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.     

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.     

SOCIAL INFLUENCES ON “SELF-STIMULATORY” BEHAVIOR: ANALYSIS AND TREATMENT APPLICATION

We tested the hypothesis that the “self-stimulatory” behaviors exhibited by some individuals may be socially mediated. Four developmentally disabled children who exhibited hand flapping and body rocking participated in a series of three experiments conducted to assess the influence of social variables on stereotyped behavior and to develop a treatment based on the assessment. Experiment 1 used an assessment procedure to determine the relative influences of social attention and task demands on stereotyped behavior. For all four children, hand flapping and body rocking increased when difficult academic tasks were introduced. Experiment 2 involved the use of a procedural time-out and demonstrated that removing task demands contingent on stereotyped behavior resulted in increased rates of hand flapping and body rocking. In Experiment 3, these results were used to develop a communication treatment that consisted of teaching the children to request assistance on the difficult tasks. This treatment resulted in significant reductions in self-stimulatory behavior. These results are consistent with the hypothesis that some forms of repetitive stereotyped behavior may come to serve social functions (e.g., escape from aversive situations). Teaching a functionally equivalent communicative alternative to escape-motivated stereotyped behavior can be an effective form of intervention for this problem.     

Unprogrammed effects of training high-status peers to interact with severely handicapped children.

We examined the effects of a peer initiation intervention with high- and low-status nonhandicapped students on the behavior of untrained peers toward handicapped students. In the context of a counterbalanced withdrawal design, high- and low-status nonhandicapped students were taught to direct social initiations to eight severely handicapped students during recess activities. The interactions of the high-status students resulted in higher levels of initiations by untrained peers toward the handicapped students than did the interactions of the low-status students. Social response levels were also differentially affected by the status of the peer initiator.     

The fundamental rule: a study of current usage

Members of the editorial boards of the Journal of the American Psychoanalytic Association, Psychoanalytic Quarterly, and Psychoanalytic Inquiry, plus selected analysts from Canada, France, and England, were asked how they presented the fundamental rule to their analysands and what considerations led to their choice of initial guidelines. Forty-nine of eight-three analysts responded to the survey. The respondents described diversity in phrasing of the fundamental rule, the time in analysis when the guidelines are given, and the reasons for the practice they follow. The method each chose appears to reflect the differing conceptions analysts have of the analytic process. Two major trends emerged: either our respondents emphasized delineating a work or functional framework or contract, or they emphasized establishing an attitude or spirit of cooperation, mutuality and work sharing. In each group respondents differed as to whether they favored minimal or more lengthy instructions. They also differed as to whether they followed a consistent approach or one tailored to the needs of the individual analysand. A source of tension lay in an inclination either to remain in the tradition set by Freud or to experiment with different phrasings and timings. The authors give their reasons for choosing to give explicit instructions, requesting associational material beyond thoughts and feelings, and describing resistance as inevitable and a potential source of insight.