with one’s usual level of
installment payment plan.] functioning. It may be necessary to seek addi-
If your account is more than 60 days in ar- tional approval after a certain number of ses-
638 part x • practice management

sions. In my experience, while quite a lot can be you will be available. [In emergencies, you can
accomplished in short-term therapy, many try me at my home number.] If you cannot
clients feel that more services are necessary af- reach me, and you feel that you cannot wait for
ter insurance benefits expire. [Some managed me to return your call, you should call your
care plans will not allow me to provide services family physician or the emergency room at the
to you once your benefits are no longer avail- nearest hospital and ask for the [psychologist or
able. If this is the case, I will do my best to find psychiatrist] on call. If I am unavailable for an
you another provider who will help you con- extended time, I will provide you with the
tinue your psychotherapy.] name of a trusted colleague whom you can con-
You should also be aware that most insur- tact if necessary.
ance agreements require you to authorize me to
provide a clinical diagnosis and sometimes ad-
Professional Records
ditional clinical information such as a treat-
ment plan or summary or in rare cases a copy Both law and the standards of my profession re-
of the entire record. This information will be- quire that I keep appropriate treatment records.
come part of the insurance company files, and, You are entitled to receive a copy of the records,
in all probability, some of it will be computer- but if you wish, I can prepare an appropriate
ized. All insurance companies claim to keep summary. Because these are professional records,
such information confidential, but once it is in they can be misinterpreted and/or can be up-
their hands, I have no control over what they setting to lay readers. If you wish to see your
do with it. In some cases they may share the in- records, I recommend that you review them in
formation with a national medical information my presence so that we can discuss the con-
data bank. If you request it, I will provide you tents. [I am sometimes willing to conduct such
with a copy of any report I submit. a meeting without charge.] Clients will be
Once we have all of the information about charged an appropriate fee for any preparation
your insurance coverage, we will discuss what time that is required to comply with an infor-
we can expect to accomplish with the benefits mation request.
that are available and what will happen if the
insurance benefits run out before you feel
Professional Records
ready to end our sessions. It is important to re-
member that you always have the right to pay [This section is for psychologists who practice
for my services yourself and avoid the com- in states that do not require that psychologists
plexities described above. provide clients with access to their records.]
As I am sure you are aware, I am required
to keep appropriate records of [the professional
Contacting Me
services I provide] [your treatment] [our work
I am often not immediately available by tele- together]. Because these records contain infor-
phone. While I am usually in my office be- mation that can be misinterpreted by someone
tween 9 A.M. and 5 P.M., I usually will not an- who is not a mental health professional, it is
swer the phone when I am with a client. I do my general policy that clients may not review
have call-in hours at XXXXX on XXXXX. When them. However, if you request, I will provide
I am unavailable, my telephone is answered by you with a treatment summary unless I be-
an automatic [answering machine] that I mon- lieve that to do so would be emotionally dam-
itor frequently [is answered by my secretary, or aging. If that is the case, I will be happy to for-
answering service who usually knows where ward the summary to another appropriate
to reach me, or voice mail that I monitor fre- mental health professional who is working
quently]. I will make every effort to return with you. [This service will be provided with-
your call on the same day you make it with the out any additional charge.] [You should be
exception of weekends and holidays. If you are aware that this will be treated in the same
difficult to reach, please leave some times when manner as any other professional (clinical) ser-
 125 • sample psychotherapist-patient contract 639

vice and you will be billed accordingly.] [There mation about our work to others with your
will be an additional charge for this service.] written permission. However, there are a num-
ber of exceptions.
In most judicial proceedings, you have the
Professional Records
right to prevent me from providing any in-
[This section is for psychologists who practice formation about your treatment. However, in
in states that require psychologists to provide some circumstances such as child custody pro-
clients with access to their records unless to do ceedings and proceedings in which your emo-
so would cause emotional damage, upset, etc.] tional condition is an important element, a
Both law and the standards of my profession judge may require my testimony if he or she
require that I keep appropriate treatment rec- determines that resolution of the issues before
ords. You are entitled to receive a copy of the him or her demands it.
records, unless I believe that seeing them would There are some situations in which I am
be emotionally damaging, in which case, I will legally required to take action to protect others
be happy to provide them to an appropriate from harm, even though that requires reveal-
mental health professional of your choice. Be- ing some information about a client’s treat-
cause these are professional records, they can be ment. For example, if I believe that a child, an
misinterpreted and/or can be upsetting, so I elderly person, or a disabled person is being
recommend that we review them together so abused, I must [may be required to] file a report
that we can discuss what they contain. [I am with the appropriate state agency.
sometimes willing to conduct such a meeting If I believe that a client is threatening seri-
without charge.] Clients will be charged an ap- ous bodily harm to another, I am [may be] re-
propriate fee for any preparation time that is quired to take protective actions, which may
required to comply with an information re- include notifying the potential victim, notify-
quest. ing the police, or seeking appropriate hospital-
ization. If a client threatens to harm himself
or herself, I may be required to seek hospital-
Minors
ization for the client or to contact family
If you are under 18 years of age, please be members or others who can help provide pro-
aware that the law may provide your parents tection.
with the right to examine your treatment These situations have rarely arisen in my
records. It is my policy to request an agreement practice. Should such a situation occur, I will
from parents that they consent to give up access make every effort to fully discuss it with you
to your records. If they agree, I will provide before taking any action.
them only with general information about our I may occasionally find it helpful to consult
work together unless I feel that there is a high about a case with other professionals. In these
risk that you will seriously harm yourself or consultations, I make every effort to avoid re-
another, in which case I will notify them of my vealing the identity of my client. The consul-
concern. I will also provide them with a sum- tant is, of course, also legally bound to keep
mary of your treatment when it is complete. the information confidential. Unless you object,
Before giving them any information I will dis- I will not tell you about these consultations
cuss the matter with you, if possible, and will unless I feel that it is important to our work to-
do the best I can to resolve any objections you gether.
may have about what I am prepared to discuss. While this written summary of exceptions to
confidentiality should prove helpful in inform-
ing you about potential problems, it is impor-
Confidentiality
tant that we discuss any questions or concerns
In general, the confidentiality of all communi- that you may have at our next meeting. The
cations between a client and a psychologist is laws governing these issues are quite complex,
protected by law, and I can only release infor- and I am not an attorney. While I am happy to
640 part x • practice management

discuss these issues with you, should you need Koocher, G. P., & Keith-Spiegel, P. C. (1998). Ethics
specific advice, formal legal consultation may be in psychology: Professional standards and
desirable. If you request, I will provide you with cases (2nd ed.). New York: Oxford University
relevant portions or summaries of the applicable Press.
Miller, L. J. (1990). The formal treatment contract in
state laws governing these issues.
the inpatient management of borderline per-
Your signature below indicates that you
sonality disorder. Hospital and Community
have read the information in this document and Psychiatry, 41, 985 – 987.
agree to abide by its terms during our profes- Selzer, M. A., Koenigsberg, H. W., & Kernberg, O. F.
sional relationship. (1987). The initial contract in the treatment of
borderline patients. American Journal of Psy-
References & Readings chiatry, 144, 927 – 930.
Standards for Privacy of Individually Identifiable
American Psychological Association. (2002). Ethical Health Information (2000 as amended). U.S.
principles of psychologists and code of conduct. Department of Health and Human Services,
American Psychologist, 57, 1060 –1073. Office of Civil Rights (45 CFR Parts 160 and
Bennett, B. E., Bryant, B. K., VandenBos, G. R., & 164).
Greenwood, A. (1990). Professional liability Yoemans, F. E., Selzer, M. A., & Clarkin, J. F. (1992).
and risk management. Washington, DC: Amer- Treating the borderline patient: A contract-
ican Psychological Association. based approach. New York: Basic Books.
Berglas, S., & Levendusky, P. G. (1985). The Thera-
peutic Contract Program: An individual-
oriented psychological treatment community. Related Topics
Psychotherapy, 22, 36 – 45.
Chapter 38 “Patients’ Rights in Psychotherapy”
Greene, G. L. (1989). Using the written contract for
Chapter 127, “Basic Elements of Consent”
evaluating and enhancing practice effective-
Chapter 132, “Billing Issues”
ness. Journal of Independent Social Work, 4,
135 –155.

FUNDAMENTALS OF THE
126 HIPAA PRIVACY RULE

Jason M. Bennett

This chapter summarizes the fundamentals of of patient health information. The Privacy Rule
the Standards for Privacy of Individually Iden- compliance date was April 14, 2003. Of course,
tifiable Health Information, otherwise known no part of this chapter is intended as a substi-
as the “Privacy Rule.” The Privacy Rule, pro- tute for specific legal or consulting advice. This
mulgated by the Department of Health and chapter does not create an attorney-client rela-
Human Services (HHS), is the most compre- tionship.
hensive federal regulation related to the privacy
 126 • fundamentals of the hipaa privacy rule 641

BACKGROUND ties” under the Privacy Rule. The Privacy Rule

applies to all covered entities including health
The Health Insurance Portability and Account- plans, health care clearinghouses, and health
ability Act of 1996, or HIPAA, as it is com- care providers who transmit any health infor-
monly known among mental health practition- mation in electronic form in connection with
ers, is an expansive and complex law. The gen- “covered transactions.” Covered transactions
eral purpose of the HIPAA statute is to require are those transmissions of information between
portability, nondiscrimination, and renewabil- two parties to carry out financial or adminis-
ity of health benefits provided by group health trative activities related to health care. Such
plans and group health insurance issuers. The transactions include, but are not limited to,
HIPAA statute includes “administrative sim- payment of health care claims, benefit eligibil-
plification” provisions that require the adoption ity inquiries, referral authorization requests, or
of national standards related to electronic trans- other transactions the federal government may
actions, security, and privacy of health infor- establish by regulation.
mation. A specific privacy regulation, the Pri- Many mental health practitioners have had
vacy Rule, was drafted in order to ensure that difficulty in determining if they are covered en-
a patient’s health information is protected and tities. The confusion primarily stems from at-
kept confidential when maintained or transmit- tempting to understand what is and is not an
ted electronically. This chapter does not specif- “electronic transmission.” The mere utilization
ically address any other rule or standard under of electronic technology such as personal use of
HIPAA other than the Privacy Rule. the Internet or e-mail does not constitute an
According to HHS, there are three major electronic transmission. The following are two
purposes for the Privacy Rule: (1) to protect and examples of covered electronic transmissions
enhance the rights of consumers by providing under the Privacy Rule: (1) practitioners who
them access to their health information and con- transmit patient information by e-mail or over
trolling the inappropriate use of that informa- the Internet (using a Web application or soft-
tion; (2) to improve the quality of health care by ware product) when determining eligibility of
restoring trust in the health care system among benefits; and (2) practitioners who use billing
consumers, health care professionals, and the services to transmit patient information elec-
multitude of organizations committed to the de- tronically. Mental health practitioners making
livery of care; and (3) to improve the efficiency these types of transmissions are considered cov-
and effectiveness of health care delivery by cre- ered entities.
ating a national framework for health privacy The following are not examples of covered
protection that builds on efforts by states, electronic transmissions under the Privacy Rule:
health systems, and individual organizations. (1) practitioners who share patient information
The Privacy Rule has many concepts with during telephone calls when determining eligi-
specific definitions. An important term for this bility of benefits; (2) practitioners who seek re-
chapter is individual, which generally includes imbursement from third-party payers by send-
patients, research participants, and any other ing a paper claim through the mail and the
person who is the subject of the health infor- third-party payer converts the paper claim into
mation. For the purposes of this chapter, how- an electronic format; and (3) practitioners who
ever, the term patient will be used instead of in- transmit patient information using a computer-
dividual because the focus is on the delivery of generated fax program to a plain-paper fax
services to patients. machine. Mental health practitioners making
these types of transmissions will not be consid-
ered covered entities. (Note that practitioners
COVERED ENTITIES are considered to be covered entities if health
information is transmitted from a computer by
Mental health practitioners will need to ascer- a computer fax.)
tain whether they are considered “covered enti- Many mental health practitioners have ques-
642 part x • practice management

tioned whether the Privacy Rule applies to empt those state laws that provide higher levels
them. A better question for almost all practi- of privacy protections to patients. Additionally,
tioners may be, “When will HIPAA apply?” those state laws that allow patients greater
Many insurance companies are moving toward access to or amendment of their individually
handling health claims through electronic sub- identifiable health information will not be pre-
mission in order to reduce transactional costs. empted.
The health care industry will probably soon re- Most important, the Privacy Rule requires
quire electronic submission of claims for the re- that all privacy forms presented to patients
imbursement of treatment. Additionally, those must include the results of the preemption
practitioners who continue to deal solely with analysis between the Privacy Rule and state
paper claims may face barriers in seeking reim- law. Additionally, all internal written policies
bursement for treatment from third-party pay- and procedures must include this state-specific
ers. One such barrier is part of HIPAA’s new ad- analysis.
ministrative simplification provision, which
requires all Medicare claims to be submitted
electronically after October 16, 2003, with the ADMINISTRATIVE REQUIREMENTS
exception of certain small providers (defined as
either a provider of services with fewer than 25 The privacy of patient information is not a new
full-time equivalent employees or a practi- concept to psychologists. Many jurisdictions al-
tioner with fewer than 10 full-time equivalent ready have fairly strong confidentiality laws
employees). In addition, practitioners who deal related to mental health care. Practitioners
solely with paper claims will face delays in re- should view the Privacy Rule as a formalization
ceiving payment because Medicare is required of many of the current practices and adminis-
by law not to pay paper claims until 28 days af- trative issues that are part of practitioners’ daily
ter receipt of the claim; electronic claims will be practice.
processed in 14 days. There are, however, several labor-intensive
administrative requirements that practitioners
must meet that are expressly required by the
PREEMPTION ANALYSIS—STATE Privacy Rule. Several of these activities include:
SPECIFIC INFORMATION (1) designating a “privacy official” within the
practice responsible for developing, implement-
The Privacy Rule establishes a national floor ing, and overseeing written privacy policies and
of privacy protection for patients. In order to procedures (a contact person should also be des-
be compliant, the physician must conduct an ignated for receiving and documenting com-
analysis in each state to determine if the Pri- plaints from patients); (2) training employees (if
vacy Rule preempts the state laws. This is a any) in the practice’s written privacy policies and
complicated process that oftentimes requires a procedures so that each member may carry out
legal background. The results of the preemption his or her respective functions; (3) safeguarding
analysis for each jurisdiction will almost al- all patient information from those who do not
ways be different. need or are not permitted access; and (4) pro-
Generally, state laws that are contrary to the viding patients with information about their
Privacy Rule are preempted and the federal privacy rights and explaining how their personal
standards or requirements apply. “Contrary” information may be used (within the practice)
means that a practitioner would find it impossi- or disclosed (to others outside of the practice).
ble to comply with both the state and federal re-
quirements, or a provision of state law stands as
an obstacle to the “accomplishment and execu- NOTICE OF PRIVACY PRACTICES
tion of the full purposes and objectives” of the
Privacy Rule and other relevant HIPAA stan- The Privacy Rule requires mental health prac-
dards and rules. The Privacy Rule will not pre- titioners in direct treatment relationships with
 126 • fundamentals of the hipaa privacy rule 643

patients to give a Notice of Privacy Practices to use or disclosure of patient information that is
each patient no later than the date of first ser- not for treatment, payment, or health care op-
vice delivery and to make a good-faith effort to erations. There are specific “core elements” and
obtain each patient’s written acknowledgment “required statements” to be included in written
of receipt of the notice. The notice must contain authorizations that are outlined in the Privacy
specific core elements including, but not limited Rule. Practitioners should not release patient
to, each patient’s rights in relation to his or her information after receiving a written autho-
health information and the practitioner’s duties rization if the authorization does not contain
to each patient. Practitioners are required to the necessary core elements and required state-
abide by the terms of their current privacy no- ments. Therefore, it will be important for prac-
tice. Additionally, practitioners who maintain titioners to become familiar with, and likely de-
an office must also post the notice in the office velop, written authorization forms.
in a clear and prominent location. The posted
notice must contain the same information that
is distributed directly to patients. PSYCHOTHERAPY NOTES

The Privacy Rule allows mental health practi-

CONSENT tioners to maintain certain types of sensitive
private information in psychotherapy notes.
The Privacy Rule permits mental health prac- The rule requires that psychotherapy notes be
titioners to obtain consent to use or disclose pa- kept separate from the rest of the patient’s
tient information for treatment, payment, and record. Psychotherapy notes are “notes re-
health care operations. Mental health practi- corded (in any medium) by a [. . .] mental
tioners generally must comply with stronger health professional documenting or analyzing
laws and ethical standards regarding confiden- the contents of conversation during a private
tiality than other non–mental-health care pro- counseling session or a group, joint, or family
viders. Many jurisdictions require that mental counseling session.” Such notes exclude med-
health practitioners obtain “consent to release ication prescription and monitoring; counseling
information” and “informed consent” on the session start and stop times; the modalities and
first date of treatment. In almost all instances, frequencies of treatment furnished; results of
mental health practitioners should continue to clinical tests; and any summary of the follow-
obtain consent from their patients as they al- ing items including diagnosis, functional status,
ways have for these purposes. the treatment plan, symptoms, prognosis, and
Practitioners are required by the Privacy progress to date.
Rule to make “reasonable efforts” to limit the Psychotherapy notes are afforded an extra
amount of patient information they disclose to layer of privacy protection due to the sensitive
the “minimum necessary” to accomplish the nature of this type of information. Except in
intended purpose of a use, disclosure, or re- limited circumstances, practitioners must ob-
quest. The “minimum necessary” standard does tain a written authorization for any use or dis-
not apply to: (1) disclosures made to other closure of psychotherapy notes. For instance,
health care providers for treatment purposes; practitioners may share a patient’s psychother-
(2) uses or disclosures permitted by a written apy notes for treatment purposes with another
authorization (see below); and (3) uses or dis- practitioner only if the latter is within the same
closures that are required by law. practice. Generally, however, practitioners must
obtain a written authorization from the patient
in order to disclose psychotherapy notes to
AUTHORIZATION practitioners outside of their practice, third-
party payers, or others. Health plans and third-
The Privacy Rule requires mental health prac- party payers may not condition treatment, pay-
titioners to obtain written authorization for any ment, enrollment, or eligibility for benefits on
644 part x • practice management

obtaining information in psychotherapy notes. practitioner, or if the practice is large enough, a

Each written authorization for psychotherapy full-time employee solely dedicated to the posi-
notes must contain only the request for the tion of privacy official. The scalability of the
psychotherapy notes and not for any of the in- Privacy Rule does not remove the requirement
formation kept in the patient’s separate “clini- for each practice, whether large or small, to im-
cal record.” plement written policies and procedures that
Obviously, psychologists maintaining psy- reflect the results of the state specific preemp-
chotherapy notes will face some additional com- tion analysis.
plexities when attempting to achieve com-
pliance with the Privacy Rule. Therefore, prac-
titioners should make an informed decision BUSINESS ASSOCIATES
before electing to maintain psychotherapy
notes. This will include weighing the additional A business associate is an individual or entity
complexities of maintaining psychotherapy that carries out specific services or activities re-
notes against providing specific patient infor- lated to the use or disclosure of patient infor-
mation an extra layer of privacy protection. mation on behalf of a practitioner. The Privacy
Rule requires that practitioners enter into
business-associate contracts with such individ-
INCIDENTAL DISCLOSURES uals or entities. Business-associate contracts
must obligate business associates to safeguard
Mental health practitioners will be happy to patient information and preclude any use or
know that they are not required to eliminate all disclosure of patient information that would vi-
risks of “incidental uses and disclosures” of olate the Privacy Rule.
their patients’ information. Any use or disclo-
sure of patient information that is “incident to”
another permitted use or disclosure is permit- COMPLIANCE AND
ted so long as “reasonable safeguards” to pro- ENFORCEMENT
tect patient information have been adopted by
the practitioner. An example of a permitted in- The Office for Civil Rights of HHS has respon-
cidental disclosure is when an individual in the sibility for enforcement of the Privacy Rule.
practitioner’s waiting room accidentally over- HHS has stated it will take an educative posi-
hears a confidential conversation between an- tion for the initial period after the Privacy Rule
other patient and the doctor. compliance date. During this initial period,
HHS will follow a complaint-driven model for
enforcing compliance with the Privacy Rule.
SCALABILITY OF THE The Office for Civil Rights will investigate all
PRIVACY RULE properly submitted complaints. One of the
foremost reasons for the incredible amount of
In order to ease the burden of becoming com- attention to the Privacy Rule is the possibility
pliant, the Privacy Rule requirements are “scal- that civil monetary and/or criminal penalties
able” to apply to the various types and sizes of can be levied against practitioners.
practices. The scalability of the Privacy Rule al- Investigations may include a review of the
lows for flexibility when a practice creates its pertinent policies, procedures, or practices of
own privacy information that is disseminated the covered entity and of the circumstances re-
to patients, as well as the practice’s internal garding any alleged acts or omissions concern-
written policies and procedures. For instance, ing compliance. Psychologists should be aware
the privacy official in a solo practitioner’s prac- that site visits are possible during investiga-
tice will, in most instances, be the solo practi- tions.
tioner; the privacy official in a large group prac- The following are likely to be considered
tice may be a receptionist, the office manager, a some of the least invasive measures taken by
 127 • basic elements of consent 645

HHS during an investigation: (1) a request for American Psychological Association Practice Orga-
the notice of privacy practices the practitioner nization. (n.d.). Home page. Retrieved 2004 from
has disseminated to patients; (2) a request for http://www.apapractice.org
the written policies and procedures maintained U.S. Department of Health and Human Services.
(2000). Standards for privacy of individually
by the practitioner; (3) a request for any docu-
identifiable health information (amended). Office
mentation required by the Privacy Rule (in-
of Civil Rights (45 CFR Parts 160 and 164).
cluding the documentation of training of all in- Washington, DC: Government Printing Office.
dividuals working within the practice); and (4) U.S. Department of Health and Human Services.
[a showing] that the practitioner has in place (n.d.). HHS resources on complying with the Pri-
appropriate administrative, technical, and phys- vacy Rule. Retrieved 2004 from http://www.hhs.
ical safeguards to protect the privacy of patient gov/ocr/hipaa
information.
Related Topics
References, Readings, & Internet Sites
Chapter 104, “Privacy, Confidentiality, and Privi-
American Psychological Association Insurance Trust. lege”
(n.d.). Health Insurance Portability and Account- Chapter 127, “Basic Elements of Consent”
ability Act site. Retrieved 2004 from http://www. Chapter 128, “Basic Elements of Release Forms”
apait.org/hipaa

BASIC ELEMENTS OF
127 CONSENT

Gerald P. Koocher

Competence is a prerequisite for informed con- • In most jurisdictions, persons over the age of
sent. An offer to provide a person with informed 18 years are presumed to be competent un-
consent is not meaningful unless the individual less proved otherwise before a court. When a
in question is fully competent to make use of it. determination of incompetence is made for
Consent is a voluntary act by which one compe- such adults, it is usually quite precise. That
tent person agrees to allow another person to do is to say, under law a person’s competence is
something, such as provide treatment to them, conceptualized as a specific functional ability.
study them in research, or release their confi- In legal parlance, the noun competence is
dential records to another. usually followed by the preposition to rather
than presented as a general attribute of the
• Competence to grant consent is generally person. An adult who is deemed incompetent
categorized as either de facto or de jure. De to stand trial for a particular offense is still
jure refers to competence under law, while de presumed competent to function as a custo-
facto competence refers to the actual or prac- dial parent or manage his or her financial af-
tical capacities of the individual to render a fairs. For the adult, incompetence must be
competent decision. proved on a case-by-case basis.
646 part x • practice management

• Conversely, minor children are presumed in- ment prior to intervening in the lives of their
competent for most purposes without any con- minor children or adults adjudged incompetent.
cern for whether or not the child has the cog- Assent, a relatively new concept in this con-
nitive and emotional capacity to make the req- text, recognizes that minors or incompetent
uisite decision(s). Children who are deemed adults may not, as a function of their develop-
legally competent for one purpose are likewise mental level or mental state, be capable of giv-
still considered generally incompetent in other ing fully reasoned consent but may still be ca-
decision-making contexts. For example, juve- pable of reaching and expressing a preference.
nile offenders who have been transferred to Assent recognizes the involvement of the child
adult court for trial and found competent to or incompetent adult in the decision-making
stand trial are still considered generally in- process, while also indicating that the child’s
competent to consent to their own medical level of participation is less than fully compe-
treatment or enter into legal contracts. tent. Granting assent power is essentially the
same as providing a veto.
Assessment of specific competence (in the
case of children) or incompetence (in the case of References, Readings, & Internet Sites
adults) revolves around four basic elements:
Appelbaum, P. S., Lidz, C. W., & Meisel, A. (1987).
Informed consent: Legal theory and clinical prac-
1. The person’s access to and ability to under-
tice. New York: Oxford University Press.
stand all relevant information about the na- Koocher, G. P., & Keith-Spiegel, P. C. (1990). Chil-
ture and potential future consequences of dren, ethics, and the law. Lincoln: University of
the decision to be made (i.e., informed con- Nebraska Press.
sent). Koocher, G. P., & Keith-Spiegel, P. C. (1998). Ethics
2. The ability to manifest or express a decision. in psychology: Professional standards and cases
3. The manner in which the decision is made (2nd ed.). New York: Oxford University Press.
(e.g., whether it is rational or reasonably Malcolm, J. G. (1988). Treatment choices and in-
considered). formed consent: Current controversies in psy-
4. The nature of the resulting decision (e.g., chiatric malpractice litigation. Springfield, IL:
whether it is a lawful decision). Charles C. Thomas.
Office for Protection from Research Risks. (n.d.).
Tips on informed consent. Retrieved 2004 from
Psychological factors in competence assess- http://www.ohrp.osophs.dhhs.gov/humansub-
ment include the following: jects/guidance/ictips
Pope, K. S., & Vasquez, M. J. T. (1991). Ethics in
1. Comprehension psychotherapy and counseling: A practical guide
2. Assertiveness and autonomy for psychologists. San Francisco: Jossey-Bass.
3. Rational reasoning Public Responsibility in Medicine and Research.
4. Anticipation of future events (n.d.). Home page. Retrieved 2004 from http://
5. Judgments in the face of uncertainty or con- www.primr.org
tingencies Stanley, B. H., Sieber, J. E., & Melton, G. B. (Eds.).
(1996). Research ethics: A psychological ap-
proach. Lincoln: University of Nebraska Press.
University of Washington. (n.d.). Ethics in medi-
MAKING DECISIONS FOR OTHERS:
cine, informed consent. Retrieved 2004 from
PROXY CONSENT, PERMISSION, http://eduserv.hscer.washington.edu/bioethics/to
AND ASSENT pics/consent
White, B. C. (1994). Competence to consent. Wash-
Consent is defined as a decision that one can ington, DC: Georgetown University Press.
make only for oneself. Thus, the term proxy
consent is decreasingly used in favor of the Related Topics
term permission. Parents or guardians are usu-
ally those from whom permission must be Chapter 104, “Privacy, Confidentiality, and Privilege”
sought as both a legal and an ethical require- Chapter 128, “Basic Elements of Release Forms”
 BASIC ELEMENTS OF
128 RELEASE FORMS

Gerald P. Koocher

What is a “release form” anyway? As used by • Indicate the purpose of releasing the duty of
mental health professionals, this term refers to confidentiality (e.g., assisting in treatment,
a legally appropriate authorization that releases educational planning, teaching, research, or
the clinician from some particular duty to a other purpose to be specified).
client or research participant. Most often the • State who is granting authority (e.g., is a
release permits the sharing of otherwise confi- competent person granting informed con-
dential information or records with other pro- sent, is a legally responsible party granting
fessionals or agencies. Other types of releases permission, or is a person who is not deemed
may authorize the recording of voice or images legally competent granting assent?). Note
by any means (e.g., photographic, magnetic that at least one signer of the release form
tape, or digital) of otherwise confidential con- must be legally authorized to do so.
tent, the storage of data or recorded material in • Explain the grantor’s relationship to the par-
databases, or the use of such material for teach- ties to whom a duty is owed (e.g., is the
ing purposes. Releases are sometimes sought grantor of the authorization the focal party
prior to application of certain treatment proce- himself or herself, a parent, or some other
dures that may have potential adverse conse- person having legal guardianship?).
quences (e.g., electroconvulsive therapy); how- • Indicate for what duration the release is
ever, no release can legally absolve a practi- granted. Each release should have a specific
tioner from the negligent infliction of damages. time limit. For example, the release may au-
Releases should be drafted for highly specific thorize a onetime issuance of records, an on-
purposes, addressing each of the key elements going communication between two profes-
cited below. In addition to these basic elements, sionals for a specified period, or open-ended
releases should be used only in the context of access to archival data in a research database.
informed consent (see chapter 127). Use the fol- • Include a valid signature. The name of the
lowing guidelines in preparing a release form. person signing the release form should be
printed as well as signed, in the event that
• Identify the person(s) to whom the release the signature is difficult to read. Although
applies. Ideally this will include a name, ad- not strictly necessary in most situations, it is
dress, telephone number, birth date, and any ideal to have the release signed by a third
known record-identifying numbers. This will party who witnessed the grantor’s signing.
minimize risk of improper releases when
names are similar, as well as permitting con-
firmation that the release is valid should a SAMPLE RELEASE FORMS
question arise.
• Indicate what is being authorized (e.g., trans- Copies of the sample forms outlined below and
fer of oral information, transfer of records, suitable for editing with a word processing pro-
audio or video recording, or other disclosure gram are included on the Web site accompany-
of protected data). ing this book.

647
648 part x • practice management

Authorization for Release of Information

Patient’s name:

Date of birth:

Address:

Telephone number:

Record number:

I hereby authorize the release of information records on: [the psychological assessment of,
psychotherapeutic treatment of, etc.]

Name:

Address:

For the purposes of: [assisting in treatment planning, preparing an educational plan, use in
court-ordered evaluation, etc.]

This release shall be valid for [90 days] from the date signed, unless withdrawn sooner and
shall [include all professional records; be limited to the psychological testing data; be limited
to services provided between September 1996 and March 1998; etc.].

Signed: [printed name, date]

Relationship to patient: [parent, legal guardian]

Witnessed by: [printed name, date]

Sample Release for Recording and Subsequent Teaching

This release form would be similar to the record release form in terms of the client informa-
tion and signature sections. The statements of “authorization” (i.e., what type of recording or
disclosure is being allowed) and the statement of “purpose” (i.e., how the material will be
used). Sonic examples follow: “I authorize Mr. Jones to make videotape recordings of my ther-
apy sessions at the University Counseling Center for purposes of supervision. I understand
that these will be viewed only by Mr. Jones and his clinical supervisor, Dr. Smith. I also un-
derstand that the tapes will be destroyed following the supervisory session.”
Suppose one of the sessions seems particularly useful or exemplary for teaching purposes
and that Dr. Smith would like to use it in the future. An additional release with the follow-
ing text might be sought: “I authorize Dr. Smith and his successors as director of the Uni-
versity Counseling Center to use previously authorized video recordings of my psychother-
apy sessions with Mr. Jones between January 1996 and May 1996 for teaching purposes with
future classes of doctoral students. I understand that although my likeness will be visible, my
name will not be used and all observers will have a professional obligation to treat the mate-
(continued)
 129 • prototype mental health records 649

rial confidentially. I also understand that I may revoke this authorization at any time in the
future by notifying Dr. Smith or any subsequent director of the clinic.”
Similar elements should be included in release forms developed for other confidential ma-
terial that may be stored and used by others in the future, such as longitudinal research data
archives. In the case of institutional clinical records that are routinely collected as a function
of clinical care (i.e., medical records or clinic case files) or that were collected years earlier from
clients who are no longer easily located, the agency’s official institutional review board (some-
times called a clinical investigations committee) should be consulted and that group’s proce-
dures followed.

Readings & Internet Sites Sieber, J. E., & Stanley, B. (1988). Sharing scientific
data I: New problems for IRBs. IRB: A Review of
American Psychological Association. (2002). Ethical Human Subjects Research, 11, 4 – 7.
principles of psychologists and code of conduct. Stanley, B. H., Sieber, J. E., & Melton, G. B. (Eds.).
Washington, DC: Author. (1996). Research ethics. Lincoln: University of
Keith-Spiegel, P., Wittig, A. F., Perkins, D. V., Balogh, Nebraska Press.
D. W., & Whitley, B. E. (1993). The ethics of United States Department of Health and Human
teaching: A casebook. Muncie, IN: Ball State Uni- Services, Office for Civil Rights. (n.d.). Office for
versity Office of Academic Research and Spon- Civil Rights Web site. Retrieved 2004 from http://
sored Projects. www.hhs.gov/ocr/hipaa/
Koocher, G. P., & Keith-Spiegel, P. C. (1998). Ethics United States Department of Health and Human
in psychology: Professional standards and cases Services, Administrative Simplification. (n.d.).
(2nd ed.). New York: Oxford University Press. Administrative simplification in the health care
Lawson, C. (1995). Research participation as a con- industry. Retrieved 2004 from http://aspe.hhs.
tract. Ethics & Behavior, 5, 205 –215. gov/admnsimp/
National Institutes of Health. (n.d.). HIPAA Privacy
Rule. Retrieved 2004 from http://privacyrule
andresearch.nih.gov/pr_02.asp

PROTOTYPE MENTAL
129 HEALTH RECORDS

Gerald P. Koocher

This article describes a recommended style and keeping aside from content. Not all of the con-
content for mental health practitioners’ clinical tent information described here will be neces-
case records covering 15 specific content do- sary for every record, nor would one expect to
mains and 4 other important issues in record complete a full record as described here during
650 part x • practice management

the first few sessions with a new client. By the was his or her last physical exam? Does the
end of several sessions, however, a good-quality client have a personal physician? Are there
clinical record will reflect all of the relevant any pending medical problems or condi-
points summarized below. tions?). This is especially important if the
client has physical complaints or psycholog-
ical problems that might be attributable to
CONTENT ISSUES organic pathology.
• Medication profile: Collect information on
• Identifying information: Name, record or file all medications or drugs used, past and pres-
number (if any), address, telephone number, ent, including licit (e.g., prescribed medica-
sex, birth date, marital status, next of kin (or tions, alcohol, tobacco, and over-the-counter
parent/guardian), school or employment sta- drugs) and illicit substances. Also note any
tus, billing and financial information. consideration, recommendation, or referral
• First contact: Date of initial client contact and for medication made by you or others over
referral source. the course of your work with the client.
• Legal notifications: The Health Insurance • Why is the client in your office? Include a full
Portability and Accountability Act (HIPAA) description of the nature of the client’s condi-
requires that clients be given specific notifi- tion, including the reason(s) for referral and
cations regarding privacy and other matters presenting symptoms or problems. Be sure to
(discussed elsewhere in this volume) at the ask clients what brought them for help at this
initiation of the professional relationship. point in time, and record the reasons.
Some states have parallel or more extensive • Current status: Include a comprehensive
requirements, and the APA Code of Conduct functional assessment (including a mental
specifically requires psychologists to notify status examination), and note any changes or
clients about the limits of confidentiality at alterations that occur over the course of
the outset of the professional relationship. treatment.
Provision of this notice, ideally by means of • Diagnostic impression: Include a clinical im-
a signed notice form, should be noted in the pression and diagnostic formulation using
record. the most current DSM or ICD model. Do not
• Relevant history and risk factors: Take a de- underdiagnose to protect the patient. If you
tailed social, medical, educational, and voca- believe it is absolutely necessary to use a
tional history. This need not necessarily be “nonstigmatizing” diagnosis as opposed to
done in the very first session and need not be some other diagnostic label, use the R/O
exhaustive. The more serious the problem, (rule-out) model by listing diagnoses with
the more history you should take. Get enough the notation “R/O,” indicating that you will
information to formulate a diagnosis and an rule each “in” or “out” based on data that
initial treatment plan. Be sure to ask: “What emerge over the subsequent sessions. Your
is the most impulsive or violent thing you diagnosis must also be consistent with the
have ever done?” and “Have you thought of case history and facts (e.g., do not use “ad-
hurting yourself or anyone else recently?” justment reaction” to describe a paranoid hal-
Seek records of prior treatment based on the lucinating client with a history of prior psy-
nature of the client (e.g., the more complex chiatric hospital admissions).
the case, the more completely one should re- • Treatment plan: Develop a treatment plan
view prior data). Always ask for permission with long- and short-term goals and a pro-
to contact prior therapists, and consider re- posed schedule of therapeutic activities. The
fusing to treat clients who decline such per- plan should be updated every 4 to 6 months
mission without giving good reason (e.g., and modified as needed.
sexual abuse by former therapist). • Progress notes: Note progress toward achieve-
• Medical or health status: Collect informa- ment of therapeutic goals. Use clear, precise,
tion on the client’s medical status (i.e., When observable facts (e.g., I observed; patient re-
 129 • prototype mental health records 651

ported; patient agreed that . . .). As you write, place to preserve client confidentiality and
imagine the patient and his or her attorney to release records only with proper consent.
looking over your shoulder as they review The medium used (e.g., paper, magnetic, op-
the record with litigation in mind. Avoid the- tical) is not especially important, so long as
oretical speculation or reports of unconscious utility, confidentiality, and durability are as-
content. Do not include humorous or sarcas- sured.
tic personal reflections or observations. Your In multiple-client therapies (e.g., family or
record should always demonstrate that you group treatment), records should be kept in a
are a serious, concerned, dedicated profes- manner that allows for the preservation of
sional. If you must keep theoretical or specu- each individual’s confidentiality should the
lative notes (e.g., impressionistic narratives records of one party be released. Psycho-
for review with a supervisor), use a separate logists are responsible for construction and
“working notes” format, but recognize that control of their records and those of people
these records may be subject to subpoena in they supervise.
legal proceedings. • Retention of records: Psychologists must be
• Service documentation: Include documenta- aware of and observe all federal and state
tion of each visit, noting the client’s response laws that govern record retention. In the ab-
to treatment. In hospitals or large agencies, sence of clear regulatory guidance under law,
each entry should be dated and signed or ini- the American Psychological Association
tialed by the therapist, with the service pro- (1993) recommends maintaining complete
vider’s name printed or typed in legible form. records for 3 years after the last client contact
It is not necessary to sign each entry in one’s and summaries for an additional 12 years.
private (i.e., noninstitutional) case files, since If the client is a child, some records should
it is reasonable to assume that you wrote be maintained until at least 3 to 5 years be-
what is in your own private practice files. yond the date at which the child attains the
• Document follow-up: Include documentation age of majority. All records, active or inac-
of follow-up for referrals or missed appoint- tive, should be stored in a safe manner, with
ment, especially with clients who may be limited access appropriate to the practice or
dangerous or seriously ill. Retain copies of all institution.
reminders, notices, or correspondence sent to • Outdated records: Outdated, obsolete, or in-
clients, and note substantive telephone con- valid data should be managed in a way that
versations in the record. assures no adverse effects will result from its
• Obtain consent: Include copies of consent release. Records may be culled regularly so
forms for any information released to other long as this is consistent with legal obliga-
parties, or for other forms of recording (e.g., tions. Records to be disposed of should be
consent to record interviews). handled in a confidential and appropriate
• Termination: Include a discharge or termina- manner. Never remove items from a record
tion summary note for all clients. In cases of that has been subpoenaed or is otherwise
planned termination, be certain that case notes subject to legal proceedings.
prior to the end of care reflect planning and • Death or incapacity: Psychologists need to
progress toward this end. make arrangements for proper management
or disposal of clinical records in the event of
their death or incapacity.
NONCONTENT ISSUES

• Control of records: Psychologists should main- References, Readings, & Internet Sites
tain (in their own practice) or support (in in- American Psychological Association. (1993). Record
stitutional practice) a system that protects keeping guidelines. American Psychologist, 48,
the adequate control over and confidentiality 308 –310.
of records. Clear procedures should be in Koocher, C. P., & Keith-Spiegel, P. C. (1998). Ethics
652 part x • practice management

in psychology: Professional standards and cases stance abuse treatment. Retrieved 2004 from http://
(2nd ed.). New York: Oxford University Press. aspe.hhs.gov/datacncl/reports/MHPrivacy
National Guideline Clearinghouse. (n.d.). Home
page. Retrieved 2004 from http://www.guideline.
Related Topic
gov
U.S. Department of Health and Human Services. Chapter 25, “Assessing the Quality of a Psychologi-
(n.d.). Privacy issues in mental health and sub- cal Testing Report”

130 UTILIZATION REVIEW CHECKLIST

Gerald P. Koocher

This chapter is intended to assist clinicians in • Presenting problem: Are the client’s com-
conducting internal utilization review of mental plaints and symptoms at the time of the ini-
health records. The purpose of utilization review tial visit clearly described? Is notation made
is to focus on the client’s progress in a systematic of thought disorder, delusions/hallucinations,
course of treatment and to monitor the adequacy paranoia, obsessive-compulsive behavior, iso-
of clinical records. The goal is to audit records in lation, inappropriate affect, depression, anxi-
order to assure that effective treatment is taking ety, eating or sleeping disturbance, peer re-
place using clinical documentation. For purposes lationship difficulties, bizarre behavior, vio-
of internal utilization review, create a checklist lent/aggressive behavior, appositional/defiant
using the points listed below and review the case behavior, manic behavior, sexual inappropri-
record to determine whether sufficient content ateness, substance abuse, physical abuse, or
appears in the record to address each category. suicidal ideation? Is a history of present ill-
Ascertain whether the clinical record has been ness and prior treatment noted? Are specific
updated with reasonable frequency. Records focal problems requiring attention listed,
should be updated at least quarterly, unless data such as affective, attitudinal, family, school
are routinely updated as they change on a or work, social, medical conditions, and oth-
session-by-session basis. ers? Are recent environmental stressors such
as marital changes, death, illness, financial
• Vital statistics: Are the following noted: full losses, or employment changes noted?
name, record or file number (if any), address, • Diagnosis: Has a problem list or a complete
telephone number, sex, birth date, marital diagnosis been formulated, preferably using
status, employment or educational status, all 5 DSM axes, with R/O (rule-out) diag-
family structure, next of kin, ethnicity, pri- noses specified, as needed? Is the diagnosis
mary language, name of primary care physi- consistent with symptoms reported in the
cian (if any)? record? For example, if hallucinations and
• First contact: Are the date of initial contact delusions are described in the record, schizo-
and referral source recorded? phrenia should be a confirmed or rule-out di-
 131 • contracting with managed care organizations 653

agnosis. Similarly, if depression is a diagno- client’s presenting complaints. Notes should

sis, the record should reflect an inquiry about address any movement toward or away from
suicidal ideation. prior goals since the last plan. Progress should
be documented with test data, diary entries,
Axis I: Clinical disorders and other condi-
behavior records, school reports, or other
tions that may be a focus of treatment.
data.
Axis II: Personality disorders and mental re- • Authentication: Are the record notes dated
tardation. and signed, including the degree and institu-
Axis III: General medical conditions. tional title (if any) of the writer? If the writer
Axis IV: Psychosocial and environmental is unlicensed or a trainee, are the notes coun-
problems, with notation of severity. tersigned by someone with legal responsibil-
ity?
Axis V: Global Assessment of Functioning
(GAF) with numerical score.
• Current status: Is a comprehensive func- References & Readings
tional assessment (including a mental status American Psychiatric Association. (1994). Diagnos-
examination) provided? Are any changes since tic and statistical manual of mental disorders
intake and last treatment plan noted? Is the (4th ed.). Washington, DC: Author.
status of presenting and diagnostic symp- American Psychological Association. (1993). Record
toms reported periodically, documenting keeping guidelines. American Psychologist, 48,
progress or lack of same? 984 – 986.
• Consultations obtained: Is a summary of any Koocher, G. P., & Keith-Spiegel, P. C. (1998). Ethics in
consultations (e.g., medication or psycholog- psychology: Professional standards and cases
ical testing) obtained since last update in- (2nd ed.). New York: Oxford University Press.
cluded?
• Long- and short-range goals: Are therapeu- Related Topics
tic goals mentioned and discussed over the
course of treatment? Are modalities of treat- Chapter 47, “Psychotherapy Treatment Plan Writ-
ment reported and any referrals noted? Goals ing”
should reference initial symptoms and the Chapter 129, “Prototype Mental Health Records”

CONTRACTING WITH MANAGED

131 CARE ORGANIZATIONS

Stuart L. Koman & Eric A. Harris

Managed care is the general term used to de- tions whose primary raison d’être and motiva-
scribe organizations and practices of organiza- tion is controlling the cost of health care. Typ-
654 part x • practice management

ically, a managed care organization (MCO) re- passing along financial risk to providers in
ceives a standard monthly fee from a payer, return for directing referrals to them. Risk-
usually an employer or government entity, to based contracting comes in many forms but
purchase a defined set of health care services always provides incentives for the clinician to
(benefit plan) for each individual (covered life) complete the treatment in the fewest sessions
utilizing the plan. Mental health or behavioral or the least costly manner.
health services can be included as part of a
comprehensive package of medical services
or carved-in, as is the case with health main- KEY ISSUES IN DECIDING TO JOIN
tenance organizations (HMOs) like Kaiser- A MANAGED CARE PANEL
Permanente Health Plan or Harvard Commu-
nity Health Plan, or contracted for separately, The following questions and issues should be
or carved-out, to a managed behavioral health reviewed when considering potential relation-
provider such as Value Options Behavioral ships with MCOs.
Health or Magellan Behavioral Health. Re-
gardless of type, most MCOs seek maximum
Business Issues
cost efficiency and utilize some variation of the
following techniques to manage cost and qual- • Is the company financially stable?
ity of care. • What is the proposal for payment of profes-
sional services, and how long will it take to be
• Utilization management and utilization re- paid? What has been the experience of other
view: This is the general practice of closely clinicians in terms of the reliability of the
scrutinizing the manner in which decisions MCO’s claims payment system?
are made about when, where, and how many • What is the company’s volume of business in
of each type of service is used in responding your geographic area, and what level of refer-
to the needs presented by a participant in the rals are you likely to receive? What types of
health plan. Decisions for care are judged patients will be referred?
against an organizationally defined standard
known as medical necessity. Many MCOs
Professional Practice Issues
require that services be preauthorized and
periodically reviewed (concurrent review) by • What is the philosophy or general approach
company-employed case managers who are to providing care, and does it fit your clini-
clinicians specially trained in the company’s cal model?
criteria for medical necessity and treatment • How is care managed, and what are the cre-
preferences. dentials of the individuals employed by the
• Selective contracting: This is the practice of company to make decisions about the treat-
defining a group of providers to perform re- ment?
quired services. The provider network, as it is • What has been the experience of other pro-
often called, is chosen from a pool of poten- viders in the area in terms of satisfaction
tial providers by an application process that with the care management process?
weighs various company preferences in mak-
ing selections. These preferences may include
Legal Issues
the type of degree and specialization, sex, age,
geographic location, availability in the eve- • Is the provider contract fair to both parties or
nings and on weekends, and other character- seemingly one-sided?
istics about the manner in which the provider • Does the contract contain any provisions that
practices, especially as they may relate to the are particularly problematic?
cost of care.
• Favorable payment structure: This is the
practice of negotiating price discounts and/or
 131 • contracting with managed care organizations 655

Administrative Issues surance carrier before signing these agree-

• What are the requirements for authorizing ments, and attempt to have the provision re-
treatment both at the outset and as treatment moved if the insurance company indicates
proceeds? What medical records documenta- that it will not cover actions resulting from
tion is required? this clause. Providers should also insist that
• What billing documentation is required? indemnification responsibility is mutual and
• Are there any special requirements such as that the managed care company agrees to in-
outcome evaluations? demnify the practitioner in the same manner
• Are the case managers and claims personnel that the managed care company is proposing
available in a reasonable time frame to dis- to be indemnified.
cuss clinical or administrative problems? What • No legal action: This provision eliminates
has been the experience of other providers in your right to bring action against the man-
dealing with problems? aged care company for any reason.
• What is the process for appealing decisions • Exclusive dealing: This provision restricts
regarding authorization and/or payment of you from working with patients who have a
care? different insurance plan. You should consider
agreeing to this only if the managed care
company has guaranteed very high volume
REVIEWING MCO CONTRACTS and payment, and then only if you can can-
cel the contract on short notice should serious
Many MCOs would have providers believe that problems arise.
the contract document sent for review is invio- • Most favored nation: This provision guaran-
late, immutable, and unchangeable. Resist the tees that the managed care company will al-
temptation to go quietly along, and be sure to ways have charges equal to or lower than any
review the contract carefully. Be especially other company you contract with now or in
careful if the contract seems one-sided; look for the future. You can consider an arrangement
sections that clearly spell out the obligations of like this if the volume is high, the adminis-
the company to pay promptly, to notify you of tration relatively moderate, and the payment
changes in the benefit plan, to authorize treat- history good, but only if you have the right
ment in a timely manner, to publish criteria for to cancel should circumstances change.
treatment decisions, and to process appeals and • No-cause terminations: This provision al-
grievances. Managed care contracts are written lows the managed care company to eliminate
by company attorneys who are paid to look out you from its provider panel for no reason. It
for the company’s interest. The following is a is fairly standard language at this point and
list of potentially problematic clauses to watch is currently being challenged in court by a
out for. group of practitioners with support from the
American Psychological Association. Their
• Indemnification: In one form or another, in- argument is that the managed care com-
demnification agreements state that if the panies are using this clause to eliminate
managed care company is sued because of the practitioners who do not conform to their
provider’s activities, the practitioner agrees rules or have publicly spoken out against the
to reimburse the company for its expenses company and that this is really a “for-cause”
and for any damages assessed against it. This termination, which the practitioner has
clause can be drafted in many ways, but in the right to appeal. By using the “no-cause”
any case, since the responsibility is created provision, the providers argue, the company
by the provider’s agreement to the contract, eliminates the individual’s right to due pro-
not by the provider’s professional activities, cess.
malpractice insurance companies can refuse • Nondisparagement: This “gag” clause pro-
to provide coverage of any expenses that re- hibits you from publicly speaking out di-
sult from this provision. Check with your in- rectly against the company in any way.
656 part x • practice management

• Agreement not to bill for covered services bursement is fixed by the MCO in accordance
except for copayments and deductibles: This with the clinician’s training and the type of ser-
provision prohibits you from collecting re- vice being delivered. When this is the case, net-
imbursement from patients to augment the work selection is based on a variety of other fac-
managed care company’s payment; it also tors that are important to the MCO and/or the
prohibits you from billing for services that consumer. Generally, MCOs look for the fol-
you and the client agree are indicated but lowing attributes:
which the managed care company has not
authorized. • Use of short-term and group treatment mo-
• Agreement not to provide services when dalities because this helps to contain cost by
benefits are exhausted: In some cases, this limiting the length of the treatment episode
provision may put you at risk for client aban- or by utilizing less expensive units of service
donment and leave you vulnerable to both le- • Ease of access as demonstrated by 24-hour
gal and ethical challenge. availability, night and weekend services, reli-
• Agreement to abide by utilization review able phone answering, and responsive emer-
processes and decisions: This provision binds gency coverage
you contractually to the company’s decisions • Wide range of clinical expertise often found in
regarding the treatment of your patients re- multidisciplinary groups so that consumers
gardless of your professional evaluation of the and the MCO itself can conveniently access
patient and situation at any given time. In fact, different services that are required for treat-
you are legally and ethically required to act in ment of an individual or his or her family
the best interest of the patient at all times and • Professional affiliations with other health
would be at severe risk if you followed the care providers, especially primary care phy-
company’s decision despite your own assess- sicians who are responsible for medical man-
ment and some tragic consequence ensued. agement of individuals in HMOs
• Agreement to abide by contract provisions • Unambiguous professional credentials, in-
which have not yet been developed or pub- cluding clinical licensure at the indepen-
lished: This practice is common in situations dent practice level, absence of professional
where the managed care company is under liability claims, listing in a national practi-
pressure to put a network together. tioner data bank, and a well-organized clini-
cal record-keeping system
As always, the best advice is to consult an at- • Demonstrated expertise in a specific clinical
torney, preferably one who specializes in health specialty area
care, if you are uncomfortable with any contract • Demonstrated value of services provided by
provisions you encounter. Other sources of sup- outcome evaluation data
port can often be found through your profes- • Location in an underserved area or area of
sional liability insurance carrier, your state pro- high need
fessional association, and the legal and regula-
tory office of the Practice Directorate of the
American Psychological Association. NEGOTIATING WITH MCOS

In general, negotiating leverage and the ability

ATTRACTING MANAGED to achieve a successful outcome for your practice
CARE CONTRACTS revolve around the perception of “who needs
who more.” Factors that enhance your negotiat-
MCOs seek contracts with competent clinicians ing position are often related to simple supply
who will work within their management sys- and demand. For instance, a practice in a rural
tems with little complaint and will price or ac- community where few clinicians are available is
cept reimbursement for clinical services at a in a good negotiating position. This is especially
low rate. In many instances, however, reim- true if the MCO operates under a contract with
 132 • billing issues 657

the primary payer, a governmental or business References & Readings

entity, which specifies performance standards Feldman, J., & Fitzpatrick, R. (1992). Managed men-
for geographic access to care. Similarly, a prac- tal health care. Washington, DC: American
tice known for its highly specialized services is Psychiatric Press.
in a good position whether or not it is in an area Giles, T. R. (1993). Managed mental health care.
where there is an abundance of practitioners be- Boston: Allyn and Bacon.
cause it offers a unique service that specifically Minkoff, K., & Pollack, D. (1997). Managed mental
addresses the needs of a particular group of con- health care in the public sector. Amsterdam:
sumers. Most MCOs will not want to be viewed Harwood Academic Publishers.
as denying legitimate specialized care to their Oss, M., & Smith, A. (1994). Behavioral health
practice management audit workbook. Gettys-
subscribers. These kinds of complaints often find
burg, PA: Behavioral Health Industry News.
their way back to the payer or, even worse, to Psychotherapy Finances. (1993). Managed care hand-
the media. Professional and political affiliations book. Hawthorne, NJ: Ridgewood Financial In-
can also enhance your negotiating leverage. If stitute.
you are the preferred provider of mental health
services for an important group of physicians in
the area, the MCO will probably want to make Related Topics
sure that you are in the network. If you find Chapter 124, “Essential Features of Professional Li-
yourself in a less than ideal position, you can do ability Insurance”
a number of things to improve your contract Chapter 125, “Sample Psychotherapist-Patient Con-
possibilities: lower your price, increase the value tract”
of your offer by providing more service, and Chapter 130, “Utilization Review Checklist”
provide evidence of superior performance through
outcome data or case example.

132 BILLING ISSUES

Gerald P. Koocher

This section is intended as a summary guide to • Providing information and good communi-
the most common practice questions involving cation is more important than the actual
billing for mental health services, along with a amount charged. Clients should be informed
discussion of related ethical issues. about fees, billing and collection practices,
and other financial contingencies as a routine
part of initiating the professional relation-
BASIC PRINCIPLES ship whether or not they ask. This informa-
tion should also be repeated later in the rela-
• Psychologists ideally perform some services tionship if necessary. Ascertain the client’s
at little or no fee as a pro bono service to the ability to pay for services as agreed. Be sure
public as a routine part of their practice. to include the following:
658 part x • practice management

1. Amount of fee or “hourly rate,” includ- abandon a dependent client. Referral to com-
ing the duration of the “hour” munity agencies or some limited continuation
2. When fees are payable (i.e., weekly, of services may be an option when abrupt ter-
monthly) mination would cause harm to a client.
3. Other services for which you will charge • Legal obligations: The professional must
a fee (e.g., telephone contacts, prepara- obey all laws governing debtor-creditor rela-
tion of documents, completing insurance tions in his or her jurisdiction. Such laws
forms) may include prohibitions against adding sur-
4. Your policy for missed or canceled ses- charges to unpaid bills, making threatening
sions telephone calls, and certain other collection
5. What happens if the client cannot or does practices. See the discussion regarding use of
not pay the bill collection agencies below.
• Do not permit clients to accumulate an in-
ordinately large bill. Practitioners should
THIRD-PARTY RELATIONSHIPS
carefully consider the client’s overall ability
to afford services early in the relationship
Relationships with insurance companies and
and should help the client to make a plan for
managed care organizations (known collectively
obtaining services that will be both clini-
as third-party payers) can be strained at times.
cally appropriate and financially feasible.
It is important to clarify with all clients that
Encouraging clients to incur significant debt
you will assist them in obtaining all benefits to
is not psychotherapeutic. In that regard,
which they are entitled; however, clients must
psychologists should be aware of referral
also be informed of their responsibilities in the
sources in the community. Offering exces-
event third-party payment is not made. Some
sive credit, when a reduced fee cannot be of-
third parties seek to sign a contract with
fered, may create an unreasonable burden
providers before agreeing to pay for their ser-
on the client.
vices; Blue Shield is an example of such a pro-
• Consider the realities of client finances in fu-
vider in many states. In the typical contract, a
ture fee increases. In some cases it may be
provider is asked to agree to accept the com-
most appropriate to apply rate increases to
pany’s payment as specified in full for the ser-
new, rather than continuing, clients.
vice rendered to the subscriber or client. The
• Honor all posted or advertised fees.
provider also promises not to charge a policy-
• Be prepared to justify fees that deviate sig-
holder more for any given service than would
nificantly from comparable services in the
be charged to another client. In other words, the
community.
provider agrees to accept certain set fees de-
• Never agree to a contingency fee arrange-
termined by the company and agrees not to
ment based on the outcome of a case when
treat policyholders differently from nonpolicy-
testifying as an expert in forensic matters.
holders. In this way, the company attempts to
provide good, inexpensive coverage, while at-
tempting to prevent its policyholders from be-
COLLECTION PRACTICES ing overcharged or treated in a discriminatory
manner. Ideally, the psychologist gains access to
• Ethical obligations: The professional is obli- a client population, timely payment for ser-
gated to develop a respectful contractual rela- vices, and the ability to treat covered clients at
tionship with the client and follow it. This in- less expense to them. The precise nature of
volves all of the points listed above. In the these financial obligations will vary as a func-
event that a client cannot pay for services, it is tion of the particular company, specific policy
desirable to work out an appropriate plan. If the coverage, and any contractual relationships be-
practitioner must decline to continue services tween the provider and payer. Some particular
for nonpayment, care must be taken not to issues of concern include the following:
 132 • billing issues 659

• It is important for psychologists to pay care- specify certain types of diagnostic or thera-
ful attention to all contractual obligations, peutic procedures that are not “covered ser-
understand them, and abide by them. Simi- vices.” Such treatments or services might be
larly, psychologists should not sign contracts considered ancillary, experimental, unproven,
with stipulations that might subsequently or simply health-promoting (e.g., weight
place them in ethical jeopardy. control and smoking cessation) but not treat-
• Balance billing: Some contracts between in- ment for a specific illness. Attempts to con-
surers and practitioners require that the cli- ceal the actual nature of the service rendered
nician accept a specific fee schedule. Such or otherwise attempt to obtain compensation
contracts may prohibit billing a client for in the face of such restrictions may constitute
more than the specified payment. fraud. Some third-party payers will not pay
• Burying the deductible or ignoring the co- for services that are not clearly tied to the
payment: At times a clinician may be asked treatment of a psychological disorder. Exam-
to issue a false invoice inflating actual charges ples include divorce mediation, child custody
to cover a required deductible amount. In evaluations, smoking cessation programs, or
other circumstances a client may ask the weight loss consultations. If in doubt, con-
practitioner to waive a copayment required sult with the third party’s representative (as
under his or her policy without informing described above) and do not misrepresent
the insurer. Agreeing to either practice is un- the service provided.
ethical and may constitute fraud. • Fraud: As a legal concept, fraud refers to an
• Musical chairs (in family therapy): “Musical act of intentional deception resulting in harm
chairs” refers to a practice of switching billing or injury to another. There are four basic el-
from the name of one family member to an- ements to a fraudulent act:
other in order to extend reimbursement ben-
efits as the limit for an individual is reached. 1. False representation is made by one party
This practice may be acceptable to some pay- who either knows it to be false or is know-
ers but not to others. The best strategy is ingly ignorant of its truth. This may be
to check with the claims department of the done by misrepresentation, deception,
third-party payer, explain the services being concealment, or simply nondisclosure of
provided, and bill as directed. Keep a record of some key fact.
the call, including the date, person consulted, 2. The maker’s intent is that false represen-
and instructions you were given. tation will be relied on by another.
• Services not covered: Another common 3. The recipient of the information is un-
problem relates to billing for services that aware of the intended deception.
are not covered under the third party’s obli- 4. The recipient of the information is jus-
gations. Most third parties are health insur- tified in relying on or expecting the
ance companies and as a result limit their truth from the communicator. The re-
coverage to treatment for illness or health- sulting injury may be financial, physi-
related problems, usually defined in terms of cal, or emotional.
medical necessity. One must invariably as-
sign a diagnosis to the client to secure pay-
ment. Some services provided by psychol- IMPORTANT DON’TS
ogists are not, strictly speaking, health or
mental health services. For example, mar- • Never bill for services you have not actually
riage counseling, educational testing, school rendered. If you are billing for services pro-
consultation, vocational guidance, child cus- vided by a supervisee, this should be made
tody evaluations, and a whole variety of for- clear on all bills and claim forms.
ensic functions may not be considered health • Never give anyone a blank insurance claim
services and as such would not be covered by form with your signature on it. This is an in-
health insurance. Some insurance carriers also vitation to fraud.
660 part x • practice management

• Never change diagnoses to fit reimburse- 1. Psychologists may be held responsible for

ment criteria. financial misrepresentations effected in
• Never bill insurance companies for missed or their name by an employee or agent they
late canceled sessions. You may have an agree- have designated (including billing and
ment with clients to pay for such missed ap- collection agents). They must, therefore,
pointments; however, third-party payers may choose their employees and representa-
be billed only for services rendered. tives with care and supervise them
• Never change the date when you first saw the closely.
client in order to fit reimbursement criteria. 2. In all debt collection situations, psychol-
• Never bill for multiple client therapy sessions ogists must be aware of the laws that ap-
(i.e., couple, family, or group) as though they ply in their jurisdiction and make every
were individual treatment sessions. When in effort to behave in a cautious, busi-
doubt about who to bill, contact a claims rep- nesslike fashion. They must avoid using
resentative at the company. Note the name of their special position or information
the claims representative, follow instruc- gained through their professional role to
tions, and keep a record of the conversation. collect debts from clients.
• Do not forgive or waive copayments or de- 3. In dealing with debt collection, whether
ductibles without informing the third-party through an agency or small claims court,
carrier. the clinician should remember that only
pertinent elements (e.g., client status,
number of sessions, and amount owed)
AREAS OF CONTROVERSY can be disclosed without violating the
confidentiality of the client. Disclosure of
• Bill collecting: Creditor and debtor relation- client status in such situations is gen-
ships are just as much a part of the psychol- erally allowed because the client has vi-
ogist-client relationship as in most other olated his or her contract to pay the
purchases of service. Inevitably, some clients agreed-upon fees.
will fall behind in paying for services or fail
• Caution: Fee disputes are a frequent basis
to pay for them at all. Because of the nature
of legal complaints against psychologists
of clients’ reasons for consulting psycholo-
(Bennett, Bryant, VandenBos, & Greenwood,
gists and the nature of the relationships that
1990; Woody, 1988), and this is also true in in-
are established, however, psychologists have
stances of client-initiated ethical complaints.
some special obligations to consider in for-
• Bartering: Although permitted under limited
mulating debt collection strategies. When a
provisions of the APA’s Code of Conduct
client remains in active treatment while in-
(Section 1.18), this should be undertaken
curring a debt, the matter should be dealt
thoughtfully and only as a last resort to as-
with frankly, including a discussion of the
sist a client who might otherwise be unable
impact of the debt on treatment. In most
to afford services.
cases, however, the problems that arise occur
• Missed appointments and last-minute can-
after formal service delivery has terminated.
cellations: These may represent a significant
• Collection agencies: As a general concept, it
economic loss to a practitioner; however, not
is not inappropriate for a psychologist to use
all practitioners charge for occasional events
a professional collection agency. Ideally, a
of this sort. The key point is not to surprise
client should be cautioned that this may hap-
the client with such a charge. Either discuss
pen and should be given the opportunity to
such charges at the outset of treatment or
resolve the matter without involving a col-
caution clients that repeated incidents will
lection agency. Practitioners who employ
result in such charges. Such charges are not
such agencies are responsible for any mis-
payed for services rendered and hence may
conduct by the agency.
not be billed to third parties.
 132 • billing issues 661

• Fee splitting: Relationships involving kick- of therapy at a community mental health cen-
backs, fee splitting, or payment of commis- ter. Journal of Consulting and Clinical Psy-
sions for client referrals may be illegal and chology, 45, 504.
unethical. Careful attention to the particular Bennett, B. E., Bryant, B. K., VandenBos, G. R., &
Greenwood, A. (1990). Professional liability
circumstances and state laws is important
and risk management. Washington, DC: Amer-
before agreeing to such arrangements. Fee
ican Psychological Association.
splitting refers to a general practice, often Dightman, C. R. (1970). Fees and mental health ser-
called a “kickback,” in that part of a sum re- vices: Attitudes of the professional. Mental Hy-
ceived for a product or service is returned or giene, 54, 401– 406.
paid out because of a prearranged agreement Koocher, G. P., & Keith-Spiegel, P. C. (1998). Ethics
or coercion. As it is practiced in medicine or in psychology: Professional standards and
the mental health professions, the client is cases (2nd ed.). New York: Oxford University
usually unaware of the arrangement. Tradi- Press.
tionally there was nearly universal agree- Kovacs, A. L. (1987). Insurance billing: The growing
ment among mental health professionals that risk of lawsuits. Independent Practitioner, 7,
21–24.
such practices are unethical, chiefly because
Pope, K. S. (1988). Fee policies and procedures:
they may preclude a truly appropriate refer-
Causes of malpractice suits and ethics com-
ral in the client’s best interests, result in de- plaints. Independent Practitioner, 8, 24 –29.
livery of unneeded services, lead to increased Pope, K. S., Geller, J. D., & Wilkinson, L. (1975). Fee
costs of services, and generally exploit the assessment and out-patient psychotherapy.
relative ignorance of the client. Unfortu- Journal of Consulting and Clinical Psychology,
nately, fee splitting may exist in rather com- 43, 835 – 841.
plex and subtle forms that tend to mask the Pope, K. S., Tabachnik, B. T., & Keith-Spiegel, P. C.
fact that it is occurring. There is a continuum (1987). Ethics of practice: The beliefs and be-
of types of agreements that range from rea- haviors of psychologists as therapists. Ameri-
sonable and ethical to clearly inappropriate. can Psychologist, 42, 993 –1006.
Woody, R. H. (1988). Protecting your mental health
At the two extremes are employer-employee
practice: How to minimize legal and financial
relationships (clearly appropriate) and ar-
risk. San Francisco: Jossey-Bass.
rangements wherein the person making the
referral gets money solely for making the re- Related Topics
ferral.
Chapter 112, “Fifteen Hints on Money Matters and
Ethical Issues”
References & Readings Chapter 125, “Sample Psychotherapist-Patient Con-
Balch, P., Ireland, J. F., & Lewis, S. B. (1977). Fees and tract”
therapy: Relation of source of payment to course
 PSYCHOLOGISTS’ FEES
133 AND INCOMES

John C. Norcross

This brief chapter extracts the highlights of re- These fees are quite similar to those reported
cent studies on the psychotherapy fees, psy- in a separate study conducted of 480 doctoral-
chological testing fees, and professional in- level psychologists belonging to the APA Divi-
comes of psychologists across the United States. sion of Psychotherapy (Norcross, Orlinsky, &
Beutler, 1999). Their mean and median fees for
three types of patients are summarized in Table 2.
PSYCHOTHERAPY FEES From 1979, when the first Psychotherapy
Finances survey was conducted, median fees
Probably the most systematic study of psy- had constantly risen for private practitioners.
chotherapy fees is that undertaken by the Starting in the mid-1990s, however, there was
Ridgewood Financial Institute every two or a definite downward pressure on fees. Most
three years and published in Psychotherapy Fi- psychotherapists reported that their usual and
nances. Since 1979, this nationwide survey of customary fees had either remained the same
private practice mental health clinicians has (thus actually decreasing when adjusted for in-
covered individual and group therapy fees, flation) or eroded by an average of $5. In fact,
psychological testing fees, regional variations
in fees, managed-care allowances, practice ex-
penses, and total professional income, among
table 1. Psychologists’ Median Fees for Individ-
other elements of the financial profile of psy- ual and Group Therapy Sessions
chotherapy practice. (Subscriptions for monthly
issues of Psychotherapy Finances can be di- Direct Managed Indemnity
rected to 1-800-869-8450 or purchased through Pay Fee Care Fee Insurance Fee
its Web site; see References.) The most recent
Individual therapy $95 $75 $90
survey, conducted in early 2000, encompassed Group therapy $50 $37 $45
1,565 psychotherapists, principally psycholo-
gists (n = 621) and social workers (n = 434). Source: October 2000 Psychotherapy Finances, extracted with per-
mission of the publisher.
Slightly more than half of the respondents
were women, and 99% were licensed in their table 2. Psychologists’ Mean and Median Fees for
respective states. Solo practice was still king of Three Types of Patients
the private practice sample with 57%, followed
by 23% of psychotherapists in solo practice Direct Managed Third-Party
Pay Patients Care Patients Patients
with expense sharing and 17% in group prac-
tice. Mean fee $94 $70 $93
Table 1 presents the median individual and Median fee $100 $75 $90
group psychotherapy fees for the national sam- Inter-quartile
ple of psychologists. Three types of fees are range $80 –110 $65 –$85 $80 –$110
provided: direct pay; managed care; and indem- Source: October 2000 Psychotherapy Finances, extracted with per-
nity insurance. mission of the publisher.

662
 133 • psychologists’ fees and incomes 663

the consumer price index (CPI) is climbing year from psychologists across the United
faster than psychotherapy fees are rising. States. The 2001 Salaries in Psychology report
In several respects, the results substantiate (Singleton, Tate, & Randall, 2003) represents
the obvious economics: providing psychother- the twelfth in the series and is based on the cur-
apy to managed-care patients yields lower rent salaries or net incomes of APA members
hourly reimbursements. Managed care exacts who are working full time in a variety of posi-
significant “costs” from the practitioner: a 25% tions. A total of 10,082 psychologists (50% re-
fee reduction on average and the additional pa- sponse) responded to the latest survey. The data
perwork and administrative duties that such are divided by employment setting, experience
programs typically entail. Heavy reliance on level, and geographic region, and they are pub-
managed-care fees concretely translates into lished in reports available for purchase at a
decreasing annual incomes for full-time clinical modest cost from the APA or for perusal on
practitioners. APA’s home page (see References).
Table 4 presents the 2001 median and mean
salaries for doctoral-level psychologists in aca-
PSYCHOLOGICAL TESTING FEES demic positions by rank. These are the salaries
for individuals employed full time in 9- or 10-
The Psychotherapy Finances study also collects month positions. Because many psychologists
data on psychologists’ fees for administering in academic settings have additional sources of
various psychological tests. The mean fees income from multiple work settings, these fig-
charged for psychological testing are presented ures may not represent total income.
in Table 3 for four types of patients: managed Table 5 presents the salaries for doctoral-
care, indemnity insurance, self-pay, and Medi- level clinical psychologists employed in institu-
care. As seen there, there are large discrepan- tional settings for at least 35 hours per week, as
cies in testing fees between self-pay and man- well as the net incomes for doctoral-level clini-
aged-care patients. cal psychologists employed at least 32 hours per
week in private practice. Because many psy-
chologists will work in more than one position
PSYCHOLOGIST INCOMES or setting, these figures may not represent to-
tal income.
The American Psychological Association (APA) The 2000 Psychotherapy Finances survey
Research Office collects salary data every other reports comparable incomes for psychologists

table 3. Mean Fees Charged by Psychologists for Psychological Tests

Test Insurance Self-Pay Medicare Managed Care Indemnity

Wechsler Adult Intelligence Scale III $134 $211 $209 $151

Wechsler Intelligence Scale for Children III $134 $214 $209 $157
Leiter International Performance Scale—Revised $145 $160 $168 $132
Wechsler Memory Scale III $129 $176 $182 $139
Minnesota Multiphasic Personality Inventory II
(or MMPI-A) $ 89 $121 $131 $106
Millon Clinical Multiaxial Inventory III (or MACI) $ 97 $133 $127 $ 98
NEO Personality Inventory $ 99 $140 $141 $100
Rorschach (Exner system) $117 $194 $219 $118
Wechsler Individual Achievement Test $101 $160 $159 $100
Wide Range Achievement Test III $ 78 $ 96 $ 99 $ 67
Peabody Individual Achievement Test $ 92 $119 $128 $ 75
Child Behavior Checklist $ 55 $ 78 $ 82 $ 84
Dementia Rating Scale $ 97 $107 $123 $ 96

Source: October 2000 Psychotherapy Finances, extracted with permission of the publisher.
664 part x • practice management

table 4. Salaries for Doctoral-Level Psychologists in Academic Settings

Setting and Rank Median Mean SD

University, psychology department

Full professor $ 78,000 $ 81,887 $24,024
Associate professor $ 53,000 $ 54,796 $12,330
Assistant professor $ 44,000 $ 46,408 $25,392
University, education department
Full professor $ 75,000 $ 76,672 $16,750
Associate professor $ 52,500 $ 54,734 $ 9,986
Assistant professor $ 45,000 $ 45,431 $ 6,133
University, business department
Full professor $115,000 $124,385 $45,875
Associate professor $ 78,000 $ 83,867 $25,292
Assistant professor $ 73,000 $ 73,148 $19,382
Four-year college, psychology department
Full professor $ 54,500 $ 59,074 $17,966
Associate professor $ 48,000 $ 48,960 $10,687
Assistant professor $ 39,000 $ 38,733 $ 6,478
Medical school, psychiatry department
Full professor $ 96,500 $112,222 $46,545
Associate professor $ 73,500 $ 71,083 $19,233
Assistant professor $ 47,000 $ 47,537 $ 9,484

Source: 2001 Salaries in Psychology, American Psychological Association (2003).

table 5. 2001 Salaries for Doctoral-Level Clinical Psychologists in Practice

Settings

Setting and Experience Median Mean SD

Public psychiatric hospital

10 –14 years $ 61,000 $ 59,500 $12,422
20 –24 years $ 60,000 $ 56,667 $12,340
25 –29 years $ 62,000 $ 62,800 $ 2,775
VA hospital
5 – 9 years $ 71,000 $ 70,200 $ 7,208
10 –14 years $ 77,000 $ 59,200 $ 5,848
15 –19 years $ 78,500 $ 76,200 $ 8,728
20 –24 years $ 78,000 $ 75,333 $ 6,593
25 –29 years $ 80,500 $ 76,875 $11,154
Individual private practice
5 – 9 years $ 66,000 $ 70,355 $28,711
10 –14 years $ 76,500 $ 91,767 $69,828
15 –19 years $ 87,000 $ 92,752 $43,555
20 –24 years $ 90,500 $100,019 $46,766
25 –29 years $ 75,000 $ 85,127 $41,225
Group private practice
5 – 9 years $ 52,000 $ 59,154 $21,969
10 –14 years $ 70,000 $ 83,100 $68,988
15 –19 years $ 95,000 $ 94,174 $39,093
20 –24 years $ 80,000 $ 93,676 $41,763
25 –29 years $110,000 $ 99,733 $28,679

Source: 2001 Salaries in Psychology, American Psychological Association (2003).

 133 • psychologists’ fees and incomes 665

table 6. Private-Practice Psychologists’ Income Although the incomes of psychologists in

academia, administration, and hospitals have
Private Total
steadily increased of late, such is not the case
Practice Professional
Income Income
for psychologists employed full time in private
practice. Starting in the mid-1990s, the re-
$140,000+ 9% 12% search studies consistently document the nega-
$130,000 –$139,999 3% 4% tive impact of managed care on clinicians’ in-
$120,000 –$129,999 3% 5% comes, especially for more experienced inde-
$110,000 –$119,999 2% 4% pendent practitioners (see also Phelps, Eisman,
$100,000 –$109,000 9% 9% & Kohout, 1998; Rothbaum, Bernstein, Haller,
$90,000 –$99,999 6% 7%
Phelps, & Kohout, 1998; Williams, Kohout, &
$80,000 –$89,999 9% 9%
$70,000 –$79,999 10% 11%
Wicherski, 2000). Practice income is down in
$60,000 –$69,999 11% 11% real dollars. In the 2000 Psychotherapy Fi-
$50,000 –$59,999 11% 11% nances survey, for example, private-practice
$40,000 –$49,999 11% 8% psychologists’ incomes decreased by 1.7% since
$30,000 –$39,999 8% 6% 1997. In the 2001 APA study, for another ex-
$29,999 or less 7% 3% ample, 46% of private practitioners reported
decreased income. For those reporting a decrease,
Source: October 2000 Psychotherapy Finances, extracted with per-
mission of the publisher. the mean and median reduction in net income
was 15% over the years.

in full-time private practice. The median pri- References, Readings, & Internet Sites
vate practice income was $71,856 and the total
professional income was $80,000. Psychologists American Association of University Professors
(AAUP). (n.d.). Annual Report on the Economic
were more likely than other mental health pro-
Status of the Profession. Retrieved 2004 from
fessionals to draw professional income from or- http://www.aaup.org/research/Index.htm
ganizations other than insurance companies and American Psychological Association Research Of-
managed care. That is, they are likely to con- fice. (n.d.). Home page. Retrieved 2004 from www.
sult, teach, supervise, or contract with entities research.apa.org/
such as school systems or health services in ad- Norcross, J. C., Orlinsky, D., & Beutler, L. E. (1999).
dition to their private practice. Managed care involvement and psychotherapy
More detailed data on psychologists’ in- fees among APA Division 29 members. Psycho-
comes are presented in Table 6 in terms of the therapy Bulletin, 34(4), 40 – 43.
percentage of full-time practitioners falling into Phelps, R., Eisman, E. J., & Kohout, J. (1998). Psy-
discrete income ranges. chological practice and managed care: Results of
the CAPP Practitioner Survey. Professional Psy-
The APA Salaries in Psychology report also
chology: Research and Practice, 29, 31–36.
provides salaries for psychologists employed Pingitore, D., Scheffler, R., Sentell, T., Haley, M., &
in a multitude of positions. Doctoral-level psy- Schwalm, D. (2001). Psychologist supply, man-
chologists in educational administration, for aged care, and effects on income: Fault lines be-
example, reported a median 11- or 12-month neath California psychologists. Professional Psy-
salary of $90,000 in 2001. Doctoral psycholo- chology: Research and Practice, 32, 597 – 606.
gists employed in full-time research positions Psychotherapy Finances. (n.d.). Home page. Re-
reported a median salary of $65,000. The me- trieved 2004 from http://www.psyfin.com/
dian 11- or 12-month salary for master-level Rothbaum, P. A., Bernstein, D. M., Haller, O.,
school psychologists was $61,000. And the me- Phelps, R., & Kohout, J. (1998). New Jersey psy-
dian 11- or 12-month salary for doctoral-level chologists’ report on managed mental health care.
Professional Psychology: Research and Practice,
industrial/organizational psychologists was
29, 37 – 42.
$96,000 in 2001. Singleton, D., Tate, A., & Randall, G. (2003). Salaries
666 part x • practice management

in psychology 2001: Report of the 2001 APA 1999 salaries in psychology. Washington, DC:
Salary Survey. Washington, DC: American Psy- American Psychological Association.
chological Association Research Office.
Williams, S., Kohout, J. L., & Wicherski, M. (2000).
Related Topics
Salary changes among independent psychologists
by gender and experience. Psychiatric Services, Chapter 112, “Fifteen Hints on Money Matters and
51, 1111. Related Ethical Issues”
Williams, S., Wicherski, M., & Kohout, J. L. (2000). Chapter 132, “Billing Issues”

ESTABLISHING A
134 CONSULTATION AGREEMENT

Len Sperry

As health care delivery continues to evolve, velop a corporation-wide depression aware-

mental health clinicians are likely to become ness program.
more involved as consultants to various organi- • Consultee-centered administrative con-
zations and agencies. This chapter overviews sultation: The goal is to diagnose and re-
considerations the clinician may face in estab- solve the consultee’s difficulty in dealing
lishing an agreement for consultation services. with administrative problems, such as
As a backdrop for this overview, the focus and functioning as a consultation-liaison psy-
types of consultation are briefly discussed. chologist to a weight management pro-
1. The focus of consultation: Caplan (1970) gram at a community hospital.
describes a classification system based on the
2. The types of intervention: It is useful to
focus of consultation. Consultation can be fo-
distinguish two types of consultant interven-
cused in four ways:
tions: organizational interventions and clinical-
• Client-centered consultation: The goal is to organizational interventions (in contrast to clin-
aid the client, such as executive coaching. ical interventions). Traditionally, clinicians were
• Consultee-centered case consultation: The thought to provide clinical interventions such
goal is to enhance the consultee’s skills; as individual, family, marital, or group therapy,
for example, a psychologist meets with a whereas organizational consultants were more
group of line supervisors to study their likely to provide individual, team, and organi-
understanding of and recognition of sub- zational interventions such as executive coach-
stance dependence in the workplace. ing, team building, and reengineering. Whereas
• Program-centered administrative consul- traditional forms of organizational consultation
tation: The goal is to diagnose and resolve require considerable skill and experience, there
the consultee’s difficulty in dealing with are a number of clinical-organizational inter-
administrative problems. A common ex- ventions that mental health clinicians can com-
ample is assisting EAP personnel to de- petently provide corporations, schools, health
 134 • establishing a consultation agreement 667

care agencies and organizations, community ministrator phones a clinician asking if he

groups, and government agencies. Corporate or she can “do something about employee
Therapy and Consulting (Sperry, 1996) pro- morale,” what is the administrator really
vides a detailed description of 10 common orga- asking for help with? As in psychotherapy,
nizational interventions and 14 clinical-organi- the initial presenting problem is often not
zational interventions. The following is a listing the client’s reason for seeking consultation.
of the clinical-organizational interventions: Consultation requests may be disguised
because of lack of understanding of the
• Hiring, discipline, and termination con- consultation request, embarrassment, mis-
sultation perception of the basic problem, or even
• Work-focused psychotherapy deceit. So, the consultant would inquire
• Outplacement counseling and consultation about what is meant by “morale” and,
• Stress-disability and fitness-for-duty con- specifically, by whom, where in the orga-
sultation nization, and how it is being manifested
• Dual-career couples counseling and con- and what effects it is having on productiv-
sultation ity and communication between manage-
• Conflict resolution consultation with work ment and employees.
teams • Why now? As in psychotherapy, the an-
• Conflict resolution in a family business swer to this question can be extremely re-
• Crisis intervention consultation vealing. Consultations are often requested
• Consulting on resistance to planned change only after the agency or organization has
efforts attempted to deal with its difficulty for
• Merger syndrome consultation a period of time without requesting out-
• Downsizing syndrome consultation side help. What efforts were tried, and to
• Treatment outcomes consultation what extent were they successful? In the
• Mental health policy consultation “morale” example, it is critical to know
• Violence prevention consultation what efforts the administrator has made
and why these efforts have not worked as
3. Assessing the request for consultation:
well as expected.
Irrespective of the type of consultation offered,
• What is the client’s readiness to change?
the process begins with a request from a pro-
The likelihood that the client is willing to
spective client. These requests can include a
make changes to resolve the problem
workshop on stress management, a violence pre-
must also be assessed. Because the client
vention policy, team conflict resolution, stress-
and personnel resources are involved, it is
disability evaluation, or strategic planning, to
essential that the clinician-consultant de-
name a few. The request is usually made by
termine the client’s willingness to allocate
phone or face-to-face. How the clinician-con-
such resources. If it emerges that the
sultant handles the request can greatly impact
hospital’s problem is widespread and the
not only whether a consultation contract is of-
administrator will authorize only two or
fered but also the outcome of the intervention
three workshops on “team building,” it
itself. Just as in psychotherapy, the first five
may well be that the client’s readiness is
minutes of the prospective consultant and client
insufficient. Extended inquiry and discus-
relationship is critical.
sion may be required before an appropri-
Backer (1982) argues that an accurate as-
ate level of readiness is achieved.
sessment of client need must occur very early
• Can I competently provide the requested
in the consultation process. This assessment
consultation? The prospective consultant
will probably address the following questions:
needs to ask himself or herself whether he
• What is the context of the consultation re- or she has sufficient content knowledge,
quest? Specifically, what is the client re- technical and interpersonal skills, and ex-
questing? For example, if a hospital ad- perience to undertake this consultation.
668 part x • practice management

For fairly straightforward requests, such projects, such as presenting a stress manage-
as presenting a lecture on stress manage- ment workshop or conducting a fitness-for-
ment or providing a disability evaluation, duty evaluation, are usually billed as a fixed fee,
both of which require specific technical whereas facilitating team development or orga-
expertise, the question may be easily an- nizational restructuring is usually billed as day
swered. When process plus technical ex- rate, called a per diem. Some consulting activi-
pertise is required, the question of compe- ties, such as critical incident stress debriefing
tence is more complex. (CISD) or facilitating a strategic planning re-
• Can I ethically perform this consultation? treat, may be charged on a project or a per diem
Potential conflict of interest and dual roles basis depending on local or regional customs.
must be considered by the consultant. Ob- Generally speaking, government contracts re-
viously, if the clinician is providing or has quire fixed-fee agreement. For complex consult-
provided marital therapy to the hospital ing activities, consultants tend not to use fixed-
administrator, he or she probably should fee rates for projects with which they have lit-
not be directly involved in consultation. tle experience (see Metzger, 1993, for further
discussion of this point).
4. Responding to the consultation request:
The clinician-consultant now is in a position to • Calculating utilization rate: Billable
respond to the service request. As in psycho- hours refers to the number of working
therapy, the clinician-consultant first responds hours the consultant bills the client. Expe-
to the manifest content of the request by ex- rienced, full-time consultants do not actu-
pressing awareness of the need and/or discom- ally consult full-time. They have down
fort of the client organization. Next, the clini- time in which they may devote up to 20%
cian-consultant proposes a plan for meeting the of their time marketing their services to
request. This may involve a face-to-face meet- secure new consulting arrangements. Ob-
ing— or a series of meetings— to discuss a plan viously, this time is nonbillable. Utiliza-
of action for more complex consultations, or it tion rate refers to the percentage of total
may require only a brief phone meeting for working hours the client can be billed. Ac-
straightforward consultations such as a work- cording to Kelley (1981), the utilization
shop presentation. rate is the number of billable hours di-
5. Drafting a consultation agreement or vided by the number of total working
contract: Usually, a letter of agreement or a for- hours available. For instance, if a clinician-
mal consulting contract will finalize these dis- consultant plans to consult 12 hours per
cussions. Although most consultants routinely week and actually bills for 6 hours per
draft a written contract, some do not (Lippitt & week, the utilization rate is 50%. Obvi-
Lippitt, 1978). The written document of agree- ously, the higher the utilization rate, the
ment becomes a contract if a consideration is greater one’s compensation. Utilization
stated (i.e., the provision of specified consulta- rate indicates how much consulting time
tion for a given fee), and both parties sign the clients are directly paying for, as com-
document. Typically, the document should con- pared with the time the consultant must
tain the specified service to be performed, the absorb as overhead.
time frame, travel and lodging expenses, cost of • Calculating billable rate: The “rule of
assessment and/or intervention materials, and three” is widely used by consultants to
the consulting fee, which may include prepara- calculate their billing rate (Kelley, 1981).
tion time. The rule assumes that a consultant should
6. Establishing a consulting fee: The fee a generate overhead and benefits that should
clinician-consultant charges a client can be es- equal base salary, while also producing a
tablished either on a project or a fixed-fee basis profit equal to base salary. For example,
or on a time basis, in which the increments can suppose a clinician-consultant works half-
be hours or days. Circumscribed activities or time as a clinician at a college counseling
 134 • establishing a consultation agreement 669

center and develops a half-time consulting sultation was specified in the agreement, the re-
practice. If he or she specifies a half-time port is also sent. Following payment, it is cus-
base consulting salary as $50,000 a year, tomary to send a follow-up thank-you note.
the total revenues of $150,000 should be 8. Marketing/soliciting future consultations:
estimated. This is derived from $50,000 Experienced consultants usually do not view
for base salary, plus $50,000 for overhead termination of consultation services rendered as
plus benefits and $50,000 for profit. The termination of the consultation relationship.
billing rate is estimated by dividing total Successful consultations often result in other
revenue by yearly billable hours. For ex- consultation requests from the same client.
ample, $150,000 is divided by 1,000 hours These clients tend to communicate their satis-
(based on 2,000 hours/year as full-time faction with a consultant to their professional
work). The minimum hourly billing rate colleagues and friends. Since word-of-mouth
is thus $150 per hour, and the minimum advertising is the consultant’s most effective
billing rate would be $1200 per day. A marketing strategy, it behooves the consultant
corollary of the rule of three is that the to make his or her initial consultations as suc-
more hours billed, the less one needs to cessful as possible. Consultants may also seek
charge to maintain profit levels, whereas written permission to mention the names of
the fewer the hours billed, the more that clients of their most successful consultations in
must be charged to maintain profit level. written materials — such as brochures — or in
• Other ways of establishing a billing rate: verbal conversation with prospective clients.
A second way of setting a billing rate is
based on the usual and customary fees in
References & Readings
a geographic region. Usually, there is a
typical daily rate for psychologists in par- Backer, T. E. (1982). Psychological consultation. In
ticular metropolitan areas. For example, J. R. McNamara & A. G. Barclay (Eds.), Critical
while $1,200 per day is considered the issues in professional psychology (pp. 227 –
norm in some midwestern cities, the rate 269). New York: Praeger.
in large northeastern cities may be $2,000 – Biech, E. (1999). The business of consulting: The ba-
sics and beyond. San Francisco: Jossey-Bass.
$2,500 per day. Finding out the billing
Caplan, G. (1970). The theory and practice of mental
rates of three or four clinician-consultants health consultation. New York: Basic Books.
should reveal the usual and customary Kelley, R. E. (1981). Consulting: The complete guide
rate for a given community. A third way to a profitable career. New York: Scribner’s.
of establishing fee arrangements is to con- Lippitt, G., & Lippitt, R. (1978). The consulting pro-
sider the client’s circumstances. Schools and cess in action. San Diego, CA: University As-
community organizations may have lim- sociates.
ited funds for consultation, whereas de- Metzger, R. (1993). Developing a consulting prac-
fense attorneys may have unlimited funds tice. Newbury Park, CA: Sage.
for expert testimony. The beginning clin- Sperry, L. (1996). Corporate therapy and consult-
ician-consultant also may be willing to of- ing. New York: Bruner/Mazel.
fer a low-cost consultation fee to one or
more clients in return for gaining experi- Related Topics
ence and receiving a positive reference
from that client. Chapter 117, “Forensic Referrals Checklist”
Chapter 125, “Sample Psychotherapist-Patient Con-
7. Completion of consultation services ren- tract”
dered: Following completion of the consultation Chapter 131, “Contracting With Managed Care Or-
services rendered, it is customary to send or de- ganizations”
liver the bill for payment. If a report of the con-
 COMPUTERIZED BILLING
135 AND OFFICE MANAGEMENT
PROGRAMS

Edward L. Zuckerman

Computerization of clinical practice is not only SELECTING A PROGRAM

almost unavoidable but also quite beneficial.
Typing on a computer is easier than handwrit- You probably turned to this section to find out
ing, computers rarely lose anything and can which program to buy. I wish I could tell you
find it anywhere in a few seconds, and the In- the answer, but I can’t know your situation or
ternet holds great riches. Commonly available needs, so here is a general strategy. First, look
programs allow you to cope with billing and at the available features and decide which are
managed-care needs, assist in psychological most important. As you explore, add more fea-
assessment, construct reports, survey the re- tures or more explanation of them to your
search, administer treatments, and put you in checklists. Get the demos and experiment with
instant touch with colleagues around the world. them. Do not decide on the basis of price. Your
However, for many, the most pressing need income and stress level will depend on this pro-
is a program that can ensure accurate and gram for many years, and a program that is
timely billing and that can handle routine office confusing or unnecessarily complex will be a
tasks like appointment scheduling and record- continuing source of distress. If you have an of-
ing progress notes. Most of the software de- fice manager, he or she should make the final
scribed below will do these tasks, and many decision even though you have the advanced de-
programs offer additional functions. This list is gree.
not exhaustive. It omits programs for the larger
systems like clinics. Small programs for billing
are listed at the end. I estimate that this list is FORMAT OF THE ENTRIES
98% complete and certainly contains all the
major developers of these programs for mental • The developer’s name, address, phone, and
health offices. This listing is current as of April Web site. The list is alphabetical. The size of
2003. the description is not related to the size of the
Since developers are constantly improving program.
and modifying their products, confirm impor- • The name of the program. I have put this
tant aspects of a program before you make a second because many programs have similar
purchase. Because the Health Insurance Pri- names.
vacy and Accountability Act (HIPAA) will sub- • A description of the program. Since all these
stitute a new electronic billing form — the programs do billing, only unusual aspects
ANSI 827-P for the familiar HCFA-1500—ask are listed. Where they do additional func-
each developer how he or she is handling this. tions, they are called “office management”
All computers, software, and other product programs and may include schedulers, mail-
names listed herein are property of their re- ing list handling, treatment plan writing,
spective copyright and trademark holders. recording of medications, and the like. ECS

670
 135 • computerized billing and office management programs 671

means electronic claims submission— the 800-437-4307

ability to send a claim for payment to the in- http://www.internexsys.com/main/htm/info
surance company over the phone line using manager.asp
your modem and specialized software. This Medical InfoManager is an integrated collec-
makes the insurance company’s work easier, tion of modules for accounting and billing,
it may speed up your payment, and it cer- word processing, reports, scheduling, treatment
tainly speeds up their denying your claim. plans, and ECS. Highly medical but adaptable to
• The computer hardware or “platforms” the psychology. No prices on the Web site. Macin-
program is designed to run on. All of these tosh and Windows.
programs work under Microsoft’s operating
system, Windows, and they are not so iden- Applied Computing Services
tified. There are fewer that work on Apple’s 212 Fair View Road
Macintosh computers (but you only need Elk, WA 99009
one program); these are indicated with the 800-553-4055
word Macintosh. http://www.pma2000.com/
• The current costs of the program, where ad- PMA-2000 does billing, insurance, scheduling,
vertised or available. These may change or and progress notes, especially for mental health.
your needs may not fit the configuration of ECS through a clearinghouse and directly is
the program listed, so call to confirm prices. $195. Full-featured demo for 20 patients is $20
• The availability of downloads or cost of on CD or a free download. Solo version is $295,
demonstration disks. Some of these contain three providers is $495, each with a year’s sup-
only a “guided tour” that describes and il- port but additional years are $100 to $180.
lustrates the program’s major features. Oth-
ers contain a limited version of the whole Beaver Creek Software
program or limit you to a small number of 525 SW 6th Street
clients or a fixed period of time. You can en- Corvallis, OR 97333-4324
ter data and see how the program works, but 800-895-3344
you cannot use the demo to run your prac- http://www.beaverlog.com
tice. These “fully functional” demos will The Therapist for Windows is a full-scale
take a lot of your time to enter client infor- billing program; its features are as follows: fills
mation, but you will then really understand in forms, all diagnostic codes (DSM-IV, CPT,
their strengths and limitations. ICD-9), prints on letterhead or HCFA 1500,
makes mailing labels, deposit slips; tracks refer-
rals and pre-authorizations, simple clinical
THE PROGRAMS notes; password protection, backup and restora-
tion of data, pre-authorizations and insurance
Accurate Assessments maximums, dunning messages, form letters,
1823 Harney Street, Suite 101 and so on. Program cost is $499 with more for
Omaha, NE 68102 added clinicians and networks. Demo on CD
http://www.accurateassessments.com/ ($20) or free download, includes 60 days tech
software.htm support. Options: Appointment scheduler ($150),
AccuCare is a suite of integrated programs for case manager ($200) with treatment plans, prog-
billing, ECS, assessment, and monitoring of ress notes, histories, managed-care data, group
progress and outcomes that offers specialized therapy note, medications.
modules for addictions, criminal justice, and
Native Americans. Free demos by download. Blumenthal Software
No prices on Web site. 528 Palmer Farm Drive
Yardley, PA 19067
Affinity Software Corporation 215-702-9550
Walpole, MA 02175 http://www.blumenthalsoftware.com
672 part x • practice management

PBS: The Psychologist’s Billing System. This http://www.delphipbs.com/index.htm

mature, full-featured billing program does it Delphi/PBS. This very complete package has
all — accounting, forms generation and print- been around for many years and includes all
ing, management reports; transfers data into billing functions, scheduling, ECS through a
spreadsheets, sliding scale and Medicare fee clearinghouse, passwords, mailing labels, on-
generation, handles managed-care limitations, line help, payroll calculation, finance charges,
etc. Solo or groups $595. Inherently network- networkable, backups, and more. No demos are
able. $100 more for version with encryption. listed at the Web site. Toll-free phone support.
Free annual updates. $895 for solo and $100
Cornucopia Software more for each additional provider.
626 San Carlos Avenue
Albany, CA 94706 Practice Management Software
510-528-7000 285 Engle Street
http://www.practicemagic.com Englewood, NJ 07631
Practice Magic is a very complete billing and 800-874-2159
office management system at a low price; it http://www.pm2.com
runs on Macintoshes as well. It prints to HCFA PM/2 is a longstanding and complete billing
1500, uses an appointment book format (and program with dozens of features including in-
prints Daytimer inserts); exports to Quicken; surance billing, scheduling, managed-care track-
does progress notes, managed-care functions, ing, and security. PM/2 Clinical Planner gener-
bank deposit slips, and more. ECS billing through ates treatment plans and OTRs from checklists.
a clearinghouse. The standard version is $130 Solo practitioner is $600, additional providers
with manual. After three years updates are $40 are $300. ECS, $300. Clinical Planner, $395.
per year. For $180, the yearly updates cost is
eliminated. Multiusers are 50% more. Demo Pragmatic
free download or $10 on CD. PO Box 33551
Reno, NV 89533
DocuTrac 877-773-4481
20140 Scholar Drive, Suite 218 http://www.centerdigital.com/software/
Hagerstown, MD 21742-6575 Center Psych. This is a combination of a billing
800-850-8510 program and, with options, additional services. It
http://www.quicdoc.com can serve 1–99 providers, a single office or mul-
Office Therapy is a fully featured insurance and tiple locations, and makes good use of the Mac-
billing program with ECS through clearing- intosh interface. There are no prices or down-
houses. Managed-care information is well inte- loads at the Web site, but a slideshow is available.
grated, data can be easily exported to other data-
bases, and much of the program can be user- Psychotherapy Practice Manager
modified. Free fully functional demo by down- 800-895-1618
load or by request. $499. Now available for the http://www.anacapa.net/~jhmullin/#toc13
Palm OS. QuickDoc is a fully featured records The Psychotherapy Practice Manager is a quite
program with documentation for intakes, comprehensive and mature office management
progress and discharge notes, scheduling, treat- set of programs for basic client records (client
ment goals and plans, patient satisfaction, practice registration, intake assessment, progress notes),
forms, letters, mail merge, etc. QuicForms fit all billing, appointments (intake form, scheduler,
managed-care formats. QuicWord allows easy reminders, “To Do” lists), Rolodex (sorting codes,
creation and integration of records with other address books, labels), accounting (revenues,
programs. $549 or both programs for $863. expenses, profit and loss, IRS 1040 Schedule C
summary), management reports (accounts re-
PC Consulting Group ceivable, aging, detailed and summary activity),
800-847-8446 DSM-IV/CPT codes, and generic forms (con-
 135 • computerized billing and office management programs 673

sent to treat, release of information). 90-day Windows offers very flexible clinical records in-
free tech support. Single therapist version for cluding intake, history, problem/goal/asset/ob-
Windows and Macintosh $395; multiple- stacle-oriented treatment plans and progress
therapist practices are $100 more. Options: notes, group therapy progress notes, medica-
managed-care module $195, ECS $195. Full- tion, a glossary for reusable text, templates for
featured demo $20, credited toward purchase. most used information. $495 for solo, more for
networks.
Psyquel
12758 Cimarron Path, Suite 127 SumTime
San Antonio, TX 78249 995 Vintage Avenue, Suite 102
877-779-7835 St. Helena, CA 94574
http://www.psyquel.com 888-821-0771
Scheduling, billing, and insurance for mental http://www.sumtime.com
health providers with a twist. It is a subscrip- SumTime is a very complete and full featured
tion based Internet service. They pursue unpaid billing and practice management software pack-
claims, track authorizations, backup records, age including ECS and scheduler, billing and
and provide free support training, upgrades, managed-care functions, 10 pages of password
and more. The program also supports progress protected notes per session, customized form
notes and other patient records. letters, etc. Free demo by download or on CD
for $10. Windows or Macintosh, $499 single
Saner Software user, $599 for group practice. 90-day support
253, 2460 W. Main Street D included, additional tech support by the year.
St. Charles, IL 60175
630-513-5599 VantageMed
http://www.sanersoftware.com 600 West Cummings Park, Suite 3450
ShrinkRapt is a very complete billing and in- Woburn, MA 01801
surance program with some records features 800- 3-HELPER/ 800-343-5737
like clinical notes and treatment plans. It is http://www.helper.com
available for the Macintosh and technical sup- Therapist Helper. A very comprehensive mul-
port is free. A walk-through demo on a CD is tifunctional program that, besides billing,
free and includes sample reports and manual. includes scheduling, managed-care and meds
Modules for scheduling and ECS are an addi- tracking, many reports, progress notes. Options
tional $49 each. Solo practitioner $585, $985 for include ECS, credit card processing, Palm Or-
multiple users of one machine. ganizer version, and QuicDoc (see DocuTrac,
above). No prices on the Web site. Download-
SOS Software able fully functional demo.
352-242-9100
http://www.sosoft.com Related Topics
SOS Office Manager is a fully featured mature
product based on the familiar daysheet/ledger Chapter 112, “Fifteen Hints on Money Matters and
Related Ethical Issues”
card model. Simplified data entry, managed-
Chapter 132, “Billing Issues”
care tracking, useful management reports, and
much more. Prices start at $1,999 for single
computer and more for networks. A very func-
tional scheduler is $150 solo and $300 net-
worked. ECS is $395. SOS Case Manager for
This page intentionally left blank
PART XI
Professional Resources
This page intentionally left blank
 THERAPIST SELF-CARE
136 CHECKLIST

John C. Norcross & James D. Guy, Jr.

Mental health professionals, by definition, in press), and is divided into 11 broad strategies
study and modify human behavior. That is, we of self-care.
study and modify other humans. Psychological
principles, methods, and research are rarely
brought to bear on psychotherapists ourselves, MIND THE BODY
with the probable exception of our unsolicited
attempts to diagnose one another (Norcross, • We occasionally become so intent and fo-
2000). Although understandable and explicable cused on sophisticated self-care methods that
on many levels, this paucity of systematic we overlook the basics. What is the quality of
study on psychotherapists’ self-care is unset- your nutrition, your body? Do you obtain
tling indeed. sufficient exercise and healthy food during
Our aims in this brief chapter are threefold: the day, or, as one of us discovered himself
first, to remind busy practitioners of the per- doing a few years ago, are you subsisting
sonal and professional need to tend to their own throughout the day without exercise and
psychological health; second, to provide evidence- with only diet soda and hard pretzels?
based methods to nourish themselves; and third, • How many hours of sleep do you average per
to generate a positive message of self-renewal evening? How many hours do you need?
and growth. • Increase your sensory awareness: beholding
The following list summarizes practitioner- your surroundings using vision, hearing,
recommended and research-informed methods touch, and olfaction can be a powerful elixir
of alleviating the distress of clinical work, or and can counterbalance the primarily cogni-
more optimistically, of replenishing the practi- tive and affective work of psychotherapy.
tioner. Unfortunately, the research on psy- • Take your own advice: exercise and relax reg-
chotherapist self-care has not progressed to the ularly.
point where controlled studies have been con- • Take minibreaks between sessions to self-
ducted. Nonetheless, the list presents a practi- massage your face and neck muscles; perhaps
cal synthesis of clinical wisdom, research liter- schedule regular massages to nourish your-
ature, and therapist experience on self-care self and relieve muscle tension.
methods from disparate theoretical traditions. • Monitor your use of substances. Are you
The list is adapted from a more extensive cata- self-medicating with alcohol, tobacco, food,
logue of self-care activities published in our or drugs?
book Leaving It at the Office (Norcross & Guy,

677
678 part xi • professional resources

REFOCUS ON THE REWARDS OF that you experience each day. What steps can
CLINICAL WORK you take to create more opportunities for
contact with other clinicians?
• Attend to the rewards associated with clinical • Invite family and friends to point out when
work. For example, recall the life-transform- you become too interpretive and “objective”
ing psychotherapies in which you were priv- when it would be healthier to be spontaneous
ileged to participate. and genuine.
• Satisfaction from helping others is crucial, so • The possibility of patient violence is disturb-
be sure to include at least some clinical activ- ing but important to consider. How can you
ities that demonstrate you are actually help- act now to enhance your personal safety at
ing someone! the office?
• Enjoy maintaining relationships with clients • Do you frequently hear stories of abuse and
spanning years, even decades, that include cruelty in your work with clients? Limit
intermittent courses of treatment. your exposure to traumatic images outside
• Your work will ideally capitalize on both the therapy room by choosing movies, liter-
your natural and acquired abilities. Do what ature, and other entertainment carefully.
you do well. • How much confidential client material do
• Be careful when applying your expertise to you share with your significant others? Have
your family of origin (fools rush in where you thought out all of the implications of
angels fear to tread). what you do share?
• Remember: you are actually self-employed, • Consider how you have managed the delicate
regardless of whom you work for. Look for balance between empathic connection and
ways to create a greater sense of freedom and self-preserving distance in your work with
independence in your work. distressed patients. Do you find yourself on
• Clinical practice may not make you rich, but one end of the pendulum more often than
if it is your calling, it is a wonderful way to you would like? How might you intention-
make a living. ally pursue balance here?
• There are typically many more benefits than • Reflect on the number of clients that you’ve
hazards associated with the practice of psy- said good-bye to over the years. What has
chotherapy. If you’ve forgotten this, find been the cumulative impact of these termi-
methods to help you remember. nations?
• Therapists tend to minimize their own limi-
tations and needs, particularly when talking
RECOGNIZE THE HAZARDS OF with colleagues. With which colleague can
THE “IMPOSSIBLE PROFESSION” you be vulnerable and honest?
• Periodically reevaluate why you became a
• All accounts indicate that clinical practice ex- psychotherapist and why you continue to
acts a negative toll on the practitioner, partic- practice. Look for ways to work through those
ularly in the form of problematic anxiety, unhealthy motivations.
moderate depression, and emotional under- • You can’t always keep your personal life
involvement with family members. Have from influencing your practice. Accept some
you identified the impact of clinical practice spillover as an inevitable cost of being hu-
on you and your loved ones? man.
• Reading about and reflecting on the stresses • Marital and relationship difficulties related
of psychotherapy commonly leads to the re- to the practice of psychotherapy are fre-
alization that similar strains are experienced quently reported by clinicians. Discuss with
by virtually all mental health professionals. your spouse the topics covered in this chap-
Can you affirm the universality of these ter. How does he or she perceive their impact
stresses? on your relationship?
• Consider the amount of physical isolation • Burnout among therapists is a real but rela-
 136 • therapist self-care checklist 679

tively rare phenomenon. What steps are you SET BOUNDARIES

taking to reduce the possibility of burnout?
• Setting boundaries emerges in our research
as the most frequent self-care strategy of
NURTURE RELATIONSHIPS mental health professionals. Be clear with
your clients about professional expectations
• In one study of well-functioning psycholo- and limitations.
gists (Coster & Schwebel, 1997), peer sup- • Clearly delineate your policies regarding ex-
port emerged as the highest priority. How tra sessions, late appointments, telephone
does your peer support fare? contacts, payment for services, and the like.
• Are you getting enough alone time? Do you • Your work expresses a combination of per-
know what to do with it when it’s available? sonal style, theoretical orientation, and indi-
• Identify the three most nurturing people in vidual preferences. Caring professionals cus-
your life. What can you do to increase the tomize their work to individual patients, but
amount of support you receive from them? there is a limit to bending.
• Ongoing peer supervision or consultation • Clarify your expectations of your clients
is highly valued by experienced clinicians early in your work. What are the ground
throughout their careers. Do you have such rules for treatment?
arrangements in your own life? Under what • Understand what your client needs most, and
circumstances do you seek supervision or don’t allow that goal to be compromised by
consultation? conflicting roles and agendas.
• Try to include phone calls, lunches, and • Your clients are not there to meet your
breaks in your workday several times each needs; treatment relationships are not recip-
week to provide contact with family and rocal.
friends. • Define your relationships with colleagues
• What have you learned about yourself as a with care. Transference influences these rela-
result of experiencing loss following comple- tionships, too.
tion of treatment with a favorite patient? • Establishing an identity apart from your role
Specifically, what interpersonal gratifications as a clinician will enrich your private life
did you receive? with variety and meaning. Don’t get stale!
• Name your most significant mentor during
your career. What made this relationship so
important? How are your needs for mentor- RESTRUCTURE COGNITIONS
ing being met today?
• A spouse/significant other is an important • Self-monitor your internal dialogue, partic-
source of nurturance for many clinicians. How ularly in regard to countertransference feel-
important is this in your life? ings.
• Have your friendships become fewer in • Attend to what Ellis calls “stinking think-
number and diminished in significance over ing” through introspection, reflection, using
the years of professional practice? What does triple column logs, or sharing concerns with
this tell you, if anything? others.
• Support groups and peer supervision groups • Think through your reactions to transferen-
offer multiple advantages. Consider joining tial feelings directed to you. To whom are
or creating one. they aimed and to whom do they belong?
• Something may be askew if you are habitu- • Beware of absolutistic thinking: musturba-
ally giving out more nurturance than you tion and the tyranny of the shoulds. They can
are receiving. Consider corrective actions. affect you as much as your patients.
• Dispute the common fallacy that “good psy-
chotherapy is equivalent to having all pa-
tients like us.” It is not!
680 part xi • professional resources

• Yes, you are an expert on human behavior— • How much adventure and other diversions
but you’re still nutty at times! do you have away from the office? Is play a
• Recall that the other side of caring consists of steady staple for your emotional diet?
confrontation. Caring about others includes • Consider taking steps to create variety in
being tough at times. your day, such as intermingling psychother-
• Take Coach John Wooden’s advice and refuse apy sessions with supervision, consultations,
to believe either your most idealizing or your study breaks, a trip to the gym, and so on.
most demeaning client — you are neither • Involvement in other professional activities
God nor the devil. balances your workload and expresses a full
• Remind yourself that you cannot cure every array of your skills. Psychotherapy, teaching,
patient. supervision, administration, consultation, as-
• Balance the amount of time you devote to sessment, and writing are all part of the men-
thinking about your successful cases and your tal health professional landscape.
frustrating cases. Dwell on your successes as
well as your failures.
• Assertively lessen unrealistic demands made UNDERGO PERSONAL THERAPY
on you: don’t take on more work than you
need to or wrongly believe you’re expected to • Freud (1964) recommended that every ther-
do more. apist should periodically—at intervals of five
• Consider alternate explanations that may years or so —reenter or initiate psychother-
cause events. Psychotherapy is not the only apy without shame as a form of continued
causal event in clients’ lives. Nor are you the education. Do you heed his sage advice? Do
sole or primary causal agent! you struggle with the shame?
• Calculate real probabilities. The worst does not • Between 52% and 65% of psychotherapists
always happen— to you or to your patients. enter personal treatment following com-
• Evaluate events on a continuum to avoid pletion of formal training. Do you subscribe
dichotomous thinking; psychotherapy out- to the illusion, or perhaps the delusion, that
comes are rarely on either extreme of a con- mental health professionals do not experience
tinuum. a need for personal therapy once they are in
practice?
• Can you give yourself 50 minutes of time
SUSTAIN HEALTHY ESCAPES every few weeks in a holding environment?
Are you practicing what you preach about
• A sense of humor is one of your most im- the value of psychotherapy?
portant stress relievers. Practice! • If you do not participate in formal psy-
• In one study (Mahoney, 1997), over 80% of chotherapy, consider an annual satisfaction
therapists routinely engage in reading or a checkup with a valued mentor, trusted col-
hobby, take pleasure trips or vacations, and league, or former therapist.
attend artistic events and movies as part of
their self-care patterns. Is your life balanced?
• Monitor your vacation and down time. Is it CREATE A FLOURISHING
less than you, as a psychotherapist would ENVIRONMENT
recommend to patients in similarly stressful
occupations? • Do you fall prey to American individualism
• Variety and intellectual stimulation are in- and neglect systemic forces in and outside of
dispensable. What can you do to increase your office? Employ stimulus control: struc-
their impact on your schedule and profes- ture your environment to help, not hinder,
sional duties? your clinical effectiveness.
• Pace your day, space appointments, and take • Are your clinical talents and interpersonal
a break or two. interests poorly invested in paperwork? If so,
 136 • therapist self-care checklist 681

consider a computer, a clerical assistant, or FOSTER CREATIVITY AND

other alternatives. GROWTH
• Search for ways to create a greater sense of
freedom and independence in your work. • Opportunities for dedicated reflection and
• Enhance your work environment: comfort in discernment are a professional obligation,
your furniture, aesthetics in your decor, re- not a luxury. How often do you engage in
plenishment in your refrigerator, and nour- spiritual exercises, journaling, meditation, or
ishment in your peers. other forms of renewal?
• Are you finding ways of nurturing your cre-
ativity? Are staleness and repetition starting
CULTIVATE SPIRITUALITY to get you down?
AND MISSION • Diversify, diversify, diversify.
• Attending clinical conferences, reading liter-
• We emphasize the personal experience of ature, and continuing your education are the
spirituality or what Maslow called mission. life springs of a committed professional. Do
Can you identify and resonate to an abiding you feel you are just getting CE hours or
mission or spirituality? truly refining and building your skills?
• Embrace your sense of calling to be a clini- • Everything comes together for a therapist in
cian. What are the spiritual antecedents to the creative process (Kottler, 1999). How are
your career choice? you coming together, nourishing yourself,
• Your work grows out of a legacy of socially and growing as a psychotherapist?
sanctioned healers that extends back for
many centuries. Try to feel connected to the References & Readings
heritage and to the privilege of practicing
Baker, E. K. (2003). Caring for ourselves: A thera-
psychotherapy.
pist’s guide to personal and professional well-
• A sense of personal mission can fruitfully in- being. Washington, DC: American Psychologi-
corporate larger societal concerns, such as en- cal Association.
hancing women’s rights, promoting social Brady, J. L., Norcross, J. C., & Guy, J. D. (1995).
justice, teaching conflict resolution, eradicat- Managing your own distress: Lessons from
ing poverty, and abolishing sexual abuse. psychotherapists healing themselves. In L.
What are the sympathies that renew you? VandeCreek, S. Knapp, & T. L. Jackson (Eds.),
• Optimism and belief in the potential for per- Innovations in clinical practice (pp. 293 –306).
sonality change are prerequisites for good Sarasota, FL: Professional Resource Press.
clinical practice. Assess yourself and then ask Coster, J. S., & Schwebel, M. (1997). Well-function-
ing in professional psychologists. Professional
a friend to assess you.
Psychology: Research and Practice, 28, 5 –13.
• How does your belief in a mission, God, or
Dryden, W. (Ed.). (1995). The stresses of counselling
a transcendent force influence your work? in action. Thousand Oaks, CA: Sage.
How does this serve as a resource for you? Freud, S. (1937/1964). Analysis terminable and in-
Are you squarely confronting your own terminable. In J. Strachey (Ed.), Complete psy-
yearnings for a sense of transcendence and chological works of Sigmund Freud. London:
meaning? Hogarth.
• Try to invoke and augment your client’s spir- Geller, D. D., Norcross, J. C., & Orlinsky, D. E.
ituality worldview to enrich their experience (Eds.). (2005). The psychotherapist’s own psy-
of psychotherapy. chotherapy: Patient and clinician perspectives.
• Since the practice of psychotherapy is not to New York: Oxford University Press.
Guy, J. D. (1987). The personal life of the therapist.
provide ultimate meaning for your life, what
New York: Wiley.
does? What should?
Kottler, J. A. (1999). The therapist’s workbook: Self-
assessment, self-care, and self-improvement
exercises for mental health professionals. San
Francisco: Jossey-Bass.
682 part xi • professional resources

Mahoney, M. J. (1997). Psychotherapists’ personal Norcross, J. C., & Guy, J. D. (in press). Leaving it at
problems and self-care patterns. Professional the office: Psychotherapist self-care. New
Psychology: Research and Practice, 28, 14 –16. York: Guilford Press.
Norcross, J. C. (2000). Psychotherapist self-care: Rippere, V., & Williams, R. (Eds.). (1985). Wounded
Practitioner-tested, research-informed strate- healers. New York: Wiley.
gies. Professional Psychology: Research and Schaufeli, W. B., Maslach, C., & Marek, T. (Eds.).
Practice, 31, 710 –713. (1993). Professional burnout: Recent develop-
Norcross, J. C., & Aboyoun, D. C. (1994). Self- ments in theory and research. Washington,
change experiences of psychotherapists. In DC: Taylor & Francis.
T. M. Brinthaupt & R. P. Lipka (Eds.), Chang- Scott, C. D., & Hawk, J. (1986). Heal thyself: The
ing the self (pp. 253 –278). Albany: State Uni- health of health care professionals. New York:
versity of New York Press. Brunner/Mazel.

CONDUCTING EFFECTIVE
137 CLINICAL SUPERVISION

Nicholas Ladany

Supervision is the primary means of imparting liance has been empirically shown to relate to
psychotherapy knowledge and skills to super- supervision process and outcome.
visees. Yet, relative to the psychotherapy liter- 2. Apply models of supervision, as opposed
ature, the supervision literature is in an earlier to generalizing models of psychotherapy to su-
phase of development in terms of generating pervision. Supervision-based models, albeit
evidence-based advice for performing supervi- only moderately comprehensive, have been in
sion. The following pantheoretical recommen- place for decades. Two general types have been
dations for conducting effective clinical super- identified: developmental models (e.g., Stolt-
vision are derived from the extant theoretical enberg, McNeill, & Delworth, 1998) and gen-
and empirical literature, and are grounded in eral skill-based or competency models (e.g.,
clinical experience. Holloway, 1995). Most of the empirical work
1. Emphasize and readily attend to the su- has focused on the developmental models; how-
pervisory relationship. The supervisory work- ever, this preference seems more heuristically
ing alliance is the likely foundation for the ef- useful than empirically supported. It seems su-
fectiveness of all supervisor interventions. Bor- pervisors like to think developmentally, but act
din (1983) conceptualized the working alliance from a skills-based approach. Although multi-
as consisting of a mutual agreement on the (a) ple models have been expounded, only one
goals and (b) tasks of supervision, and (c) an technique has demonstrated efficacy in super-
emotional bond between the supervisor and su- vision: Interpersonal Process Recall (Watkins,
pervisee. The strength of the supervisory al- 1997).
 137 • conducting effective clinical supervision 683

3. Attend to supervision’s own unique dy- selecting supervisees, and ensuring that super-
namics. The art and science of conducting su- visees with rigid interpersonal difficulties are
pervision is different from the art and science of prevented from continuing to work with clients.
conducting psychotherapy in at least three pri- In addition, the supervisory work has a legal di-
mary ways. First, it is intended to be primarily mension that varies by jurisdiction and super-
educative. Supervision occurs with the inherent visors are reminded to familiarize themselves
assumption that the supervisee is there to with those laws and rules.
become more adept at psychotherapy-related 6. Supervision should not be psychotherapy
skills. Second, supervision is evaluative. A crit- for the supervisee. Although it can be legiti-
ical role for the supervisor is to evaluate the su- mately argued that part of supervision is to help
pervisee on these predefined skills. Third, su- the supervisee explore how her or his reactions
pervision is typically (especially pre-licensure may influence the therapy work, supervision is
and outside the United States) involuntary for not a place solely for therapeutic change in the
the supervisee. In many instances, the su- supervisee. Supervision should focus on super-
pervisee has little choice in whether, or from visee interpersonal dynamics inasmuch as they
whom, he or she receives supervision. These relate to work with the client. More thorough
three conditions create different dynamics than attention should be provided by a therapist out-
does psychotherapy, and as such, supervision side of supervision.
should be viewed through a supervision, rather 7. Balance the 16 general supervisor tasks.
than a psychotherapy, lens. In pursuit of achieving positive supervision
4. Engage in role induction and contracting outcomes, supervisors essentially engage in 16
with all supervisees. In role induction and con- tasks (Ladany, Nelson, & Friedlander, in press).
tracting, supervisors provide supervisees with These are focusing on the supervisory alliance,
explicit and understandable parameters of su- normalizing the supervisee’s experience, focus-
pervision work. Although it may be reasonably ing on countertransference, focusing on multi-
assumed that more advanced supervisees are cultural awareness, focusing on evaluation, at-
aware of what transpires in supervision, it is tending to parallel process, focusing on concep-
frequently the case that supervisees’ experi- tual skill, focusing on technical skill, focusing
ences do not consist of typical experiences. on interpersonal skill, focusing on the thera-
Therefore, supervisors should engage in role peutic process, focusing on self-efficacy, explo-
induction and contracting that includes super- ration of feelings, focusing on the supervisee’s
visor disclosures about educational, training, interpersonal dynamics, assessing ethical aware-
and clinical experience; theoretical approach to ness, assessing theoretical knowledge, assessing
supervision and therapy, and confidentiality research knowledge, and case discussion. The
limits; supervision parameters that include supervisor must decide when and how much,
meeting time, length of time, place, fee ar- each of these competing demands must be at-
rangements, contact and crisis information, and tended.
use of taping; and supervisee expectations such 8. Supervisors should attend to both super-
as informed consent, who is primarily respon- visee-focused and client-focused outcomes.
sible for initiating the supervisory discourse, Client outcome, while always alluded to as im-
supervisee disclosure, note taking, supervisee’s portant, has been examined in only a handful of
use of self in supervision, supervisory goals, mostly case study empirical investigations, and
and supervisor evaluation. a clear link between supervision and client out-
5. Tend to administrative responsibilities. come has not been established. Conversely,
Supervisors must fulfill a variety of adminis- supervisee-based outcomes have been identified
trative responsibilities that include keeping in the literature and include strengthening the
records of supervision, keeping abreast of all supervisory relationship; enhancing supervisee
clients supervised, ensuring clients are aware of conceptualization skills, therapy knowledge,
the supervisee’s and supervisor’s status, signing multicultural awareness, self-efficacy, tolerance
off on supervisee notes, using due diligence in of ambiguity, awareness of countertransference,
684 part xi • professional resources

awareness of parallel process, and therapy skills; tion, assessment), method (supervisee self-
decreasing supervisee anxiety; and facilitating report, case notes, audiotape, videotape, live su-
the development of supervisee self-evaluation. pervision), proportion of caseload (all clients,
Supervisors should flexibly approach the super- subgroup of clients), segment of experience
visee with a mix of collegial, interpersonally (e.g., a specific session, or a segment of a ses-
sensitive, and task-oriented styles in order fa- sion), time period (early, middle, or late in client
cilitate these positive outcomes. treatment as well as early, middle, or late in
9. Recognize the importance of covert pro- training experience), evaluator (e.g., supervisor,
cesses. Although supervisee self-disclosure and, clients), level of expected proficiency (e.g.,
at least to some extent, supervisor self-disclo- demonstrated skill, comparison to cohort group)
sure are implicit assumptions in most models of and feedback (e.g., quantitative vs. qualitative).
supervision, it is likely that what they leave un- No single evaluation can account for all of these
said is critical to the supervisor work. Some components, however, having a clear set of pa-
typical supervisee nondisclosures include neg- rameters, will enhance the effectiveness of su-
ative reactions to the supervisor, clinical mis- pervisor’s evaluation.
takes, sexual attraction toward a client, and 12. Set clear goals and provide both sum-
negative reactions to a client. Some typical su- mative and formative feedback. Supervisor
pervisor nondisclosures include negative reac- evaluation consists of two components: goal-
tions to the supervisees’ therapy and supervi- setting and feedback (summative and forma-
sion work, supervisor self-efficacy, and sexual tive). Effective goal-setting consists of goals
issues in supervision. Hence, it behooves su- that are explicit, specific, feasibly reached, re-
pervisors to consider what may not be said in lated to identified tasks, clarified early, and mu-
supervision, as well as ways of conducting su- tually agreed upon. To be effective in giving
pervision to minimize important nondisclo- feedback, the supervisor should provide it in a
sures. way that is systematic, timely, clearly under-
10. Keep abreast of ethical and legal issues stood, positively and negatively balanced, and
that influence the practice of supervision. reciprocal.
Supervisors accept two types of liability: first, 13. Enhance your own multicultural com-
direct liability when supervisors are found re- petence in order to enhance supervisee multi-
sponsible for specific actions in which they en- cultural therapy competence. As multicultural
gage causes harm to a client; and second, vicar- training has become an integral part of many
ious liability when supervisors are found re- psychotherapy training programs, so too has
sponsible for actions of supervisees. Along with the situation in which supervisees are more
liability for supervisees’ clients, supervisors knowledgeable about multicultural issues than
also need to be concerned with malpractice are supervisors. In order to avoid becoming part
where the supervisee is harmed. of these “regressive” relationships, supervisors
11. Evaluate supervisees consistently and need to keep current on the evolving content of
objectively. Bernard and Goodyear (1998), not multicultural therapy. Multicultural (i.e., gen-
completely facetiously, postulate that there may der, race, ethnicity, sexual orientation, disabil-
be as many evaluation instruments as there are ity, socioeconomic status) competence can be as-
training sites. With this lack of consistency, su- sessed along six dimensions for the supervisee:
pervisor evaluation has been a problematic en- self-awareness, general knowledge about mul-
terprise. Supervisors should consider, and com- ticultural issues, multicultural therapy self-
municate to the supervisee, the components of efficacy, understanding of unique client vari-
supervisee work that are under scrutiny. These ables, an effective therapy working alliance, and
components will frequently entail: mode of multicultural therapy skills (Constantine &
therapy (e.g., individual, group, family), do- Ladany, 2001). Hence, supervisors need to de-
main of supervisee behaviors (e.g., therapy, su- velop these skills in themselves in order to be
pervision, professional), competence area (e.g., adept in assessing supervisees along these di-
therapy techniques, theoretical conceptualiza- mensions.
 137 • conducting effective clinical supervision 685

14. Consider group supervision and peer su- sions for assessing multicultural counseling
pervision as adjuncts to individual supervision. competence. In J. G. Ponterotto, J. M. Casas, L.
Group supervision, consisting of a leader and A. Suzuki, & C. M. Alexander (Eds.), Hand-
typically three to six supervisees, offers an ed- book of multicultural counseling (2nd ed., pp.
215 –236). Thousand Oaks, CA: Sage.
ucative experience whereby supervisees can ex-
Ekstein, R., & Wallerstein, R. (1972). The teaching
perience the benefit of group work (e.g., uni-
and learning of psychotherapy (2nd ed.).
versality) along with skill development. Addi- Madison, WI: International Universities Press.
tionally, peer supervision is one avenue Ellis, M. V., Ladany, N., Krengel, M., & Schult, D.
through which supervisees may disclose more (1996). Clinical supervision research from
readily their challenges and receive supplemen- 1981 to 1993: A methodological critique. Jour-
tal guidance. nal of Counseling Psychology, 43, 35 – 50.
15. Secure training in clinical supervision. Falvey, J. E. (2002). Managing clinical supervision:
The majority of psychotherapy supervisors did Ethical practices and legal risk management.
not complete formal training in supervision Pacific Grove, CA: Brooks/Cole.
themselves (Bernard & Goodyear, 1998) nor Forrest, L., Elman, N., Gizara, S., & Vacha-Haase, T.
(1999). Supervisee impairment: A review of
does any mental health organization currently
identification, remediation, dismissal, and legal
require supervisor training. It seems likely that
issues. The Counseling Psychologist, 27, 627 –
the lack of supervisor training may be respon- 686.
sible for many of the unmet challenges that su- Holloway, E. L. (1995). Clinical supervision: A sys-
pervisors face. Hence, systematic and compre- tems approach. Thousand Oaks, CA: Sage.
hensive supervisor training is recommended for Ladany, N., Hill, C. E., Corbett, M., & Nutt, L.
those who engage in supervision. (1996). Nature, extent, and importance of what
therapy supervisees do not disclose to their su-
pervisors. Journal of Counseling Psychology,
References, Readings, & Internet Sites
43, 10 –24.
American Association of State and Provincial Psy- Ladany, N., Lehrman-Waterman, D. E., Molinaro,
chology Boards. (2003). Supervision guide- M., & Wolgast, B. (1999). Psychotherapy su-
lines. Retrieved 2004 from http://www. pervisor ethical practices: Adherence to guide-
asppb.org/pubs/Supervision%20Guidelines.asp lines, the supervisory working alliance, and su-
American Psychological Association, Division 17, pervisee satisfaction. The Counseling Psychol-
Society of Counseling Psychology, Supervision ogist, 27, 443 – 475.
and Training Special Interest Group. (2003). Ladany, N., Nelson, M. L., & Friedlander, M. L. (in
Supervision and training resources. http:// press). Critical incidents in supervision. Wash-
www.lehigh.edu/~nil3/stsig/ ington, DC: American Psychological Associa-
Bernard, J. M., & Goodyear, R. K. (1998). Funda- tion.
mentals of clinical supervision (2nd ed.). Ladany, N., & Walker, J. A. (2003). Supervisor self-
Boston: Allyn & Bacon. disclosure. In Session: Journal of Clinical Psy-
Bordin, E. S. (1983). A working alliance based model chology, 59, 611– 621.
of supervision. The Counseling Psychologist, Stoltenberg, C., McNeill, B., & Delworth, U. (1998).
11, 35 – 41. IDM supervision: An integrated developmen-
Bradley, L. J., & Ladany, N. (Eds.). (2001). Coun- tal model for supervising counselors and ther-
selor supervision: Principles, process, & prac- apists. San Francisco: Jossey-Bass.
tice (3rd ed.). Philadelphia: Brunner-Rout- Watkins, C. E., Jr. (Ed.). (1997). Handbook of psy-
ledge. chotherapy supervision. New York: Wiley.
Constantine, M. G., & Ladany, N. (2001). New vi-
 GUIDE TO INTERACTING
138 WITH THE MEDIA

Lilli Friedland & Florence W. Kaslow

Psychologists interact with the media both di- relations release, the psychologist is responsi-
rectly and indirectly. This article will cover the ble for the content and should critique it care-
traditional media of radio, television, maga- fully before it goes to press. Frequently, the
zines, and newsprint, as well as the new tech- psychologist cannot exercise the same power
nologies, given that these have become a major over what is released by media personnel. It is
venue of psychologists’ interactions and contri- important to be aware that public relations,
butions, and they are the avenue that much of publishing, marketing and media personnel are
the public we serve turns to for information. not familiar with psychologists’ ethical or pro-
Initially, media psychology developed as a for- fessional standards, and therefore may be ac-
mal field to address the ethical and professional customed to exaggerating the claims of the
concerns of “on air” psychologists. Currently, individuals with whom they work. It is recom-
media psychology encompasses a much broader mended that psychologists give a printed docu-
array of activities (Luskin & Friedland, 1998). ment describing their training and expertise to
New, increasingly complicated opportunities media personnel and publicists to minimize er-
exist for psychologists to interact with the me- ror. This printed copy should include one’s de-
dia and new technologies. Though it is clear gree, training, and a list of publications and
that professional standards and ethics are the speaking engagements on the given subject.
same when psychologists use the new tech-
nologies as when they use traditional processes,
prudent professionals need to be vigilant as ON-AIR MEDIA PSYCHOLOGY
they participate in these cutting-edge areas.
There are constructive steps psychologists can
take when receiving a call from a program di-
PUBLICITY BY AND ABOUT rector of a show or someone involved with elec-
PSYCHOLOGISTS tronic media asking for an interview or infor-
mation regarding a particular topic. If one is not
Public statements encompass but are not lim- an expert on the requested subject matter and
ited to paid or unpaid advertising, product the time allocated is insufficient to acquire the
endorsements, grant applications, licensing ap- requisite information, then the psychologist
plications, other credentialing applications, should decline the interview and recommend
brochures, printed materials, directory listings, someone else who has expertise in the given
personal resumes or curricula vitae, or com- area. Because the period to provide the infor-
ments for use in the media for print or elec- mation or interview is often immediate to a few
tronic transmission, statements in legal pro- hours; there may not be sufficient time to locate
ceedings, lectures and public oral presentations, an available expert. If this request does not fall
published materials, or online chat or open fo- within the psychologist’s areas of expertise, the
rums. When the psychologist pays for the de- psychologist who is approached can offer to
velopment of a marketing brochure or public rapidly conduct a literature search. To mini-

686
 138 • guide to interacting with the media 687

mize inaccuracies, it is recommended that the • Determine the source for the story idea (a
most significant findings and conclusions be current headline or a standing topic).
written, including citations, and submitted to • Determine if the host has a particular view-
the interviewer. Experienced media psycholo- point that the show wants to substantiate, al-
gists have noted that electronic and print edi- though current psychological knowledge does
tors rarely refer to or cite the researchers. None- not confirm the particular position.
theless, these efforts can be viewed as an op-
portunity to educate media personnel. If the program or media personnel have a
Frequently, media psychologists are asked history of seeking sensationalism or of de-
to comment on a particular individual’s psy- meaning their guests, it is wise to refuse to be
chotherapist or mode of therapy. Usually the involved, no matter how tempting the invita-
personal information provided by the individ- tion. When psychologists do participate, they
ual posing the question is brief. Psychologists should alert media personnel as to potential
should indicate that they are commenting about harm, stress, or need for referrals for program
the general psychological issues or processes guests, audience, or staff if they become aware
posed rather than on the type of treatment that psychotherapeutic help seems warranted.
given for a particular individual’s symptoms or When approached by TV and radio program
behaviors, or about the specific therapy itself. If personnel, psychologists are sometimes re-
another professional’s competence or treatment quested to bring along guests, preferably past
is questioned, the psychologist should encour- or present clients. If a client is asked to partici-
age the questioner to discuss the concerns with pate, the reason for this can be questioned: For
the therapist directly. whose benefit the client is participating — for
Psychologists who work with the media need his/hers, the show’s ratings, or the psycholo-
to be aware of the possible myriad ramifications gist’s? Even if the client gives informed consent
of their participation. It is not appropriate to to submitting his or her name, and the potential
compensate any member of the media in return emotional effects of participating have been dis-
for publicity or for being showcased. The psy- cussed, it is urged (in accordance with American
chologist must realize that, to the consumer or Psychological Association [APA] ethical guide-
viewer, he or she is seen as representing the pro- lines; APA, 2002) that psychologists not partic-
fession; therefore, the information imparted ipate in this manner, especially with current
must be accurate and current. Further, the psy- clients. Some patients are apt to say yes to
chologist needs to be aware of the real and po- please their therapist, and this seeming induce-
tential effects on viewers of the media activities ment should be avoided. Psychologists should
in which he or she participates. Is the psycholo- attempt to educate members of the media to the
gist seen as endorsing or condemning a behav- possible dual relationships entailed and the
ior? Is the psychologist’s stance a subjective one negative long-term effects on guests when
(based upon personal values or opinions) or an brought in by their treating professional. There
objective one (based upon research and prevail- are additional issues that need to be considered
ing community practice standards)? Clearly, the if a minor is the client. The effects on clients of
positions stated need to be based upon the cur- being on TV shows and “telling all” before
rent state of research and treatment. scores of viewers sometimes do not surface for
Every effort should be made by psychologists a long time (McCall, 1990).
to determine the media person’s sources, in- When psychologists are being paid for their
tegrity, and previous history of type of guests services, this should be made clear, if relevant.
and experts. To do this, one can try to become fa- They can be paid as actors if their professional
miliar with the media staff and program format identity is not known or the presentation can-
prior to agreeing to participate. For example: not be seen as an endorsement. In working with
the media, there is a distinction that can be
• Observe if the host habitually interrupts the made between advertisements (i.e., using an ac-
guest experts. tor to speak about a product or service) and an
688 part xi • professional resources

infomercial (i.e., the professional endorses and • Wear clothing, makeup, and hairstyles that
gives a testimonial about the particular service are in fashion but not too trendy.
or product). Some infomercials are camouflaged
as news programs. Psychologists should be sure When interacting with the media, prudent
that the infomercials and programs in which psychologists ask themselves: What is the mes-
they participate do not mislead the public. As sage I want to send about this topic? It is rec-
in all media communications, any information ommended that psychologists prepare three to
provided by the psychologist must be based on five clearly stated points to facilitate their clar-
current research, practice, and ethical standards. ity and succinctness about the subject matter.
Remember, while working with media per- They should also rehearse their “talking points”
sonnel, that nothing is “off the record” or “con- in order to become more comfortable and elo-
fidential” for them; informal comments and ex- quent in their delivery, as this is the customary
pressions have been known to be used in the fi- practice of media professionals.
nal product. Sometimes psychologists are asked Experienced media psychologists know the
to agree a statement or give an example of a key to the successful media interview is to make
public figure whose behavior is illustrative of a the points, and not necessarily to answer the
particular psychological problem; the circum- questions posed (American Psychological Asso-
spect professional does not do so, for this com- ciation, 2003). Therefore, if psychologists are
ment may well be taken out of context and also asked questions that do not speak to particular
this does not fall within the realm of psychol- information they deem necessary to present on
ogists’ capabilities and ethics. It is essential to this subject, they can bring up their “talking
maintain one’s professional stance and com- points” by using bridges such as “the real issue
posure until one is out of range of all micro- . . . ” or “the three issues involved are . . . ”
phones, cameras, and telephones (Koocher, Nor- (personal communications in APA Media Psy-
cross, & Hill, 2001). chology Division Board dialogues; Friedland &
When being interviewed, it is important to Kaslow, 1995 –2003).
use language at the level of the general public “Talking points” can be printed on the psy-
and not use jargon, technical terms, or acro- chologist’s letterhead and given to the inter-
nyms. Try to find out characteristics of the usual viewer after the taping, as a technique for af-
audience (e.g., age, gender, education). Success- firming the importance of these points and re-
ful strategies for presenting “on air” are: ducing the possibility that the psychologist’s
information is unclear or misquoted.
• Smiling The information presented by psychologists
• Leaning toward the interviewer should be based upon current psychological re-
• Keeping legs together with feet flat on the search and practice. Be consistent with the
floor (not crossed) APA’s current ethical code (American Psycho-
• Using relaxed, slow, deep breathing logical Association, 2002). Don’t lead the audi-
• Engaging in casual (though not “off the re- ence to infer that the psychologist has a per-
cord”) conversation with media personnel sonal relationship with the individual asking
the questions, or with a personal particular
Certain visual factors influence the appear- product.
ance of the psychologist: In sum, psychologists can follow the follow-
ing steps when called upon by the media for ex-
• Clothing and overall appearance can affect pertise:
the presentation, so solid colors should be 1. Clarify the objectives of the caller. Does
worn (many types of stripes or designs are he or she want support for a particular position?
problematic). Does he or she want a thoughtful psychological
• Wear conservative professional clothing, perspective on a topic or individual? For exam-
without accessories that may distract from ple, frequently the caller asks about a person-
what is being said. ality type, and then asks if the information
 138 • guide to interacting with the media 689

given would apply to a particular public figure. state important points. Experienced media psy-
What is the type of information requested? chologists find that planning and rehearsing the
What is the context in which the information three or five of the most salient facts on the
will be used? What type of psychological ex- subject yield a successful presentation.
pertise is necessary to provide the interview or 4. Recognize that the appearance of on-air
information necessary? Does the psychologist psychologists contributes to the message.
have this type of expertise? If not, is there an Therefore, professional dress is recommended.
appropriate psychologist with the requisite This generally means a solid-colored outfit.
knowledge to recommend? If not, can a litera-
ture search on the topic suffice? Also, what is
the time frame for the interview or informa- PRINT MEDIA
tion? Is this time frame sufficient for the psy-
chologist to develop a cogent presentation? All of the principles cited above also apply when
2. Know the medium. Psychologists should one is contacted by a newspaper reporter or
familiarize themselves with the format of the writer for a magazine. These principles will be
magazine, newspaper, radio or TV program, or reiterated here briefly, interspersed with some
other media forum prior to giving the inter- additional points.
view to be both better prepared with the type of
information that could be useful and also to de- • Only give an interview if you are knowl-
termine how the interviewer uses experts. For edgeable about and up to date on a topic/
example, (a) if it will be an on-air program, be- breaking story.
come acquainted with the type of questions • If the media staff stress the immediacy of
asked to anticipate the questions and research their deadline, try to be cooperative, but do
answers prior to the show. not participate in the interview if you are
Be aware of the audience and gear your pre- not well prepared or they are placing you un-
sentation to their level of interest and under- der duress. Remember, it is their deadline,
standing. For example, if it is a woman’s televi- not yours (and you cannot interrupt a ther-
sion show, use examples aimed at the type of apy hour, cancel a class, stop while conduct-
women who watch that program (i.e., educa- ing research, or disrupt a consultation) for
tional level, socioeconomic status, ethnic/cul- what will be a one- or two-line or paragraph
tural level). quote.
Note the manner that the host uses to bring • Whenever possible, if accepting their re-
in experts and question them. Does the host try quest, ask for a minimum of half an hour to
to get experts to give definitive opinions or one organize your thoughts and for them to call
word answers to complex issues? Does the ex- you back at a mutually agreed upon time.
pert have an opportunity to explain multiple While preparing, check the accuracy of any
viewpoints or factors about particular issues? statements you plan to make about which
3. Develop three to five “talking points” on you are dubious.
the subject. Rehearse the “talking points.” Give • Keep comments short, straightforward, suc-
a brief outline of these points printed on pro- cinct, pithy, and free of jargon.
fessional letterhead to the host following the • Ask any newspaper reporter to e-mail or fax
interview to further clarify the position. A brief you the article before it is submitted to go to
biographical sketch can be attached. Media per- press to review for accuracy. When there is
sonnel usually want simple, definitive answers sufficient time, we have found many re-
and clear 30-second sound bites. Psychologists porters will do so.
typically need to be trained or practice giving • Most magazines have fact checkers who call
brief, yet accurate information. before the article goes to press. When they
The format of on-air programs is such that call, listen carefully and suggest needed cor-
the hosts control the focus. It is common for in- rections.
experienced guest experts to feel they did not • Ask the author to see that a complimentary
690 part xi • professional resources

copy of the magazine is sent to you with the of therapist-patient interaction portrayal usu-
particular article checked in the table of con- ally is not harmful, but one should be cautious
tents. about ensuring that characters do not resemble
• Thank the individual for calling. If a local specific patients.
newspaper reporter approaches you more The definition of the “therapeutic relation-
than once, see if you can arrange to meet the ship” has been undergoing reexamination, in
individual in person. If so, this can lead to part due to the impact of new media technolo-
more frequent usage by this person and per- gies. Using the new technologies raises issues
haps additional recommendations that other of substantiating the identity of the clients, lo-
colleagues will call also. cation of clients (crossing geographic borders
where there may be licensing and training dif-
ferences), being sensitive to different ethnic
THE NEW TECHNOLOGIES: or cultural populations, authentication of in-
GENERAL CONSIDERATIONS formed consent and fee arrangements, and risks
to privacy and limits to confidentiality. Because
To participate in the new media technologies, these issues remain unclear, psychologists are
the psychologist may be working outside the urged to inform potential clients/patients about
customary benchmark practices of the profes- these concerns and take all reasonable precau-
sion. The wise professional will substantiate the tions to protect the clients. Whenever there is
underlying scientific bases or assumptions a question, consultation with peers is advised,
when going into new areas, and obtain supervi- as well as documenting the process with careful
sion or consultation from respected colleagues. notes.
The new technologies enable interactions be- “Virtual communities” such as chat groups
tween individuals and groups throughout the and forums are ongoing entities on the Inter-
world; therefore psychologists need to consider net. These modalities serve as sources of sup-
a specific client’s language, ethnicity and cul- port and information to their members: studies
ture, and the licensing and credentialing re- substantiate that these modalities reach clients
quirements in the geographic locale. It is im- in rural areas, as well as disabled or challenged
portant to ensure that the psychologist’s mal- individuals who might not otherwise receive
practice insurance coverage extends to the new service. However, there are ethical implications
modalities of practice. It is recommended that to be considered when a psychologist estab-
before psychologists employ the new technolo- lishes or participates as the professional in a
gies, they consult with respected peers and/or “group therapy” online with individuals he or
ethics committees, and document the process, she has not met. For example, if the psycholo-
safeguards, and procedures used (APA, 2002; gist has never met the patient, he or she has no
Kutner, 1997). idea whom he or she is “treating,” and if that
individual is participating using his or her real
identity. Currently, the knowledgeable media
THERAPY ON THE AIR psychologist refrains from involvement in such
AND ONLINE endeavors, as consumer protection parameters
have not yet been developed (e.g., to whom
In an effort to educate the public, some profes- would the consumer make a complaint given
sionals have conducted “live” therapy sessions that the licensing boards and the various men-
on television or other types of media technol- tal health professions may not yet have pro-
ogy. Because psychologists cannot work ethi- mulgated standards for these modalities, and
cally with current patients in such a manner, it where these standards exist, they may differ
is advised that actors be used. Personality char- across states?). As issues get resolved, it is likely
acteristics and typical responses for a character that online therapy groups will become per-
can be discussed beforehand and actors can ad missible and professionally acceptable.
lib the situations. This kind of media broadcast
 139 • common clinical abbreviations and symbols 691

IN RETROSPECT conferences with APA Division of Media Psy-

chology Board.
Despite all of the possible pitfalls, being a me- Kutner, L. (1997). New roles for psychologists in the
dia psychologist is challenging, expands the mass media. In D. Kirschner & S. Kirschner.
person’s knowledge and horizons, and enables (Eds.), Perspectives on psychology and the me-
the individual to share the benefits of psycho- dia. Washington, DC: American Psychological
Association.
logical research and practice with the public.
Luskin, B. J., & Friedland, L. (1998). Task Force Re-
port: Media Psychology and the New Technolo-
References, Readings, & Internet Sites gies, Division of Media Psychology, American
Psychological Association. Retrieved 2004 from
American Psychological Association. (2002). Ethical
http://www.apadiv46.org/arttaskforcereport.
principles of psychologists and code of conduct.
html
Washington, DC: Author.
McCall, R. (1990). Ethical considerations of psychol-
American Psychological Association. (2003). How to
ogists working in the media. In C. B. Fisher &
work with the media: Interview preparation for
W. W. Tryon, Ethics in applied developmental
the psychologist. http://www.apa.org/journals/
psychology: Emerging issues in an emerging
media/index.html#identifying
field (pp. 163 –185). Norwood, NJ: Ablex Pub-
American Psychological Association, Division of Me-
lishing.
dia Psychology. (n.d.). Home page. Retrieved
2004 from http://www.apadiv46.org/
American Psychological Association, Public Affairs Related Topics
Office. (n.d.). Home page. Retrieved 2004 from
Chapter 127, “Basic Elements of Consent”
http://www.apa.org/publicinfo
Chapter 128, “Basic Elements of Release Forms”
Friedland, L. & Kaslow, F. (1995 –2003). Personal

COMMON CLINICAL
139 ABBREVIATIONS AND
SYMBOLS

John C. Norcross

a before ADHD attention-deficit/hyperactivity

AA Alcoholics Anonymous disorder
A&B apnea and bradycardia ad lib as desired
AAV AIDS-associated virus AFL activities of daily living
abd abduction; abdomen adm admission
ABG arterial blood gas ADTP alcohol and drug treatment
a.c. before meals program
692 part xi • professional resources

aero, aero Rx aerosol inhalation equipment, B/S breath sounds

treatment BUN blood urea nitrogen
AF auricular fibrillation
A/G albumin-globulin ratio c̄ with
AIDS acquired immune deficiency/ C centigrade
immunodeficiency syndrome ca calcium; chronological age
AK above knee CA cancer, carcinoma
A&O alert and oriented CAM cardiac medical
alb albumin C&S culture and sensitivity
alks, p’tase alkaline phosphatase cap capsule
ALL allergy CAS cardiac surgery
AMA against medical advice CAVC complete atrioventricular canal
amb ambulatory CBC complete blood count
anes anesthesia CBG capillary blood gas
angio angiogram CBT cognitive-behavior therapy
ANS anesthesia cc cubic centimeter
AODM adult-onset diabetes mellitus CC chief complaint
Ao DT descending aorta CDC Centers for Disease Control and
AP anteroposterior Prevention
AP & Lat anteroposterior and lateral CDI Children’s Depression Inventory
approximate CF cystic fibrosis
AQ achievement quotient ⌬ change
ARC AIDS-related complex CHD congenital heart disease
art mon arterial pressure monitor check
ARV AIDS-related virus chol cholesterol
AS aortic stenosis; left ear Cl chloride
ASA aspirin cldy cloudy
AsAo ascending aorta cm centimeter
ASD atrial septal defect c. monitor cardiac monitor
@ at CNS central nervous system
A2 aortic second sound c/o, CO complaint of
AU both ears coarc coarctation
AV arteriovenous conj conjunctive
AVC atrioventricular canal conv convergence
AVVR atrioventricular valve regurgitation CO2 carbon dioxide
AWOL away without official leave CP cerebral palsy
AX angle jerk CPAP continuous positive airway
pressure
b born CPC clinicopathological conference
Bab Babinski CPR cardiopulmonary resuscitation
bact bacteria CPT chest physiotherapy
BBS bilateral breath sounds CRC clinical research
BC/BS Blue Cross/Blue Shield C/S cesarean section
BD birth defect CSF cerebrospinal fluid
BDD body dysmorphic disorder CT chest tube
BDI Beck Depression Inventory CT, CT scan, CAT computerized tomography
BE barium enema CVA cerebrovascular accident
b.i.d. twice a day CVL central venous line
BJM bones, joints, muscles CVP central venous pressure
BK below knee CVS clean-voided specimen
BM bowel movement CXR chest X-ray
BMT bone marrow transplant CYS cystic fibrosis
BP blood pressure
BPD borderline personality disorder D&C dilation and curettage
BS bowel sound DAT diet as tolerated
 139 • common clinical abbreviations and symbols 693

d/c discontinue FFP fresh frozen plasma

D/C discharge FH family history
decrease FIO2 fractional inspired oxygen
DID dissociative identity disorder flex flexion
dil dilute FOO family of origin
DOA dead on arrival for. bend forward bending
DOB date of birth FP family physician
DOC doctor on call FTT failure to thrive
DOE dyspnea on exertion; date of f/u follow up
evaluation FUO fever of unknown origin
DOPP duration of positive pressure
DP dorsalis pedis g, gm gram
DPT diphtheria, pertussis, tetanus GAD generalized anxiety disorder
DS Down Syndrome GB series gallbladder series
D/S dextrose and saline GC gonorrhea
DSM-IV Diagnostic and Statistical Manual g/dl grams per hundred millimeters
of Mental Disorders, fourth GF&R grunting, flaring, and retracting
edition GI gastrointestinal
DTR deep tendon reflex GIS gastroenterology
DTV due to void GNS general surgery
D/W dextrose and water gr grain
DX, Dx, dx diagnosis gtt drops
GTT glucose tolerance test
EAP employee assistance program gyn gynecology
ECG, EKG electrocardiogram
ECHO enterocytopathogenic human h hour
orphan viruses H husband
ECMO extracorporeal membrane HA headache
oxygenation HC head circumference
ECT electroconvulsive treatment HCT hematocrit
EDC endocrine HEENT head, eyes, ears, nose, throat
EEG electroencephalogram HEM hematology
e.g. for example Hgb hemoglobin
EMDR eye movement desensitization and HI homicidal ideation
reprocessing HIV human immunodeficiency virus
EMV expired minute volume HLHS hypoplastic left heart syndrome
ENT ears, nose, throat; HMO health maintenance organization
otolaryngology HO2 humidified oxygen
EOM extraocular movement HPF high-power field
eos eosinophils HR heart rate
ER emergency room HRT hormone replacement therapy
ERG electroretinogram h.s. at bedtime
ESR erythrocyte sedimentation rate ht height
ETOH alcohol HTN hypertension
ETT endotracheal tube Hx history
eve evening
ext extension IA intra-arterial
extrem extremities I&D incision and drainage
EYE ophthalmology I&O intake and output
ICP intracranial pressure
f frequency ICU intensive care unit
F fahrenheit; father IDS infectious diseases
FAS fetal alcohol syndrome i.e. that is, namely
FBS fasting blood sugar IJ internal jugular vein
Ɋ female IL intralipid
694 part xi • professional resources

IM intramuscular MCL midclavicular line

imp impression MCMI-III Millon Clinical Multiaxial
increase (elevated) Inventory-III
in rot in rotation med medicine
inv inversion mEq milliequivalent (per liter, mEq/L)
IOFB intraocular foreign body mets metastasis
IP inpatient mg milligram
IQ intelligence quotient Mg magnesium
IT intrathecal mg/dl milligrams per hundred
IV intravenous milliliters
IVC inferior vena cava MHC mental health center
IVH intraventricular hemorrhage MI myocardial infarction
IVP intravenous push ml milliliter (preferred over cc)
ML middle lobe
JT jejunostomy tube M&M morbidity and mortality
MMPI Minnesota Multiphasic Personality
K potassium Inventory
kg kilogram Mn manganese
KJ knee jerk mod moderate
KUB kidney, ureter, bladder mono monocyte infectious;
kV kilovolt mononucleosis
MR mental retardation
L left MS multiple sclerosis
LA left atrium MSE mental status examination
lab laboratory MVA motor vehicle accident
L&A light and accommodation
LAO left anterior oblique Na sodium
LAP left atrial pressure NAD no apparent distress
lat. bend lateral bending neb, htd neb nebulizer, heated nebulizer
LBP low back pain NEC necrotizing enterocolitis
LFT liver function test NEO neonatology
LL lower lid neph nephrotomy
LLE left lower extremity NG nasogastric
LLL left lower lobe NICU newborn ICU
LLQ left lower quadrant NIH National Institutes of Health
L/min liters per minute NIMH National Institute of Mental
LMP last menstrual period Health
LOA leave of absence NKA no known allergies
LP lumbar puncture NKDA no known drug allergies
LPA left pulmonary artery nl normal
LTM long-term memory NLS neurology
LUE left upper extremity NMJ neuromuscular joint
LUL left upper lobe NOS not otherwise specified
LUQ left upper quadrant NP nasopharyngeal
LV left ventricular NPO nothing by mouth
lymphs lymphocytes NRC normal retinal correspondence
lytes electrolytes N/S normal saline
NSS neurosurgery
m meter NT nasotracheal
M mother NTA nothing to add
ɉ male N2 nitrogen
M&T myringotomy and tubes N2O nitrous oxide
MAP mean arterial pressure N/V nausea and vomiting
MAPI Millon Adolescent Personality NVD normal vaginal delivery
Inventory N/V/D nausea, vomiting, diarrhea
 139 • common clinical abbreviations and symbols 695

O&P ova and parasites, stool plts platelets

obs obstetrics or obstetrical PMH past medical history
OBS organic brain syndrome p.o. by mouth
occ occasionally PO2 partial pressure oxygen
OCD obsessive-compulsive disorder PPH persistent pulmonary
OD right eye hypertension
ODD oppositional defiant disorder p.r. per rectum
odont odontectomies PRBC packed red blood cells
OHID oxygen tent premie premature
OM otitis media prep preparation
1:1 one to one p.r.n. as needed
OOB out of breath; out of bed prot protein (total protein preferred)
OOP out on pass PS pulmonic stenosis; pulmonary
op operation stenosis
OP oropharyngeal psi pounds per square inch
OPD outpatient department PSP phenolsulfonphthalein
OR operating room psy; psych psychiatry; psychology
ORL otorhinolaryngology (ENT) pt patient
orth, ORT orthopedics PT physical therapy;
OS left eye prothrombin time
OT occupational therapy PTMDF pupils, tension, media, disk,
O2 oxygen fundus
O2sat oxygen saturation PTSD posttraumatic stress disorder
OU both eyes PUL pulmonary
PVC premature ventricular contraction
p after PWS Prader-Willi syndrome
P phosphorous
PA posteroanterior; pulmonary artery q every
PA cath pulmonary artery catheter q.a.m. every morning
P&A percussion and auscultation q.d. every day
P&V percussion and vibration q4h every 4 hours
PAP pulmonary artery pressure q.h. every hour
p.c. after meals q.h.s. every night
PCA patient-controlled analgesia q.i.d. four times a day
PCO2 partial carbon dioxide pressure q.n.s. quantity not sufficient
PDD pervasive developmental disorder q.o.d. every other day
PE physical examination QR Quiet Room
ped, pedi, peds pediatrics qs quantity sufficient
PEEP positive end-expiratory pressure q3h every 3 hours
PERLA pupils equal, reactive to light and q2h every 2 hours
accommodation
PF plantar flexion R right
PFC persistent fetal circulation RA right atrium
PFO patent foramen ovale RAO right anterior oblique
PFT pulmonary function test RBC red blood cell; red blood count
pg per gastric RD radial deviation
pH hydrogen ion concentration RDS respiratory distress syndrome
PH past history re regarding
PHP posthospital plans REBT rational-emotive behavior therapy
PI present illness REN renal/dialysis
PIE pulmonary interstitial Rh+, Rh– rhesus blood factor
emphysema RHD rheumatic heart disease
PIV peripheral intravenous RLE right lower extremity
PKU phenylketonuria RLL right lower lobe
PLS plastics RLQ right lower quadrant
696 part xi • professional resources

RML right middle lobe TCA tricyclic antidepressant

R/O rule out TCO2 total (calculated) carbon dioxide
RPA right pulmonary artery TENS transcutaneous electrical nerve
RR respiratory rate stimulator
RRE round, regular, and equal TF, TOF tetralogy of Fallot
RT respiratory therapy; reaction time TGA transposition of great arteries
RTC return to clinic TGV transposition of great vessels
RTH radiation therapy t.i.d. three times a day
RTO return to office TLC tender loving care
RUE right upper extremity TM tympanic membrane
RUL right upper lobe TP total protein
RUQ right upper quadrant TPR temperature, pulse, and
RV right ventricle or ventricular respiration
Rx treatment; treatment with Tq tourniquet
medication TSH thyroid stimulating hormone
tsp teaspoon
s̄ without TT tracheostomy tube
S suction TTX tumor therapy
SAD seasonal affective disorder TV tidal volume
SC subcutaneous 2 secondary to
SCA subclavian artery TX, Tx treatment
sed. rate erythrocyte sedimentation rate
SG specific gravity U unit
SH social history; serum hepatitis UA urinalysis
SI suicidal ideation UDT undescended testicles
SIDS sudden infant death syndrome UGI upper gastrointestinal series
SLR straight leg raising umb(i) umbilical
SOB shortness of breath UO urinary output
sol solution ureth urethral
SP special precautions URI upper respiratory infection
S/P status post uro, urol urology or urological
SPA serum protein analysis US ultrasound
SS signs and symptoms
SSRI selective serotonin reuptake V, VA volt; vision or visual acuity
inhibitor vag vagina or vaginal
STAT immediately and only once VAMC Veterans Administration Medical
stm short-term memory Center
strep streptococcus VC vital capacity
sub AS subaortic stenosis VCO2 carbon dioxide production
surg surgery or surgical VD venereal disease
SV single ventricle VDRL Venereal Disease Research
SVC superior vena cava Laboratory
SW social worker vert vertebrae (D. vert: dorsal; L. vert:
Sz seizure lumbar)
VF volar flexion; vocal fremitus
TA tricuspid atresia vit vitamin when followed by specific
tab tablet letter (e.g., vit A)
T&A tonsillectomy and adenoidectomy VO2 oxygen consumption
T&C type and crossmatch VS vital signs
T&H type and hold Vx vertex
TAT Thematic Apperception Test
TB tuberculosis W wife
TBA to be announced WAIS-III Wechsler Adult Intelligence Scale-
tbsp tablespoon Third Edition
 140 • major professional associations 697

WB whole blood w/u work-up

WBC white blood cell; white blood count
y.o. years old
WD well developed
WDWN well developed, well nourished
See accompanying Web site for additional
WISC-III Wechsler Intelligence Scale for
materials.
Children-III
wk week
Related Topics
WMS Wechsler Memory Scale
WN well nourished Chapter 89, “Normal Medical Laboratory Values
WNL within normal limits and Measurement Conversions”
WRAT Wide Range Achievement Test Chapter 111, “Glossary of Legal Terms of Special
wt weight Interest in Mental Health Practice”

MAJOR PROFESSIONAL
140 ASSOCIATIONS

John C. Norcross

The following list provides the mailing ad- CORE MENTAL HEALTH
dresses, telephone numbers, and Web sites of DISCIPLINES IN THE UNITED
the major professional associations of interest STATES
to psychologists and other mental health pro-
Psychology
fessionals. The compilation is divided into three
sections: American Board of Professional Psychology
(ABPP)
1. Core mental health disciplines in the United 514 East Capitol Avenue
States. Psychology, psychiatry, clinical so- Jefferson City, MO 65101
cial work, mental health nursing, and mari- Phone: 573-634-7157
tal and family therapy. For each discipline, Web site: http://www.abpp.org
we feature the largest professional organiza-
tions, certification/diplomate providers, and American Psychological Association (APA)
national registers. 750 First Street, NE
2. Interdisciplinary mental health organiza- Washington, DC 20002-4242
tions Phone: 800-374-2721
3. Regional psychological associations in the Web site: http://www.apa.org
United States
698 part xi • professional resources

American Psychological Society (APS) National Association of Social Workers (NASW)

1010 Vermont Avenue, NW, Suite 1100 750 First Street, NE, Suite 700
Washington, DC 20005-4907 Washington, DC 20002-4241
Phone: 202-783-2077 Phone: 202-408-8600
Web site: http://www.psychologicalscience.org Web site: http://www.naswdc.org

Association for the Advancement of Psychology NASW Register of Clinical Social Workers
PO Box 38120 750 First Street, NE, Suite 700
Colorado Springs, CO 80937 Washington, DC 20002-4241
Phone: 800-869-6595 Phone: 800-742-4089, ext. 298
Web site: http://www.aapnet.org Web site: http://www.naswdc.org

National Register of Health Service Providers in

Mental Health Nursing
Psychology
1120 G. Street, NW, Suite 330 American Nurses Association (ANA)
Washington, DC 20005 600 Maryland Avenue, SW, Suite 100 W
Phone: 202-783-7663 Washington, DC 20024-2571
Web site: http://www.nationalregister.com Phone: 800-274-4ANA
Web site: http://www.nursingworld.org

Psychiatry
American Nurses Credentialing Center
American Board of Psychiatry and Neurology 600 Maryland Avenue, SW, Suite 100 W
500 Lake Cook Road, Suite 335 Washington, DC 20024-2571
Deerfield, IL 60015 Phone: 202-651-7000
Phone: 847-945-7900 Web site: http://www.nursingworld.org/
Web site: http://www.abpn.com ancc/ancc

American Psychiatric Association (ApA) American Psychiatric Nurses Association

1000 Wilson Boulevard, Suite 1825 1555 Wilson Boulevard, Suite 515
Arlington, VA 22209 Arlington, VA 22209
Phone: 703-907-7300 Phone: 703-243-2443
Web site: http://www.psych.org Web site: http://www.apna.org

Clinical Social Work Marital and Family Therapy

Academy of Certified Social Workers (ACSW) American Association for Marriage & Family
750 First Street, NE, Suite 700 Therapy (AAMFT)
Washington, DC 20002-4241 112 South Alfred Street
Phone: 800-742-4089, ext. 367 Alexandria, VA 22314
Web site: http://www.socialworkers.org/ Phone: 703-838-9808
credentials.acsw.asp Web site: http://www.aamft.org

Diplomate in Clinical Social Work American Family Therapy Academy

750 First Street, NE, Suite 700 1608 20th Street, NW, 4th Floor
Washington, DC 20002-4241 Washington, DC 20009
Phone: 800-742-4089 Phone: 202-333-3692
Web site: http://www.naswdc.org Web site: http://www.afta.org
 140 • major professional associations 699

INTERDISCIPLINARY MENTAL Society of Behavioral Medicine (SBM)

HEALTH ORGANIZATIONS 7600 Terrace Avenue, Suite 203
Middleton, WI 53562
American Association of Sex Educators, Phone: 608-826-7267
Counselors and Therapists Web site: http://www.sbm.org
PO Box 5488
Richmond, VA 23220 Society for the Exploration of Psychotherapy
Phone: 315-895-8407 Integration (SEPI)
Web site: http://www.aasect.org/home The Derner Institute
Adelphi University
American Counseling Association (ACA) Garden City, NY 11530
5999 Stevenson Avenue Phone: 516-877-4803
Alexandria, VA 22304 Web site: http://www.cyberpsych.org/sepi
Phone: 800-347-6647
Web site: http://www.counseling.org
REGIONAL PSYCHOLOGICAL
American Group Psychotherapy Association ASSOCIATIONS IN THE
25 East 21st Street, 6th Floor UNITED STATES
New York, NY 10010
Phone: 212-477-2677 Eastern Psychological Association
Web site: http://www.groupsinc.org Department of Psychology
Rowan University
American Psychoanalytic Association Glassboro, NJ 08028
309 East 49th Street Phone: 856-256-4500, ext. 3783
New York, NY 10017 Web site: http://www.easternpsychological.org
Phone: 212-752-0450
Web site: http://www.apsa.org/ Midwestern Psychological Association
Department of Psychology
Association for Advancement of Behavior DePaul University
Therapy (AABT) 2219 North Kenmore
305 Seventh Avenue, 16th Floor Chicago, IL 60614
New York, NY 10001 Phone: 773-325-4243
Phone: 212-647-1890 Web site: http://www.condor.depaul.edu/
Web site: http://www.aabt.org ~psych/mpa/

Association for Humanistic Psychology (AHP) New England Psychological Association

1516 Oak Street, 320A Department of Psychology
Alameda, CA 94501 Johnson & Wales University
Phone: 510-769-6495 8 Abbott Place
Web site: http://www.ahpweb.org Providence, RI 02903
Phone: 609-895-5437
International Psychoanalytical Association Web site: http://www1.rider.edu/~brosvic/
Broomhills, Woodside Lane frame.html
London N12 8UD
United Kingdom Rocky Mountain Psychological Association
Phone: 44-20-8446-8324 Department of Psychology
Web site: http://www.ipa.org.uk McKee 14
University of Northern Colorado
Greeley, CO 80639
Phone: 308-234-8235
Web site: http://www.rockymountainpsych.org/
700 part xi • professional resources

Southeastern Psychological Association Western Psychological Association

Department of Psychology 5929 Westgate Boulevard, Suite C
University of West Florida Tacoma, WA 98406
Pensacola, FL 32514 Phone: 253-752-9829
Phone: 850-474-2070 Web site: http://www.westernpsych.org
Web site: http://www.cas.ucf.edu/sepa/
See accompanying Web site for additional
Southwestern Psychological Association materials.
Department of Psychology
Bethany College
Related Topic
421 North First Street
Lindsborg, KS 67456 Chapter 101, “National Self-Help Groups and Orga-
Phone: 785-827-5541, ext. 1280 nizations”
Web site: http://www.swpsych.org/
 INDEX

AABT (Association for Advancement of Behavior ACCESS (A Comprehensive Custody Evaluation

Therapy), 699 Standard System), 615 –619
AAMD Adaptive Behavior Scale, 127 –128 Accountability, patients’ rights, 183
AAMFT (American Association for Marriage & AccuCare, 671
Family Therapy), 698 Acculturation
Aamiry, Arwa, 401– 405 definition, 77
AARP (American Association of Retired Persons), ethnic minority child, 48
507 –508 linguistic measures, 77 – 78
Abandonment, definition, 572–573 measures of, 77 –79
Abbreviations, 691–697 negative effects of acculturative stress, 77
Abdomen, examination, 52 self-report, 78
Abdominal trauma, child abuse, 419 standardized measures, 78 – 79
Abnormal physical traits, in MSE, 8 Acculturation Rating Scale for Mexican
About Psychotherapy, Internet site, 491 Americans-II (ARSMA-II), 78
ABPP (American Board of Professional Psychol- Accuracy, clinical judgment, 23 –27
ogy), 697 Accurate Assessments, 671
Abrasive clients, 259 Ackerman-Schoendorf Scales for Parent Evaluation
Abstinence violation effects (AVE), 352–353 of Custody (ASPECT), 603 – 604
Abuse. See also Alcohol abuse/dependence; Child Acquired immunodeficiency syndrome. See AIDS
abuse; Drug abuse/dependence; Sexual ACSW (Academy of Certified Social Workers), 698
abuse/assault; Substance abuse/dependence ACT (Acceptance and Commitment Therapy), 213
abuse-focused therapy, 433 ACT (American College Testing Program), 108
common drugs, 481– 487 Action stage, 227
couples and families, 376 Activity, in MSE, 8 – 9
multiple forms of child mistreatment, 430 – 431 Acute stress disorder, DSM-IV, 42
ACA (American Counseling Association), 699 ADAA (Anxiety Disorders Association of
Academy of Certified Social Workers (ACSW), 698 American), 509
Acceptance and Commitment Therapy (ACT), 213 Adaptation, childhood chronic illness, 406 – 407

701
702 index

Adaptive functioning tests, 127 –128 African American Acculturation Scale (AAAS), 78
ADDA (Attention Deficit Disorder Association), Age. See also Older adults
509 pharmacotherapy, 460
Addition Potential Scale (APS), MMPI-2, 139 recovery after disasters, 253 –254
ADEAR (Alzheimer’s Disease Education and Refer- self-help groups, 507 – 508
ral Center), 507 suicide risk, 64 – 65
Adequate Intake (AI), 476 – 478 Age equivalents, 115 –116
Adherence Agency, definition, 573
adult disease management, 275 Aggression, disasters, 252
childhood chronic illness, 407 – 408 Agoraphobia
enhancement, 208 –211 DSM-IV, 43
motivational interviewing, 270 empirically supported therapies, 184
Adjustment disorders Agoraphobia without panic disorder, prevalence of,
DSM-IV, 42 3
DSM-IV-TR classification, 89 Agoraphobics in Motion (AIM), 507
prevalence of, 3 AGS (American Guidance Service), 108
Admitted carriers, professional liability insurance, AHP (Association for Humanistic Psychology), 699
630 –631 AI (Adequate Intake), 476 – 478
Adolescent diagnosis, DSM-IV, 41– 44 AIDS (acquired immunodeficiency syndrome),
Adolescents 291–292
assessment, 411 assessment of risk, 292–294
confidentiality, 412 burden of denial, 293
countertransference, 414 CDC National AIDS Clearinghouse, 509
empirically supported therapies, 189 –190 HIV transmission, 292
empowerment, 413 – 414 infection with HIV, 291–295
group therapy, 413 National AIDS hotline, 295, 512
involving parents, 412– 413 questions for assessment, 293 –294
methods to engage reluctant, 410 – 415 risk reduction counseling, 294 –295
psychological testing, 411– 412 AIM (Agoraphobics in Motion), 507
recovery after disasters, 253 Alateen and Al-Anon Family Groups, 507
Adoption, self-help groups, 510, 512 Alcohol abuse/dependence. See also Drug
Adult Children of Alcoholics World Services abuse/dependence; Substance abuse/
Organization, 507 dependence
Adults. See also Older adults administration, effects, and interactions, 483
attention-deficit/hyperactivity disorder, 62 empirically supported therapies, 185
cognitively impaired, 342–346 identification and assessment, 71–75
disease management, 274 –278 intoxication and suicidal risk, 64
empirically supported therapies, 184 –188 MMPI-2 scales, 138 –139
involuntary psychiatric hospitalization, 548 – 550 prevalence of, 3
moderate to severe traumatic brain injury, prevalence rates, 481
342–343 relapse prevention, 456, 459
neuropsychological assessment, 33 –37 self-help groups, 507, 513, 515
older, 305 –307 treatment matching, 263 –267
recovery after disasters, 253 –254 withdrawal, 456, 458 – 459
Rorschach assessment, 174 Alcoholics Anonymous, 507
self-help groups, 507-508, 510, 514 Alcohol scales, MMPI-2, 138 –139
Values in Action Inventory of Strengths, 97 Alcohol use disorders, DSM-IV-TR classification,
Advertising, ethical standards, 535 – 536 82– 83
Aerosols, administration, effects, and interactions, Alcohol Use Disorders Identification Test (AUDIT),
485 73
Affect, in MSE, 9 Alexithymia, normative male, 278 –281
Affective disorders, treatment manuals, 194 –195 Allegation, definition, 573
Affidavit, definition, 573 Alliance
Affinity Software Corporation, 671 emphasis on building, 374
 index 703

repairing ruptures, 216 –219 guidelines for treating women, 296 –297
ruptures, 204 –205 Internet site, 491
therapeutic, 203 American Psychological Society (APS), 698
Alopecia areata, self-help, 512 American Red Cross (ARC), 249, 251
Alternative medicines. See Complementary and American Sleep Apnea Association, 508
alternative medicines (CAMs) American Social Health Association, 508
Alzheimer’s American Society for Deaf Children, 508
accuracy of clinical judgment, 24 American Society on Aging, 508
DSM-IV-TR classification, 81 American Stroke Association, 508
prevalence of, 3 American Suicide Foundation, 508 –509
Alzheimer’s Association, 507 Americans with Disability Act (ADA), 345
Alzheimer’s Disease and Related Disorders Associa- Amnestic disorders
tion, 507 DSM-IV, 44
Alzheimer’s Disease Education and Referral Center DSM-IV-TR classification, 82
(ADEAR), 507 Amphetamine abuse/dependence
American Association for Marriage & Family Ther- administration, effects, and interactions, 486
apy (AAMFT), 698 DSM-IV-TR classification, 83
American Association of Retired Persons (AARP), prevalence of, 4
507 –508 AMT (Anxiety Management Training), 271–273
American Association of Sex Educators, Counselors ANA (American Nurses Association), 698
and Therapists, 699 Anamnestic interviews, 16
American Association on Mental Retardation, 507 Anatomically detailed dolls, 425 – 426
American Board of Professional Psychology Androgyny, 303
(ABPP), 697 Anesthetics, administration, effects, and interac-
American Board of Psychiatry and Neurology, 698 tions, 485
American Cancer Society, 508 Anfang, Stuart A., 548 – 552
American College Testing Program (ACT), 108, 115 Anger. See also Violence
American Council of the Blind, 508 adult disease management, 276
American Counseling Association (ACA), 699 Anxiety Management Training (AMT),
American Diabetes Association, 508 271–273
American Family Therapy Academy, 698 conflict resolution, 381, 382
American Foundation for Suicide Prevention, 508 disasters, 252
American Group Psychotherapy Association, 699 high-conflict couples, 379 –380
American Guidance Service (AGS), 108 Anonymous testing, human immunodeficiency
American Heart Association, 508 virus (HIV), 294
American Lupus Society, 508 Anorexia nervosa. See also Bulimia nervosa; Eating
American Nurses Association (ANA), 698 disorders
American Nurses Credentialing Center, 698 dietary supplements, 477
American Parkinson’s Disease Association, 508 DSM-IV, 43
American Professional Society on the Abuse of empirically supported therapies, 186
Children (APSAC) Study Guides, 416 – 422 prevalence of, 4
American Psychiatric Association (ApA), 698 psychopharmacology, 459
DSM-IV-TR classification, 80 –90 self-help group, 512, 513
use of Global Adaptive Functioning (GAF) scale Answer, definition, 573
of DSM-IV-TR, 91– 92 Anticonvulsants, 457
American Psychiatric Nurses Association, 698 Antidepressants, pharmacotherapy, 461– 462,
American Psychoanalytic Association, 699 469 – 471, 472, 473
American Psychological Association (APA), 697 Antihypertensives, 470
APA Salaries in Psychology report, 665 Antipsychotics, 457, 464, 471, 473, 473 – 474
Committee on Lesbian and Gay Concerns, 299 Antisocial disorders, movie recommendations, 499
competence, 346 –347 Antisocial personality disorder, prevalence of, 4
confronting an unethical colleague, 580 Anus, examination, 53
“Ethical Principles of Psychologists and Code of Anxiety
Conduct (2002),” 525 – 545, 612 conflict resolution, 381
704 index

Anxiety (continued) borderline personality disorder, 255 –256

dietary supplements, 477 character strengths, 93 – 97
kava, 519 –520 child custody evaluation, 617 – 619
medical conditions that may present as, 448 – 449 client’s stage of change, 227 –228
Anxiety disorders consultation, 667 – 668
Anxiety Management Training (AMT), 271–273 couple and family therapy, 374
disasters, 252 drug-use patterns, 482
DSM-IV, 43 drug use risks and negative consequences, 482,
DSM-IV-TR classification, 86 –87 487
empirically supported therapies, 184 –185, 189 ethical standards, 541– 543
MACI, 164 ethnic minority children using DSM-IV-TR,
movie recommendations, 498 45 – 49
pediatric pharmacotherapy, 468, 471– 472 executive dysfunction, 39 – 40
prevalence of, 4 feigned cognitive impairment, 69 –70
psychopharmacology, 457 – 458 feigned mental disorders, 68 – 69
self-help group, 509 gay men, 299 –301
treatment manuals, 193 –194 genograms, 366 –372
Anxiety Disorders Association of American global, of functioning (GAF) scale, 92
(ADAA), 509 height and weight, 445 – 447
Anxiety Management Training (AMT), 271–273 human immunodeficiency virus (HIV), 291–295
Anxiolytic-related disorders, DSM-IV-TR classifi- individual functioning, 369 –370
cation, 84 –85 infant, 124 –125
Anxiolytics, 463 – 464 journal, 168
APA, 697. See American Psychological Association lesbians, 299 –301
(APA) male sexual dysfunction, 282–286
ApA (American Psychiatric Association), 80 –90, malingering, 67 – 70
91–92, 698 MMPI-2 profile validity, 128 –132
Appeal, definition, 573 normative male alexithymia, 279
Appearance, in MSE, 8 older adults, 306
Appelbaum, Paul S., 548 – 552 play, for children, 122–123
Applied Computing Services, 671 psychotherapy outcome, 236 –239
APSAC (American Professional Society on the quality of psychological testing report, 117 –118
Abuse of Children) Study Guides, 416 – 422 Rorschach questions and reservations, 169 –172
APS (Addition Potential Scale), MMPI-2, 139 sex offenders, 416 – 417
APS (American Psychological Society), 698 suicidal patient, 243
ARC, 509 suicidal risk, 63 – 65
ARSMA-II (Acculturation Rating Scale for Mexi- suicide lethality, 247
can Americans-II), 78 systematic, 220 –222
Arterial blood gas values, 442 teleassessment, 120 –121
ASGW (Association of Specialists in Group Work), tools for relapse prevention, 351
393 Values in Action (VIA) strengths, 94 – 97
ASPECT (Ackerman-Schoendorf Scales for Parent Assimilation, problematic experiences, 207
Evaluation of Custody), 603 – 604 Association for Advancement of Behavior Therapy
Asperger’s syndrome, DSM-IV, 44 (AABT), 699
Assault. See Sexual abuse/assault Association for Humanistic Psychology (AHP), 699
Assault, definition, 573 Association for Repetitive Motion Syndromes, 509
Assent, definition, 646 Association for the Advancement of Psychology,
ASSESS-LIST, 605 698
Assessment. See also Interviewing; Neuro- Association of Specialists in Group Work (ASGW),
psychological (NP) assessment 393
adherence, 209 Association of State and Provincial Psychology
alcohol abuse, 71– 75 Boards, 108
behaviorally disordered children, 403 AtHealth, Internet site, 491– 492
bisexuals, 299 –301 Attachment behavior, children, 121
 index 705

Attention Battery, definition, 573

in MSE, 11 Beaver Creek Software, 671
neuropsychological assessment, 35 Beck System, 166
Attention-deficit disorder (ADD), children, Behavioral Assessment of the Dysexecutive Syn-
121–122 drome (BADS), 40
Attention Deficit Disorder Association (ADDA), Behavioral disorders. See also Developmental
509 disorders
Attention-deficit/hyperactivity disorder (ADHD) DSM-IV, 42
adults, 62 laboratory tests and indications, 53
bibliotherapy, 62 medical evaluation of children with, 50 – 54
children, 62 parent management training for childhood,
DSM-IV, 42, 61 327 –331
empirically supported therapies, 189 treatment, 401– 405
evaluation, 61–62 Behavioral indicators, sexually abused children,
ginseng and ginkgo biloba, 520 424
medical conditions that may present as, 449 Behavioral observation, neuropsychological assess-
parent management training, 328 ment, 34
pediatric psychopharmacology, 466, 467, Behavioral referents, interviewing, 14
469 – 470 Behaviors, Multimodal Life History Inventory, 19,
prenatal factors, 50 22
prevalence of, 4 Belanoff, Joseph K., 454 – 459
self-help groups, 509, 510 Bender Visual Motor Gestalt Test-Second Edition,
through life span, 60 –62 126
treatment, 62, 401– 405 Beneficence, 528 – 529
Attire/grooming, in MSE, 8 Bennett, Bruce E.
Attitude, in MSE, 8 professional liability insurance, 625 –631
Attribute by treatment interaction (ATI), 264 –265 psychotherapist-patient contract, 635 –640
Atypical presentations, malingering, 70 Bennett, Jason M., 640 – 645
AUDIT (Alcohol Use Disorders Identification Test), Benzodiazepines, 463 – 464, 472, 482, 483
73 Bereavement, suicide risk, 65
Authorization, release forms, 647 –649 Bernstein, Jane Holmes, 28 –32
Autism Beutler, Larry E., 220 –225
Autism Society of America, 509 Biases in interviewing, 15
children, 122 Bibliotherapy, 62, 387, 494 – 496
DSM-IV, 44 Bicultural Involvement Scale, 78
pediatric pharmacotherapy, 469 Biedenharn, Paula J., 517 –521
prevalence of, 4 Biederman, Joseph, 466 – 476
Autobiographies, 351, 496 Bilateral listening, 383
Automatic movements, in MSE, 8 – 9 Billable hours, 668
AVE (abstinence violation effects), 352–353 Billing
Aversion to sex, 290 –291 basic principles, 657 –658
Avoidant personality disorder collection, 658, 660
empirically supported therapies, 188 consultation, 668 – 669
prevalence of, 4 controversy, 660 – 661
psychopharmacology, 456, 458 important don’ts, 659 – 660
issues, 657 –661
Back F (F(B)) Scale, MMPI-2, 130, 131 managed care organizations, 656
BADS (Behavioral Assessment of the Dysexecutive psychotherapist-patient contract, 637
Syndrome), 40 third-party relationships, 658 – 659
Baker, Jeannie, 416 – 422 utilization rate, 668
Baker, Robert W., 7 –12 Binge-eating disorder, empirically supported thera-
Bartering, 660 pies, 186. See also Eating disorders
Base rates of behaviors, 14 –15 Biological factors, Multimodal Life History Inven-
Batterers Anonymous, 509 tory, 22, 23
706 index

Bipolar disorders DSM-IV, 43

DSM-IV-TR classification, 86 empirically supported therapies, 186
empirically supported therapies, 186 pharmacotherapy, 456, 459
pediatric pharmacotherapy, 467 – 468, 471 prevalence of, 4
prevalence of, 4 self-help group, 512, 513
psychopharmacology, 455, 457 Bupropion, 456, 462, 479
treatment manuals, 194 Burden of denial, AIDS, 293
Bisexuals, 299 –303, 510 – 511 Burlingame, Gary M., 393 –398
Bishop, Matthew, 192–202 Burns, child abuse, 420
Black cohosh, 520 Burying deductible, 659
Blind, self-help group, 508 Buspirone, 464
Blood injury phobia, empirically supported thera- Butcher, James N.
pies, 184 assessing MMPI-2 profile validity, 128 –132
Blumenthal Software, 671–672 empirical interpretation of MMPI-2 codetypes,
BMI (body mass index), 52, 445 – 447 149 –153
Body disapproval, MACI, 163 Bybee, Taige, 192–202
Body mass index (BMI), 52, 445 – 447
Body part or function disorders, DSM-IV, 43 – 44 Caffeine-related disorders, DSM-IV-TR classifica-
Bongar, Bruce, 240 –245 tion, 83
Bootzin, Richard R., 325 –327 CAI (Competency Assessment Instrument), 608,
Borderline character of childhood Axis II, DSM-IV, 610 – 611
44 Calzada, Esther J., 401– 405
Borderline personality disorder Cancer
assessment, 255 –256 children, 51
empirically supported therapies, 188 self-help groups, 508, 509, 516
MACI, 163 Cancer Care, 509
prevalence of, 4 Candlelighters Childhood Cancer Foundation, 509
psychopharmacology, 456, 458 Cannabis-related disorders, DSM-IV-TR classifica-
treatment, 255 –257 tion, 83
Borum, Randy, 603 –607 Cannot Say Score, MMPI-2, 128 –129, 131
Boundaries, clients’ rights, 181–182 Cantor, Dorothy W., 181–183
BPD. See Borderline personality disorder CAPS (Clinician-Administered PTSD Scale), 14
BPS (Bricklin Perceptual Scales), 604 Carbamazepine, 457, 463, 479
Brain injury. See Traumatic brain injury (TBI) Carey, Michael P., 291–295
Brain Injury Association Family Helpline, 509 Carpal tunnel syndrome, self-help, 509
Brazelton Neonatal Behavioral Scale (NBAS), 124 Causation, definition, 573
Breast cancer, self-help group, 516 Cause of action, definition, 573
Breastfeeding mothers, La Leche League, 511 CDC National AIDS Clearinghouse, 509
Bricklin, Barry, 615 –619 Center Psych, 672
Bricklin Perceptual Scales (BPS), 604 Centers for Medicare & Medicaid Services (CMS),
Brief Acculturation Scale for Hispanics, 78 standards for restraint and seclusion, 554, 556
Brief Situational Confidence Questionnaire Central nervous system (CNS), 29
(BSCQ), 73 Cerebral palsy, self-help group, 516
Brodsky, Stanley L. Cerebral spinal fluid lab values, 443
forensic evaluations and testimony, 591–593 CFIDS Association, 509
psychotherapy with reluctant and involuntary CHADD (Children and Adults with Attention-
clients, 257 –262 Deficit/Hyperactivity Disorder), 510
Brown, Laura S., 295 –298 Chambless, Dianne L., 183 –192
BSCQ (Brief Situational Confidence Question- Chamomile, 520
naire), 73 Change
Buhrke, Robin A., 299 –304 client motivation, 270
Bulimia nervosa. See also Anorexia nervosa; Eating concrete changes, 261
disorders mechanisms of, for female sex therapy, 287 –291
dietary supplements, 477 mechanisms of, for male sex therapy, 283 –286
 index 707

motivational interviewing, 269 physical abuse, 419 – 421

prescriptive guidelines, 227 –231 recovery after disasters, 253
readiness in alcohol abusers, 73, 75 reliability of information, 424
stages of, 206, 226 –231 Rorschach assessment, 174
substance abuse, 266 self-help groups, 507, 508, 509, 510, 513, 516
Character strengths, assessment, 93 – 97 sexual abuse, 417 – 422
Chemical abuse/dependence, empirically supported sexually transmitted diseases (STDs), 422
therapies, 185 suggestibility, 426
Chemical vasodilators, 285 treatment of behavioral disorders, 401– 405
Chemotherapy side effects, empirically supported treatment of sexual abuse, 430 – 435
therapies, 186 Children and Adults with Attention-Deficit/
Chenneville, Tiffany, 584 – 588 Hyperactivity Disorder (CHADD), 510
Chest examination, 52 Children’s Health Act, restraint and seclusion,
Chest injuries, child abuse, 420 553 – 554
Child abuse. See also Sexual abuse/assault Child therapy, termination, 358 –359
MACI, 163 Chromosome determination, children, 54
physical, 419 – 421 Chronic fatigue and immune dysfunction syn-
questioning children, 428 drome (CFIDS), 509
self-help groups, 509, 515, 516 Chronic illness, psychological interventions in
sexual, 417 – 422 childhood, 406 – 409
treatment of sexual abuse, 430 – 435 Chronic pain
Child behavior observations, 119 –123, 376 –377 empirically supported therapies, 186, 189
Child custody, 603 –605, 615 – 619 medical conditions that may present as pelvic,
Child diagnosis, DSM-IV, 41– 44 451
Child-directed interaction (CDI), 330 –331 self-help group, 513
Child Help USA Hotline, 509 Chronic renal disease, children, 51
Child heritage, 30 Chronic severe illnesses, children, 51
Childhood adolescent disorders, treatment manu- CIDI (Composite International Diagnostic Inter-
als, 195 view), 14
Childhood behavioral disorders, parent manage- Civil action, definition, 573
ment training, 327 –331 Civil commitment, 548 – 551
Childhood disorders, movie recommendations, Clarkin, John F.
500 –501 borderline personality disorder, 255 –257
Childhood schizophrenia, DSM-IV, 44 choice of treatment format, 363 –365
Children. See also Ethnic minorities; Neuro- Clients
psychological (NP) assessment clinical supervision, 682–685
assessment of sexual offenders, 416 – 417 early termination and referral, 346 –349
assumptions of neuropsychological assessment, inviting hypnosis and relaxation, 333 –337
28 litigious, 260
attention-deficit/hyperactivity disorder (ADHD), Privacy Rule, 640 – 645
60 –62 problem members in psychoeducational groups,
childhood behavior disorders, 330 396
disclosure of abuse, 425 psychotherapy with reluctant and involuntary,
empirically supported therapies, 189 –190 257 –262
interviewing sexually abused, 423 – 430 reactions to termination, 355 –357
interview outline, 427 – 429 religiously committed, 338 –341
involuntary psychiatric hospitalization, 550 – 551 reluctant, 257 –262
medical evaluation of, with behavioral or devel- right to refuse treatment, 258
opmental disorders, 50 – 54 self-help groups, 502– 506
medical lab values, 444 sexual involvement between therapist and, 532,
memories, 424 – 425 533, 538, 544
pain management for chronic illness, 408 signs for relapse prevention, 352
parent management training, 327 –331 top Internet sites, 491– 494
pediatric psychopharmacology, 466 – 474 Clinical abbreviations and symbols, 691–697
708 index

Clinical geropsychology, 307 Communication

Clinical interviewing, 13 –15. See also Interviewing high-conflict couples, 382–383
Clinical issues, commitment, 551 neuropsychological assessment, 31–32
Clinical judgment, accuracy, 23 –27 Communication disorders, DSM-IV-TR classifica-
Clinical method, neuropsychological assessment, tion, 81
34 –37 Community reinforcement approach, substance
Clinical psychologists, widely used tests, 101–102 abuse, 264
Clinical scales Community resources, suicidal patient, 244
high and low scores on MMPI-2, 141–148 Comorbidity
MMPI-2, 132–136 alcohol abuse, 73, 74
Clinical social work, 698 drug problems, 74 – 75
Clinical supervision, 682–685 substance use disorders, 487
Clinical syndromes, MACI, 160, 164 Comparative negligence, definition, 573
Clinical utility, Rorschach assessment, 176 –177 Compassionate Friends, 510
Clinician-Administered PTSD Scale (CAPS), 14 Compassion fatigue, 349
Clonidine, 473 Compensatory damages, definition, 573
Clozapine, 464, 479 Competence
Club drugs, administration, effects, and interac- clinical supervision, 684
tions, 484 ethical standard, 530 – 531
CNS (central nervous system), 29 informed consent, 645
CNS depressants, administration, effects, and inter- Competency Assessment Instrument (CAI), 608,
actions, 483 610 – 611
Cocaine Competency Screening Test (CST), 608 – 610
administration, effects, and interactions, 486 Competency to stand trial, evaluation, 607 –611
Cocaine Anonymous, 510 Competing behaviors, 328
empirically supported therapies, 185 Complaint, definition, 573
prevalence rates, 481 Complementary and alternative medicines
Cocaine-related disorders, DSM-IV-TR classifica- (CAMs)
tion, 83 cautions for herbal CAMs, 517 – 518
Code of conduct, 525 –545 ginkgo biloba for memory, 518 – 519
Codependents of Sex Addicts (COSA), 510 ginseng for well–being, 519
Codetypes of MMPI-2, 149 –152 kava for anxiety, 519 – 520
Cognition, in MSE, 11–12 St. John’s wort for depression, 518
Cognitions, restructuring, 679 valerian for sleep, 520
Cognitive-behavioral treatment, substance abuse, Complexity
263 assessment, 221
Cognitive behavior therapy (CBT), 212 treatment matching, 223 –224
Cognitive processes, executive dysfunction, 38 Compliance, 208. See also Adherence
Cognitive therapy, substance abuse, 263 Privacy Rule, 644 – 645
Colitis, self-help group, 510 psychotherapy homework, 319 –324
Collaboration Composite International Diagnostic Interview
psychotherapy, 204 (CIDI), 14
psychotherapy homework compliance, 323 Comprehension
Collaborative interview style, 13 in MSE, 10
Collection, bill, 658, 660 questions in interview, 14
The College Board, 108 Comprehensive Assessment-to-Intervention Sys-
Coming out process, 301–303 tem (CAIS), 55, 57 – 59
Commitment, clinical issues, 551 A Comprehensive Custody Evaluation Standard
Commitment, involuntary outpatient, 550 System (ACCESS), 615 –619
Common Alcohol Logistic (CAL) scale, MMPI-2, Comprehensive intervention, impaired psycholo-
139 gist, 623
Common law, definition, 573 Comprehensive System (CS) norms, caution,
Communicating findings, neuropsychological as- 169 –170
sessment, 31–32 Compulsions, in MSE, 9
 index 709

Computed tomography (CT), children, 54 Contract, psychotherapist-patient, 635 –640

Computerized billing, 670 –671 Contracting managed care organizations, 653 – 657
Concentration Contraindications, couple therapy, 380
in MSE, 11 Contributory negligence, definition, 573
neuropsychological assessment, 35 Control and inhibition, MMPI-2, 138
Concerned United Birthparents (CUB), 510 Cooperation, crisis intervention, 248
Conduct disorder Cooperativeness, in MSE, 8
DSM-IV, 42 Co-payment, ignoring, 659
empirically supported therapies, 189 Coping skills
family therapy, 377 adult disease management, 275
parent management training, 328 relapse prevention, 351–352
pharmacotherapy, 467 Coping styles, assessment, 222
prevalence of, 4 Core concerns, high-conflict couples, 382
treatment, 401– 405 Cornucopia Software, 672
Confidentiality Correia, Christopher J., 481– 487
adolescents, 412 COSA (Codependents of Sex Addicts), 510
breaching, 546 –547, 612, 613 Counseling, risk reduction for human immuno-
clinical recommendations, 586 –588 deficiency virus (HIV), 294 –295
couple and family therapy, 374 Counseling psychologists, widely used tests,
definition, 546, 584 101–102
duty to protect and, 584 –588 Counterconditioning, 229
ethical standards, 534 – 535 Countertransference, 205, 347 –348, 414
HIV testing, 294 Couples therapy
marital infidelity, 385 –386 bibliotherapy, 387
media, 688 communication, 382–383
patient right, 181 confidentiality, 374
peer monitoring, 580 conflict levels, 379 –380
psychotherapist-patient contract, 639 –640 conjoint, 376
sexually abused children, 423 – 424 contraindications, 380
Confidential testing, human immunodeficiency ethical standards, 543 – 545
virus (HIV), 294 guidelines for conducting, 373 –378
Conflict of interest, ethics, 532 marital infidelity, 384 –387
Conflict resolution, couples, 381, 382 selection criteria, 364
Conflicts and personal problems, 531 substance abuse, 264
Conforming, MACI, 163 termination, 383
Confrontation of unethical colleague, 579 – 583 treating high-conflict couples, 378 –383
Confrontive intervention, impaired psychologist, Courage, Values in Action (VIA) classification, 96
623 Court-mandated treatment, substance abuse, 264
Congenital heart disease, children, 51 Court order and subpoena, 570 – 571
Congruence, psychotherapy, 204 Courtroom, expert testimony in deposition vs.,
Connectedness, in MSE, 10 599 – 602
Consciousness level, in MSE, 8 Covered transactions, Privacy Rule, 641–642
Consciousness raising, 229 Creativity, therapist self-care checklist, 681
Consent. See also Informed consent Criminals. See Forensic matters; Reluctant and in-
basic elements, 645 –646 voluntary clients; Sex offenders
definition, 573, 646 Crisis characteristics, 246
Privacy Rule, 643 Crisis intervention
Consultation adult disease management, 275 –276
agreement, 666 –669 disasters, 251
suicidal patient, 243 guidelines, 245 –249
Consulting Psychologists Press, 108 Crisis reduction counseling, 251
Contemplation stage, 226 –227 Criticism, divorce risk, 376
Contempt, divorce risk, 376 Crohn’s & Colitis Foundation of America, 510
Contingency management, 229 CST (Competency Screening Test), 608 – 610
710 index

CTB/McGraw-Hill, 108 –109 Depositions, 591– 592, 599 – 602

CUB (Concerned United Birthparents), 510 Depression
Cult Awareness Network, 510 Anxiety Management Training (AMT), 272
Cultural history, family, 369 atypical, 456
Culture, definition, 46. See also Ethnic minorities conflict resolution, 381
Curtis, Rebecca C., 354 –359 dietary supplements, 477
Customizing therapy, 206 –207 disasters, 252
Cyclothymia, DSM-IV, 43 DSM-IV, 43
Cyclothymic disorder, prevalence of, 4 empirically supported therapies, 186, 189
Cytomegalovirus (CMV), 50 – 51 interpretation of high scores, 143
MACI, 164
DAFS (Direct Assessment of Functional Status), medical conditions that may present as, 449 – 450
605 MMPI-2 codetype, 151–152
Damages, definition, 573 movie recommendations, 498 – 499
Dangerousness, crisis intervention, 248 pediatric pharmacotherapy, 467, 470 – 471
Dangerousness criteria psychotic, 456 – 457
breaching confidentiality, 546 St. John’s wort, 518
involuntary psychiatric hospitalization, Scale 2 of MMPI-2, 133
548 –549, 551 screen, 210 –211
Dangerous patients, 612– 614 self-help groups, 512, 513
Daubert v. Merrell Dow Pharmaceuticals, Inc., 602 suicide risk, 64
Deaf, self-help groups, 508, 512 treatment manuals, 194 –195
DeBattista, Charles, 454 – 459 Depressive disorders, DSM-IV-TR classification,
Debiasing strategies, 15 86
Debriefing, disasters, 251 Designer drugs, administration, effects, and inter-
Debt collection, 658, 660 actions, 484
Debtors Anonymous, 510 Developmental disorders. See also Behavioral
Decisional Balance Exercise, 73 disorders
Deductible, burying, 659 laboratory tests and indications, 53
Defamation, definition, 573 medical evaluation of children with, 50 – 54
Defendant, definition, 573 pediatric pharmacotherapy, 468 – 469
Defense mechanism, in MSE, 12 Developmental neuropsychological assessment,
Defensiveness, divorce risk, 376 28 –32
Defusing, disasters, 251 Diabetes
Delinquent predisposition, MACI, 164 Anxiety Management Training (AMT), 272
Delirium self-help group, 508
DSM-IV-TR classification, 81 Diagnosis
medical conditions that may present as, 452– 453 DSM-IV, 41– 44
prevalence of, 4 high-conflict couples, 379
Delphi/PBS, 672 mental health records, 650
Delusional disorders neuropsychological assessment, 36 –37
movie recommendations, 501 older adults, 305
prevalence of, 4 treatment plan writing, 235
Delusions, in MSE, 10 utilization review checklist, 652–653
Dementia Diagnostic and Statistical Manual of Mental Dis-
DSM-IV-TR classification, 81–82 orders, 4th edition. See DSM-IV
empirically supported therapies, 188 Diagnostic and clinical interviewing, 13 –15. See
medical conditions that may present as, 453 also Interviewing
prevalence of, 4 Diagnostic strategy, neuropsychological assess-
psychopharmacology, 456 ment, 29 –30
Department of Health and Human Services (HHS), DiClemente, Carlo C.
Privacy Rule, 644 –645 stages of change, 226 –231
Depersonalization disorder, DSM-IV, 44 treatment matching in substance abuse, 263 –267
Deposition, definition, 573 Dietary supplements, 476 – 478
 index 711

Digestive listening, 383 Documentation

Dignity, 529 suicidal patient, 243
DiMatteo, M. Robin, 208 –212 treatment planning, 232, 233
Dimethyltrypyamine, administration, effects, and Document production, subpoena, 571– 572
interactions, 485 DocuTrac, 672
Diplomate in Clinical Social Work, 698 Dolefulness, MACI, 162
Direct Assessment of Functional Status (DAFS), Dolls, anatomically detailed, 425 – 426
605 Domestic violence, self-help, 509, 510, 513
Directed verdict, definition, 573 –574 Dopamine receptor antagonists, 457
Direct observation, children, 119 –120 Dopamine/serotonoin receptor antagonists, 457
Directory of Unpublished Experimental Mental Dorado, Joyce S., 423 – 430
Measures, 106 Down syndrome, self-help group, 513
Disabilities, self-help groups, 511, 513 Dramatic relief, 229
Disaster Response Network, 249 –250 Dramatizing, MACI, 162
Disasters Drug abuse/dependence
age-related issues, 253 –254 administration, effects, and interactions,
common mental health problems after, 252 483 – 486
context of evaluation and intervention, 250 assessment considerations, 482, 487
crisis intervention, 251 common drugs of abuse, 481– 487
crisis reduction counseling, 251 comorbidity, 74 – 75, 487
debriefing and defusing, 251 drugs of abuse, 481, 482
elements of traumatic exposure, 250 drug-use patterns, 482
factors influencing recovery, 252–253 prevalence of, 4
impact, 249 –254 prevalence of drug use, 481– 482
impact and short-term adaptation phases, risks and negative consequences, 482, 487
250 –251 self-help groups, 510, 512, 513, 515
long-term adaptation phase, 251–254 treatment matching, 263 –267
predisaster planning, 249 –250 Drug Abuse Screening Test (DAST–10), 73
psychological first aid, 250 –251 DrugDigest, Internet site, 492
Disclosure, patients’ rights, 182–183 Drug scales, MMPI-2, 138 –139
Disconfirmation strategy, 15 Drug use, prevalence, 481– 482
Disconnection disorders, DSM-IV, 44 Drug Use History Questionnaire (DUHQ), 73
Discovery DSM-IV (Diagnostic and Statistical Manual of
definition, 574 Mental Disorders, 4th edition)
extramarital involvement, 385 –387 child and adolescent diagnosis, 41– 44
Discrepancy, motivational interviewing, 268 lifetime prevalence of mental disorders, 3 –6
Dissociative anesthetics, administration, effects, multiaxial system, 80 –90, 90
and interactions, 484 Structured Clinical Interview, 14
Dissociative disorders, DSM-IV-TR classification, Due process, definition, 574
87 DUHQ (Drug Use History Questionnaire), 73
Dissociative fugue, prevalence of, 4 Dusky v. United States, 608
Dissociative identity disorders Duty to protect, confidentiality and, 584 –588
DSM-IV, 44 Dyscontrol and dysinhibition scales, MMPI-2,
movie recommendations, 498 138
prevalence of, 4 Dysmenorrhea, Anxiety Management Training
treatment manuals, 196 (AMT), 272
Distress Dyspareunia, 290
assessment, 221 Dysthymia, 457
treatment matching, 223 –225 Dysthymic disorder
Diversity, therapist self-care checklist, 681 DSM-IV, 43
Divorce, couples therapy, 376 prevalence of, 4
Dizziness, medical conditions that may present as,
452 Ear examination, 52
DNA testing, children, 54 Eastern Psychological Association, 699
712 index

Eating disorders. See also Anorexia nervosa; EMS (extramarital sex), 384
Bulimina nervosa Encopresis
dietary supplements, 477 DSM-IV, 43
DSM-IV-TR classification, 81, 88 empirically supported therapies, 189
Food Addicts Anonymous, 511 prevalence of, 4
MACI, 164 Endocrinology lab values, 442– 443
pharmacotherapy, 459 Enforcement, Privacy Rule, 644 – 645
self-help groups, 511, 512, 513, 514 Entactogens, administration, effects, and interac-
treatment manuals, 196 tions, 484
ECA (Epidemiological Catchment Area), 3 – 6 Enuresis
Ecstasy, 484 DSM-IV, 43
ECT (electroconvulsive therapy), 456 empirically supported therapies, 189
Edelstein, Sari pediatric pharmacotherapy, 468
dietary supplements and psychological function- prevalence of, 4
ing, 476 – 480 Epidemiological Catchment Area (ECA), 3 – 6
height and weight assessment, 445 – 447 Epilepsy Foundation, 510
EdITS (Educational & Industrial Testing Service), Erectile failure, 284 –285
109 Ethical issues
Education advertising and public statements, 535 – 536
ethical standards, 537 – 538 APA “Ethical Principles of Psychologists and
neuropsychological assessment, 32 Code of Conduct (2002),” 525 – 545, 612
Educational & Industrial Testing Service (EdITS), assessment, 541– 543
109 bill collection, 658
Educational Testing Service (ETS), 109 breaching confidentiality, 546 –547
Education and training programs child sexual abuse, 434
Anxiety Management Training (AMT), 271–273 clinical supervision, 684
parent management training (PMT), 327 –328 competence, 530 – 531
refusal skills training (RST), 308 –311 confronting an unethical colleague, 579 – 583
EEG (electroencephalography), children, 54 education and training, 537 – 538
Efficacy, motivational interviewing, 270 fees, 536 –537
Egocentricity Index, 174 human relations, 532– 534
Egotism, MACI, 162 money matters and, 577 –579
Electroconvulsive therapy (ECT), 456 physical restraint and seclusion, 553 –557
Electroencephalography (EEG), children, 54 privacy, confidentiality, and privilege, 545 – 547
Electronic listings, psychological tests, 105 privacy and confidentiality, 534 – 535
Elimination disorders, DSM-IV-TR classification, psychoeducational groups, 396
81 record keeping, 536 –537
Ellis, Albert, 212–215 research and publication, 538 –541
Emergencies, older adults, 306 resolution, 529 –530
Emergency mental health intervention, 245 –246 sexual involvement between therapist and client,
EMI (extramarital involvement), 384 –385 532, 533, 538, 544, 620 – 621, 627 – 628
Emotion, neuropsychological assessment, 36 therapy, 543 – 545
Emotional arousal, 229 Ethics issues, dealing with ethics complaints,
Emotions, normative male alexithymia, 278 –281 566 – 569
Emotions Anonymous, 510 Ethnic history, family, 369
Empathy Ethnicity, pharmacotherapy, 460
interviewing alcohol abusers, 72 Ethnic minorities
motivational interviewing, 268 acculturation, 48
psychotherapy, 204 assessment of minority children using
Empirically supported therapies DSM-IV-TR, 45 – 49
adults, 184 –188 treatment planning for children, 47 – 49
children and adolescents, 189 –190 ETS (Educational Testing Service), 109
comparison, 190 Evaluation
reactions, 190 –191 attention-deficit/hyperactivity disorder (ADHD),
Empowerment, adolescents, 413 – 414 61– 62
 index 713

disasters, 250 play genograms, 371

suicidal patient, 243 professional associations, 698
Exclusive dealing, managed care organizations, 655 selection criteria, 364
Executive dysfunction self-help groups, 510 – 516
assessment, 39 – 40 substance abuse, 264
cognitive processes, 38 Fatigue, chronic, 509
common disorders, 39 Fatigue, medical conditions that may present as,
intervention, 40 450
Executive functions Faust, David, 23 –27
description, 38 F(B) or Back F Scale, MMPI-2, 130, 131
in MSE, 12 Fears
neuropsychological assessment, 36 death, 276
Expectations, customizing therapy, 206 –207 psychotherapy, 338
Experience, witnesses, 592 Feedback
Expert testimony, 591–593, 599 – 602 clinical supervision, 684
Expert witness, definition, 574 neuropsychological assessment, 37
Express consent, definition, 573 psychotherapy, 204
Expressed concerns, MACI, 160, 163 Feeding disorders, DSM-IV-TR classification, 81
Externalization Feelings, Multimodal Life History Inventory,
coping style, 222 19 –20, 22
treatment matching, 224 –225 Fees. See also Billing
Externally induced disorders, DSM-IV, 44 consultation, 668 – 669
Extramarital involvement (EMI), 384 –385 debt collection situations, 579, 658, 660
Extramarital sex (EMS), 384 ethical standards, 536 – 537
Extremities, examination, 53 forensic testimony, 597
Eyberg, Sheila M. missed appointments, 578, 660
behaviorally disordered children, 401– 405 pro bono services, 577
parent management training for childhood be- psychotherapist-patient contract, 637
havior disorders, 327 –332 psychotherapy, 662– 663
Eye contact, in MSE, 8 therapy, 577 – 579
Eye examination, 52 Fee splitting, 578, 661
Eye injuries, child abuse, 421 Feigned cognitive impairment, assessment, 69 –70
Feigned mental disorders, assessment, 68 – 69
Facial injuries, child abuse, 420 Females. See also Gender issues
Factitious disorders, DSM-IV-TR classification, 87 guidelines for treating, 295 –298
Failure to thrive, medical conditions that may pre- guidelines for treating women, 295 –298
sent as, 451– 452 National Organization for Women, 513 –514
FAIs (forensic assessment instruments), 603 – 607 medical conditions that may present as chronic
False allegations, sexual abuse, 418 – 419, 426 pelvic pain, 451
Family sexual dysfunction, 286 –291
resistance to doing genogram, 369 Fetal alcohol syndrome, self-help, 513
social context of older adults, 306 Fetal causes, intrauterine growth retardation, 51
Family discord, MACI, 163 Fidelity, 529
Family history, children, 51– 52 Films, clinical benefits, 497 – 498
Family information, genograms, 366 –369, 372 First-generation antipsychotics (FGAs), 464
Family interaction patterns, genogram format, 372 F-K Index of MMPI, 130 –131
Family involvement, adult disease management, Flemons, Douglas, 332–337
276 Flexibility, executive dysfunction, 40
Family Pride Coalition, 510 – 511 Floor effect, malingering, 69
Family therapy Fluency, in MSE, 9 –10
billing, 659 Fluoxetine, 454, 455, 479
confidentiality, 374 Foelsch, Pamela A., 255 –257
ethical standards, 543 – 545 Food Addicts Anonymous, 511
guidelines for conducting, 373 –378 Forcefulness, MACI, 163
musical chairs, 659 Forensic assessment instruments (FAIs), 603 –607
714 index

Forensic examination, sexually assaulted child, 422 prevalence of, 4

Forensic matters. See also Legal issues psychopharmacology, 455, 458
child custody and parental capacity, 603 – 605, Generalized emotional distress scales, MMPI-2,
615 –619 137
clinical decision making with dangerous patients, Genitalia and anus, examination, 53
612–614 Genograms
competency to stand trial evaluation, 607 –611 assessment tool, 366, 372, 375
criminal forensic evaluations, 603 dealing with family resistance to, 369
expert testimony in depositions, 599 –602 difficult questions about individual functioning,
forensic assessment instruments, 603 – 607 369 –370
forensic evaluation outline, 593 – 595 ethnic and cultural history, 369
forensic evaluations and testimony, 591–593 family information net, 366 –369
forensic referrals checklist, 595 –598 format, 372
guardianship, 605 index person (IP), 366
professional liability insurance, 625 –631 mapping, for those in multiple settings, 370 –371
recognizing, assisting, and reporting impaired Ortiz-Brown family, 367
psychologist, 620 –624 play, for individual child and family therapy, 371
treatment manuals, 196 setting priorities for organizing, 370
violence risk assessment, 605 – 606 standard symbols, 368
Forensic psychologists, widely used tests, 101–102 Geriatric anxiety, empirically supported therapies,
Foundation Center, Internet site, 492 185
F(P) (Psychopathology Infrequency Scale), MMPI-2, Geriatric depression, empirically supported thera-
130, 131 pies, 186
Fractures, child abuse, 420 Geropsychology, 307
France, Kenneth, 245 –249 Ginger, 520
Fraud, billing, 659 Ginkgo biloba
Fraud, definition, 574 ginseng and, for ADHD children, 520
Friedland, Lilli, 686 –691 memory, 518 – 519
Friends for Survival, 511 Ginseng
F Scale, MMPI-2, 129 –130, 131 ginkgo biloba and, for ADHD children, 520
Functional impairment, psychotherapy, 206 well-being, 519
Future editions, 701 Gioia, Gerard A., 38 – 41
Global, lifelong inorgasmia, 287 –288
GAD. See Generalized anxiety disorder Global assessment of functioning (GAF) scale,
Gabapentin, 463 DSM-IV-TR, 91– 92
Gam-Anon Family Groups, 511 Glossary of legal terms, 572–576
Gamblers Anonymous, 511 Goal consensus, psychotherapy, 204
Garb, Howard N., 169 –172 Goal development, treatment plan writing, 234
Gases, administration, effects, and interactions, 485 Goal-setting, executive dysfunction, 40
Gatz, Margaret, 305 –307 Godinez v. Moran, 608
Gault, In re, 550 Goldhaber, Samuel Z., 439 – 444
Gay men, 299 –303, 510 – 511 Goldman, Stuart M., 41– 45
Gender identity disorders Gonzalez, Juan Carlos, 77 – 80
DSM-IV-TR classification, 88 Goodheart, Carol D., 274 –278
movie recommendations, 500 Goodman Lock Box, 122
prevalence of, 4 Gordon, Betty N., 55 – 60
Gender issues. See also Females; Males Grade equivalents (GE), 115 –116
guidelines for treating women, 295 –298 Graf, Thomas P., 553 – 557
normative male alexithymia, 278 –281 Graham, John R.
psychotherapy models, 297 clinical scales of MMPI-2, 132–136
suicide risk, 64 high and low scores on MMPI-2 clinical scales,
Generalized anxiety disorder 141–149
Anxiety Management Training (AMT), 272 Greene, Roger L.,137 –141
empirically supported therapies, 184 GRE scores, 112, 114
 index 715

Grohol, John M., 491– 494 Headaches

Grooming/attire, in MSE, 8 empirically supported therapies, 186, 190
Grossman, Seth D. self-help group, 513
Millon Adolescent Clinical Inventory (MACI), Head circumference, 52
159 –165 Head injuries, child abuse, 421
Millon Clinical Multiaxial Inventory HEADSSS Psychosocial Interview, 52
(MCMI–III), 153 –159 Healthfinder, Internet site, 492
Group conversation method, 261 Health insurance, right to know, 182–183
Group dynamics, psychoeducational groups, Health Insurance Portability and Accountability
395 –396 Act of 1996 (HIPAA)
Group psychotherapy. See also Psychoeducational computerized billing, 670
groups (PEGs); Psychotherapy legal notifications, 650
applications, 388 Privacy Rule, 640 – 645
cohesion, 203 –204 Health problems, empirically supported therapies,
common errors, 390 –391 186 –187
issue-focused groups, 392 Health status, suicide risk, 65
mandatory, 538 Hearing testing, children, 53
obstacles to forming and starting groups, Heart, self-help, 508
391–392 Height, assessment tools, 445 – 446
refusal skills training (RST), 311 Heitler, Susan, 378 –384
selection criteria, 364 Hematology lab values, 441– 442
self-help groups, 502– 506 Herbal treatments, 517 – 521
substance abuse, 263 Herbold, Nancie H.
tasks of therapist, 389 –390 dietary supplements and psychological function-
theory, 388 –389 ing, 476 – 480
Growth, therapist self-care checklist, 681 height and weight assessment, 445 – 447
Guardian, definition, 574 Heritage, child, 30
Guardian ad litem, definition, 574 Heroin
Guardianship, 605 administration, effects, and interactions, 486
Guidelines for Psychological Practice with Girls prevalence rates, 481
and Women, 296 HHS (Department of Health and Human Services),
Gustafson, Kathryn E., 406 – 409 Privacy Rule, 644 – 645
Guy, James D., Jr., 677 –682 High-conflict couples, 378 –383
Hill, Clara E., 202–208
Habits, 461 Hill, Sam S., III
Haldeman, Douglas C., 299 –304 APSAC Study Guides, 416 – 422
Hallucinations, in MSE, 11 children’s psychological development, 124 –128
Hallucinogen-related disorders future editions, 701
DSM-IV-TR classification, 83 – 84 money matters and ethical issues, 577 – 579
Hallucinogens Hill-Briggs, Felicia, 342–346
administration, effects, and interactions, 485 HIPAA (Health Insurance Portability and Account-
prevalence rates, 481 ability Act of 1996), Privacy Rule, 640 – 645
Hall v. Clifton Precision, 602 Hippocratic Oath, confidentiality, 585 – 586
Harassment, 532 The Hiskey-Nebraska Test of Learning Aptitude,
Harcourt Educational Measurement, 109 127
Hard of hearing people, self-help group, 515 History
Harris, Eric A. medical history of children with behavioral or
managed care organizations, 653 – 657 developmental disorders, 50 – 52
psychotherapist-patient contract, 635 –640 neuropsychological assessment, 30, 34
Harvard University Press, 109 pharmacology and psychiatric history, 460 – 461
Hashish Histrionic personality disorder, prevalence of, 4
administration, effects, and interactions, 483 HIV. See Human immunodeficiency virus (HIV)
prevalence rates, 481 Hogan, Thomas P.
HCR–20, 605 –606 psychological tests, widely used, 101–104
716 index

Hogan, Thomas P. (continued) Illness

publishers of psychological tests, 108 –111 adult disease management, 274 –278
sources of information about psychological tests, empirically supported therapies, 186 –187
105 –107 sexual dysfunction, 282
test scores and percentile equivalents, 111–116 ILS (Independent Living Scales), 605
Home Observation for Measurement of the Envi- Images, Multimodal Life History Inventory, 20, 22
ronment Inventory (HOME), 120 Imaging procedures, children with behavioral or
Home visit observation, children, 120 developmental disorders, 53 – 54
Homework compliance, 319 –324 Immunity, definition, 574
Homosexuality. See Bisexuals; Gay men; Lesbians Impaired psychologist, 620 – 624
Hopelessness, suicide risk, 64 Implied consent, definition, 573
Hospitalization Impossible profession, 678 – 679
crisis, 247 Impulse-control disorders
involuntary psychiatric, 548 – 551 DSM-IV-TR classification, 89
suicide risk upon release, 65 pharmacotherapy, 459
Houston, Ryan, 192–202 treatment manuals, 196
Human immunodeficiency virus (HIV) Impulsiveness, MACI, 164
assessing and reducing risk of infection, 291–295 Incest, self-help group, 516
assessment of risk, 292–294 Incomes, psychotherapists, 663, 665
HIV transmission, 292 Incompetency, definition, 574
risk reduction counseling, 294 –295 Inconsistent presentations, malingering, 70
Humanity, Values in Action (VIA) classification, 96 The Incredible Years, 330
Human relations, ethical standards, 532– 534 Indemnification, managed care organizations, 655
Humphreys, Keith, 502– 506 Indemnity, definition, 574
Hyperbilirubinemia, 51 Independent contractor, definition, 574
Hypertension, Anxiety Management Training Independent Living Scales (ILS), 605
(AMT), 272 Indications, neuropsychological assessment, 29
Hypnosis, 332–337 Individual, definition, 641
Hypnotic-related disorders, DSM-IV-TR classifica- Individual therapy
tion, 84 –85 mandatory, 538
Hypochondriasis play genograms for child, 371
DSM-IV, 43 selection criteria, 364
empirically supported therapies, 188 Infant development, measures, 124 –125
interpretation of high scores, 142–143 Infertility, self-help group, 515
Scale 1 of MMPI-2, 133 Infidelity, 384. See also Marital infidelity
Hypomania Influence, refusal skills training (RST), 308
interpretation of high scores, 147 –148 Informed consent. See also Consent
Scale 9 of MMPI-2, 136 assessments, 541– 542
Hypothetical question, definition, 574 clients’ rights, 182
Hysteria competence, 645
interpretation of high scores, 143 –144 definition, 574
Scale 3 of MMPI-2, 133 –134 research, 538 –539
therapy, 533, 543
ICD-10 (International Classification of Diseases, Infrequency F Scale, MMPI-2, 129 –130, 131
10th edition), 7, 47 Inhalant-related disorders, DSM-IV-TR classifica-
ICPE (International Consortium in Psychiatric tion, 84
Epidemiology), 3 –6 Inhalants, prevalence rates, 481
Identification, alcohol abuse, 71– 75 Inhibition, MACI, 162
Identity diffusion, MACI, 163 Injection drug users (IDUs), 294
Idiopathic pain, empirically supported therapies, Injunction, definition, 574
186 Inorgasmia, global lifelong, 287 –288
IDU (injection drug users), 294 Insight
IFI (Interdisciplinary Fitness Interview), 608, 610 in MSE, 12
Illicit drugs, prevalence rates, 481 sex therapy, 290
 index 717

Insight-action crossover, 228 older adults, 306

Insomnia, 455, 458 refusal skills training (RST), 308 –309, 310
stimulus control instructions, 325 –326 sexual dysfunction, 283 –284
Institute for Personality and Ability Testing twelve-step, 623
(IPAT), 109 voluntary, 622– 623
Insurance Interviewing
adolescent, 410 anamnestic interviews, 16
health insurance coverage, 182–183 collaborative style, 13
professional liability, 625 –631 Comprehensive Assessment-to-Intervention
reimbursement, psychotherapist-patient con- System (CAIS), 55, 57 –59
tract, 637 –638 delaying decision reaching during, 15
third-party relationships, 658 – 659 diagnostic and clinical, 13 –15
Integrity, 529 HEADSSS Psychosocial Interview Technique, 52
Intelligence, neuropsychological assessment, 35 listening, 13 –14
Intelligence tests motivational, 72, 74, 267 –271
preschool, 125 parents, 55 –60
school-age, 126 purpose, 13
Intercoder agreement, Rorschach assessment, sexually abused children, 417, 418, 423 – 430
173 –174 Structured Interview of Reported Symptoms
Interdisciplinary Fitness Interview (IFI), 608, 610 (SIRS), 68 – 69
Intermittent explosive disorder, 459 structured interviews, 14
Internalization termination, 15
coping style, 222 testing with, 14
treatment matching, 224 –225 Values in Action Structured Interview (VIA-SI),
International Classification of Diseases, 10th edi- 97
tion (ICD-10), 7, 47 Intestate, definition, 574
International Consortium in Psychiatric Epidemiol- Intoxication, 458. See also Alcohol abuse/
ogy (ICPE), 3 –6 dependence; Drug abuse/dependence
International Psychoanalytical Association, 699 Intrauterine growth retardation (IUGR), 50, 51
International Society for Mental Health Online, Introversion, MACI, 162
Internet site, 492 Invasion of privacy, definition, 574
Internet sites, psychologists and clients, 491– 494 Involuntary clients. See Reluctant and involuntary
Interpersonal relationships, Multimodal Life His- clients
tory Inventory, 21–22, 23 Involuntary movements, in MSE, 8
Interpretations, psychotherapy, 205 Involuntary outpatient commitment, 550
Interrogatories, definition, 574 Involuntary psychiatric hospitalization, 548 – 551
Interruption, therapy, 544 IPAT (Institute for Personality and Ability Test-
Intervention ing), 109
adult disease management, 275 –276 IQ scores, 112–114
Anxiety Management Training (AMT), 272 Irritable bowel syndrome, empirically supported
child-focused, 433 therapies, 187
childhood chronic illness, 406 – 409 Isquith, Peter K., 38 – 41
comprehensive, 623 Item response theory (IRT), 116
confrontive, 623 IUGR (Intrauterine growth retardation), 50, 51
consultation, 666 –667
couple and family therapy, 374, 375 Jackson v. Indiana, 607
creation, treatment plan writing, 235 Jasper, Bruce W., 236 –239
crisis, 245 –249 Johnson, Ronn, 45 – 50
disasters, 250 Joint and several liability, definition, 574
executive dysfunction, 40 Joint Commission on Accreditation of Healthcare
family, parent-child, and parent-focused, 433 Organizations (JCAHO), 232, 233
female sex dysfunction, 290 –291 standards for restraint and seclusion, 555 – 556
guidelines, 621–623 Jongsma, Arthur E., Jr., 232–236
motivational interviewing, 269 Journal for Personality Assessment, 168
718 index

Judgment, in MSE, 12 Lamotrigine, 463

Justice, 96, 529 Language
in MSE, 9 –10
Kammerer, Betsy, 28 –32 neuropsychological assessment, 36
Karg, Rhonda S., 13 –16 Language trouble, DSM-IV, 43
Karpiak, Christie P., 3 –7 Lapse, 351
Kaslow, Florence W., 686 –691 Lavender, 520
Kaufman Assessment Battery for Children–II, 125 Lazarus, Arnold A., 16 –23
Kava for anxiety, 519 –520 Lazarus, Clifford N., 16 –23
Keith-Spiegel, Patricia Learning, neuropsychological assessment,
confronting an unethical colleague, 579 – 583 35 –36
dealing with licensing boards and ethics com- Learning Disabilities Association of America, 511
plaints, 566 – 569 Learning disorders
Ketamine, administration, effects, and interactions, DSM-IV-TR classification, 81
484 executive dysfunction, 39
Klaw, Elena, 502–506 prevalence of, 5
Klinefelter Syndrome and Associates (KSA), 511 Learning trouble, DSM-IV, 43
Klopfer System, 166 Lebow, Jay L., 373 –378
Knight, Bob G., 305 –307 Legal issues. See also Forensic matters
Knowledge, Values in Action (VIA) classification, 96 bill collection, 658
Koch, Manferd D., 346 –349 clinical supervision, 684
Koman, Stuart L., 653 –657 dealing with licensing boards and ethics com-
Koocher, Gerald P. plaints, 566 – 569
billing issues, 657 –661 defending against legal complaints, 560 –565
consent, 645 –646 forensic referrals checklist, 595 –598
dealing with licensing boards and ethics com- glossary of terms, 572–576
plaints, 566 – 569 liability risk situations, 558 – 559
future editions, 701 managed care organizations, 654
glossary of legal terms, 572–576 subpoenas, 570 – 572
legal liability risk situations, 558 – 559 Legal liability risk situations, 558 – 559
mental health records, 649 –652 Legal risks, intervention with impaired psycholo-
money matters and ethical issues, 577 – 579 gist, 624
normal medical laboratory values and measure- Leiter International Performance Scale-Revised
ment conversions, 439 – 444 (Leiter-R), 127
privacy, confidentiality, and privilege, 545 – 547 Lesbians, 299 –303, 510 – 511
quality of psychological testing report, 117 –118 Lessard v. Schmidt, 548
release forms, 647 –649 Levant, Ronald F., 278 –281
subpoenas, 570 –572 Liability and risk situations, 558 –559
utilization review checklist, 652–653 Liability insurance, 625 – 631
Kortte, Kathleen B., 342–346 Libel, definition, 574
KSA (Klinefelter Syndrome and Associates), 511 Licensing boards, 563, 566 – 569
K Scale, MMPI-2, 129, 131 Life skills enhancement, 260
Kuehnle, Kathryn, 430 – 435 Lifestyle balance, 353
Lilienfeld, Scott O., 169 –172
Labeling, interviewing alcohol abusers, 74 Lipsitt, Paul D., 607 – 611
Laboratory studies, pharmacotherapy, 461 Listening
Laboratory tests, children with behavioral or devel- diagnostic and clinical interviewing, 13 –14
opmental disorders, 53 – 54 high-conflict couples, 383
Ladany, Nicholas, 682–685 Lithium, 457, 462– 463
Lafayette Instrument Company, 109 Litigaphobia, 560, 563
La Leche League, 511 Litigastress, 560, 563
Lambert, Michael J. Litigious clients, 260
psychotherapy outcome, 236 –239 Long-term memory, in MSE, 12
psychotherapy treatment manuals, 192–202 LoPiccolo, Joseph
 index 719

female sexual dysfunction, 286 –291 Marijuana Anonymous (MA), 511

male sexual dysfunction, 282–286 prevalence rates, 481
L Scale, MMPI-2, 129, 131 Marital discord, empirically supported therapies,
Lukefahr, James L., 50 –54 187
Lupus Foundation of America, 511 Marital infidelity, treatment, 384 –387
Lupus, self-help groups, 508, 511 Marital relationship, sexual problem, 283
Lusterman, Don-David, 384 –388 Marital therapy, professional associations, 698
Lysergic acid diethylamide, 485 Marketing, consultation, 669
Marlatt, G. Alan, 350 –353
McCarthy Scales of Children’s Abilities–Second Masculinity/femininity
Edition, 125 interpretation of high scores, 145
McGoldrick, Monica, 366 –373 Scale 5 of MMPI-2, 134 –135
MACI. See Millon Adolescent Clinical Inventory Maternal causes, intrauterine growth retardation,
McKee, Geoffrey R. 51
expert testimony in depositions, 599 –602 Mathematics anxiety, Anxiety Management
forensic referrals checklist, 595 –598 Training (AMT), 272
Magnetic resonance imaging (MRI), children, 54 MCMI–III. See Millon Clinical Multiaxial
Magnitude of error, malingering, 70 Inventory
MAI (Millon Adolescent Inventory), 160 MCOs (managed care organizations), 653 –657
Maintenance, refusal skills training (RST), 310 Measurement conversions, 439
Maintenance stage, 227 Mechanisms, change, 228 –229
Major depressive disorder Media
DSM-IV, 43, 44 guide to interaction with media, 686 –691
pediatric pharmacotherapy, 467, 470 – 471 on-air psychology, 686 – 689
pharmacotherapy, 454 – 457 print, 689 –690
prevalence of, 5 Medical conditions, presenting as psychological
Malaise, medical conditions that may present as, disorders, 447 – 453
450 Medical evaluation
Male orgasmic disorder, 285 –286 children with behavioral or developmental dis-
Males. See also Gender issues orders, 50 – 54
normative male alexithymia, 278 –281 physically and sexually abused children,
sexual dysfunction, 282–286 419 – 422
self-help group, 512, 513 Medical history, 461
Malice, definition, 574 children with behavioral or developmental dis-
Malicious prosecution, definition, 574 –575 orders, 50 – 54
Malingering, assessment, 67 –70 genogram format, 372
Malpractice, 559, 630. See also Legal issues Medical InfoManager, 671
Malpractice, definition, 575 Medical issues, suicidal patient, 243 –244
Malpractice action, suicidal patients, 240, 243 Medical laboratory values, 440 – 444
MA (Marijuana Anonymous), 511 Medication. See also Complementary and alterna-
Managed care organizations, 653 – 657 tive medicines (CAMs)
Management, suicidal patient, 241–243 DSM-IV-TR classification of induced movement
Management plan, neuropsychological assessment, disorders, 89
32 mental health records, 650
Manic-depressive disorder nutritional effects, 478 – 480
DSM-IV, 43, 44 Medicine. See Complementary and alternative
prevalence of episode, 5 medicines (CAMs)
self-help group, 513 Meetings, psychotherapist-patient contract, 636 –637
Mantell, Elaine Orabona, 460 – 465 Memory
Manuals, psychotherapy treatment, 192–199 children, 424 – 425
MAPI (Millon Adolescent Personality Inventory), ginkgo biloba, 518 – 519
160 neuropsychological assessment, 35 –36
Marijuana Memory loss, medical conditions that may present
administration, effects, and interactions, 483 as, 452– 453
720 index

Menstrual history, Multimodal Life History Inven- Millon Adolescent Inventory (MAI), 160
tory, 22 Millon Adolescent Personality Inventory (MAPI),
Mental disorders 160
assessment of feigned, 68 – 69 Millon Clinical Multiaxial Inventory (MCMI–III)
childhood and adolescence in DSM-IV-TR, 47 administration and scoring, 156
data sources, 6 –7 description, 153 –155
popular films portraying, 497 –501 interpretation, 156 –158
prevalence of, 3 – 6 uses, settings, and limitations, 155 –156
Mental health Mind Garden, 109
glossary of legal terms, 572–576 Minnesota Multiphasic Personality Inventory-2.
intervention, 245 –246 See MMPI; MMPI-2
professional associations, 697 – 700 Minorities. See Ethnic minorities
self-help group, 512, 513 Minority-Majority Relations Survey, 78 –79
Mental health-crime false syllogism, 258 Minors, psychotherapist-patient contract, 639
Mental Health InfoSource, Internet site, 492 Mirtazapine, 456, 462
Mental health nursing, professional associations, Mission, 681
698 MMPI (Minnesota Multiphasic Personality
Mental health records, 649 –652 Inventory)
Mental Measurements Yearbooks (MMY), comparison with MMPI-2, 149 –150
105 –106 F-K Index, 130 –131
Mental retardation subtle-obvious items, 131
children, 122 MMPI-2 (Minnesota Multiphasic Personality
DSM-IV-TR classification, 80 Inventory-2)
prevalence of, 5 alcohol and drug scales, 138 –139
self-help group, 507, 509 assessing profile validity, 128 –132
Mental status examination (MSE), 7 –12 cannot say score, 128 –129
Merck Manual of Diagnosis and Therapy, 274 clinical scales, 132–136
Merrill-Palmer Scale of Mental Tests, 127 codetypes, 149 –152
Mescaline, 485 control/inhibition and dyscontrol/dysinhibition
Methamphetamine, 486 scales, 138
Methylenedioxyamphetamine, 484 F(B) or Back F Scale, 130
Methylenedioxyethlylamphetamine, 484 F-K Index, 130 –131
Methylenedioxymethamphetamine, 484 F Scale, 129 –130
MET (Motivational Enhancement Therapy), 269 –270 generalized emotional distress scales, 137
MHS (Multi-Health Systems), 109 high and low scores on clinical scales, 141–148
Midwestern Psychological Association, 699 K Scale, 129
Migraine, empirically supported therapies, 187 personality psychopathology five (PSY–5) scales,
Mild traumatic brain injury, 342 140
Miller, William R., 267 –271 Psychopathology Infrequency Scale F(P), 130
Millon, Theodore Scale 0 (social introversion), 136, 148
Millon Adolescent Clinical Inventory (MACI), Scale 1 (hypochondriasis), 133, 142–143
159 –165 Scale 2 (depression), 133, 143
Millon Clinical Multiaxial Inventory Scale 3 (hysteria), 133 –134, 143 –144
(MCMI-III), 153 –159 Scale 4 (psychopathic deviate), 134, 144 –145
Millon Adolescent Clinical Inventory (MACI) Scale 5 (masculinity-femininity), 134 –135,
administration and scoring, 161–162 145
clinical syndromes, 164 Scale 6 (paranoia), 135, 145 –146
comparison of MACI and MAPI scales, 160 Scale 7 (psychasthenia), 135, 146
expressed concerns, 163 Scale 8 (schizophrenia), 135 –136, 146 –147
historical development, 160 –161 Scale 9 (hypomania), 136, 147 –148
interpretation and computer–generated reports, subtle-obvious items, 131
164 –165 Superlative Self-Description (S) Scale, 129
personality patterns, 162–163 supplementary scales, 137 –141
scale descriptions, 162–164 TRIN (True Response Inconsistency), 130
 index 721

validity assessment guidelines, 131 NARSAD (National Alliance for Research on

VRIN (Variable Response Inconsistency), 130 Schizophrenia and Depression), 512
MMY (Mental Measurements Yearbooks), NASW (National Association of Social Workers),
105 –106 698
Mobility, in MSE, 9 NASW Register of Clinical Social Workers, 698
Modality analysis of problems, Multimodal Life National Adoption Center, 512
History Inventory, 19 –22 National AIDS Hotline, 512
Model, decision making with dangerous clients, 613 National Alliance for Research on Schizophrenia
Money matters. See Fees and Depression (NARSAD), 512
Monitoring, executive dysfunction, 40 National Alliance for the Mentally Ill, 512
Monoamine oxidase inhibitors (MAOIs), 454, 455, National Alopecia Areata Foundation, 512
461– 462 National Association for the Deaf, 512
Mood, in MSE, 9 National Association of Anorexia Nervosa and As-
Mood disorders sociated Disorders, 512
DSM-IV, 42– 43 National Association of Social Workers (NASW),
DSM-IV-TR classification, 86 –87 698
movie recommendations, 498 – 499 National Career Assessment Services, 109
pediatric pharmacotherapy, 467 – 468, 470 – 471 National Center for Men, 512
prevalence of, 5 National Child Traumatic Stress Network, 249
Mood stabilizers, 462– 463, 471 National Chronic Pain Outreach Association, 513
Mothers Against Drunk Driving, 511 National Clearinghouse for Alcohol and Drug In-
Mothers, self-help groups, 511 formation, 513
Motivational Enhancement Therapy (MET), National Depressive and Manic Depressive Associa-
269 –270 tion, 513
Motivational interventions, substance abuse, 264 National Domestic Violence Hotline, 513
Motivational interviewing, 72, 74, 267 –271 National Down Syndrome Congress, 513
Motivation for change. See Change National Eating Disorders Association, 513
Motor functions, neuropsychological assessment, National Headache Foundation, 513
35 National Information Center for Children and
Motor skills disorder, DSM-IV-TR classification, 81 Youth with Disabilities, 513
Movie recommendations, 498 – 501 National Institute of Mental Health, Internet site,
Moyers, Theresa B., 267 –271 492
Mueller, Felicia A., 295 –298 National Mental Health Association, Internet site,
Multiaxial system, DSM-IV-TR classification, 90 492
Multi-Health Systems (MHS), 109 National Mental Health Association (NMHA), 513
Multimodal Life History Inventory, 16 –23 National Multiple Sclerosis Society, 513
Multiple relationships, 532 National Organization for Men, 513
Multiple sclerosis, self-help groups, 511, 513 National Organization for Women (NOW),
Multiple settings, mapping genograms, 370 –371 513 – 514
Multiple treatments, adolescents, 413 National Organization on Fetal Alcohol Syndrome,
Murphy, James G., 481– 487 513
Muscular Dystrophy Association, 511– 512 National Parkinson Association, 514
Musical chairs, family therapy, 659 National Register of Health Service Providers in
Psychology, 698
Naming, in MSE, 10 National Stroke Association, 514
Nar-Anon World Wide Service, 512 NBAS (Brazelton Neonatal Behavioral Scale), 124
Narcissistic personality disorder NCAST (Nursing Childhood Assessment Tool),
domain descriptors, 157 122
prevalence of, 5 NCS (National Comorbidity Study), 3 – 6
Narcolepsy, 455, 458 NCS Pearson, 109 –110
prevalence of, 5 Neck examination, 52
self-help, 512 Nefazodone, 454, 455, 462
Narcolepsy Network, 512 Negligence, definition, 575
Narcotics Anonymous, 512 Negotiating, managed care organizations, 656 – 657
722 index

Nelson, Aaron P., 33 –37 self-help books and autobiographies, 494 – 497
Neonatal jaundice, 51 stages of change, 226 –231
Neurological examination, 53 therapist self–care checklist, 677 – 682
Neuropsychological (NP) assessment Normal curve equivalents (NCEs), 113 –114, 115
adults, 33 –37 Nose examination, 52
assumptions of developmental analysis, 28 –29 NOW (National Organization for Women),
behavioral domains, 30 513 – 514
clinical method, 34 –37 Nursing Childhood Assessment Tool (NCAST),
communication of findings, 31–32 122
developmental, 28 –32 Nutritional effects, medications, 478 – 480
diagnostic formulation, 36 –37
diagnostic strategy, 29 –30 OA (Overeaters Anonymous), 514
domains of neuropsychological function, 35 –36 Obesity, 445 – 447
education, 32 empirically supported therapies, 187, 189
fundamental assumptions of, of children, 28 Objective construction, treatment plan writing,
fundamental assumptions of clinical, 33 234 –235
indications, 29 Objective self-awareness, 260
management plan, 32 Observations, child behavior, 119 –123
recommendations, 32 Obsessions, in MSE, 10 –11
recommendations and feedback, 37 Obsessive-Compulsive Anonymous, 514
sources of data, 30 –31 Obsessive-compulsive disorder
use of psychological tests, 31 DSM-IV, 43
uses, 33 –34 empirically supported therapies, 185, 189
Neuropsychologists, widely used tests, 101–102 movie recommendations, 499 – 500
New England Psychological Association, 699 pediatric pharmacotherapy, 468, 472
Nicotine, 486 prevalence of, 5
Nicotine Anonymous World Service, 514 psychopharmacology, 455, 458
Nicotine-related disorders, DSM-IV-TR classifica- self-help groups, 514
tion, 84 Obsessive-Compulsive Foundation, 514
Nightmares, DSM-IV, 43 OCD. See Obsessive-compulsive disorder
Night terrors, DSM-IV, 43 O’Connor, Margaret, 33 –37
NIMH Epidemiological Catchment Area (ECA) O’Connor v. Donaldson, 548
study, 3 –6 Office for Civil Rights of HHS, Privacy Rule,
NIMH Treatment of Depression Collaborative Re- 644 – 655
search Program (TDCRP), 216 Office management programs, 671– 673
Nitrites, 485 Office Therapy, 672
NMHA (National Mental Health Association), 513 “Off the record,” media, 688
Nominal damages, definition, 573 O’Grady, Kari A., 338 –341
Nonadherence, 210 –211 Olanzapine, 464
Nonaffective psychosis, prevalence of, 5 Older adults
Nondiscrimination, patients’ rights, 183 AARP, 507 – 508
Nondisparagement, managed care organizations, assessment, 306
655 cognitively impaired, 343 –344
Nonmaleficence, 528 –529 differential diagnosis, 305
Noradrenergic agents, 469 family, 306
Norcross, John C. psychotherapy, 305 –307
abbreviations and symbols, 691– 697 referrals, 307
empirically supported therapy relationships, relationship issues, 306 –307
202–208 self-help groups, 507 – 508, 514
future editions, 701 suicide, 306
national self-help groups and organizations, Olmstead v. L.C., 549
506 –516 Online therapy, 690
prevalence of mental disorders, 3 –7 Opiate dependence, empirically supported thera-
psychologists’ fees and incomes, 662–666 pies, 185
 index 723

Opinion evidence, definition, 575 parents at risk, 329

Opioid-related disorders, DSM-IV-TR classifica- problem-solving skills training and, 329 –330
tion, 84 The Incredible Years, 330
Oppositional defiant disorder Parent psychopathology, 403
DSM-IV, 42 Parents
empirically supported therapies, 189 characteristics, 58
family therapy, 377 Comprehensive Assessment-to-Intervention
parent management training, 328 System, 55, 57 –59
pharmacotherapy, 467 interviewing, 55 –60
prevalence of, 5 rating scales and questionnaires,, 55 –56
treatment, 401– 405 reluctant adolescents, 410 – 411, 412– 413
Oppositional pattern, MACI, 163 social context of family, 57
Organic brain syndromes, dietary supplements, Parents Anonymous, 514
478 Parents Without Partners, 514
Ortiz-Brown family genogram, 367 Parham v. JR, 551
Outcome of psychotherapy, 236 –239 Park, Nansook, 93 – 98
Outpatient commitment, involuntary, 550 Parkinson’s disease, self-help, 508, 514
Outpatient services contract, 636 – 640 PAR (Psychological Assessment Resources), 110
Outpatient therapy, crisis, 247 Partner relational problems, treatment manuals,
Outpatient treatments, manuals, 196 –197 197
Overeaters Anonymous (OA), 514 Passion flower, 520
Overtesting, neuropsychological assessment, 29 Pathological gambling, prevalence of, 5
Overvalued ideas, in MSE, 10 Payments, 637. See also Billing; Fees
PBS: The Psychologist’s Billing System, 672
Pain and suffering, definition, 575 PC Consulting Group, 672
Pain management, childhood chronic illness, 408 PCI (Parenting Custody Index), 604
Pain reduction, adult disease management, 275 PCL-R (Psychopathy Checklist-Revised), 606
Pain relievers, prevalence rates, 481 PCRI (Parent-Child Relationship Inventory), 604–605
Panic attacks PDI (parent-directed interaction), 330 –331
DSM-IV, 43 Peabody Picture Vocabulary Test-Revised, 126
medical conditions that may present as, 448 – 449 Pediatrics. See Children
Panic disorder Peer insecurity, MACI, 163
empirically supported therapies, 184, 185 Peer monitoring, 580
pediatric pharmacotherapy, 468 Penile prostheses, 284
prevalence of, 5 People’s rights, 529
psychopharmacology, 455, 457 Percentile equivalents of test scores, 111–116
Paranoia Percentile ranks, 115
interpretation of high scores, 145 –146 Percentiles, 115
Scale 6 of MMPI-2, 135 Perception, neuropsychological assessment, 35
Paranoid personality disorder, prevalence of, 5 Perceptual abnormalities, in MSE, 11
Parens patriae, involuntary hospitalization, 548 Performance anxiety, 282, 283
Parental capacity assessment, 603 –605 Performance curve, malingering, 69
Parent-child interactions, 122, 330 –331 Perinatal factors, 51
Parent-child interaction therapy, 330 –331 Perjury, definition, 575
Parent-Child Relationship Inventory (PCRI), Permission, definition, 646
604 –605 Personal and social history, Multimodal Life His-
Parent-directed interaction (PDI), 330 –331 tory Inventory, 18
Parenting Custody Index (PCI), 604 Personality disorders
Parenting Stress Index (PSI), 604 DSM-IV-TR classification, 89
Parent management training movie recommendations, 499 – 500
childhood behavior disorders, 327 –331 treatment manuals, 197
The Incredible Years, 330 Personality patterns, MACI, 160, 162–163
long-term effectiveness, 328 –329 Personality psychopathology five (PSY-5) Scales,
parent-child interaction therapy, 330 –331 MMPI-2, 140
724 index

Pervasive developmental disorders, DSM-IV-TR Plaintiff, definition, 575

classification, 81 Planned Parenthood, 514
Peterson, Christopher, 93 – 98 Planning of treatment. See Treatment planning
Petry, Sueli S., 366 –373 Play assessments, children, 122–123
Pharmacotherapy Play therapy
adult psychopharmacology, 454 – 465 disruptive children, 401
anorexia nervosa, 459 genograms, 366, 371
anxiety disorders, 455, 457 – 458, 468, 471– 472 Pleadings, definition, 575
avoidant personality disorder, 456, 458 PM/2, 672
bipolar disorder, 455, 457, 467 – 468, 471 PMA-2000, 671
borderline personality disorder (BPD), 455, 458 PMT. See Parent management training
bulimia nervosa, 456, 459 Police power, involuntary hospitalization, 548
common drugs of abuse, 481– 487 Pope, Kenneth S.
depression, 454 – 457, 470 – 471 assessment of suicidal risk, 63 – 66
dietary supplements and psychological function- sexual feelings, actions, and dilemmas in psy-
ing, 476 – 480 chotherapy, 313 –319
eating disorders, 459 Portland Digit Recognition Test (PDRT), malinger-
impulse-control disorders, 459 ing, 69
intermittent explosive disorder, 459 Position/posture, in MSE, 8
major depression, 454 – 457 Postmodern sex therapy, 282–283, 287
obsessive-compulsive disorder (OCD), 455, 458, Postpartum Support International, 514
468, 472 Post-traumatic stress disorder
panic disorder, 455, 457, 468, 472 DSM-IV, 42
pediatric, 466 – 474 empirically supported therapies, 185
personality disorders, 455 – 456, 458 prevalence of, 5
psychiatric history, 460 – 461 Practice Magic, 672
psychosis, 473 – 474 Practice management
schizophrenia, 455, 457 billing issues, 657 – 661
schizotypal personality disorder, 455, 458 computerized billing and office management pro-
side effects and warnings, 460 – 465 grams, 670 – 673
sleep disorders, 455, 458 consent, 645 – 646
social phobia, 458 consultation agreement, 666 – 669
somatoform disorders, 459 managed care organizations, 653 – 657
substance abuse and withdrawal, 456, 458 – 459 mental health records, 649 –652
tics, 472– 473 Privacy Rule, 640 – 645
Tourette’s disorder, 472– 473 psychologists’ fees and incomes, 662–666
trichotillomania, 459 psychotherapist-patient contract, 635 –640
Phencyclidine, 484 release forms, 647 – 649
Phencyclidine use disorders, DSM-IV-TR classifica- utilization review checklist, 652–653
tion, 84 Practice Management Software, 672
Philosophy, crisis intervention, 246 Pragmatic, 672
Phobias Prather, Penny A., 28 –32
empirically supported therapies, 189 Precontemplation stage, 226
in MSE, 11 Preemption analysis, Privacy Rule, 642
prevalence of, 5 Premature ejaculation, 285
Physical abuse, children, 419 – 421 Premature terminations, therapy, 358
Physical examination, children with behavioral or Prenatal factors, 50 – 51
developmental disorders, 52– 53 Preoccupation, in MSE, 11
Physical restraint and seclusion, 553 –557 Preparation stage, 227
Physical sensations, Multimodal Life History In- Preschool intelligence tests, 125
ventory, 20, 22 Prescription analgesics
Pictorial Test of Intelligence-Second Edition, 127 abuse, 482
Placental causes, intrauterine growth retardation, administration, effects, and interactions, 486
51 Prescriptive guidelines, stages of change, 227 –231
 index 725

Prevalence, adherence, 209 Psychiatric history, 460 – 461

Preventative preparation, suicidal patient, 244 Psychiatric hospitalization, involuntary, 548 – 551
Pride skills, 330 –331 Psychiatry, professional associations, 698
Prima facie case, definition, 575 Psychoeducational groups (PEGs)
Prima facie evidence, definition, 575 application and effectiveness, 393 –394
Print media, 689 –690 distinctive characteristics, 394 –395
Privacy, 584 ethical issues, 396
ethical standards, 534 – 535 group climate, 396
ethics, 545 –546 group dynamics, 395 –396
Privacy Rule, 640 –645 leader competencies and training, 396
Private-practice psychologists’ income, 665 problem members, 396
Privilege, 546, 584 shared characteristics with other group treat-
Probate court, definition, 575 ments, 395 –396
Problem definition, treatment plan writing, 234 steps in forming and running PEG, 397
Problem selection, treatment plan writing, 234 treatment, 393 –398
Problem solving, crisis intervention, 246 Psychoeducational tests, publishers, 108 –111
Problem-solving skills training, 329 –330 Psychological Assessment, journal, 168
Processes of change, 228 –229 Psychological Assessment Resources (PAR), 110
Prochaska, James O., 226 –231 The Psychological Corporation, 110
Product of documents, subpoena, 571– 572 Psychological disorders, medical conditions that
PRO-ED, 110 may present as, 447 – 453
Professional associations, 697 – 700 Psychological factors, neuropsychological assess-
Professional fees, psychotherapist-patient contract, ment, 36
637 Psychological factors affecting medical condition,
Professional liability insurance, 625 –631 DSM-IV-TR classification, 89
Professional records, psychotherapist-patient con- Psychological first aid, disasters, 250 –251
tract, 638 –639 Psychological resources, recovery after disasters,
Professional resources 252
clinical abbreviations and symbols, 691– 697 Psychological self-help, Internet site, 493
clinical supervision, 682– 685 Psychological sequelae, malingering, 70
interacting with media, 686 –691 Psychological services, psychotherapist-patient
major professional associations, 697 – 700 contract, 636
therapist self–care checklist, 677 – 682 Psychological tests. See also Testing
Proficiency levels, 116 50 widely used, 101–104
Programs, computerized billing, 671– 673 assessing quality of report, 117 –118
Project MATCH, substance abuse, 265 publishers, 108 –111
Project Release v. Prevost, 549 sources of information about, 105 –107
Prolapse, 351 Psychologists. See also Psychotherapists
Prosody, in MSE, 10 rated autobiographies, 496
Proximate causation, definition, 575 rated self-help books, 495
Proximate cause, definition, 575 top Internet sites, 491– 494
Proxy consent, definition, 646 The Psychologist’s Billing System (PBS), 672
Psilocybin, 485 Psychology
PSI (Parenting Stress Index), 604 choice of treatment format, 363 –365
PSST (Problem-solving skills training), 329 –330 professional associations, 697 – 698
Psy Broadcasting Corporation, Internet site, Psychology Information Online, Internet site, 493
492– 493 Psychology of Cyberspace, Internet site, 493
Psychasthenia Psychopathic deviate
interpretation of high scores, 146 interpretation of high scores, 144 –145
MMPI-2 codetype, 151–152 Scale 4 of MMPI-2, 134
Scale 7 of MMPI-2, 135 Psychopathology, parent, 403
Psych Central, Internet site, 493 Psychopathology Infrequency Scale (F(P)), MMPI-2,
Psychiatric comorbidity, alcohol abusers, 73, 74 130, 131
Psychiatric Diagnostic Screening Questionnaire, 14 Psychopathy Checklist-Revised (PCL-R), 606
726 index

Psychopharmacology. See Pharmacotherapy general elements of therapy relationship, 203 –205

Psychophysiological disorder, empirically sup- genograms, 366 –372
ported therapies, 190 group therapy, 203 –204
Psychosis guidelines for terminating, 354 –359
medical conditions that may present as, 452 high-conflict couples, 378 –383
pediatric psychopharmacology, 473 – 474 homework compliance, 319 –324
Psychosomatic, pediatric and adolescent medical introducing and assigning films, 498
complaints, 448 methods to reduce and counter resistance,
Psychotherapist-patient contract, 635 –640 212–215
Psychotherapists older adults, 305 –307
APA “Ethical Principles of Psychologists and outcome, 236 –239
Code of Conduct (2002),” 525 – 545 Privacy Rule, 643 – 644
case settlement role, 630 religiously committed clients, 338 –341
chronically ill adults, 276 –277 reluctant and involuntary clients, 257 –262
confronting an unethical colleague, 579 – 583 repairing ruptures in therapeutic alliance,
dealing with licensing boards and ethics com- 216 –219
plaints, 566 – 569 sexual feelings, actions, and dilemmas, 313 –319
defending against legal complaints, 560 –565 stages of change, 226 –231
early termination and referral of clients, systematic assessment, 220 –222
346 –349 therapeutic alliance, 203
expert witness, 599 therapy on air and online, 690
fees and incomes, 662–666 treatment manuals, 192–199
general principles, 528 –529 treatment matching, 222–225
informed consent to therapy, 543 treatment plan writing, 232–236
inviting hypnosis and relaxation, 333 –337 treatment women, 295 –298
metatherapeutic issues, 344 –345 Psychotherapy Practice Manager, 672– 673
motivational interviewing, 267 –271 Psychotic disorders
outcome assessment, 236 –237 DSM-IV-TR classification, 85 –86
recognizing, assisting, and reporting impaired pediatric pharmacotherapy, 468, 473 – 474
psychologist, 620 –624 Psyquel, 673
salaries for doctoral-level, in academic settings, PTSD Support Services, 514
664 Publication
salaries for doctoral-level, in practice settings, definition, 575
664 ethical standards, 538 – 541
self-care checklist, 677 – 682 Publicity, psychologists, 686
sexual involvement with client, 181–182, Public speaking anxiety, empirically supported
313 –319, 620 –621, 627 – 628 therapies, 185
tasks of group psychotherapist, 389 –390 Public statements, ethical standards, 535 – 536
terminating therapy, 354 –359 Publishers, psychological and psychoeducational
therapeutic meta-communication, 217 –219 tests, 108 –111
Psychotherapy PubMed, Internet site, 493
abuse-focused therapy, 433 Punitive damages, definition, 573
brain functioning, 344
chronically ill adults, 274 –278 Quality of speech, in MSE, 10
clients’ rights, 181–183 Quetiapine, 465
cognitively impaired adults, 342–346 QuickDoc, 672
customizing relationship to individual patient,
205 –207 Race. See also Ethnic minorities
early termination and referral of clients, suicide risk, 65
346 –349 RAINN (Rape Abuse and Incest National Net-
empirically supported therapies, 183 –191 work), 515
empirically supported therapy relationships, Rapaport System, 166
202–207 Rape Abuse and Incest National Network
ethical standards, 543 – 545 (RAINN), 515
 index 727

Rational emotive behavior therapy (REBT), 212, Reluctant and involuntary clients
213 abrasive clients, 259
Rational Recovery (RR), 515 coping skills, 261
Rauwolfia, antipsychotic and tranquilizer, 520 errors in technique, 260
RCIs (Reliable Change Indices), 238 –239 group conversation method, 261
R-CRAS (Rogers Criminal Responsibility Assess- guidelines for working with, 257 –261
ment Scales), 603 life skills enhancement, 260
RDA (Recommended Dietary Allowance), 476 – 478 litigious clients, 260
Reactive attachment disorder, DSM-IV-TR classifi- low trust-high control dilemmas, 259
cation, 81 mental health-crime false syllogism, 258
Reactivity, in MSE, 9 methods to engage adolescent, 410 – 415
Readiness to Change Ruler, 73 objective self-awareness, 260
Reading, in MSE, 10 psychotherapists’ reactions to, 258
Reasonable medical/psychological certainty, defini- referral clarification, 258
tion, 575 resistance, 260
Recommendations, neuropsychological assessment, right to refuse treatment, 258
32, 37 therapy as aversive contingency for inappropri-
Recommended Dietary Allowance (RDA), 476 – 478 ate behavior, 259
Record keeping time and therapy, 261
ethical standards, 536 – 537 Remarriage, couples therapy, 376
mental health records, 651 Repetition, in MSE, 10
Recovery, disasters, 252–253 Repetitive motion, self-help, 509
Recurrent illnesses, children, 51 Repression scale, MMPI-2, 138
Recycling treatment, 228 Research, ethical standards, 538 – 541
substance abuse, 264 Residential treatment, substance abuse, 264
Reed, William J., 447 – 453 Resistance. See also Reluctant and involuntary
Referrals clients
early termination and referral of clients, assessing level, 221–222
346 –349 family’s, to genogram, 369
forensic referrals checklist, 595 –598 motivational interviewing, 268
reluctant and involuntary clients, 258 in MSE, 8
Reflex Sympathetic Dystrophy Syndrome Associa- psychotherapy, 205
tion, 515 reducing and countering, in psychotherapy,
Refusal skills training, 308 –311 212–215
Registration, in MSE, 11 reluctant and involuntary clients, 260
Reidy, Dennis E., 506 –516 transference, 348 –349
Reinforcement, 408 Resnick, Robert J., 60 – 63
Relapse, term, 351 Resolution, ethical issues, 529 – 530
Relapse prevention, 264, 350 –353 RESOLVE: The National Infertility Association,
Relational problems, DSM-IV-TR classification, 515
89 –90 Respect for people’s rights and dignity, 529
Relationship issues Respondeat superior, definition, 575
older adults, 306 –307 Responsibility
restructuring, 679 –680 psychologist’s, 529
Relaxation, 332–337 reporting impaired psychologist, 621
Release, definition, 575 Restraint, definition, 555
Release forms, 647 –649 Restraint and seclusion, 553 – 557
Reliability Retention, motivational interviewing, 270
children’s reports, 424 Retinal hemorrhages, child abuse, 421
quality of psychological testing report, 117 Rey-Casserly, Celiane, 28 –32
Rorschach assessment, 174 Rey-Osterrieth Complex Figures Test, 126
Reliable Change Indices (RCIs), 238 –239 Rheumatic disease pain, empirically supported
Religion, suicide risk, 65 therapies, 187
Religiously committed client, 338 –341 Rice, Sara, 192–202
728 index

Richards, P. Scott, 338 –341 SAFE (Self-Abuse Finally Ends) Alternative Infor-
Ridge, Nathanael W., 393 –398 mation Line, 515
Right to know, health insurance coverage, 182–183 Safety
Right to refuse treatment, 258 high-conflict couples, 380
Risk time-out routines, 381
diagnostic strategy, 30 Safran, Jeremy D., 216 –219
parents, 329 St. John’s wort for depression, 518
psychotherapy, 635 –636 Sanders, A. Danielle, 192–202
reduction, 26 Saner software, 673
relationship with insurance, 625 SARA (Spousal Assault Risk Assessment Guide), 606
Risk assessment, suicidal patient, 241–243 SAT scores, 112–114
Risk factors Saywitz, Karen J., 423 – 430
dangerous patients, 614 SBM (Society of Behavioral Medicine), 699
mental health records, 650 Schatzberg, Alan F., 454 – 459
nonadherence, 211 Schedule for Affective Disorders and Schizophrenia
Risk reduction, human immunodeficiency virus (SADS), 14
(HIV), 294 –295 Schizophrenia
Risperidone, 464 – 465, 480 debiasing strategies, 15
Ritzler, Barry A., 166 –168 dietary supplements, 477 – 478
Riverside Publishing, 110 DSM-IV-TR classification, 85 –86
Rocky Mountain Psychological Association, 699 empirically supported therapies, 188
Rogers, Richard, 67 –71 interpretation of high scores, 146 –147
Rogers Criminal Responsibility Assessment Scales movie recommendations, 501
(R-CRAS), 603 prevalence of, 5
Rorschach Comprehensive System, 166, 169 –172, psychopharmacology, 457
175 –176 Rorschach assessment, 175
Rorschachiana, yearbook, 168 Scale 8 of MMPI-2, 135 –136
Rorschach Method self-help group, 512
administration procedures, 166 –167 structured interview, 14
applications, 168 treatment manuals, 198
clinical utility, 176 –177 Schizotypal personality disorder
coding (scoring), 167 prevalence of, 5
frequently used systems, 166 psychopharmacology, 455, 458
information sources, 168 Schoener, Gary R., 620 – 624
intercoder agreement, 173 –174 Schoenfield, Laura J., 327 –332
interpretation, 167 School-age intelligence tests, 126
normative reference base, 175 –176 School psychologists, widely used tests, 101–102
questions and reservations for assessment, Schroeder, Carolyn S., 55 –60
169 –172 SCID-I and SCID-II (Structured Clinical Interview
reliability, 174 for the DSM-IV), 14
scientific status, 173 –176 SCID Screen Patient Questionnaire, 14
training, 167 –168 Scientific status, Rorschach assessment, 173 –176
validity, 174 –175 Seclusion, definition, 555
Roth, Robert M., 38 – 41 Seclusion and physical restraint, 553 –557
RR (Rational Recovery), 515 Second-generation antipsychotics (SGAs), 464
RSD (reflex sympathetic dystrophy syndrome), Sedative-related disorders
515 DSM-IV-TR classification, 84 –85
Rubenstein, Alice K., 410 – 415 Sedatives, prevalence rates, 481
Rumination Seizure disorders, children, 51
DSM-IV, 43 Selective mutism, prevalence of, 5
in MSE, 11 Selective serotonin reuptake inhibitors (SSRIs),
454, 455, 456, 460, 462, 472
SADS (Schedule for Affective Disorders and Schiz- Self-Abuse Finally Ends (SAFE) Alternative Infor-
ophrenia), 14 mation Line, 515
 index 729

Self-awareness of strengths/weaknesses, executive false allegations, 418 – 419

dysfunction, 40 interviewing children, 423 – 430
Self-care checklist, therapist, 677 – 682 interview outline, 427 – 429
Self-control self-help groups, 510, 515
Anxiety Management Training (AMT), 272 treatment of child, 430 – 435
childhood chronic illness, 408 Sexual attraction to patients, 315 –316
Self-demeaning, MACI, 163 Sexual Compulsives Anonymous, 515
Self-devaluation, MACI, 163 Sexual desire, 290 –291
Self-disclosure, psychotherapy, 205 Sexual discomfort, MACI, 163
Self-efficacy, motivational interviewing, 268 Sexual disorders
Self-expression, communication, 383 DSM-IV-TR classification, 87 –88
Self-harm ideation, in MSE, 11 movie recommendations, 500
Self-help books, 494 – 495 treatment manuals, 198
Self-Help for Hard of Hearing People (SHHH), 515 Sexual dysfunction
Self-help groups, 502–506, 506 – 516 dyspareunia, 290
Self-Help Sourcebook, 507 empirically supported therapies, 187
Self-liberation, 229 female, 286 –291
Self Management and Recovery Training female arousal and orgasm dysfunctions,
(SMART), 515 287 –289
Self-monitoring, relapse prevention, 351 global lifelong inorgasmia, 287 –288
Self-Monitoring (SM), 73 low sexual desire and aversion to sex, 290 –291
Self-reevaluation, 229 male, 282–286
Self-report measures, aculturation, 78 patient problem/diagnosis, 364
Seligman, Martin E. P., 93 – 98 situational orgasmic dysfunction, 288 –289
Sensation, neuropsychological assessment, 35 vaginismus, 289
Sensitivity to medical issues, suicidal patient, Sexual harassment, 532
243 –244 Sexual involvement, ethical standards for thera-
Separation anxiety disorder pists, 532, 533, 538, 544, 620 – 621
DSM-IV, 43 Sexually transmitted diseases (STDs), children, 422
pediatric pharmacotherapy, 468 Sexual orientation. See Bisexuals; Gay men;
prevalence of, 6 Lesbians
SEPI (Society for the Exploration of Psychotherapy Sexual victimization, 287
Integration), 699 Shape Up America!, 515
Serotonic reuptake inhibitors (SRIs), 472 Shapiro, David L., 593 –595
Services, disasters, 251 Shefet, Oren M., 354 –359
Settlement, definition, 576 SHHH (Self-Help for Hard of Hearing People), 515
Settlement vs. trial, professional liability coverage, Short-term memory, in MSE, 11–12
629 –630 ShrinkRapt, 673
Severity S.I.A. (Survivors of Incest Anonymous), 516
assessment, 220 –221 Sickle cell disease pain, empirically supported ther-
treatment matching, 222–225 apies, 187
Sex, pharmacotherapy, 460 Side effects in psychopharmacology, 460 – 465
Sex Addicts Anonymous, 515 SIDS Alliance (Sudden Infant Death Syndrome
Sex offenders, assessment, 416 – 417 Alliance), 515
Sex therapy Sigma Assessment Systems, 110
female sexual dysfunction, 286 –291 Simansky, Jennifer A., 494 – 497
male sexual dysfunction, 282–286 Simple phobia, DSM-IV, 43
postmodern, 282–283, 287 Situational orgasmic dysfunction, 288 –289
therapist-client sexual involvement, 313, 314 Skill and motivation, interviews, 14
Sexual abuse/assault. See also Abuse; Child abuse Skin evaluation, 53
anatomically detailed dolls, 425 – 426 Skin injuries, child abuse, 421
APSAC Study Guides, 416 – 422 Skull and extremity X–rays, children, 54
behavioral indicators of children, 424 Skullcap, 520
children, 417 – 422 Slander, definition, 576
730 index

Sleep, valerian for, 520 empirically supported therapies, 185

Sleep disorders prevalence of, 6
DSM-IV-TR classification, 88 –89 Speech, in MSE, 9 –10
empirically supported therapies, 188 Spencer, Thomas J., 466 – 476
insomnia treatment, 325 –326 Sperry, Len, 666 – 669
medical conditions that may present as, Spiral pattern, 227
450 – 451 Spirituality, 339, 681
self-help groups, 508, 512 Spousal Assault Risk Assessment Guide (SARA), 606
treatment manuals, 198 Stage-based methods, substance abuse, 264
Sleep terror disorder, prevalence of, 6 Stages of change, 226 –231
Sleepwalking disorder, prevalence of, 6 Standard of care, definition, 576
Slosson Educational Publications, 110 Standard scores, 111–115
SMART (Self Management and Recovery Train- Stanford-Binet, Fifth Edition (SB5), 114 –115
ing), 515 Stanford-Binet Intelligence Scale-Fifth Edition, 125
Sobell, Linda Carter, 71– 76 Stanines, 113 –114, 115
Sobell, Mark B., 71–76 State laws, Privacy Rule, 642
Social health, self-help, 508 Statute of limitations, definition, 576
Social history, 52 Stens, 115
Social insensitivity, MACI, 163 Stepfamily Association of America, 515
Social introversion Stimulants, prevalence rates, 481
interpretation of scores, 148 Stimulus control, 229, 408
Scale O of MMPI-2, 136 Stimulus control instructions, insomnia, 325 –326
Social liberation, 229 Stipulations, definition, 576
Social network therapy, substance abuse, 264 Stoelting Company, 110
Social phobia, 458 Stonewalling, divorce risk, 376
empirically supported therapies, 185 Stressful events, suicide risk, 65
prevalence of, 6 Stress reduction, adult disease management, 275
Social Psychology Network, Internet site, 493 Stroke, 343, 508, 514
Social support, recovery after disasters, 252 Structural profile, Multimodal Life History Inven-
Society for the Exploration of Psychotherapy Inte- tory, 22–23
gration (SEPI), 699 Structured Clinical Interview for the DSM-IV
Society of Behavioral Medicine (SBM), 699 (SCID-I and SCID-II), 14
Socioeconomic status, recovery after disasters, Structured Interview of Reported Symptoms
252–253 (SIRS), 68 – 69
Solicitation, consultation, 669 Structured interviews. See Interviewing
Solvents, administration, effects, and interactions, Stuttering, prevalence of, 6
485 Submissiveness, MACI, 162
Somatic complaints, disasters, 252 Subpoena, definition, 576
Somatic disorders, treatment manuals, 198 Subpoena duces tecum, definition, 576
Somatization disorder, prevalence of, 6 Subpoenas, 570 – 572
Somatoform, pediatric and adolescent medical com- Substance Abuse and Mental Health Services Ad-
plaints, 448 ministration, 481
Somatoform disorders Substance abuse/dependence. See also Alcohol
DSM-IV, 43 abuse/dependence; Drug abuse/dependence
DSM-IV-TR classification, 87 DSM-IV, 44
pharmacotherapy, 459 DSM-IV-TR classification, 82–85
Somatoform pain disorders, empirically supported family therapy, 377
therapies, 187 MACI, 164
SOS Office Manager, 673 movie recommendations, 500
SOS Software, 673 nutritional supplementation, 478
Southeastern Psychological Association, 700 prevalence of, 6
Southwestern Psychological Association, 700 sexual dysfunction, 282
Special damages, definition, 573 treatment manuals, 198 –199
Specific/simple phobia treatment matching, 263 –267
 index 731

Sudden Infant Death Syndrome Alliance (SIDS Systematic assessment, psychotherapy, 220 –222
Alliance), 515 Systematic assessment and treatment matching,
Suggestibility 220 –225
precautions to minimize, 428 – 429 Systematic reviews, psychological tests, 105 –106
sexually abused children, 426 Systematic Treatment Selection (STS), 220
Suicidal ideation, in MSE, 11
Suicide Talking points, media, 688, 689
age and risk, 64 –65 Tarasoff v. Regents of the University of California,
bereavement, 65 584 – 585, 586, 587, 612
depression, 64 Tardive Dyskinesia/Tardive Dystonia National As-
gender, 64 sociation, 516
health status, 65 TC (Test Critiques), 105 –106
hopelessness, 64 TEA (Test of Everyday Attention), 40
intervention, 247 Teachers, childhood behavior disorders, 330
intoxication, 64 Teleassessment, 120 –121
lethality assessment, 247 Temperance, Values in Action (VIA) classification,
MACI, 164 96
malpractice action, 240, 243 Temperature conversions, 439
movie recommendations, 498 – 499 Termination
older adults, 306 assessing and avoiding premature, 358
past attempts, 64 child therapy, 358 –359
race, 65 couples therapy, 387
release from hospital, 65 early termination, 346 –349
religion, 65 guidelines, 354 –359
risk assessment, 63 –65 high-conflict couples therapy, 383
self-help groups, 508 – 509, 511 interview, 15
treatment and management of suicidal patient, managed care organizations, 655
240 –245 mental health records, 651
unemployment, 65 tasks, 357 –358
verbal warning, 64 therapy, 544 – 545
Suinn, Richard M., 271–273 timing, 354
Suinn-Lew Asian Self-Identity Acculturation Scale, Terrorism and Disaster Branch (TDB), 249 –250
79 Test Critiques (TC), 105 –106
Sullivan, Glenn R., 240 –245 Testimony. See Expert testimony
Summary judgment, definition, 576 Testing
Summons, definition, 576 adaptive functioning, 127 –128
SumTime, 673 adolescents, 411– 412
Superlative Self-Description (S) Scale, MMPI-2, children with behavioral or developmental dis-
129, 131 orders, 53 – 54
Supervision, conducting effective clinical, ethical standards, 541– 543
682–685 executive dysfunction, 40
Supplements, dietary, 476 – 478 fees by psychologists for, 663
Support, crisis intervention, 248 interviewing with, 14
Surplus lines carriers, professional liability insur- neuropsychological assessment, 31
ance, 630 –631 psychological tests, 101–104
Survivors of Incest Anonymous (S.I.A.), 516 scores and percentile equivalents, 111–116
Swidler & Berlin and James Hamilton v. United vision and hearing for children with disorders,
States, 584 53
Symbols, 691–697 Test Locator, 105, 107
genogram format, 368, 372 Test of Everyday Attention (TEA), 40
Symptom Checklist 90-R (SCL-90-R), 73, 237 Tests: A Comprehensive Reference for Assessments
Symptoms, pharmacotherapy, 460 in Psychology, Education, and Business, 5th
Symptom validity testing (SVT), malingering, edition, 106
69 Tests in Print (TIP), 103, 106
732 index

Therapeutic alliance Treatment

failure to form, 348 accuracy of clinical judgment, 24
maintaining, with coerced patient, 551 approaches, 222–225
psychotherapy, 203 attention-deficit/hyperactivity disorder (ADHD),
repairing ruptures, 216 –219 62
Therapeutic impasse, resistance and, 348 –349 behaviorally disordered children, 401– 405
Therapist for Windows, 671 bisexuals, 301–303
Therapist Helper, 673 borderline personality disorder, 255 –257
Therapy. See Psychotherapy child sexual abuse, 430 – 435
Theta scores, 116 choice of format, 363 –365
Third-party relationships, billing, 658 – 659 clients’ rights, 181, 182, 183
Thompson, Robert J., Jr., 406 – 409 erectile failure, 284 –285
Thought content, in MSE, 10 –11 female sexual dysfunction, 286 –291
Thought process, in MSE, 10 gay men, 301–303
Thoughts, Multimodal Life History Inventory, guidelines for treating women, 295 –298
20 –21, 23 herbal for psychological disorders, 517 – 521
Throat examination, 52 high-conflict couples, 378 –383
Thyroid function tests, children, 52, 54 insomnia, 325 –327
Tic disorders lesbians, 301–303
DSM-IV, 43 male sexual dysfunction, 282–286
DSM-IV-TR classification, 81 marital infidelity, 384 –387
in MSE, 9 normative male alexithymia, 280
pediatric pharmacotherapy, 472– 473 psychoeducational groups (PEGs), 393 –398
Time, therapy, 261 psychotherapy manuals, 192–199
Timeline Followback (TLFB), 73 self-help groups, 502– 506
Time-out routines, emotional safety at home, substance abuse, 263 –266
381 suicidal patient, 240 –245
Timing, therapy termination, 354 vaginismus, 289
TIP (Tests in Print), 103, 106 Treatment matching
Tobacco, prevalence rates, 481 psychotherapy, 222–225
Tobacco use, stages of change, 228 substance abuse, 264 –265
Tompkins, Michael A., 319 –324 Treatment of Depression Collaborative Research
Topiramate, 463 Program (TDCRP), 216
Tort, definition, 576 Treatment planning
Tourette’s disorder benefits, 23 –233
DSM-IV, 43 development, 233 –236
pediatric pharmacotherapy, 468, 472– 473 diagnosis determination, 235
prevalence of, 6 ethnic minority children, 47 – 49
Tourette’s Syndrome Association, 516 goal development, 234
Toxicology lab values, 444 historical background, 232
Training. See also Education and training programs individuality, 235 –236
ethical standards, 537 – 538 intervention creation, 235
restraint and seclusion, 556 mental health records, 650
Tranquilizers, prevalence rates, 481 objective construction, 234 –235
Transcendence, Values in Action (VIA) classifica- problem definition, 234
tion, 96 problem selection, 234
Transference, 347, 389 Treatment populations, cognitively impaired
Transmission, human immunodeficiency virus adults, 342–344
(HIV), 292 Trial vs. settlement, professional liability coverage,
Traumatic brain injury (TBI) 629 – 630
mild, 342 Trichotillomania, prevalence of, 6
moderate to severe, 342–343 Tricyclic antidepressants (TCAs), 454, 455, 460, 461
Traumatic exposure, 250 TRIN (True Response Inconsistency), MMPI-2,
Trazodone, 454, 455, 462 130, 131
 index 733

True Response Inconsistency (TRIN), MMPI-2, Victimization, sexual, 287

130, 131 Vineland Adaptive Behavior Scale–Third Edition,
Trzepacz, Paula T., 7 –12 127
T scores, 112–114 Violence. See also Anger
Twelve-step approach aggression after disasters, 252
intervention, impaired psychologist, 623 decision making with dangerous clients, 612– 614
self-help, 505 family, 376
substance abuse, 264, 265 high-conflict couples, 379 –380
Type A characteristics, Anxiety Management relapse prevention, 350 –353
Training (AMT), 272 risk assessment, 605 – 606
self-help groups, 509, 510, 513
ULA (unconditional life-acceptance), 215 women survivors, 298
Unconditional life-acceptance (ULA), 215 Violence Prediction Scheme (VPS), 605
Unconditional other-acceptance (UOA), 213, 215 Violence Risk Assessment Guide (VRAG),
Unconditional self-acceptance (USA), 212–213, 215 605 – 606
Unemployment, suicide risk, 65 Violent ideas, in MSE, 11
Unethical colleague, confronting, 579 – 583 Vision testing, children, 53
Unipolar major depression, DSM-IV, 43 Visuoconstructional ability, in MSE, 12
United Cerebral Palsy Association, 516 Visuospatial functions, neuropsychological assess-
University of Minnesota Press, 110 ment, 36
Unruliness, MACI, 163 Vital signs, 52
UOA (unconditional other-acceptance), 213, 215 Voluntary intervention, impaired psychologist,
Urge-surfing, 352 622– 623
Urine lab values, 443 Voluntary movement, in MSE, 8
USA (unconditional self-acceptance), 212–213, 215 VRAG (Violence Risk Assessment Guide),
Utilization rate, 668 605 – 606
Utilization review checklist, 652–653 VRIN (Variable Response Inconsistency), MMPI-2,
130, 131
Vacuum erection device (VED), 285
Vaginismus, treatment, 289 Waist circumference (WC), 445, 447
Valerian, sleep, 520 Waiver, definition, 576
Validation, Rorschach scores, 171 Wanton, definition, 576
Validity Ware, Janice, 119 –123
psychological testing report, 117 Warnings in psychopharmacology, 460 – 465
Rorschach assessment, 174 –175 Weapons, dangerous patients, 614
Validity assessment guidelines, MMPI-2, 131 WebMD, Internet site, 493 – 494
Valproic acid, 457, 463, 480 Wechsler Intelligence Scale for Children-IV, 126
Values in Action (VIA) Classification of Strengths, Wechsler Preschool and Primary Scale of
93 –97 Intelligence-III, 125
VandeCreek, Leon, 612–615 Wechsler subtests, 112–114
Van Male, Lynn M. Wedding, Danny, 497 – 501
female sexual dysfunction, 286 –291 Wegener, Stephen T., 342–346
male sexual dysfunction, 282–286 Weight
VantageMed, 673 assessment tools, 445 – 447
Varela, R. Enrique, 249 –254 Shape Up America!, 515
Variable Response Inconsistency (VRIN), MMPI-2, Weight loss, medical conditions that may present
130, 131 as, 451– 452
Vasquez, Melba J. T., 63 – 66 Weight management, treatment manuals, 196
Venlafaxine, 454, 455, 462, 470 – 471, 480 Weiner, Irving B., 173 –177
Vernberg, Eric M., 249 –254 Well-being, ginseng for, 519
Vertigo, medical conditions that may present as, Western Psychological Association, 700
452 Western Psychological Services, 110
Vicarious liability, definition, 576 White, Joanne, 236 –239
Victimhood, marital infidelity, 386 Wide Range, 111
734 index

Wide Range Assessment of Memory and Woody, Robert H.

Learning-II (WRAML-2), 126 defending against legal complaints, 560 –566
Wiens, Arthur N., 13 –16 refusal skills training (RST), 308 –312
Wilens, Timothy E., 466 – 476 Work reentry, impaired psychologist, 623 – 624
Wilkinson, Ron, 192–202 WRAML-2 (Wide Range Assessment of Memory
Willful, definition, 576 and Learning-II), 126
Williams, Oliver B., 220 –225 Writing, in MSE, 10
Wisdom, Values in Action (VIA) classification,
96 Yalom, Victor J., 388 –393
Withdrawal, substance abuse, 458 – 459 Yanick, Kathryn, 220 –225
Witkiewitz, Katie, 350 –353 Yearbook of American and Canadian Churches, 338
Witnesses, children, 418 Y-ME National Breast Cancer Organization, 516
Women. See Females; Gender issues Youth, Values in Action Inventory of Strength
Wood, James M., 169 –172 (VIA–Youth), 97
Woodcock-Johnson Psychoeducational Battery III,
126 Ziprasidone, 465
Woody, Jennifer K. H., 308 –312 Zuckerman, Edward, 670 – 673
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The second edition of the Psychologists’ Desk reasons, we cordially invite you, the reader, to
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