Chronic Illness and the Life Cycle:A Conceptual Framework

This article provides a conceptual framework for thinking about the system created at the interface of chronic illness with the family life cycle. First, a psychosocial typology and time phases of illness schema is described as a necessary, preliminary step to create a common language that bridges the worlds of illness, individual, and family development. This schema organizes similarities and differences between diseases in a manner useful to psychosocial-developmental rather than biomedical inquiry. Then, drawing on several major life-cycle theories in the literature, key concepts (periods of transition, life-structure building and maintaining, centripetality, and centrifugality) are used in a complementary fashion to link these three lines of development. Equipped with these psychosocial languages, consideration is given to transgenerational aspects of illness, loss, and crisis, and the interwoven threads of illness, family, and individual development. Clinical vignettes are provided to highlight this conceptual framework.     

Toward a generative theory of the therapeutic field

In the various models of family therapy, family systems are described as being patterned and programmed in their operations and development. The regularities and patterns found in family life are believed to be the expression of a program that determines the behavior of the family system and each of its members. Therapists holding this view will use "programming methods" in order to map family phenomena, and therapeutic work will consist of disrupting the problematic sequences in a deterministic way. However, if we take into consideration the impossibility of always linking inputs and outputs and the inability to evaluate consistently the behaviors in a system, problems associated with indeterminancy appear. Under such conditions, it may be impossible for therapists to formulate programs of family functioning. Therefore, we have operationalized a set of methodological principles that can be applied in such conditions. In this article we present the theoretical and practical implications for the field of therapy of "nonprogramming methods." A videotaped session is analyzed in order to show the application of the nonprogramming methods in clinical practice.     

Interventive Interviewing: Part I. Strategizing as a Fourth Guideline for the Therapist

A clinical interview affords far more opportunities to act therapeutically than most therapists realize. Because so many of these opportunities remain outside the therapist's conscious awareness, it is useful to elaborate guidelines that orient his or her general activity in directions that are liable to be therapeutic. The Milan associates defined three such basic guidelines: hypothesizing, circularity, and neutrality. Hypothesizing is clear and easy to accept. The notions of circularity and neutrality have aroused considerable interest but are not as readily understood. These guidelines may be clarified and operationalized when reformulated as conceptual postures. This process is enhanced by differentiating a fourth guideline, strategizing, which entails the therapist's decision making, including decisions about how to employ these postures. This paper, the first in a series of three, explores these four interviewing guidelines. The other papers will appear in a subsequent issue. Part II will focus on reflexive questioning, a mode of inquiry oriented toward mobilizing the family's own healing capacity. Part III will provide a scheme for analyzing and choosing among four major types of questions: linear questions, circular questions, reflexive questions, and strategic questions.     

Stability and Change in Type A Components and Cardiovascular Reactivity in Medical Students During Periods of Academic Stress1

This study examined the effects of academic stress upon components of Type A behavior and cardiovascular reactivity. In a longitudinal design, heart rate and blood pressure responses to the Type A Structured Interview (SI) and additional laboratory challenges were measured in medical students at three points during an academic semester. Sessions 1 and 3 were scheduled during vacation periods; Session 2 took place during an intensive examination week. Results indicated that three “stylistic” components of Pattern A derived from the SI—loud and explosive speech, short response latency, and potential for hostility—increased significantly during the exam period. Similar increases achieved marginal significance for another stylistic component, rapid and accelerated speech. By contrast, global Type A assessments did not increase with academic demands. Cardiovascular reactivity was significantly but only moderately stable across the three sessions, showing less consistency than has been reported in previous research. In addition, there was little evidence in this study that cardiovascular reactivity was potentiated by academic stress or by Type A behavior. These results demonstrate the influence of naturalistic environmental factors on overt behavioral components that have recently been suggested as coronary risk factors. Therefore, it is advisable for future experimental and epidemiological research to examine the social and environmental context in which these behaviors occur.     

The evolution of a therapy group for vietnam veterans on a general psychiatry unit

The evolution of a therapy group for hospitalized Vietnam veterans with post-traumatic stress disorder (PTSD) and related symptomatology is described. The literature on group treatment for this population is briefly reviewed and discussed in relation to an inpatient psychiatry setting. The prevailing conditions at the time of group inception are recalled along with the initial goals of the therapeutic intervention. Problems encountered are also discussed, along with the changes made in response to these identified difficulties. The results of three and one-half years of experience with this group are described in detail.The authors would like to thank Cynthia Sturm, Ph.D. for her helpful editorial assistance.     

Necessary factors in psychotherapy: A model for understanding iatrogenic disturbances

Psychotherapy is conceptualized within a phenomenoiogical framework as a relationship with a focus. Both these factors, the relationship and the focus, are examined as necessary factors for the creation of the therapeutic alliance which is seen as a sufficient condition for intrapsychic change. The proper balancing of the two necessary factors is seen as essential for a therapeutic alliance to evolve. The relationship factor is described in existential terms as a special form of the I-Thou encounter, while the focus factor is examined as part of the diagnostic aspect of psychotherapy. Iatrogenic distortions in psychotherapy are discussed in terms of distortions in the necessary factors-the focus and relationship. Four types of iatrogenic distortions are described: (1) overemphasis of the relationship and focus, (2) underemphasis of the relationship and focus, (3) overemphasis of the relationship and underemphasis of the focus and (4) underemphasis of the relationship and overemphasis of the focus.     

USE OF ESCAPE AND REWARD IN THE MANAGEMENT OF YOUNG CHILDREN DURING DENTAL TREATMENT

A reinforced practice procedure was used to facilitate cooperative behavior in five children, aged 3 to 6 years, during dental treatment. In a multiple baseline design across subjects, the children were rewarded with escape, inexpensive stickers, and praise for cooperative behavior in the presence of the sights, sounds, and some sensations of the dental instruments prior to actual dental treatment. Direct observations of disruptive behavior via a 15-s interval recording system indicated baseline levels as high as 90% were reduced to less than 15% by the final treatment visit. In addition, the procedure was effective in reducing overall heart rate and blood pressure reactivity to dental treatment. All children were rated by the involved dental professionals as more cooperative and relaxed following exposure to reinforced practice.     

APPARENT COVARIATION BETWEEN CHILD HABIT DISORDERS: EFFECTS OF SUCCESSFUL TREATMENT FOR THUMB SUCKING ON UNTARGETED CHRONIC HAIR PULLING

We evaluated the effects of aversive taste treatment of thumb sucking on untreated trichotillomania (habitual hair pulling) in two children who chronically pulled their hair and sucked their thumbs. A combination of withdrawal and nonconcurrent multiple baseline designs showed that, concomitant with the successful treatment of thumb sucking, hair pulling was also eliminated. The results suggest an efficient method for changing behaviors that are difficult to treat directly.     

Target Groups for Preventing AIDS Among Intravenous Drug Users

The acquired immune deficiency syndrome (AIDS) has rapidly become the most serious medical consequence of injecting illicit drugs. Its potential impact on intravenous (IV) drug use is enormous. Human immunodeficiency virus (HIV, also known as HTLV-III and LAV), the virus that causes AIDS, appears, usually, to lead to lifelong infection. At present there is no effective treatment, and the treatments under development may require lifelong antiviral therapy. Since most of the antibody produced in response to HIV infection does not neutralize the virus, and since there is substantial genetic variation in the virus, it will be difficult to develop a vaccine. Even after vaccines are developed, testing their safety and efficacy will be formidable problems. Until either effective treatment or vaccines are developed, control of the epidemic among IV drug users must be attempted through behavior change/prevention efforts. In this paper we will review the epidemiology of AIDS among IV drug users and characteristics of the IV drug-use subculture relevant to prevention efforts. We will then identify different target groups for these prevention efforts, present available evidence about behavior change in these groups, and then briefly discuss how to prevent transmission of HIV to heterosexual partners who are not themselves IV drug users and to the children of IV drug users.     

Autonomy as a Source of Pro-social Influence Among Incarcerated Adolescents1

Previous research has found that greater autonomy for incarcerated adolescents is associated with pro-social outcomes. The present paper interprets the pro-social impact of autonomy in terms of three established lines of research in social psychology: leadership style, coercive social control, and reactance. In addition, it attempts to clarify whether autonomy in this setting has a direct influence on residents' values or an indirect influence resulting from an increase in residents' acceptance of the treatment goals. Data were collected by questionnaires administered to 434 residents and 156 staff members at four residential institutions for adjudicated adolescents. The data were analyzed using a structural equation model with unobserved variables (LISREL). A model positing both direct and indirect influences of autonomy fit the data very well. Autonomy contributed to pro-social values both through greater acceptance of the treatment goals as well as through a direct influence on values.