Might Relationship “Techniques” Extend the Reach, Efficacy, and Efficiency of the Psychotherapies? The Challenge of Treatment-Resistant Outpatients

Study-based clinical observations and two premises are presented as indications for a need to identify therapeutic relationship techniques or the like that can extend the reach and efficiency of the psychotherapies. The premises are: (1) advances in psychotherapy practice and research now highlight one of the field's most longstanding challenges, signified by terms like treatment resistance; and (2) some proportion of outpatients whose problems are resistant to the psychotherapies (and medications) have marked limitations in the capacity to relate positively and productively to others, including therapists. Thus, ironically, they cannot optimally utilize a treatment modality that largely has developed to ameliorate problems relating to others.     

The Dental Subscale of the Children's Fear Survey Schedule: Predictive Value and Clinical Usefulness

This study reports on the predictive value and clinical usefulness of the Dutch parental version of the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS). Parents of 718 children (4–12 years) completed this CFSS-DS version before or during the child's visit. The dentist rated the child's dental fear during treatment on a 5-point Likert-type Scale from 1 (not afraid at all) to 5 (very afraid). Reliability analysis was performed, and correlation coefficients between the two measures were calculated. The reliability of the scale proved to be high (Cronbach's = .93) and significant correlation coefficients were found (r = .58 and r = .68, p < .01). The negative predictive value of the CFSS-DS was high (.96), whereas its positive predictive value was relatively low (0.41). It was concluded that the CFSS-DS might be of clinical value as a screening device of dental fear, whereas its predictive value of fearful behavior should not be overestimated.     

Psychosocial Treatment Strategies in the MTA Study: Rationale, Methods, and Critical Issues in Design and Implementation

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first multisite, cooperative agreement treatment study of children, and the largest psychiatric/psychological treatment trial ever conducted by the National Institute of Mental Health. It examines the effectiveness of Medication vs. Psychosocial treatment vs. their combination for treatment of ADHD and compares these experimental arms to each other and to routine community care. In a parallel group design, 579 (male and female) ADHD children, aged 7–9 years, 11 months, were randomly assigned to one of the four experimental arms, and then received 14 months of prescribed treatment (or community care) with periodic reassessments. After delineating the theoretical and empirical rationales for Psychosocial treatment of ADHD, we describe the MTA's Psychosocial Treatment strategy applied to all children in two of the four experimental arms (Psychosocial treatment alone; Combined treatment). Psychosocial treatment consisted of three major components: a Parent Training component, a two-part School Intervention component, and a child treatment component anchored in an intensive Summer Treatment Program. Components were selected based on evidence of treatment efficacy and because they address comprehensive symptom targets, settings, comorbidities, and functional domains. We delineate key conceptual and logistical issues faced by clinical researchers in design and implementation of Psychosocial research with examples of how these issues were addressed in the MTA study.Deceased     

Parenting and Family Stress Treatment Outcomes in Attention Deficit Hyperactivity Disorder (ADHD): An Empirical Analysis in the MTA Study

Parenting and family stress treatment outcomes in the MTA study were examined. Male and female (579), 7–9-year-old children with combined type Attention Deficit Hyperactivity Disorder (ADHD), were recruited at six sites around the United States and Canada, and randomly assigned to one of four groups: intensive, multi-faceted behavior therapy program alone (Beh); carefully titrated and monitored medication management strategy alone (MedMgt); a well-integrated combination of the two (Comb); or a community comparison group (CC). Treatment occurred over 14 months, and assessments were taken at baseline, 3, 9, and 14 months. Parenting behavior and family stress were assessed using parent-report and child-report inventories. Results showed that Beh alone, MedMgt alone, and Comb produced significantly greater decreases in a parent-rated measure of negative parenting, Negative/Ineffective Discipline, than did standard community treatment. The three MTA treatments did not differ significantly from each other on this domain. No differences were noted among the four groups on positive parenting or on family stress variables. Results are discussed in terms of the theoretical and empirically documented importance of negative parenting in the symptoms, comorbidities and long-term outcomes of ADHD.     

The Role of the Family in Childhood Obsessive–Compulsive Disorder

While obsessive–compulsive disorder is widely recognized to have a strong genetic component, psychosocial factors are also acknowledged to be important. The primary focus of this paper is on familial factors associated with OCD in children and adolescents. It explores the family context as a possible risk factor in the development and maintenance of the disorder, including parental modeling, expressed emotion, parenting style, and family accommodation of the child's symptoms. The involvement of the family in the treatment of the disorder is also reviewed. Finally, future directions for research investigating familial factors in childhood OCD are presented.     

Dualism and its Importance for Medicine

Cartesian dualism has been viewed by medical theorists to be oneof the chief causes of a reductionist/mechanistic treatment ofthe patient. Although I aver that Cartesian dualism is one culprit for the misapprehension of the genuine treatment of patients in termsof both mind and body, I argue that interactive dualism whichstresses the interaction of mind and body is essential to treatpatients with dignity and compassion. Thus, adequate medical carethat is humanistic in nature is difficult (if not impossible)to achieve without physicians adhering to a dualistic frameworkin which the body and person is treated during illness.     

Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase

The concept of acceptance is receiving increased attention as an alternate approach to the suffering that is often associated with persistent and disabling pain. This approach differs from established treatments in that it does not principally focus on reducing pain, but on reducing the distressing and disabling influences of pain as they concern important areas in patients' lives. The present analyses represent a preliminary evaluation of an acceptance-based approach to chronic pain within an interdisciplinary treatment program. One hundred and eight patients with complex chronic pain conditions completed treatment and provided data for the current study. Treatment was conducted in a 3- or 4-week residential or hospital-based format. It included a number of exposure-based, experiential, and other behavior change methods focused on increasing (a) engagement in daily activity regardless of pain and (b) willingness to have pain present without responding to it. Significant improvements in emotional, social, and physical functioning, and healthcare use were demonstrated following treatment. The majority of improvements continued at 3-months post-treatment. Improvements in most outcomes during treatment were correlated with increases in acceptance, supporting the proposed process of treatment.     

Recommendations for the Treatment of Hypochondriac Patients

Hypochondriasis is a debilitating condition in which patients are persistently preoccupied with the possibility of being seriously ill. Its is a costly problem for the health care system whose treatment has not received systematic attention until recently. Although based on few controlled studies, results indicated that various brief cognitive-behavioral techniques produce significant changes in illness fears and attitudes. A list of therapeutic questions that require further study is presented and some indications for both therapists and patients are given.     

The Meaning vs. The Medical Model in the Empirically Supported Treatment Program: A Consideration of The Empirical Evidence

A review of the debate on the Empirically Supported Treatment Program is presented. It is argued that underlying the specifics of the debate are fundamentally incompatible paradigms: a meaning vs. a medical model. The findings from two gold standard multi-site studies are reviewed to conclude that the control condition meets requirements for an empirically supported treatment. The empirical finding of the failure of clinical training to improve treatment outcomes is explained by the focus on rational factors in training. It is recommended that training of therapists focus on enhancing experiential capacity rather than mastery of manualized treatment approaches.     

Schizophrenia and the Developmental Moratorium

Jay B. Sisun is a Clinical Research Assistant at Taunton State Hospital. Glen A. Eskedal is the Chair and Professor of Education and Human Services at Suffolk University. Of challenge to developmental psychologists and mental health practitioners is the management of positive and negative symptoms associated with schizophrenia and their effects on mastering psychosocial developmental tasks. The intent of this article is to provide specific information pertinent to understanding this disorder, to understand the age-appropriate struggle for individuation, and to offer recommendations for effective treatment.