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by: Spencer Smitham


Spencer Smitham
GPA 3.97
Introduction to Abnormal Psychology

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Introduction to Abnormal Psychology
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This 94 page Class Notes was uploaded by Spencer Smitham on Saturday September 12, 2015. The Class Notes belongs to PSYC 3230 at University of Georgia taught by Blount in Summer 2015. Since its upload, it has received 44 views. For similar materials see Introduction to Abnormal Psychology in Psychlogy at University of Georgia.




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Date Created: 09/12/15
Journal ol Consulting and li niea Psycholog 1996 Vol 64 No 6 531168 Copyright W96 by thc American Psychological Association In 39 lll230lliX96Jll Experiential Avoidance and Behavioral Disorders A Functional Dimensional Approach to Diagnosis and Treatment Steven C Hayes Kelly G Wilson Elizabeth V Gifford and Victoria M Follette University of Nevada Reno Kirk Strosahl Group Health Cooperative Syndromal classi cation is a welldeveloped diagnostic system but has failed to deliver on its promise ofthe identi cation offunctional pathological processes Functional analysis is tightly connected to treatment but has failed to develop testable replicable classi cation systems Functional diagnostic dimensions are suggested as a way to develop the functional classi cation approach and experiential avoidance is described as I such dimension A wide range ofresearch is reviewed showing that many forms of psychopathology can be conceptualized as unhealthy efforts to escape and avoid emotions thoughts memories and other private experiences It is argued that experiential avoidance as a functional diagnostic dimension has the potential to integrate the efforts and ndings of researchers from a wide variety oftheoretical paradigms research interests and clinical domains and to lead to testable new approaches to the analysis and treatment of behavioral disorders The process of classi cation lies at the root of all scienti c behavior It is literally impossible to speak about a truly unique event alone and cut off from all others because words them selves are means of categorization Bruner Goodnow amp Aus tin 1956 Science is concerned with re ned and systematic verbal formulations of events and relations among events Be cause events are always classes of events and relations are always classes of relations classi cation is one of the central tasks of science The eld of psychopathology has seen myriad classi cation systems Hersen amp Bellack 1988 Sprock amp Blash eld 1991 The differences among some of these approaches are both long standing and relatively unchanging in part because systems are never free from a priori assumptions and guiding principles that provide a framework for organizing information Adams amp Cassidy I993 In the present article we brie y examine the differences be tween two core classi cation strategies in psychopathology syndromal and functional We then articulate one possible functional diagnostic dimension experiential avoidance Sev eral common syndromal categories are examined to see how this dimension can organize data found among topographical groupings Finally the utility and implications of this functional dimensional category are examined Steven C Hayes Kelly G Wilson Elizabeth V Gifford and Victoria M Follette Department of Psychology University of Nevada Kirk Strosahl Mental Health Center Group Health Cooperative Seattle Washington Preparation of this article was supported in part by Grant DA08634 from the National Institute on Drug Abuse Correspondence concerning this article should be addressed to Steven C Hayes Department of Psychology Mailstop 296 College ofArts and Science University of Nevada Reno Nevada 895570062 1152 Comparing Syndromal and Functional Classi cation Although there are many purposes to diagnostic classi ca tion most researchers seem to agree that the ultimate goal is the development of classes dimensions or relational categories that can be empirically wedded to treatment strategies Adams amp Cassidy 1993 Hayes Nelson amp Jarrett l987 Meehl 1959 Syndromal classi cation whether dimensional or categorical can be traced back to Wundt and Galen and thus is as old as scienti c psychology itself Eysenck 1986 Syndro mal classi cation starts with constellations of signs and symp toms to identify the disease entities that are presumed to give rise to these constellations Syndromal classi cation thus starts with structure and it is hoped ends with utility The attempt in functional classi cation conversely is to start with utility by identifying functional processes with clear treatment implica tions It then works backward and returns to the issue of identi able signs and symptoms that re ect these processes These differences are fundamental S yndromal Classi cation The economic and political dominance of the American Psy chiatric Association s Diagnostic and Statistical Manual of Mental Disorders eg 4th ed DSMIV American Psychiatric Association 1994 has lead to a worldwide adoption of syndro mal classi cation as an analytic strategy in psychopathology The only widely used alternative the International Classi ca tion of Diseases ICD system was a source document for the original DSM and continuous efforts have been made to ensure their ongoing compatibility American Psychiatric Association 1994 The immediate goal of syndromal classi cation Foulds 1971 is to identify collections of signs what one sees and symptoms what the client s complaint is The hope is that these syndromes will lead to the identi cation of disorders with SPECIAL SECTION EXPERIENTIAL AVOIDANCE a known etiology course and response to treatment When this has been achieved we are no longer speaking of syndromes but of diseases Because the construct of disease involves etiology and response to treatment these classi cations are ultimately a kind of functional unit Thus the syndromal classi cation ap proach is a topographically oriented classi cation strategy for the identi cation of functional units of abnormal behavior When the same topographical outcome can be established by diverse processes or when very different topographical out comes can come from the same process the syndromal model has a dif cult time actually producing its intended functional units cf Bandura 1982 Meehl 1978 Some medical prob lems eg cancer have these features and in these areas medi cal researchers no longer look to syndromal classi cation as a quick route to an understanding of the disease processes involved The link between syndromes topography of signs and symptoms and diseases function has been notably weak in psychopathology After over 100 years of effort almost no psy chological diseases have been clearly identi ed With the excep tion of general paresis and a few clearly neurological disorders psychiatric syndromes have remained syndromes inde nitely In the absence of progress toward true functional entities syndromal classi cation of psychopathology has several down sides Symptoms are virtually nonfalsi able because they de pend only on certain formal features Syndromal categories tend to evolve changing their names frequently and splitting into ever ner subcategories but except for political reasons eg homosexuality as a disorder they rarely simply disappear As a result the number of syndromes within the DSM system has increased exponentially Follette Houts amp Hayes 1992 Increasingly re ned topographical distinctions can always be made without the restraining and synthesizing effect of the iden ti cation of common etiological processes In physical medicine syndromes regularly disappear into dis ease categories A wide variety of symptoms can be caused by a single disease or a common symptom can be explained by very different diseases entities For example headaches are not a disease because they could be due to in uenza vision prob lems ruptured blood vessels or a host of other factors These etiological factors have very different treatment implications Note that the reliability of symptom detection is not what is at issue Reliably diagnosing headaches does not translate into reliably diagnosing the underlying functional entity which after all is the crucial factor for treatment decisions In the same way the increasing reliability of DSM diagnoses is of little consol ation in and of itself The DSM system speci cally eschews the primary impor tance of functional processes The approach taken in DSM is atheoretical with regard to etiology or pathophysiological process American Psychiatric Association 1980 p 7 This spirit of etiological agnosticism is carried forward in the most recent DSM incarnation It is meant to encourage users from widely varying schools of psychology to use the same classi ca tion system Although integration is a laudable goal the price paid may have been too high Follette amp Hayes 1992 For example the link between syndromal categories and bio logical markers or change processes has been consistently disap 1153 pointing To date compellineg sensitive and speci c physiolog ical markers have not been identi ed for any psychiatric syn drome Hoes 1986 Similarly the link between syndromes and differential treatment has long been known to be weak see Hayes et al 1987 We still do not have compelling evidence that syndromal classi cation contributes substantially to treat ment outcome Hayes et al 1987 Even in those few instances in which treatments are shown to work for speci c syndromes and not others mechanisms of change are often unclear or un examined Follette 1995 in part because syndromal catego ries give researchers few leads about where even to look With out attention to etiology treatment utility and pathological pro cess the current syndromal system seems unlikely to evolve rapidly into a functional theoretically relevant system Functional Classi cation In a functional approach to classi cation the topographical characteristics of any particular individual s behavior is not the basis for classi cation instead behaviors and sets of behaviors are organized by the functional processes that are thought to have produced and maintained them This functional method is inherently less direct and naive than a syndromal approach as it requires the application of preexisting information about psychological processes to speci c response forms It thus in tegrates at least rudimentary forms of theory into the classi cation strategy in sharp contrast with the atheoretical goals of the DSM system Functional Diagnostic Dimensions as a Method of Functional Classi cation Classical functional analysis is the most dominant example of a functional classi cation system It consists of six steps Hayes amp Follette 1992 Step 1 identify potentially relevant characteristics of the individual client his or her behavior and the context in which it occurs through broad assessment Step 2 organize the information collected in Step 1 into a preliminary analysis of the client s dif culties in terms of behavioral princi ples eg reinforcement stimulus control so as to identify im portant causal relationships that might be changed Step 3 gather additional information based on Step 2 and nalize the conceptual analysis Step 4 devise an intervention based on Step 339 Step 5 implement treatment and assess change Step 6 if the outcome is unacceptable recycle back to Step 2 or 3 There are many problems with classical functional analysis as a functional classi cation system Hayes amp Follette 1992 It is sometimes vague often dif cult to replicate and thus to test empirically and is ideographic in the extreme It may not adequately specify the relevant behavioral or contextual char acteristics to identify or which behavioral principles should be applied and in what manner Because it is vague it may fall prey to the welldocumented errors common to clinical judgment more generally Dawes 1994 Perhaps for all of these reasons functional analysis has hardly progressed from its promising be ginningSalzinger 1988 There are several possible solutions to these problems Hayes amp Follette 1992 One of the most promising is the develop 1154 ment of functional diagnostic dimensions If one performs many individual functional analyses tied to the same dimen sion these might then be arranged into a larger category with related assessment methods and treatment recommendations The guiding principle behind these collections would be the identi cation of common processes of etiology or maintenance that suggest effective courses of action This idea was prevalent early in the behavior therapy move ment eg Bandura 1968 Kanfer amp Grimm 1977 but the suggested categories were too closely tied to a speci c set of ab stract principles and too little tied to the characteristic forms of behavior that clients display For example Kanfer and Grimm s major categories included behavioral excesses and prob lems in environmental stimulus control Such categories can in principle be applied to every case Furthermore the analytic categories themselves were so speci c to behavior analysis that they were not useful unless one subscribed to this speci c theo retical approach Functional diagnostic dimensions may be most useful initially when they point to reasonably widely agreedon pathological processes without necessitating the adoption of an entire paradigmatic system Classi cation based on such dimensions may integrate the contributions of various theoretical perspectives and allow for the validation of patholog ical processes tied to clear treatment implications In the re mainder of the article we develop an example of a functional diagnostic dimension that we argue demonstrates these possibilities Experiential Avoidance as a Functional Diagnostic Dimension Experiential avoidance is a putative pathological process rec ognized by a wide number of theoretical orientations Experi ential avoidance is the phenomenon that occurs when a person is unwilling to remain in contact with particular private experi ences eg bodily sensations emotions thoughts memories behavioral predispositions and takes steps to alter the form or frequency of these events and the contexts that occasion them We occasionally use terms such as emotional avoidance or cog nitive avoidance rather than the more generic experiential avoidance when it is clear that these are the relevant aspects of experience that the person seeks to escape avoid or modify We recognize that thoughts memories and emotions are richly intermingled and do not mean to imply any necessary rigid dis tinctions among them although distinctions might be drawn by some theoretical perspectives without threat to the underlying principle of experiential avoidance Furthermore the term avoidance in this context explicitly includes both avoidance and escape in all of their forms as long as they are used as methods of altering the form or frequency of experiences and the contexts that occasion them In this article we argue that many forms of psychopathology are usefully viewed as unhealthy methods of experiential avoid ance In what follows we outline some of the perspectives and research that supports the concept of such a dimension and that shows its potential for integrating research across theoretical orientations and speci c research areas HAYES WILSON GIFFORD FOLLETTE AND STROSAHL Convergence of Views on Experiential A voidance Experiential avoidance has been recognized implicitly or ex plicitly among most systems of therapy Foa Steketee and Young 1984 have noted that the general phenomenon of emotional avoidance is a common occurrence unpleasant events are ignored distorted or forgotten p 34 Freud rec ognized the importance of the avoidance of private experiences and de ned the very purpose of psychoanalysis as the lifting of repressions and making conscious material that has been too painful or threatening to be held in conscious awareness Freud 1920 1966 In clientcentered therapy openness to experi ence is a central therapeutic goal Raskin amp Rogers 1989 Rogers 1961 Rogers argued that as the result of his therapy the individual becomes more openly aware of his own feelings and attitudes as they exist in him at an organic level He is able to take in the evidence in a new situation as it is rather than distort ing it to t a pattern which he already holds 1961 p 1 15 Similarly according to Gestalt therapists the heart of many psychological problems is the avoidance of painful feelings or fear of unwanted emotion Perls He erline amp Goodman 1951 Others from the Gestalt tradition suggest that dysfunc tion occurs when emotions are interrupted before they can en ter awareness or go very far in organizing action Greenberg amp Safran 1989 p 20 Existential psychologists agree with the centrality of experiential avoidance although they focus partic ularly on the avoidance of a fear of death to cope with these fears we erect defenses against death awareness defenses that are based on denial that shape character structure and that if maladaptive result in clinical syndromes In other words psychopathology is the result of ine ective modes of death transcendence Yalom 1980 p 47 cf Becker 1973 Somewhat unlike the aforementioned paradigms behavioral and cognitive therapy have generally focused on changing rather than accepting private experiences Traditional behav ior therapy fought anxiety with relaxation whereas cognitive therapy challenged irrational beliefs with more rational ones Essentially better forms of experiential avoidance were system atically trained as modes of intervention Even within these do mains however emotional and other forms of experiential avoidance has been recognized as a problem and such recogni tion appears to be increasing Indeed recognizing and dealing with experiential avoidance has been a central theme of modern behavioral therapies such as dialectical behavior therapy Linehan 1993 1994 acceptance and commitment therapy Hayes 1987 Hayes Strosahl amp Wilson in press Hayes amp Wilson 199439 Strosahl 1991 and revised forms of behavioral couples therapy Koerner Jacob son amp Christensen 1994 Neimeyer suggests that modern cog nitive therapy is also shifting to a position that is less interested in controlling negative feelings and more interested in interpret ing negative affect as an essential aspect of experience 1993 see also Meichenbaum 1993 Rationalemotive therapy has long embraced unconditional selfacceptance as a goal Ellis amp Robb 1994 In the traditional cognitive therapies however ex periential avoidance is not analyzed thoroughly and to the ex SPECIAL SECTION EXPERIENTIAL AVOIDANCE tent that there is an associated theory of psychopathology expe riential avoidance does not play a central role Why Would Experiential A voidance Be So Pervasive It appears that a concern with experiential avoidance is ubiq uitous across otherwise divergent psychotherapeutic systems We believe that the theme of experiential avoidance is so perva sive in various theories of psychopathology because it is such a pervasive aspect of human functioning Experiential avoidance could be analyzed in a number of ways depending on one s the oretical orientation but from our own contextual behavioral perspective Biglan amp Hayes 1996 Hayes Follette amp Follette 1995 Hayes amp Wilson 1993 there are several factors that con tribute including the bidirectional nature of human language inappropriate generalization of control rules cultural support for emotions and cognitions as causes of behavior social en couragement and modeling of experiential avoidance among others SelfKnowledge and the Bidirectional Nature of Language Let us begin an analysis of experiential avoidance with an even more general matter at the opposite end of the psychologi cal continuum Why is selfknowledge important Following in the Socratic tradition almost all schools of psychology have em phasized the importance of selfknowledge For example B F Skinner suggested that selfknowledge has a special value to the individual himself A person who has been made aware of himself is in a better position to predict and control his own behavior Skinner 1974 p 31 We agree but we argue that the bene cial elfect of selfknowledge depends entirely on the nature of human language Hayes amp Wilson 1993 Human verbal behavior is arbitrarily applicable bidirec tional and combinatorial see Hayes amp Hayes 1992 for a re view of the literature supporting these views In more com monsense terms when a human interacts symbolically with an event the functions of the referent are partially present in the symbol and vice versa and can in some circumstances spread from that symbol to others through a network of related terms For example in some contexts some of the characteristics of Tabasco sauce eg heat liquid red etc are partially psycho logically present in the word Tabasco and vice versa Hayes amp Hayes 1992 Hayes amp Wilson 1993 Because of the bidirec tional quality of human symbolic behavior when a human in teracts symbolically with his or her own behavior the psycho logical meaning of both the verbal symbol and the behavior it self can change as a result This bidirectional property makes human selfknowledge useful because it means that changes in how we view our behavior or the situations that occasion it can in turn change the functions of these situations and behaviors However this same bidirectional property also makes self knowledge potentially aversive Suppose a rat is trained to press one lever for food pellets if it has recently been shocked and another if it has not recently been shocked In effect the rat can tell whether it recently received an electric shock This is readily done because although the 1155 shock was aversive to the animal the report of it is not After all the report leads to food not to shock Simply stated it is not aversive for a nonverbal organism to report an aversive event Contrast this with the case for verbally competent humans In this case the report and the event reported are mutually re lated and therefore the functions of events are partially available in the symbolic description and vice versa Because of this for example a survivor of trauma may reexperience pain simply in the verbal reporting of that trauma In our own technical anal ysis we refer to this phenomenon as the bidirectional transfor mation of stimulus functions and have contrasted it with the unidirectional nature of normal operant and classical condi tioning Hayes amp Hayes 1992 Hayes amp Wilson 1993 Verbal awareness of one s own experience can itself change the experi ential quality of what is known Human emotions provide an example Human emotions seem to require a verbal label or appraisal as a cognitive com ponent Lazarus I982 These labels may carry with them im plications for emotional avoidance Anxiety is not just a fuzzy set of bodily states and behavioral predispositions as in nonverbal organisms it is an evaluative and descriptive verbal category that integrates a wide variety of experiences including memories thoughts evaluations and social comparisons among others The evaluative connotation of emotional labels alters the functions of private experiences that are so labeled For exam ple in most contexts anxiety is a bad emotion The bidirec tionality of human language can create the illusion that this badness is an inherent quality of the emotion itself We say this is a bad emotion not this is an emotion and I am evalu ating it as badquot These same referential or relational processes can increase the negativity of experienced events by relating the verbal label to still other verbal events in more complex ways For example if anxiety is said to be predictive of loss of con trol and less of control is predictive of social humiliation then the aversiveness of felt and labeled anxiety could increase greatly because it is verbally related to humiliation Because hu mans have been taught a wide variety of strategies for avoiding negative events it is not surprising that these would be applied to negative emotions Given our verbal abilities experiential avoidance can function generally as a Ieamed negatively rein forced behavior Giiford 1994 We are arguing that experiential avoidance is built into hu man language and is thus to some degree a basic component of the human condition The very bidirectional relations that make human verbal selfknowledge useful also can make that selfknowledge inherently dif cult and actively resisted when its content is undesirable In this view psychopathological or mal adaptive experiential avoidance is the dysfunctional range of a fairly normal behavior and it is excessive entanglements with or fusion with thoughts that particularly supports the adoption of experiential avoidance strategies Other Reasons Experiential A voidance Is Ubiquitous There are several other reasons why experiential avoidance occurs so readily First the exercise of conscious planful con trol strategies can be extremely useful in avoiding many of the 1156 hazards that life presents If one drives cautiously in the rain accidents can be avoided A program of regular brushing and flossing can help one to avoid the dentist s drill Because the exercise of such deliberate verbally guided control strategies is effective in many contexts it is only natural that we would at tempt to use these same strategies with all evaluated targets including aversive thoughts emotions and the like It is not at rst obvious that this is an inappropriate and unnecessary gen eralization of control rules to a domain in which they are nota bly ineffective Second there is a great deal of social encouragement and modeling of emotional avoidance Children are often explicitly trained to suppress emotional responding eg stop crying or 1 will give you something to cry about From the perspective of the child adults seemingly model this same behavior because they do not show emotions as readily Regulating emotional dis plays is not the same thing as regulating private experience however The child who deliberately stops crying does not nec essarily become happy only silent Third emotions and cognitions are treated as socially valid reasons for behavior As part of the socialization process people are required and able to give verbal explanations for their be havior even if its sources are unknown or obscure Semin amp Manstead 1985 Thoughts and feelings are commonly used as reasons for behavior and by extension emotions and cognitions that cause bad behavior should be avoided Unfortunately this same process excuses destructive forms of experiential avoidance itself For example a client with agoraphobia might use anxiety as a socially valid reason for social withdrawal 1 would have been too afraid if 1 left the house so 1 had to stay home Finally the immediate effects of experiential avoidance are often positive and shortterm consequences are much more im portant than longterm ones For example the immediate effect of cognitive distraction or other forms of thought suppression is positive it is only over time that the increase in avoided thoughts appears Gold amp Wegner 1995 Thus experiential avoidance appears to work even when it does not Why Would Experiential A voidance Be Detrimental These several factors may explain why experiential avoid ance is ubiquitous but they do not explain why it may result in psychopathology There are several possible reasons why emo tional avoidance may be detrimental or why its converse psychological acceptance quay be helpful These analyses must be tentative in part because data on these issues are rela tively new Until recently the importance of psychological ac ceptance was emphasized in the less empirical traditions such as the humanistic or existential approaches Greenberg 1994 Only within the past 10 years have a number of empirically based treatment approaches emerged that are oriented toward different types of psychological acceptance eg Barlow amp Beck 1984 Chiles amp Strosahl 1995 Cordova amp Kohlenberg 1994 Hayes 1984 1987 Hayes Jacobson Follette amp Dougher 1994 Hayes amp Wilson 1994 Jacobson 1991 Keener et al 1994 Kohlenberg amp Tsai I991 Linehan 1993 Marlatt 199439 Strosahl 1991 Again the analysis of detrimental effects HAYES WILSON GIFFORD FOLLETTE AND STROSAHL differs according to theoretical orientation although the exis tence of such effects seems widely accepted Our analysis of the destructive effects of some forms of experiential avoidance cen ters around certain wellestablished principles of learning as well as on some emerging analyses of social verbal contextual factors The Process of Deliberate A voidance Necessarily Contradiets the Desired Outcome In humans deliberate avoidance usually involves formulat ing and following a verbal plan In some areas of experiential avoidance this is inherently problematic because the verbal reg ulatory process includes the avoided item For example cogni tive avoidance is dif cult because deliberately trying to rid one self of a thought involves following the verbal rule that contains the thought There is a signi cant and rapidly growing body of evidence that deliberate thought suppression and control may actually be counterproductive in that an attempt not to think thoughts often creates those very thoughts eg Wegner Schneider Carter amp White 1987 Wegner Schneider Knutson amp McMahon 199 l The Regulation of Private Events Is Largely Unresponsive to Verbal Control Many private experiences are classically conditioned either directly or indirectly For example if painful emotional experi ences have been associated with a particular event that is either directly present or present indirectly through verbal relations it is likely that this event will now arouse negative emotions by association alone In these circumstances attempts at purpose ful control may be relatively ineffective because the underlying process or history is not readily verbally governed The experimental evidence for the harmful effects of emo tional suppression is not yet as great as that for thought sup pression but there seem to be many examples of these vicious cycles For instance suppose a person is extremely distressed about anxiety and tries to do everything to eliminate it because of its awful meaning and potentially terrible consequences In this case a small bit of classically conditioned anxiety may cue both purposeful attempts to avoid and reduce the anxiety and additional anxiety associated with the verbal construction of highly aversive consequences In essence the person may be come anxious about being anxious This kind of harmful effect of experiential avoidance is most likely precisely when the seeming need for it is greatest because it is then that the nega tive effects of failure would be most closely related to the avoid ance strategy and even minor levels of avoided material would be threatening Panic disorder may be an example of such a phenomenon Chambless Caputo Bright amp Gallagher 1984 Craske Sanderson amp Barlow 198739 Goldstein amp Chambless 1978 Hayes 1987 Change Is Possible But the Change Strategy Leads to Unhealthy Forms ofA voidance Suppose someone tried not to remember a given event Mem ories are not simple voluntary behavior once an event has SPECIAL SECTION EXPERIENTIAL AVOIDANCE occurred remembering it may occur relatively automatically in a wide variety of circumstances Strategies to avoid memories might include avoiding all situations that might give rise to it dissociating or other means The problem with these strategies is that even if they are successful they create additional prob lems such as constricting the person s freedom to be in other wise valuable situations or limiting conscious access to life events This is one of the processes that has been most empha sized in the humanistic tradition Emotional avoidance restricts the wisdom of humans by diminishing access to one s own his tory and the response tendency information contained therein Safran amp Greenberg 1988 cf Greenberg 1994 The E motionLaden Event Is Important Sometimes experiential control is put in the service of man aging entirely appropriate reactions to unchangeable events merely because the reaction is not pleasant For example a per son may take the view that I can t accept that my Dad was killed and use drugs to avoid the grief associated with his death Grief is a natural reaction to such losses and no amount of drug consumption will alter either the situation or the loss No effort to reduce or alter private events is called for here When an unchangeable loss occurs the healthy thing to do is to feel what one feels when losses occur Healthy Change Produces Painful Experiences Change can be frightening At times what needs to be done is avoided because it is experientially difficult This suggests a major reason experiential avoidance may lead to psychopathol ogy It restricts needed change Instead of putting deliberate change efforts in the service of necessary and useful life changes experiential avoidance emphasizes a secondary agenda that can too easily be accomplished in destructive ways One cost is that a stenotopic condition a narrow range of adaptability to changes in environmental conditions ensues We are not arguing that all forms of experiential avoidance are unhealthy In many instances there is nothing harmful about seeking relaxation or putting off distracting thoughts or avoiding physical pain Ironically however these healthy forms of experiential avoidance apply most clearly when the experi ences involved are not intense and clinically relevant For ex ample relaxation is much more likely to reduce normal stress than to eliminate panic attacks In the present article we limit our analysis to experiential avoidance that persists even when it is costly useless or life distorting In these circumstances experiential avoidance becomes pathological Evidence for Experiential Avoidance as a Pathological Dimension A functional approach is explicitly inductive The phenome non and its context are the focus of interest Unlike more de ductively oriented approaches where empirical ndings are used to argue for and against complex theoretical positions functional dimensions are organized more humbly around di 1157 rect observations Because of this data from various schools of thought and research areas become relevant to each other In the following sections we review literatures as diverse as basic experimental analyses of human cognition and emotion literature on coping styles experimental psychopathology clin ical process and psychotherapy outcome research Although the purposes and orientation of these various researchers are quite divergent the dimension of experiential avoidance can play an important role in organizing their data in a coherent way We believe that this tendency to integrate data from both basic and applied research domains is characteristic of func tional diagnostic dimensions Gifford I995 Evidence From Basic Experimental Work One major source of data relevant to experiential avoidance is from the emerging thought suppression literature A number of studies have demonstrated that when participants are asked to suppress a thought they later show an increase in this sup pressed thought compared with those who are not given sup pression instructions Clark Ball amp Pape 1991 Gold amp Weg ner I995 Wegner et al 1987 Wegner et al I991 A number of variations on this research have been done that have implications for an experiential avoidance perspective For example participants who have been asked to suppress a par ticular thought show rebound effects speci cally in contexts in which the suppression took place Wegner et al 1991 These data suggest that if an individual successfully suppresses some aversive thought or memory in a particular situation they might nd the thought remaining at fairly low levels in contexts not related to suppression but when they return to the original context they would not only be likely to reexperience the sup pressed thought but would be likely to experience it at an even higher level than before This suggests that cognitive avoidance is most likely to fail in the precise contexts in which its success is most important and desired The paradoxical effects of thought suppression have also been linked to mood In a study using mood induction participants were asked not to think a specific thought while in a speci c mood Wenzlaff Wegner amp Klein 1991 In subsequent phases of the experiment participants were assigned to either similar or different mood induction procedures All participants showed a rebound effect but those who had the same mood in duction in the second phase had a significantly higher rebound effect This suggests that if a person is avoiding a thought that is associated with anxiety for example the paradoxical increase produced by suppression is most likely to be seen when the per son is anxious precisely when a person struggling with an anx ious thought would least like suppression to fail Furthermore a separate experiment showed that the suppressed thought will come to produce the mood that was present during the original suppression Wenzlaffet al 1991 Thus a kind of selfampli fying loop can be created from precisely the kinds of mood cog nition and suppression components likely to be experienced by those with clinical disorders The paradoxical effects of suppression have also been dem onstrated in a study examining somatic sensation Ciof amp Hol loway 1993 Participants in a coldpressor pain induction pro 1158 cedure were given one of three sets of instructions They were told to think about their room at home distraction focus on the sensations in their hand or eliminate thoughts about pain entirely Recovery on discomfort ratings was slowest for the sup pression instructions and most rapid for the focusing instruc tions Later in the experimental hour they were asked to rate the unpleasantness of an innocuous vibration Participants from the suppression condition rated it as more unpleasant than did those with other instruction sets This suggests that part of the unpleasantness of avoided emotions comes from the very process of avoidance not from the emotions themselves Evidence From the Coping Styles Literature Research into coping strategies has also demonstrated the detrimental effects of experiential avoidance One of the most widely used methods of assessing coping strategies is the Ways of Coping Questionnaire WOC Folkman amp Lazarus 1988 Lazarus and Folkman 1984 have identi ed two dominant means of coping with stressful situations problemfocused and emotionfocused coping strategies Problemfocused strategies involve active attempts to alter distressing situations such as I made a plan of action and followed it Many of the emotion focused coping strategies by contrast clearly involve experien tial avoidance as we have de ned it here such as refusing to think about disturbing events supplanting bad thoughts with good ones looking at the bright side of things or telling things to oneself to help feel better Similarly factor analysis of another instrument the Coping Inventory for Stressful Situations CISS identi ed taskori ented emotionoriented and avoidanceoriented coping strate gies Endler amp Parker 1990 Items assessing avoidance involve either distraction watch TV or social diversion phone a frien Endler and Parker suggested that although these ac tivities are not focused on emotion per se they are engaged in as a way to manage emotional responses to stressful situations Consistent with an experiential avoidance perspective both emotionfocused and avoidant strategies measured using the WOC the CISS and similar instruments have been found to negatively predict outcome for a variety of di iculties including substance abuse Ireland McMahon Malow amp Kouzekanani 1994 depression DeGenova Patton J urich amp MacDermid 1994 Bruder Mattson amp Hovanitz 1990 and sequelae of child sexual abuse Leitenberg Greenwald amp Cado 1992 A different but suggestive effect has been found in the study of chronic pain patients Jensen and Karoly 1991 found that ignoring pain diverting attention and the use of coping self statements was predictive of better psychological functioning but this effect was found only for patients with low not high levels of pain Thought suppression as a general style of coping seems to be detrimental For example research using the White Bear Sup pression Inventory WBSI Wegner amp Zanakos 1994 has shown that thought suppressors tend toward depression and ob sessional symptomatology The WBSI includes such items as I often do things to distract myself from my thoughts and I always try to put problems out of mind Struggling with negatively evaluated emotions is also detri HAYES WILSON GIFFORD FOLLETTE AND STROSAHL mental For example research using the Depression Sensitivity Scale DSS Zanakos amp Wegner 1993 has shown that emo tional avoiders tend toward depressive symptomatology partic ularly when combined with thought suppression as a coping strategy Wegner amp Zanakos 1994 The DSS includes such items as when I start to feel sad I try to get rid of those feelings as quickly as I can Evidence From Psychotherapy Process Research In a review of 1100 quantitative studies of the relationships between process and outcome variables Orlinsky and Howard 1986 found that selfrelatedness was the most consis tently positive correlate of therapeutic outcomequot p 366 Cli ents high in selfrelatedness were de ned as being in touch with themselves and open to their feelings as contrasted with being out of touch with themselves p 359 The Experiencing Scale Klein Mathieu Gendlin amp Kiesler 1969 Klein MathieuCoughlan amp Kiesler 1987 is the most widely used process measure in psychotherapy research Hill 1990 The Experiencing Scale measures the extent to which ongoing bodily felt ow of experiencing is the basic datum of awareness Klein et al 1969 p 1 In our terms the Experiencing Scale measures at least in part the absence of emotional avoidance High client level of experiencing has been consistently related to a good outcome in psychotherapy Greenberg 1983 Greenberg amp Dompierre 1981 Greenberg amp Webster 1982 Kiesler 1971 Luborsky Chandler Auerbach Cohen amp Bachrach 1971 see Greenberg amp Safran 1989 for a review Emotional willingness is a marker of good outcomes in the treatment of chronic pain Geiser 1992 and other types of pain Khorakiwala 199139 McCurry 1991 Evidence From the Literature on Clinical Syndromes One approach to determining the utility of experiential avoidance as a functional dimension of psychopathology is to see if it provides a useful addendum to current syndromal cate gories Many if not most psychopathological classi cations in clude the presence of problems with private experiences al though the relevant features vary across speci c syndromal cat egories For example the form of the avoidance may vary A person who drinks to suppress anxiety may be an alcoholic a person who hides for the same reason may be an agoraphobic The avoided experience may also vary For example persons with a panic disorder may struggle with anxiety whereas those with obsessivecompulsive disorder OCD may struggle with a thought The source of the avoided material may vary A person with posttraumatic stress disorder PTSD suffered a speci able original trauma 1 person struggling with depression may not We are not claiming that all of these various syndromes are experiential avoidance disorders Rather we are suggesting that many topographically de ned syndromes may include signi cant subgroups in which experiential avoidance has been a functionally important factor in the etiology and maintenance of these pathological patterns We examine this idea in more detail with four diagnostic cat SPECIAL SECTION EXPERIENTIAL AVOIDANCE egories drawn from the current syndromal system substance abuse 0CD panic disorder with agoraphobia and borderline personality disorder BPD This list is not exhaustive indeed several other important disorders have been interpreted from an experiential avoidance point of view eg depression see Zet tle 1984 In each case we examine evidence of a unaccept able and avoided private experiences as a component of this disorder b ineffective avoidance strategies as a component and c treatment implications of an experiential avoidance in terpretation of some persons suffering from the disorder Substance Abuse and Dependence De nitionally substance abuse and dependence is not a com plicated syndrome it is de ned by very straightforward behav ioral criteria Why people use drugs is not at issue The litera ture suggests however that a subgroup of drug abusers are ex periential avoiders cf Cooper Russell Skinner Frone amp Mudar 1992 Wanberg Horn amp Foster 1977 The language of experiential avoidance applies equally well to stimulants as to depressants if one assumes that the felt absence of such stim ulation is boring or otherwise aversive E vidence for drug use an ine ective avoidance strategy There is no doubt that drug use per se is a highly effective shortterm strategy for experiential change Virtually all drugs of abuse have known psychoactive effects Furthermore drug abusers believe in these effects more than do others In the area of alco holism for example alcoholics exceed problem drinkers with problem drinkers exceeding nonproblem drinkers in their ex pectancy that alcohol will enhance pleasure and reduce stress Conners O Farrell Cutter amp Thompson 1986 Cooper et al 1992 found that psychological stressors were related to poorer alcohol outcomes only among drinkers high in use of emotional avoidance coping strategies and high in expectancies that alco hol would lessen negative affect Evidencefor avoided experiences in drug use Because the effects of drugs are broad almost any experience from boredom to anxiety attacks to withdrawal sensations can become linked to drug use Among the private experiences considered impor tant in various theories are expectancies and beliefs cravings aversive bodily states and disagreeable emotions Beck Wright Newman amp Liese 199339 Childress McLellan Natale amp O Brien 1986 Meyer 1986 SanchezCraig 1984 reported that among 297 drinking episodes described by 70 partici pants nearly 80 of the episodes involved drinking aimed at manipulating various subjective experiences eg social dis comfort attenuation of negative emotions increasing pleasure etc Childress et al 1986 demonstrated that emotions such as anxiety anger and depression function to trigger subjective experiences of craving and withdrawal among detoxi ed opiate addicts Given this it is not surprising that substance abuse is fre quent among those with affective and anxiety disorders eg Mirin Weiss amp Michael 1987 Pashko amp Druley 1987 Stock well amp Bolderston 1987 Thyer et al 1986 Researchers have suggested that some with primary affective or anxiety disorders may abuse drugs in an attempt to alter undesirable mood states or to ameliorate intolerable anxiety Mirin et al 1987 p 1159 141 Similarly because unpleasant private experiences seem most likely given aversive histories it is not surprising that the incidence of substance abuse among individuals with traumatic histories is high eg Druley Baker amp Pashko 1987 Polusny amp Follette 1995 cf Khantzian 1985 Even if drug abusers did not start their patterns of abuse as a method of experiential avoidance the effects of drugs on dysphoric or withdrawal states that are the result of excessive drug use may help maintain the pattern of abuse Marlatt 1985 Sher 1987 Treatment implications The psychological models applied to substance abuse and its treatment vary widely but almost all are sensitive to the role of the abuser s private experience in the development of the addiction or in relapse prevention or in both Most empirically oriented efforts to date have attempted to change the avoided content eg through anxiety manage ment stress reduction or pharmacotherapy and thus reduce the need for drug use as a method of experiential manipulation eg Miller amp Hester 1986 Stockwell amp Bolderston 1987 Others have tried to add conditioned aversive emotional states that are produced by reaching for tasting or imagining drink ing alcohol so that experiential avoidance works for rather than against treatment goals Rimmele Miller amp Dougher 1989 The direct use of acceptance methods in the empirical treat ment of drug and alcohol abuse is in its infancy although 12 step programs meditative approaches and others have long en couraged acceptance as a component of treatment Marlatt 1994 Wulfert 1994 No data are currently available on the relative efficacy of acceptance versus controlbased methods 0CD In this syndrome Hollander 1993 Rasmussen amp Eisen 1992 its very name describes both unacceptable experiences and ineffective change strategies designed to avoid them Evidencefor avoided experiences By definition 0CD in cludes various private experiences that the client seeks to escape or avoid Aversive thoughts intrude into conscious awareness fo cused on contamination persistent doubts about whether one has performed some act eg unplugged appliances locked doors or doing some aggressive or socially unacceptable act eg screaming an obscenity harming one s children among others Note that these thoughts usually are highly negatively valenced and thus are more likely to initiate a cycle of deliberate struggle and avoidance Evidence for ine ective avoidance strategies When such thoughts occur some individuals with 0CD may simply try to ignore or suppress the thought distract themselves and so on whereas others may develop elaborate rituals that are thought to undo the danger and experientially reduce anxiety connected to the intrusive thoughts These rituals can become quite ex tended because the person can always imagine that they did not suf ciently engage in the ritual undoing of the problematic thought Clients with 0CD become disturbed when these meth ods of experiential escape and avoidance are interrupted Exposure and response prevention the treatment of choice for 0CD is suf ciently aversive that McCarthy and Foa 1990 re ported that 25 of the clients with 0CD who seek treatment refuse this form 1160 0C D provides a clear example of an area in which the process of deliberate control may contradict the desired outcome De liberater trying to rid oneself of a thought involves following the verbal rule 1 must not think thought x However such a rule by specifying thought x produces contact with thought x and thus thoughts of thought x quot Whether by rit ual distraction or suppression experiential avoidance in OCD seems to be more the source of the lifeconstricting effects of the disorder than unwanted thoughts per se Treatment implications In general OC D is fairly treatable with psychosocial methods and those that are effective seem sensible in light of the literature on thought suppression and other forms of experiential avoidance Clark amp Purdon 1993 Gold amp Wegner 1995 Using at least 50 improvement as a cutoff approximately 75 to 80 of those suffering with DC D can be treated successfully with response prevention and exposure Foa Steketee Grayson Turner amp Latimer 1984 Hoogduin amp Duivenvoorden 1987 Rachman amp Hodgson 1980 From the current perspective response prevention and exposure may work because these methods indirectly un dermine the use ofexperiential avoidance strategies such as dis traction or rituals If this analysis is correct it is especially im portant that clients face avoided psychological material during exposure Some evidence exists in support of this idea For ex ample researchers have found that distraction strategies ap plied to situational or somatic stimuli during exposure treat ments result in reduced anxiety within session but actually in terfere with the longterm effectiveness of treatment Grayson Foa amp Steketee 1982 Foa amp Kozak 1986 Given the present perspective pure obsessive clients with the disorder should be most di icult to treat because their methods of experiential avoidance eg cognitive distraction are not overt and thus are much more difficult to undermine Research has shown this to be the case Salkovskis amp Westbrook 1987 1989 Panic Disorder With Agoraphobia Here we have a classi cation that also emphasizes the experi ence to be avoided American Psychiatric Association 1994 E vidence Or avoided experiences Clients with agoraphobia become extremely reactive to changes in their physiological state Barlow 1988 Small increases in heart rate may be in terpreted as catastrophic Pauli et al 1991 This catastrophic interpretation has been theorized to result in a positive feed back loop between internal perceptions and physiological activ ity that can culminate in a panic attack Pauli et al 1991 p 137 cf Clark 1986 Ehlers Margraf Roth Taylor amp Bir baumer 1988 Clients with agoraphobia sh0w increases in anxiety in response to both selfdetected increases in heart rate Pauli et a1 1991 as well as to false heart rate feedback Ehlers et al 1988 A wide range of external orinternal stimuli may initially trigger symptoms of physiological arousal eg elevated heart rate dizziness or shortness of breath If the anx iety prone individual misinterprets these sensations as life threatening an increase in apprehension is generated which itself creates additional arousal Clark 1986 Ehlers et a1 1988 E videncefbr ineffective avoidance strategies The fear that HAYES WILSON GIFFORD FOLLETTE AND STROSAHI clients with agoraphobia have is not of the places per se but of their potential reactions to those places This has led some to describe agoraphobia as the fear of fear or fear of panic see Barlow 1988 Chambless et al 1984 Goldstein amp Chambless 1978 and as leading to increasingly restricted lifestyles Avoid ing conditions that might give rise to fear or panic leads patients to limit travel or avoid being in the feared environment unless accompanied by a trusted companion Other dominant psychological characteristics of this disorder are interpretable from an experiential avoidance point of view Clients with agoraphobia frequently report thoughts that they will die lose control or go crazy American Psychiatric Asso ciation 1994 Such catastrophic cognitions have been repeat edly shown to be related to poor treatment outcomes Chambless amp Gracely 1988 For example Keijsers Hoog duin and Schaap 1994 found that fear ofthe effects ofpanic is a negative predictor of treatment outcome The need to control emotion to control imagined dangerous outcomes in turn leads to scanning vigilance generation of escape plans and so on All of these can be construed as methods of experiential avoidance Craske Miller Rotunda and Barlow 1990 found that clients with agoraphobia rated as extensive avoiders tended to develop more additional anxiety disorders over time than did minimal avoiders although no such dilferences existed before their cli ent s rst panic episode Experiential avoidance strategies cannot work readily in panic disorder in part because any method of avoidance of a danger reconnects the individual with the danger and anxiety is the natural response to danger whether it is established di rectly or cognitively The main problem in the anxiety disor ders is not in the generation of anxiety but in the overactive cognitive patterns schemas relevant to danger that are contin ually structuring external and or internal experience as a sign ofdangerquot Beck amp Emery 1985 p 15 Treatment implications The treatment of panic disorder has improved markedly in recent years with the addition of methods that deliberately expose clients to emotions bodily sensations and other previously avoided private experiences For example Barlow and his colleagues have emphasized an exposure to fear and its interoceptive accompaniments through deliberate hyperventilation spinning and so on Barlow Craske Cerny amp Klosko 1989 Craske amp Barlow 1990 There is some evidence that these treatments work in part by undermining experiential avoidance strategies Barlow 1988 For example Craske Street and Barlow 1989 gave clients with agoraphobia instructional sets to either focus on feared somatic sensations or to engage in distraction tasks Although the distraction group showed greater improvement posttreat ment than the focus group the focus group showed greater im provements at the 6month followup There seems to be in creasing agreement that to recover the agoraphobic must know how to face accept and go through panicquot Weekes 1978 p 362 BPD Although BPD is so broadly de ned that some researchers question its discriminant validity Akiskal 1994 Strosahl SPECIAL SECTION EXPERlENTIAL AVOIDANCE 1991 Tyrer 1994 patients with this problem face a wide vari ety of dif cult experiences and show notable avoidance patterns Evidence for avoided experiences Emotional distress is a de ning feature of BPD Among other dimensions clients with BPD are characterized by a volatile and chronic depressive state selfcondemnation emptiness fears of abandonment selfdestructive fantasies and profound hopelessness Cowdry Gardner O Leary Leibenluft amp Rubinow 199139 Rogers Wid iger amp Krupp 1995 Southwick Yehuda amp Giller 1995 com bined with intense and poorly targeted anger Gardner Leiben luft OfLeary amp Cowdry 1991 As might be expected patients with these symptoms often report painful and chaotic child hoods Diamond amp Doane 1994 Goldman D Angelo amp De Maso 1993 Weaver amp Clum 1993 Not only do patients with BPD experience chronically high levels of emotional distress but they also lack the skills required to moderate emotional arousal or to function with distress Strosahl 1991 E vidence for ine ective avoidance strategies A hallmark of these patients is impulsive repetitious selfdestructive behavior including suicide attempts Soloff Lis Kelly Cornelius amp Ul rich 1994 and self mutilation Dulit Fyer Leon Brodsky amp Frances 1994 Recurrent selfdestructive behavior is usually a primary target of clinical treatment although it is very common to encounter other problems such as an eating disorder Koepp Schildbach Schmager amp Rohner 1993 alcohol and drug ad diction Links Heslegrave Mitton Van Reekum amp Patrick 1995 Miller Abrams Dulit amp Fyer 1993 and in men spouse or partner battery Dutton amp Starzomski 1993 The common feature of all of these behaviors is that they have the experiential avoidance properties of addictive behavior Chiles amp Strosahl 1995 ie the behaviors produce emotional escape or relief from negative arousal This destructive and dysfunctional avoidance and escape behavior represents an extreme solution to the problems of a sustained negative overarousal and b the lack of verbally based methods for modulating the effects of negative private experiences The functional experiential avoid ance role of these repetitive self destructive behaviors is revealed in several studies For example some selfmutilators experience reduced or no pain during or after selfinjury Russ Shearin Clarkin Harrison amp Hull 1993 Similarly some of these pa tients show lower levels of depression anxiety and hopelessness after the index suicide attempt Strosahl Chiles amp Linehan 1992 The multiproblem patient consistently blurs the distinction between thought and thinker feeling and feeler Hayes et al in press This cognitive and emotional fusion makes negative in ner experiences intolerable and unacceptable and leads to de pressive numbing or splitting as a way of avoiding direct con tact with them Unfortunately this primary emotional avoid ance not only is purchased at great personal cost emotional numbness and avoidance of self but it ultimately fails as a method of avoiding feared private experiences Treatment implications Currently the only empirically validated treatment for borderline personality disorder is Li nehan s dialectical behavior therapy DBT This treatment model incorporates a strong affect tolerance and experiential acceptance component Linehan 1993 1994 and overall fits 1161 very well with experiential avoidance as a functional diagnostic dimension Because one of the main purposes of functional di agnostic dimensions is to arrive at analyses with treatment uti lity the effectiveness of DBT with this difficult population is very promising for the concept of experiential avoidance Evidence From the Literature on Nonsyndromal Clinical Problems There is an inherent weakness in the syndromal approach to classi cation Many areas of applied knowledge cannot be reduced to syndromes This may be because the area deals with a subclinical problem eg routine forms of marital discord because it is viewed in terms of health rather than disease eg the development of intimacy because the literature is orga nized etiologically eg the effects of childhood sexual abuse or because the problem area is related to many syndromal and nonsyndromal conditions eg suicidality Functional diag nostic dimensions do not necessarily have this problem be cause they are in principle relevant to all these areas as well as to syndromes We deal with two examples suicide and child sexual abuse Suicide as the Final I ne ective A voidance Strategy No human behavior is harder to conceptualize from a tradi tional categorical or dimensional diagnostic model than suicide Suicide cannot be explained as the symptom of a mental illness because as many as half of all victims could not be diagnosed as having a mental illness Strosahl amp Chiles in press Suicidal behavior and ideation is so prevalent in the general population that unless more than 50 of all people are going to be diag nosed as suffering from a mental disorder we must conclude that it is a common feature of contemporary existence Strosahl Linehan amp Chiles 1984 Even considering those patients with behavior disorders suicide is not the province of any particular diagnostic condition For example an equal number of suicides are seen among such diverse diagnostic groups as depression schizophrenia and the personality disor ders Buda amp Tsuang 1990 Suicide rates rise steadily with age whereas no corresponding increase is seen in the prevalence of mental disorders Men are much more likely to commit suicide whereas women are much more likely to be diagnosed with a mental disorder Chiles amp Strosahl 1995 Paradoxically those patients who do not have predisposing conditions may be the most likely to commit suicide Goldstein Black Nasrallah amp Winokur 1991 E videneejor avoided experiences and suicide as an avoidance strategy Approached as a method of experiential avoidance suicide is relatively easy to understand and investigate In the presence of seemingly bad feelings distressing thoughts un wanted memories or unpleasant bodily sensations the person formulates an if thenquot verbal relation in which suicide as verbally conceived will lead to relief ceasing of suffering proof of one s own rightness or of the wrongness of others and sim ilarly positive private outcomes Chiles amp Strosahl 1995 Hayes 1992 When the motivational conditions involved in suicide are analyzed more than half of actual or attempted sui 1162 cides involve an attempt to ee from aversive events L00 1986 Smith amp Bloom 1985 especially states of mind such as guilt and anxiety Bancroft Skrimshire amp Simkins 1976 Baumeis ter 1990 Persons who commit suicide evaluate themselves quite negatively believing themselves to be worthless inade quate rejected or blameworthy Maris 1981 Rosen 1976 Rothberg amp Jones 1987 Several studies have shown that avoidancebased problem solving is a primary characteristic of suicidal behavior For example suicide attempters generally rate suicide as a more effective way of solving problems than nonsuicidal patients Chiles et al 1989 Strosahl et al 1992 Functional analysis of the immediate time frame before the index suicide attempt reveals unsuccessful attempts to elimin ate distress that the person regards an unacceptable and intolerable by both functional calling a friend and dysfunc tional drinking means followed by the suicide attempt Chiles Strosahl C0wden Graham amp Linehan 1986 Treatment implications There are two implications for in tervening with suicidal behavior as a method of experiential avoidance Chiles amp Strosahl 1995 First it may not be nec essary to alter the form called suicidal behavior to change its psychological function The client does not have to eliminate suicidal thinking or behavior to attain psychological health Instead it may be the client s struggle to eliminate suicidal thoughts directly that leads to the sense of suicidal crisis which is really a struggle over selfcontrol Second there is no need to conceptualize suicidal behavior as aberrant Given its population prevalence it may be construed as relatively normal behavior For many suicidal patients the mystery and fear asso ciated with a clear symptom of mental illness can be replaced with a focus on alternative methods for either accepting un changeable private experiences targeting problemsolving efforts on things that can be controlled or both The Sequelae of Childhood Sexual Abuse The literature on child sexual abuse suggests that it is a major risk factor in the development of a variety of problems includ ing depression anxiety selfmutilation substance abuse so matization interpersonal isolation sexual dissatisfaction and risk for revictimization see Browne amp F inkelhor 1986 and Po lusny amp Follette 1995 for reviews of this literature Evidence for avoided experiences and ine ective avoidance strategies Sexual abuse results in intensively negative experi ences for many individuals For example some of the affective responses include guilt shame fear and rage Polusny amp Fol lette 1995 Several researchers Briere amp Runtz 1993 P0 lusny amp Follette 1995 Rodriquez Ryan amp Foy 1992 have described the correlates of child sexual abuse in terms that t the idea that experiential avoidance is a core intrapersonal vari able in the development of seqnelae to childhood sexual abuse Although the diverse outcomes observed in clinical samples of sexual abuse survivors eg dissociation substance abuse posttraumatic stress disorder highrisk sexual behavior self mutilation are quite variant in topography they may actually be relatively consistent in function For example the use of avoidant coping strategies among survivors is predictive of such indicators of poor psychological functioning Leitenberg et al HAYES WILSON GIFFORD FOLLETTE AND STROSAHL 1992 Rodriquez et al 1992 although survivors rate such cop ing strategies as most elfective in the short term Leitenberg et al 1992 This ts with the larger literature on trauma which shows that when trauma victims are assessed shortly after the traumatic event symptoms such as numbing and avoidance of trauma reminders are far more prevalent among individuals who subsequently develop PTSD than among those who do not Foa amp Riggs 1995 Similarly severity of dissociative symp toms better predicts future outcomes than does severity of an x iety Foa amp Riggs 1995 Avoidance of close interpersonal relationships may represent another emotionally avoidant coping strategy for the survivor The context of a close relationship may restimulate thoughts and feelings associated with the abuse or the fear that those feel ings would again occur For example intrusive images and thoughts of the abuse are frequently observed by survivors while engaging in sexual activity Herman Russell amp Trocki 1986 39 Treatment implications The empirically based treatment literature on survivors of childhood sexual abuse is still quite limited However many of the persons diagnosed with tradi tional syndromes may carry these syndromal labels in part as a result of their abuse history Thus the evidence reviewed in ear lier sections is relevant here From an experiential avoidance perspective however treatment of abuse survivors should in volve in part exposure to previously avoided thought feelings memories and bodily sensations and the use of methods that help undermine distraction dissociation and other forms of experiential avoidance Some evidence is supportive of these recommendations Follette 1994 Experiential A voidance Summary The core concept of experiential avoidance seems to integrate a wide body of literature drawn from basic experimental clini cal process styles of coping experimental psychopathology syndromal and nonsyndromal areas This research comes from diverse theoretical backgrounds The faults of syndromal classi cation are often noted but are justi ed in part because these atheoretical topographical entities bring together researchers from a variety of traditions and provide an avenue for research effort However functional diagnostic dimensions may do the same thing with the added bene t of etiology and treatment uti lity If many forms of psychopathology are forms of experiential avoidance then we can proceed to the theoretical and empirical analysis of this functional dimension from a wide variety of re search and theoretical traditions The Treatment Implications of Experiential Avoidance The hallmark of functional diagnostic dimensions is the effort to stay close to the pragmatic purposes of classi cation For that reason it is important that there be clear treatment implications for this dimension We believe that the recent in terest in acceptancebased treatment approaches ts directly with the present analysis of experiential avoidance In the current View many forms of psychopathology are not merely bad problems they are also bad solutions based on a SPECIAL SECTION EXPERIENTIAL AVOIDANCE dangerous and ineffective use of experiential avoidance strate gies Instead of encouraging clients to use more clever ways to ght and win this war with their own thoughts feelings and bodily sensations the ubiquity of problems associated with ex periential avoidance suggests that it might be safer to help cli ents step out of this war altogether Acceptancebased treatments attempt to alter the impact of emotions and cognitions by altering the struggle with them rather than by attempting to change their form frequency or situational sensitivity In other words in acceptancebased ap proaches the client s original aim of controlling his or her pri vate experiences eg emotions thoughts cravings bodily states etc is itself seen as modi able see Hayes et al 1994 for a booklength review of some of these acceptance methods Psychological acceptance at its lowest level is implicit in any psychotherapy because at the minimum the client and therapist must admit that there is even a problem to be worked on At a higher level it may be possible to change the change agenda it self Acceptance in this context means actively contacting psy chological experiences directly fully and without needless defense while behaving effectively For the client with agora phobia this may mean seeking out the bodily sensations that have heretofore been avoided for the client with 0CD it may mean practicing just noticing thoughts An acceptance ap proach does not abandon direct change efforts It simply targets them toward more readily changeable domains such as overt behavior or life situations rather than personal history or auto matic thoughts and feelings Hayes 1994 In accord with our analysis of the origins of experiential avoidance most forms of acceptancebased treatment target the domination of verbal and cognitive functions over other psychological functions These might include paradox meditation just noticing exercises in verbal exibility mindfulness exercises experiential exercises and the like As we have already noted in several areas empirical analyses of acceptance methods are creating excitement in many areas Hayes et al 1994 For example Barlow and his colleagues have improved the treatment of clients with agoraphobia by adding greater exposure to emotional and bodily states Barlow amp Craske 1989 Barlow et al 1989 Marlatt has worked on the addition of techniques drawn from Eastern psychology to promote acceptance of urges what he called urge sur ng as a component of relapse prevention in substance abusers Marlatt 1994 Linehan 1993 has improved the treatment of personality disorders by adding mindfulness strategies and work on the acceptance of aversive emotions mindfulness training a Buddhist tradition emphasizing emotional acceptance has also been used successfully with the treat ment of chronic pain KabatZinn 1991 Jacobson and his colleagues Jacobson 1991 Koemer et al 1994 have im proved success in behavioral marital therapy by working on ac ceptance of the idiosyncrasies of marital partners as a route to increased marital satisfaction emotionfocused therapy Greenberg amp Johnson 1988 has shown good results with cou ples by increasing emotional acceptance Chiles and Strosahl 1995 have added acceptance to the treatment of suicidality acceptance and commitment therapy Hayes 1987 Hayes Strosahl amp Wilson in press Hayes amp Wilson 1994 has shown 1163 the bene cial effects adding emotional acceptance and cognitive defusion to the treatment of depression Zettle 1984 Zettle amp Raines 1989 and other disorders Thus although the area is still very new we now have a grow ing body of data that point to the importance of psychological acceptance across a wide range of clinical disorders Interest ingly many of the less empirically oriented treatment strategies have long emphasized forms of acceptance from psychoanaly sis Freud 1924 to logotherapy Frankl 1975 to Alcoholics Anonymous Wulfert 1994 Some empirical clinicians may be worried by this overlap between the more and less empirical sides of psychology but it could be very healthy for the eld if dimensions can be found that cross these boundaries without a loss in scienti c integrity Summary Syndromal classi cation is in many ways foreign to psychol ogy because it tends to ignore the developmental functional contextual approach to behavior that is characteristic of much of our discipline in favor of a more object like pathological medical approach Hayes amp Heiby 1996 It seems extraordi narily unlikely that syndromal classi cation will go away any time soon but the slow progress of a scienti c approach to psy chopathology suggests that alternative approaches should be fostered and tested Functional diagnostic dimensions present such an altema tive of which emotional avoidance is just one example other possible dimensions might include such examples as poor rule generation inappropriate rule following or socially impover ished repertoires although defense of these dimensions awaits another day Functional diagnostic dimensions are not tradi tional disorders nor are they wellworkedout etiological theo ries They are dimensional processes not allor nothing catego ries that suggest psychological processes relevant to etiology that make coherent many topographical forms under a single functional process and that can be readily linked to treatment As such they provide a kind of functional middle ground be tween mere psychological topography on the one hand or well developed and functional psychological theories of psychopa thology on the other Functional diagnostic dimensions focus directly and nonprej udicially on the behavior of interest This allows research from many areas of our disparate eld to proceed but in a manner that is more tting with psychology and its traditions than the psychiatric nosology that we have imported References Adams H E amp Cassidy J E 1993 The classi cation of abnormal behavior In P B Sutker amp H E Adams Eds Comprehensive hand book of psychopathology pp 3 26 New York Plenum Press Akiskal H S 1994 The temperamental borders of affective disor ders Acla Psychiatrica Scandinavica 89 32 37 American Psychiatric Association 1980 Diagnostic and statistical manual ofmenlal disorders 3rd ed Washington DC Author American Psychiatric Association 1994 Diagnostic and statistical manual of mental disorders 4th ed Washington DC Author Bancroft 1 Skrimshire A amp Simkins S 1976 The reasons people 1164 give for taking overdoses British Journal ol39Rs39it hiatry I28 538 548 Bandura A 1968 A social learning interpretation of psychological dysfunctions In P London amp D Rosenhan Eds Foundations of abnormal psychology pp 293 344 New York Holt Rinehart amp Winston Bandura A 1982 The psychology of chance encounters and life paths A meriean Psychologist 3 7 747 755 Barlow D H I988 Anxiety and its disorders Nature and treatment ol39anxiety and panic New York Guilford Press Barlow D H amp Beck J G 1984 The psychosocial treatment of anxiety disorders Current status future directions In J B Williams amp R L Spitzer Eds Psychotherapy research Where are we and where should ivego pp 29 44 New York Guilford Press Barlow D H amp C raske M G I989 Mastery ol39your anxiety and panic New York Graywind Barlow D H Craske M G Cerny J A amp Klosko J S 1989 Be havioral treatment of panic disorder Behavior Therapy 20 261 282 Baumeister R F I990 Suicide as escape from self Psychological Re vieu 97 90 1 l3 Beck A T amp Emery G I985 Anxiety disorders and phobias New York Basic Books Beck A T Wright F D Newman C F amp Liese B S 1993 Cog nitive therapy ols39nbstam39e abuse New York Guilford Press Becker E 1973 The denial ol39death New York Free Press Biglan A amp Hayes S C 1996 Should the behavioral sciences be come more pragmatic The case for functional contextualism in re search on human behavior Applied and Preventive Psychology Cur rent Scientiic Perspectives 5 47 57 Briere J amp Runtz M 1993 Childhood sexual abuse Longterm sequelae and implications for psychological assessment Journal of Interpersonal I39iolenee 8 312 330 Browne A amp Finkelhor D 1986 Impact of child sexual abuse A review of the research Psychological Bulletin 99 66 77 Bruder Mattson S F amp Hovanitz C A 1990 Coping and attribu tional styles as predictors of depression Journal ofCinica Psycho 0g 46 557565 Bruner J 5 Goodnow J J amp Austin G A 1956 A study olthink ing New York Wiley Buda M amp Tsuang M 1990 The epidemiology ofsuicide Implica tions for clinical practice In S Blumenthal amp D Kupfer Eds Sui cide over the lite cycle Riskactors assessment and treatment of39sui cida patients pp 17 37 Washington DC American Psychiatric Press Chambless D L Caputo G C Bright P amp Gallagher R 1984 Assessment of fear in agoraphobics The Body Sensations Question naire and the Agoraphobic Cognitions Questionnaire Journal of C 39onsutitte and 39linica Psychology 52 I 090 I 097 Chambless D L amp Gracely E J 1988 Prediction of outcome fol lowing in vivo exposure treatment of agoraphobia In 1 Hand amp H U Wittchen Eds Panic and phobias II Treatment and vari ables affecting outcome pp 209 220 New York Springer Childress A R McLellan A T Natale M amp O Brien C P 1986 Mood states can elicit conditioned withdrawal and cravings in opiate abuse patients In L Harris Ed Probems oldrng dependence National Institute of Drug Abuse Monograph Series No 76 pp 137 144 Washington DC U S Government Printing Of ce Chiles J amp Strosahl K 1995 The suicidal patient Principles of am39essment treatment and case management Washington DC American Psychiatric Press Chiles J Strosahl K Cowden L Graham R amp Linehan M 1986 The 24 hours before hospitalization Factors related to sui HAYES WILSON GIFFORD FOLLETTE AND STROSAHL cide attempting Suicide and Life Threatening Behavior lo 335 342 Chiles J Strosahl K Yanping 2 Michael M Hall K Jamelka R Senn B amp Reto C 1989 Depression hopelessness and suicidal behavior in ChineSe and American psychiatric patients American Journal ol39Rs yehiatr 146 339 344 Ciot fi D amp Holloway J 1993 Delayed costs of suppressed pain Journal 0 quotPersonality and Social Psychology 64 2 74 282 Clark D A amp Purdon C 1993 New perspectives for a cognitive theory of obsessions Australian Psychologist 28 161 167 Clark D M 1986 A cognitive approach to panic Behaviour Re search and Therapy 24 461 470 Clark D M Ball 5 amp Pape D 1991 An experimental investiga tion of thought suppression Behaviour Research and Therapy 29 253 257 Conners G J O Farrell T J Cutter H S G amp Thompson D L 1986 Alcohol expectancies among male alcoholics problem drinkers and nonproblem drinkers Alcoholism Clinical and Exper imental Research 10 667 670 Cooper M L Russell M Skinner J B Frone M R amp Mudar P I992 Stress and alcohol use Moderating effects of gender coping and alcohol expectancies Journal at Abnormal Psychology 10 I39 152 Cordova J amp Kohlenberg R 1994 Acceptance and the therapeutic relationship In S C Hayes N S Jacobson V M Follette amp M J Dougher Eds Acceptance and change Content and context in psy chotherapvpp 125 140 Reno NV Context Press Cowdry R W Gardner D L O Leary K M Leibenluft E amp Ru binow D R 1991 Mood variability A study offour groups Amer ican Journal ot39l st chiattjl 48 1505 151 l Craske M G amp Barlow D H 1990 Nocturnal panic Response to hyperventilation and carbon dioxide challenges Journal oL39Ibnorma Psychotrey 99 302 307 Craske M G Miller P P Rotunda R amp Barlow D H 1990 A descriptive report of features of initial unexpected panic attacks in minimal and extensive avoiders Behaviour Research and Therapy 28 395 400 Craske M G Sanderson W C amp Barlow D H 1987 The relation ships between panic fear and avoidance Journal of 1n39iety Disor ders 1 153 160 Craske M G Street L amp Barlow D H 1989 Instructions to focus upon or distract from internal cues during exposure treatment ofag oraphobic avoidance Behaviour Research and Therapy 2 7 663 Dawes R M I994 louse ol39cards Mythology and psi39chotherap built on myth New York Free Press DeGenova M K Patton D M Jurich J A amp MacDermid S M 1994 Ways of coping among HIVinfected individuals Journal ofquot Social Psychoom 134 655 663 Diamond D amp Doane J A I994 Disturbed attachment and nega tive affective style An intergenerational spiral British Journal ot l sy ehiatry 164 770 781 Druley K A Baker S L amp Pashko S 1987 Stress Alcohol and drug interactions In E Gottheil K A Druly S Pashko amp S P Weinstein Eds Stresv and addietion pp 2439 New York BrunnerMazel Dulit R A Fyer M R Leon A A Brodsky B S amp Frances A J 1994 Clinical correlates ofselfmutilation in borderline personal ity disorder American Journal ovai clIiatri 15 I305 131 l Dutton D G amp Starzomski A J I993 Borderline personality in perpetrators of psychological and physical abuse Violence and lie thus 8 326 337 Ehlers A Margraf J Roth W T Taylor C B amp Birbaumer N SPECIAL SECTION EXPERIENTIAL AVOlDANCE 1988 Anxiety induced by false heart rate feedback in patients with panic disorder Behavior Research and Therapy 26 1 l 1 Ellis A amp Robb H 1994 Acceptance and rationalemotive therapy In S C Hayes N S Jacobson V M Follette amp M J Dougher Eds Acceptance and change Content and context in psychotherapy pp 91 102 Reno NV Context Press Endler N S amp Parker J D A 1990 The multidimensional assess ment of coping A critical evaluation Journal of Personality and So cial Psychology 58 844 854 Eysenck H J 1986 A critique of contemporary classi cation and diagnosis In T Millon amp G L Klerman Eds Contemporary di rections in psyclumathology Toward the DSM l V pp 7 3 98 New York Guilford Press Foa E B amp Kozak M S 1986 Emotional processing of fear Exposure to corrective information Psychological Bulletin 99 20 Foa E B amp Riggs D S 1995 Posttraumatic stress disorder follow ing assault Theoretical considerations and empirical ndings C ur rent Directions in Psychological Science 4 61 65 Foa E B Steketee G Grayson J B Turner R M amp Latimer P R 1984 Deliberate exposure and blocking of obsessivecompulsive rituals Immediate and longterm effects Behavior Therapy 15 450 472 Foa E B Steketee G amp Young M C 1984 Agoraphobia Phe nomenological aspects associated characteristics and theoretical considerations Clinical Psychology Review 4 431 457 Folkman S amp Lazarus R S 1988 Ways ol39Copt39ng Questionnaire Palo Alto CA Consulting Psychologists Press Follette V M 1994 Survivors ofchild sexual abuse Treatment using a contextual analysis In S C Hayes N S Jacobson V M Follette amp M J Dougher Eds Acceptance and change Content and context in psychotherapypp 255 268 Reno NV Context Press Follette W C 1995 Correcting methodological weaknesses in the knowledge base used to derive practice standards In S C Hayes V M Follette R D Dawes amp K GradyEds Scientific standards ofpsychological practice Issues and recommendations pp 229 247 Reno NV Context Press Follette W C amp Hayes S C 1992 Behavioral assessment in the DSM era Behavioral Assessment 14 323 343 Follette W C Houts A C amp Hayes S C 1992 Behavior therapy and the new medical model Behavioral Assessment 14 323 343 Foulds G A 1971 Personality deviance and personal symptomatol ogy Psychological Medicine 3 222 233 Frankl V E 1975 Paradoxical intention and de ection Psychother apy Theory Research and Practice 12 226 237 Freud S 1966 Introductory lectures on psychoanalysis New York Norton Original work published 1920 Freud S 1924 Collected papers Vol 1 London Hogarth Press Gardner D L Leibenluft E O Leary K M amp Cowdry R W 1991 Selfratings of anger and hostility in borderline personality disorder Journal ot39Nervotts and Mental Disease 1 79 157 I61 Geiser D 1992 A comparison ot39acceptancedocttsed and controlfo cttsed interventions in a chronic pain treatment center Unpublished doctoral dissertation University of Nevada Reno Gilford E V 1994 Setting a course for behavior change The verbal context of acceptance In S C Hayes N S Jacobson V M Follette amp M J Dougher Eds Acceptance and change Content and context in psychotherapypp 218 222 Reno NV Context Press Gifford E V 1995 Functional contextualism as a philosophical po sition for clinical psychology The Naturalist 2 15 21 Gold D B amp Wegner D M 1995 Origins of ruminative thought Trauma incompleteness nondisclosure and suppression Journal of Applied Social Psychology 25 1245 1261 1165 Goldman S J D Angelo E J amp DeMaso D R 1993 Psychopa thology in the families of children and adolescents with borderline personality disorder American Journal ot39Psychiatry 150 1832 1835 Goldstein R 8 Black D W Nasrallah A amp Winokur G 1991 The prediction of suicide Sensitivity speci city and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders Archives ot39General Psychiatry 48 418 422 Goldstein A J amp Chambless D L 1978 A reanalysis ofagorapho bia Behavior Therapy 9 47 59 Grayson J B Foa E B amp Steketee G 1982 Habituation during exposure treatment Distraction versus attention focusing Behaviour Research and Therapy 20 323 328 Greenberg L S 1983 Toward a task analysis of con ict resolution in Gestalt therapy Psychotherapy Theory Research and Practice 20 190 201 Greenberg L 1994 Acceptance in experiential therapy In S C Hayes N S Jacobson V M Follette amp M J Dougher Eds Ac ceptance and change Content and context in psychotherapv pp 53 67 Reno NV Context Press Greenberg L S amp Dompierre L M 1981 Speci c effects of Ge stalt twochair dialogue on intrapsychic con ict in counseling Journal of39Couttseing Psychology 28 288 294 Greenberg L S amp Johnson S M 1988 Emotionthquotfocused ther apyor couples New York Guilford Press Greenberg L S amp Safran J D 1989 Emotion in psychotherapy American Psychologist 44 19 29 Greenberg L S amp Webster M C 1982 Resolving decisional con ict by Gestalt twochair dialogue Relating process to outcome Journal ol39Counseing Psychology 29 468 477 Hayes S C 1984 Making sense ofspirituality Behaviorism 12 99 l 10 Hayes S C 1987 A contextual approach to therapeutic change In N Jacobson Ed Psychotherapists in clinical practice Cognitive and behavioral perspectives pp 327 387 New York Guilford Press Hayes S C 1992 Verbal relations time and suicide In S C Hayes amp L J HayesEds Understanding verbal relationspp 109 1 18 Reno NV Context Press Hayes S C 1994 Content context and the types of psychological acceptance In S C Hayes N S Jacobson V M Follette amp M J Dougher Eds Acceptance and change Content and context in psy chotherapy pp 13 32 Reno NV Context Press Hayes S C amp Follette W C 1992 Can functional analysis provide a substitute for syndromal classi cation Behavioral Assessment 14 345 365 Hayes S C Follette W C amp Follette V M 1995 Behavior therapy A contextual approach In A S Gurman amp S B Messer Eds Es sential psyctotherapies Theory and practice pp 128 181 New York Guilford Press Hayes S C amp Hayes L J 1992 Verbal relations and the evolution of behavior analysis American Psychologist 47 1383 1395 Hayes S C amp Heiby E 1996 Psychology s drug problem Do we need a x or should we just say no Atnerican Psychologist 51 198 206 Hayes S C Jacobson N S Follette V M amp Dougher M J Eds I994 Acceptance and change Content and context in psychother apy Reno NV Context Press Hayes S C Nelson R 0 amp Jarrett R 1987 Treatment utility of assessment A functional approach to evaluating the quality of assess ment Atnerican Psychologist 42 963 974 Hayes S C Strosahl K amp Wilson K G in press Acceptance and 1166 commitment therapy Understanding and treating human suffering New York Guilford Press Hayes S C amp Wilson K G 1993 Some applied implications of a contemporary behavior analytic acc0unt of verbal behavior The Behavior Analyst 16 283 301 Hayes S C amp Wilson K G 1994 Acceptance and commitment therapy Altering the verbal support for experiential avoidance The BehaviorAnalyst i 7 289 303 Herman J L Russell D E H amp Trocki K 1986 Longterm elfects of incestous abuse in childhood American Journal ofPswhi air 143 1293 1296 Hersen M amp Bellack A S 1988 DSM III and behavioral assess ment In A S Bellack amp M Hersen Eds Behavioral assessment A practical handbook 3rd ed pp 6784 New York Pergamon Press Hill C E 1990 Exploratory insession process research in individ ual psychotherapy A review Journal ol39Consuting and Clinical Psy chology 58 288 294 Hoes M J 1986 Biological markers in psychiatry Acta Psychiatrica Beigica 86 220 241 Hollander E 1993 Obsessivecompztisive related disorders Washing ton DC American Psychiatric Press Hoogduin C A L amp Duivenvoorden H J 1987 A decision model in the treatment of obsessivecom pulsive neuroses British Journal of Psychiatry 1 52 516 521 Ireland S J McMahon R C Malow R M amp Kouzekanani K 1994 Coping style as a predictor of relapse to cocaine abuse In L S Harris Ed Problems ofdrug dependence 1993 Proceedings of the 55th Annual Scienti c Meeting National Institute of Drug Abuse Monograph Series No 141 p 158 Washington DC U S Government Printing Of ce Jacobson N S 1991 November Acceptance and change Presiden tial address delivered to the meeting of the Association for Advance ment of Behavior Therapy New York Jensen M P amp Karoly P 1991 Control beliefs coping efforts and adjustment to chronic pain Journal ot39Consulting and Clinical Psy chology 59 431 438 KabatZinn J I991 Fttll catastrophy living New York Delta Kanfer F H amp Grimm L G 1977 Behavioral analysis Selecting target behaviors in the interview Behavior Modification 1 7 28 Keijsers G P J Hoogduin C A L amp Schaap C P 1994 Prognos tic factors in the treatment of panic disorder with and without agora phobia Behaviour Research and Therapy 25 689 708 Khantzian E J 1985 The selfmedication hypothesis of addictive disorders Focus on heroin and cocaine American Journal ofPsychi airy 142 1259 1264 Khorakiwala D 1991 An analysis ofthe process ofciient change in a contextual approach to therapy Unpublished doctoral dissertation University of Nevada Reno Kiesler D 1971 Patient experiencing and successful outcome in in dividual psychotherapy of schizophrenics and psychoneurotics Journal ofConsulting and Clinical Psychology 3 7 370 385 Klein M H Mathieu P L Gendlin E T amp Kiesler D J 1969 The Experiencing Scale A research and training mamtalVols l and 2 Madison University of Wisconsin Extension Bureau of Audiovi sual Instruction Klein M H MathieuCoughlan P L amp Kiesler D J I987 The Experiencing Scales In L S amp W M Pinsof Eds The psychother apeutic process A research handbook pp 21 71 New York Guil ford Press Koepp W Schildbach S Schmager C amp Rohner R 1993 Border line diagnosis and substance abuse in female patients with eating dis orders International Journal of Eating Disorders 4 107 110 Koerner K Jacobson N S amp Christensen A 1994 Emotional ac HAYES WILSON GIFFORD FOLLETTE AND STROSAHL ceptance in integrative behavioral couple therapy In S C Hayes N S Jacobson V M Follette amp M J Dougher Eds Acceptance and change Content and context in psychotherapy pp 109 118 Reno NV Context Press Kohlenberg R J amp Tsai M 1991 Functional analytic psychother apy Creating intense and curative therapeutic relationships New York Plenum Press Lazarus R S 1982 Thoughts on the relations between emotion and cognition American Psychologist 37 1019 1024 Lazurus R S amp Folkman S 1984 Stress appraisal and coping New York Springer Leitenberg H Greenwald E amp Cado S 1992 A retrospective study of longterm methods of coping with having been sexually abused during childhood Child Abuse and Neglect 16 399 407 Linehan M M 1993 Cognitive behavioral treatment ofborderine personality disorder New York Guilford Press Linehan M M 1994 Acceptance and change The central dialectic in psychotherapy In S C Hayes N S Jacobson V M Follette amp M J Dougher Eds Acceptance and change Content and context in psychotherapy pp 73 86 Reno NV Context Press Links P S Heslegrave R J Mitton J E Van Reekum R amp Pat rick J 1995 Borderline personality disorder and substance abuse Consequences of comorbidity Canadian Journal of Psychiatry39 Revue Canadienne dc Psychiatric 40 9 14 L00 R 1986 Suicide among police in federal force Suicide and Life Threatening Behavior 16 379 388 Luborsky L Chandler M Auerbach A H Cohen J amp Bachrach H M 1971 Factors in uencing the outcome of psychotherapy Psychological Bulletin 75 145 185 Maris R 1981 Pathways to suicide A survey itselfdestructive be haviors Baltimore Johns Hopkins University Press Marlatt G A 1985 Relapse prevention Theoretical rationale and overview of the model In G A Marlatt amp J R Gordon Eds Re lapse prevention Maintenance strategies in the treatment of addictive behaviors pp 3 70 New York BrunnerMazel Marlatt G A 1994 Addiction and acceptance In S C Hayes N S Jacobson V M Follette amp M J Dougher Eds Acceptance and change Content and context in psychotherapy pp 175 197 Reno NV Context Press McCarthy P R amp Foa E B 1990 Obsessivecompulsive disorder In M E Thase B A Edelstein amp M Hersen Eds Handbook of outpatient treatment ot39aduits Nonpsychotic mental disorders pp 209 234 New York Plenum McCurry S M 1991 Client metaphor use in a contextual form of therapy Unpublished doctoral dissertation University of Nevada Reno Meehl P E 1959 Some ruminations on the validation of clinical procedures Canadian Journal o Psychology 13 102 128 Meehl P E 1978 Theoretical risks and tabular asterisks Sir Karl Sir Ronald and the slow progress of soft psychology Journal ofCon stilling and Clinical Psychology 46 806 834 Meichenbaum D 1993 Changing conceptions of cognitive behavior modi cations Retrospect and prospect Journal of Consulting and Clinical Rsychoogy 61 202 204 Meyer R E Ed 1986 Psychopathology and addictive disorders New York Guilford Press Miller F T Abrams T Dulit R amp Fyer M 1993 Substance abuse in borderline personality disorder American Journal of Drug and Al cohol Abuse 19 491 197 Miller W R amp Hester R K 1986 The effectiveness of alcoholism treatment What research reveals In W R Miller amp N Heather Eds Treating addictive behaviors Processes of change pp 121 174 New York Plenum Press SPECIAL SECTION EXPERIENTIAL AVOIDANCE Mirin S M Weiss R D amp Michael J 1987 Psychopathology in substance abusers Diagnosis and treatment American Journal of Drug and Alcohol Abuse 14 139 157 Neimeyer R A 1993 An appraisal of constructivist therapies Journal of Consulting and Clinical Psychology 6 l 22 1 234 Orlinsky D E amp Howard K I 1986 Process and outcome in psy chotherapy In S L Gar eld amp A E Bergin Eds Handbook ofpsy chotherapv and behavior changepp 31 l 383 New York Wiley Pashko S amp Druley K A 1987 Anxiety and control issues in sub stance abusing veterans In E Gotthiel K A Druley S Pashko amp S P Weinstein Eds Stress and addiction pp 197 208 New York BrunnerMazel Pauli P Marquardt C Hart L Nutzinger D 0 H6121 R amp Strain F 1991 Anxiety induced by cardiac perceptions in patients with panic attacks A eld study Behaviour Research and Therapy 29 I37 I45 Perls F P Hefferline R F amp Goodman P 1951 Gestalt lherap New York Julian Press Polusny M A amp Follette V M 1995 Longterm correlates ofchild sexual abuse Theory and review of the empirical literature Applied and Preventive Rsychologji 4 143 166 Rachman S amp Hodgson R J 1980 Obsessions and compulsions New Jersey Prentice Hall Raskin N J amp Rogers C R 1989 Personcentered therapy In R J Corsini amp D Wedding Eds Current psyct iotherapies pp 155 196 Itasca IL Peacock Rasmussen S A amp Eisen J L 1992 The epidemiology and differ ential diagnosis of obsessive compulsive disorder Journal oClinical Psychiatry 53 4 10 Rimmele C T Miller W R amp Dougher M J 1989 Aversion ther apies In R K Hester amp W R Miller Eds Handbook of alcoholism treatment approaches Effective alternatives pp 128 140 New York Pergamon Press Rodriquez N Ryan S W amp Foy D W 1992 October Easier re duction and PTSD Adult survivors ol39sexual abuse Paper presented at the annual meeting of the International Society for Traumatic Stress Studies Los Angeles Rogers C A 1961 0n becoming a person A therapist is view oi psy chotherapi39 Boston Houghton Mi lin Rogers J H Widiger T A amp Krupp A 1995 Aspects of depres sion associated with borderline personality disorder American Jour nal ol39Psychiatri 152 268270 Rosen D H 1976 Suicide behaviors Psychotherapeutic implica tions of eg0cide Suicide and Li IThrealening Behaviors 6 209 215 Rothberg J M amp Jones F D 1987 Suicide in the US Army Epi demiological and periodic aspects Suicide and Life Threatening Be haviors l7 1 19 132 Russ M J Shearin E N Clarkin J F Harrison K amp Hull J W 1993 Subtypes ofselfinjurious patients with borderline personal ity disorder American Journal ofPsvchiatry 150 18691871 Safran J D amp Greenberg L S 1988 The treatment ofanxiety and depression the process of a ective change In P Kendall amp D Watson Eds Anxiety and depression Distinctive and overlapping wtures pp 455 489 Orlando FL Academic Press Salkovskis P M amp Westbrook D 1987 Obsessivecompulsive dis order Clinical strategies for improving behavioural treatments In H Dent Ed Clinical psychology Research and developments pp 200 213 London Croom Helm Salkovskis P M amp Westbrook D 1989 Behavior therapy and ob sessional ruminations Can failure be turned into success Behaviour Research and Therapy 27 149 160 1167 Salzinger K 1988 The future of behavior analysis in psychopathol ogy Behavior analvsis 23 53 60 SanchezCraig M 1984 A therapists39manualor secondary preven tion ot39alcohol probems Proceduresor teaching moderate drinking and abstinence Toronto Addiction Research Foundation Semin N amp Manstead A 1985 Social accountability Cambridge England Cambridge University Press Sher K J 1987 Stress response dampening In H T Blaine amp K E Leonard Eds Psychological theories of drinking and alcoholism pp 227 264 New York Guilford Press Skinner B F 1974 About behaviorism New York Vintage Books Smith G W amp Bloom 1 1985 A study ofthe personal meaning of suicide in the context of Baechler s typology Suicide and Lie Threat ening Behavior 15 3 13 Solo P H Lis J A Kelly T Cornelius J amp Ulrich R 1994 Risk factors for suicidal behavior in borderline personality disorder American Journal oI Ps39yctiatry 15 I 1316 I323 Southwick S M Yehuda R amp Giller E L 1995 Psychological di mensions of depression in borderline personality disorder American Journal ol39Rsichiatr 152 789 79 1 Sprock J amp Blash eld R K 1991 Classi cation and nosology In M Hersen A E Kazdin amp A S Bellack Eds The clinical psy chology handbook pp 329 344 New York Pergamon Stockwell T amp Bolderston H 1987 Alcohol and phobias British Journal a Addiction 82 971 979 Strosahl K 1991 Cognitive and behavioral treatment of the person ality disordered patient In C Austad amp B Berman Eds Psycho therapy in managed health care The optimal use of time and re sources pp 185 201 Washington DC American Psychological Association Strosahl K amp Chiles J in press The suicidal patient Assessment treatment amp crisis management In D Dunner Ed Current psychi atric therapies 2nd ed New York W B Saunders Strosahl K C hiles J amp Linehan M 1992 Prediction of suicide intent in hospitalized parasuicides Reasons for living hopelessness and depression Comprehensive Rsvchiatr 33 366 373 Strosahl K Linehan M amp Chiles J 1984 Will the real social de sirability please stand up Hopelessness depression social desirabil ity and the prediction of suicidal behavior Journal of Consulting and Clinical Rs39ycholog 52 449 457 Thyer B A Parrish R T Himle J Cameron 0 0 Curtis G C amp Nesse R A 1986 Alcohol abuse among clinically anxious pa tients Behaviour Research and Therapy 24 357 359 Tyrer P 1994 What are the borders of borderline personality disor der Acta RVJ39chiatrica Scandinavica 3 7 9 Suppl 38 44 Wanberg K W Horn J L amp Foster F M 1977 A differential as sessment model for alcoholism The scales of the Alcohol Use Inven tory Journal o Studies on Alcohol 38 512 543 Weaver T L amp Clum G A 1993 Early family environments and traumatic experiences associated with borderline personality disor der Journal oC onsulting and Clinical Rsvchologu 61 1069 1075 Weekes C 1978 Simple effective treatment of agoraphobia Ameri can Journal oRszi39chotherapi 3 2 35 7 369 Wegner D M Schneider D J Carter S R amp White T L 1987 Paradoxical effects of thought suppression Journal of Personality and Social Rsychologi 53 5 13 Wegner D M Schneider D J Knutson B amp McMahon S R 1991 Polluting the stream of consciousness The effect of thought suppression of the mind s environment Cognitive Therapy and Re search 15 141 151 Wegner D M amp Zanakos S I 1994 Chronic thought suppression Journal ofPersonait 62 615 640 Wenzlalf R M Wegner D M amp Klein S B 1991 The role of Memtall HeathJim January 17 2012 Mental Health Professionals Psychiatrist MD can prescribe medicine conduct therapy Psychologist PhD PsyD EdD clinical counseling school gt all involved in mental health 0 PhD Doctor of Philosophy university setting research oriented o PsyD Doctor of Psychology freestanding program business not usually in a university setting Social workers MSW DSW Counselors therapists psychotherapists generic terms that do not tell you much people working with human behavior is common characteristic of all of them Scientistpractitioner orientation science informs practice practice informs science both go back and forth and support each other llt is theory that decides what we can observequot Einstein Theory can be good but can be blinding it is hard for people to see outside their theories Study by Langer and Abelson Behavioral psychologists told that person was a job applicant Psychoanalytic psychologists told that person was a job applicant Behavioral psychologists told that person was a mental patient Psychoanalytic psychologists told that person was a mental patient High PA 13 PA Low Told a Job applicant patient Told a mental Two groups of doctors behavioral psychologists and psychoanalytic psychologists 15 minute video ofa person being interviewed told half the doctors that the person was a job applicant and the other half that he was a mental health patient told to rate the mental health of the person highlow PA rated mental health of person lower when told they were a mental patient saw something that wasn t there background affects what you see PA saw more pathology than B and interpreted it differently theoryparadigm makes a difference in what you see and how you interpret it Freud Psychoanalysis 0 39 39 u I p Li I g H u39i emphasized earlyageearlyyears not much later on 0 Structure ofthe mind 2 ways 1 Id present at birth only interested in gratification uses the pleasure principle Ego plans uses strategies makes decisions uses reality principl Superego uses moral principle incorporates the quotoughtsquot and quotshouldsquot of society difference between goodbad and wrongright Iceberg portrayal Most ofthe mind is unconscious Preconscious has potential to bring into conscious Goal of psychoanalysis is to make the unconscious conscious insightoriented therapy Defense mechanisms protect the ego from anxiety 0 Projection classic example is a paranoid person attribute to other people your unacceptable urges or impulses 0 Displacement transferring or redirecting an urge or impulse from a more to a less reatening person Techniques of psychoanalysis ream analysis and interpretation royal road to the unconscious dreams supposedly contain symbolic content 0 Free association talking without the usual editing that goes on in conversational speech 0 Transference client acts toward the therapist unconsciously as if the therapist was some important person in the clients 0 Instances of resistances client may exit room when subject is brought up change topic start an argument therapist notes when client avoids unpleasant but important content 0 Interpretation therapist will behin to share their theory with client about how they may be thinking Carl Ro er c Cl nt entered Thera 0 Foundational belief If people are given the right conditions they will develop into the person they are meant to be unconditional love and acceptance 0 Goals 0 Insight o Create conditions necessary for growth done by therapist characteristics more than techniques I Genuineness beinga real person ratherthan playinga role 39 Unconditionai positive regard no conditions of worth very accepting 39 Engage in empnatic understanding tnerapist refiects ciients words in orderfor them to understand 0 Not used as much anymore but has been integrated into other scnoois oftnougnt sSta es Psycnosociai stages of deveiopment 8 stages framed in terms of crises botn promise and perii Prepotency one stage buiids on the other successfui resoiution ofan eariy stage predisposes person to resoiution of higher stages Stage 5 adoiescence egoidentity vs roie diffusion or negative identity many possibie identities during this stage deveioping a sense of who you are is successfui resoiution vs not knowing or not iiilting who you are Stage 6 eariy 20 s intimacy vs isoiation entering into reiationsnips not necessary but wiii demand ofa person vs not being in any reiationsnips and choosing to be independentaione January 19 2012 Stage 7 generativity vs stagnation middieage being productive in one s iift work and concerned about and promoting the weiibeing of others vs being concerned about oniy yourseif o Midiife crisis wnen peopie attempt to come to grips by reaiizingtney are not goingto accompiisn everything they wanted intneir iives i eiings 39 39 Ha can uccui ueume iast o mptyi yi cniid ieaves home 0 Sta integrity vs despair oider age iooilting back over iife and being oilt witnit or not being ge 8 ok with it Maslow s H rarchy of Needs doesn t have to go in order seifactuaiization achieving your unique potentia Behavioral Psychology 0 Came from the lab working with animals 0 Two main branches 1 ClassicalConditioning US gt UR salivation meat powder CR salivation I Pavlov worked with dogs I US unconditioned stimulus stimulus which with no prior learning required is capable of eliciting an unconditioned response I UR unconditioned response response elicited by US I CS conditioned stimulus an originally neutral stimulus which through association with the US comes to elicit a close approximation of the UR I CR conditioned response response elicited by CS I Generalization other stimuli to the extent they resemble the CS will elicit some degree of the CR bellshaped curve I Discrimination other stimuli to the extent they resemble the CS will not elicit some degree of the CR curve I Extinction removing the US and repeatedly presenting the CS after an already welllearned response I Spontaneous recovery an increase in the CR to the CS following extinction which is due only to the passage of time 2 Operant Conditioning Positive Positive 39 Reinforcement Punishment I Negative Negative I Reinforcement Punishment I Positive behavior results in something being added following the behavior I Negative behavior results in something being taken away following the behavior I Reinforcement increase in behavior because of the consequences behavior brought about I Punishment decrease in behavior because of the consequences behavior brought about I Examples 0 PR treat following a good grade on a test Development and Psychopathology 9 1997 2517268 Copyright 1997 Cambridge University Press Printed in the United States of America Psychopathology as an outcome of development L ALAN SROUFE University of Minnesota Abstract When maladaptation is viewed as development rather than as disease a transformed understanding results and a fundamentally different research agenda emerges Within a developmental perspective maladaptation is viewed as evolving through the successive adaptations of persons in their environments It is not something a person has or an ineluctable expression of an en factors operating over time K arch questions within dogenous pathogen It is the complex result of a myriad of risk and protective this framework center on discovery of factors that place ey rese individuals on pathways probabilistically leading to later disturbances and factors and processes which maintain in ividuals on or de ect them from such pathways once en39oined Th ere is an interest in recognizing patterns of d maladaptation which while not properly considered disorder themselves commonly are precursors of disorder and also in conditions of EiSk that lie outside of the individual as well as any endogenous in uences Likewise there is a focus on factors and processes that lead individuals away from disorder that has emerged which goes beyond interes in man ement of symptoms Finally many topics that currently are capturing attention in the eld such as t 3 comorbidity and resilience are seen in new ways from within the perspective of development How childhood problems and psychological disturbance are conceptualized has a profound in uence on research that is conducted and the interpretation of research findings More than two decades ago Lazare 1973 intro duced the idea of hidden conceptual models in psychopathology By conceptual models he meant the frameworks for understanding psy chological disorder the set of guiding as sumptions utilized by clinicians and research ers to make sense out of their observations of disturbed behavior thought and affect By using the term hidden he underscored the fact that such assumptions often are not made explicit as assumptions and that people often are not aware that such models are being em ployed that is that they are viewing the world from a particular perspective One ma jor consequence of such hidden models is that Preparation of this work and the research described herein were supported by a grant from the National Instir tute of Mental Health MH 40864 ress correspondence and reprint requests to Alan Sroufe Institute of Child Development University of Minnesota 51 East River Road Minneapolis MN 55455 251 investigators may treat assumed meanings of observations as factual and may fail to recog nize powerful and compelling alternative in terpretations Another consequence is that limitations of the model for example how it constrains research questions may be ob soured Embracing a particular model of disturb ance is analogous to putting on lenses which may bring some issues or questions into focus while distorting others in ways that may not be obvious to the observer The thesis of this paper is that what will be called a develop mental model leads to a unique and at times radically different View than the position La zare referred to as the medical model a View in which disorders often are seen as dis crete and as arising from singular endoge nous pathogens While not always obvious this medical model remains a dominant in u ence in the field even though in its simple form it is outmoded in much of medicine it self Rutter 1996 Within the classic medical model an anal ogy is made between childhood behavioral 252 and emotional problems and organic disease This principal guiding assumption has sweep ing implications It is reflected in description and conceptualization of disorder itself in the nature of research questions that are given pri ority centered on endogenous factors and in how research findings are interpreted One manifestation of this model is the diagnostic classification system of disorders proposed by the American Psychiatric Association Ameri can Psychiatric Association 1994 Problems shown by children as well as adults are grouped into disorders considered to be dis crete and distinctive and often given names suggesting that they reflect enduring condi tions of the individual For example the cate gory attention de cit hyperactivity disorder not only provides the important function of summarizing an array of problem behaviors but it also implies via de cit an endogenous problem of the child This is no mere over sight of terminology It follows directly from using the organic disease analogy for consid ering behavioral and emotional disturbance Environmental factors may be viewed as play ing a role as they do of course in many medi cal conditions but core aspects of etiology are assumed to lie in neurophysiological pathol ogy whether due to genetic defect or environ mental pathogens Likewise medical treat ments are emphasized in research and clinical practice Environmental manipulations may have some role but they are seen in terms of managing symptoms not as efforts to trans form the child s adaptation or to alter the larger childienvironment system All of this is despite the fact that there is little empirical evidence that these children have an attention de cit at all Taylor 1994 Without the unac knowledged disease assumption the term def icit would have no place in the description of this set of problems Within a developmental model in contrast organism and context are viewed as insepara ble see Cohen amp Stewart 1994 There is no attempt to explain behavior as merely an ex pression of underlying endogenous neurophys iological differences Behavioral and emotional disturbance is viewed as a developmental con SUHCthIL reflecting a succession of adapta tions that evolve over time in accord with the Li A Sroufe same principles that goveni normal develop ment Just as personality or the emergence of competence involves a progressive dynamic unfolding in which prior adaptation interacts with current circumstances in an ongoing way so too does maladaptation or disorder Sroufe and Rutter 1984 presented some of the guiding assumptions of a develop mental perspective including holism and di rectedness see Santostefano 1978 Thus meaning of behavior is inseparable from its context and the influence of one factor an ex perience a stressor a genetic variation is de pendent on the other factors It is the unique combination of risk and protective factors that govenis the emergence of maladaptation see Cicchetti amp Tucker 1994 Gottlieb 1991 Rutter 1996 Sameroff amp Fiese 1989 More over with development the individual plays an increasingly active role in adaptation in terpreting and creating experience as well as responding to extenial and intenial changes From a developmental point of view behavior is not simply the interaction of genes and en vironment but genes environment and the history of adaptation to that point Sroufe amp Egeland 1991 This neglected third factor prior adaptation is of profound importance and deserves a central place on the research agenda One may argue that a caricature of the medical model is being presented and that the contrast with the developmental model is overdrawn lndeed Rutter 1996 has argued that in intenial medicine multifactorial causa tion is seen as the rule and that risk factors may be dimensional as well as discrete Rutter provides numerous examples of complex cau sality in physical ailments with environmen tal factors and context playing a powerful role interacting with endogenous factors Thus the classic medical model has been sup planted in much of medical research itself Moreover multiple causality is widely em braced by researchers of diverse persuasions in the study of psychopathology and environ mental context can be considered even when organic factors are emphasized Develop mental history also can be considered as in for example the distinction between good and poor premorbid schizophrenia An emphasis Psychopathology as development on endogenous factors can be integrated with a variety of other positions using the concept of development Eisenberg 1977 Lazare 1973 Rutter 1980 It need not be so nar rowly construed Nonetheless the position here is that the medical model henceforth referred to as the classic medical model or disease model though outmoded even in medicine still exer cises a dominant in uence in the field of child psychopathology Because the assumptions underlying this classic model are often unre ectively accepted and not explicitly ac knowledged it exercises a pervasive if often subtle in uence on the conduct and interpre tation of research Claims for the importance of a broad causal net and for an emphasis on process may be the mode but in reality prior ity is often still given to the search for particu lar endogenous pathogens of a disorder Envi ronmental as well as endogenous in uences on child psychopathology may be examined But environment often refers to prenatal te ratogens or lead painted walls which are of course surrogates for endogenous in uences as though these are broadly representative of exogenous factors Also as discussed in the section on research below physiological con comitants of disturbance are routinely inter preted as causes rather than simply as corre lates or markers The disease model takes on the status of the description of reality rather than as one point of view which may in fact often be distorted Before turning to further examples of the still prevailing in uence of the classic medical model at the expense of alternative points of view an elaboration of a contrasting developmental position will be presented The Pathways Framework Many implications of a developmental model of disturbance can be captured with the con cept of developmental pathways introduced by Waddington 1957 and adapted by Bowlby 1973 Bowlby s preferred meta phoric representation of the pathways concept is the continuous branching of tracks in a rail way train yard see also Loeber 1991 but it may be pictorially represented as a tree as well see Fig 1 Pathology may be thought 253 Figure 1 A schematic representation of the devel opmental pathways concept A Continuity of maladaptation culminating in disorder B Contin uous positive adaptation C Initial maladaptation followed by positive change resilience D Initial positive adaptation followed by negative change toward pathology of as a succession of branchings which take the child away from pathways leading to com petent functioning Five major implications of this model may be summarized as follows see also Sroufe 1989 Sroufe amp Rutter 1984 Sroufe Egeland amp Kreutzer 1990 1 Disorder as deviation over time Pathol ogy is viewed in terms of developmental devi ation This requires first an understanding of normative developmental issues eg secure attachment modulated impulse control effec tive entry into the peer group and the various patterns of positive adaptation with respect to them A significant deviation in pattern of ad aptation represents an increased probability of problems in negotiating subsequent develop mental issues Pathology generally re ects re peated failure of adaptation with respect to these issues A particular adaptational failure at any point in time is best viewed as placing an individual on a pathway potentially leading to disorder or moving the individual toward such a pathway Thus for example maladap tive patterns of attachment in infancy anxious 254 attachment are not viewed as psychopathol ogy per se but in terms of developmental risk for disturbance see below Pathology in volves a succession of deviations away from normative patterns 2 Multiple pathways to similar manifest outcomes When development is viewed in terms of a succession of branchings it follows that individuals beginning on different path ways may nonetheless converge toward simi lar pattenis of adaptation Different influences and different courses may be germain for dif ferent individuals see Cicchetti amp Rogosch 1996 A pattern of maladaptation with many features in common eg lack of social en gagement depressed mood low selfesteem may be the result of distinctly different devel opmental pathways one rooted in alienation and one rooted in anxiety and helplessness see also Blatt 1995 If so quite different interventions may prove helpful to members of these two groups and it may be inappropri ate to employ the same label to describe them despite similar manifest behavior Whether such phenotypically similar individuals differ in terms of prognosis subsequent outcome or effective intervention become key research questions eg Moffitt 1993 3 Different outcomes of the same pathway Similarly the concept of successive branch ings suggests that individuals beginning on a similar pathwa may diverge ultimately showing different pattenis of pathology or positive adaptation cf Cicchetti amp Rogosch 1996 Despite the phenotypic dissimilarity of such outcomes it remains possible that they will represent a coherent family The study of branching pathways over time may suggest radically different approaches to classifica tion based on developmental trajectory rather than final manifest behavior alone Loeber 1991 Thelen 1990 4 Change is possible at many points De spite early deviation changes in develop mental challenges or other aspects of context may lead the individual back toward a more serviceable pathway Not only is pathology typically not simply an endogenous given but even when a maladaptive pathway is en joined retuni to positive functioning often re mains possible It is generally inappropriate to Li A Sroufe think of maladaptation or disturbance as something a child either has or does not have in the sense of a permanent condition Within this perspective extremely stable con ditions such as early emerging conduct dis turbance call for research on supports for such problems centering on positive feedback cy cles between child maladaptation and envi ronmental reaction Patterson DeBarysh amp Ramsey 1989 Richters amp Cicchetti 1993 5 Change is constrained by prior adapta tion This final implication somewhat coun terbalances the fourth It suggests that the longer a maladaptive pathway has been fol lowed especially in the sense of going across phases of development the less likely it is that the person will reclaim positive adapta tion Bowlby implied that adolescence might mark the end of relative exibility This is consistent with the active child principle By creating negative experiences in an ongo ing way failing to engage positive opportuni ties and interpreting even benign experience as malevolent which often are core features of maladaptation the child s adaptation may make positive change less likely Dodge s work on attribution no longer is interpreted in terms of inherent cognitive deficit but does suggest that negative experiences of some children lead to interpretive frameworks and congruent behavior that further lead to nega tive experiences and so on Crick amp Dodge 1994 Rieder amp Cicchetti 1989 Rogosch Cicchetti amp Aber 1995 Suess Gross mann amp Sroufe 1992 This proposition also is in accord with abundant empirical data in cluding the finding that children who enjoin early and consistently pursue the path from defiance to aggression to antisocial behavior are highly likely to persist toward criminality Loeber et al 1993 Moffitt 1993 Like any metaphor this branching pathway model has its limitations implying for exam ple that certain sorts of outcomes would be absolutely impossible for some individuals whereas at this stage of our knowled e im probable would seem more likely Still it does provide a useful framework for summa rizing a great deal of information about devel opment It also provides a distinctive altenia tive for interpreting findings from research on Psychopathology as development childhood disturbance and suggests an impor tant research agenda which hitherto has been largely neglected namely processes of initia tion continuity and change in maladaptation Some distinctions between this presenta tion of the developmental pathways concept and other recent discussions should be pointed out Loeber 1991 for example has nicely summarized a set of ideas somewhat parallel to points 375 above However for him the starting point of a pathway is the presence of disordered behavior pattenrs The pathway is defined by the problem behaviors and the focus is on persistence and desistance of these Other problem behaviors that are pres ent or emerge are subsumed within the con cept of comorbidity discussed below and viewed as influences on subsequent develop ment p 107 An important contribution of the present pathways model is emphasis on pattenrs of adaptation with respect to norma tive developmental issues that precede the emergence of frank disturbance that include strengths as well as weaknesses and that are viewed as an important part of a causal net work of influences Early patterns of adapta tion are viewed as prototypesiroot forms with diverse potentialithat are linked to later outcomes as part of a multidetermined pro cess Some individuals on a pathway may in fact never go on to disorder The work of Loeber and other work that he discusses is important in indicating that early onset dura tion and number of problems are of great prognostic significance However to provide a fully viable and distinctive alternative to the classic medical model developmental path ways must be traced from a point prior to the onset of disturbance Tracing pathways from a point prior to the emergence of disturbance allows one to dis cover heterogeneity in disorder Individuals showing similar symptoms may in fact be on different pathways if examined longitudi nally and may have predictably different out comes From the viewpoint of development they may not be manifesting the same disturb ance This has been illustrated by Moffitt 1993 in work on adolescent limited and early emerging antisocial behavior Those whose problem behavior emerged first in ado 255 lescence are not on the same pathway as those whose behavior arises in and persists from early childhood Only the latter are likely to show criminality in adulthood Thus despite the overlapping conduct problems in adoles cence these two groups should not be treated as members of one disease entity group Like wise those showing the problem cluster in question plus particular pattenrs of other problems may again be distinguished by arr tecedent and subsequent development They may not be on the same pathway As a matter of intenral consistency with regard to the pathway metaphor it certainly makes no sense to say that individuals may be on two separate pathways at once one in common with another group and one distinctive Start ing with symptoms to define a pathway sim ply accepts that the medical modelbased clas sification system is valid leading inevitably to additional problems being interpreted as the cooccurrence of second diseases and dif ferential persistence as due to varying time courses of the disease The critical research questions regarding developmental process that arise from these observations are simply swept aside The existing diseasebased clas sification system and the classic medical model of psychopathology in general need to be tested not simply assumed as the starting point for studying problem behaviors over time Conceptualizing Competence and Disturbance Varying conceptualizations of basic phenom ena in the field reveal the operation of differ ent models Two examples are considered here one from the domain of competence and one from the domain of disturbance The first phenomenon to be discussed has been termed resilience and the second comorbidity That the medical model is frequently in operation in discussions of the former as well as the latter is testimony to its pervasiveness ResilienCe The concept of resilience can be used to illus trate the distinctiveness of the developmental 256 perspective Resilience simply refers to the fact that some children facing adversity none theless do well or return to positive function ing following a period of maladaptation eg Masten amp Coatsworth 1995 Such an obser vation is open to a variety of interpretations This observation often is explained in terms of endogenous traits an inherent robustness or other such characteristic of the child As is often done in discussing disorders the term resilience is therefore made the explanation for the observed phenomenon Why do some children do well in the face of adversity Be cause they are resilient Why do some chil dren manifest attention problems Because they have Attention Deficit Hyperactivity Disorder ADHD Thus in this perspective resilience is treated as a trait rather than as a process So powerful is such a preconception that ambiguous data is often interpreted as im plying such an endogenous trait The well known work of Werner and Smith 1992 is frequently cited as demonstrating that positive temperament is a determinant of resilience The significant variable underlying this inter pretation which shows up only late in in fancy actually is a parental report of the de gree to which the child is lovable Not only could this variable readily be interpreted as a caregiving variable caregiver percaption of loveableness but also the idea that loveable ness itself is a developmental product is not considered Only when this finding is uncriti cally interpreted within a classic medical model framework would a trait interpretation automatically follow from this finding Within a developmental perspective in contrast resilience is not something some children simply have a lot of It develops A capacity to rebound following periods of maladaptation or to do well in the face of stress evolves over time within the total con text of developmental influences The capaci ties for staying organized in the face of chal lenge for active coping and for maintaining positive expectations during periods of stress are evolved by the person in interaction with the environment across successive periods of adaptation And even as an acquired capacity it is not static but is continually in uenced by ongoing changes in context Prospective Li A Sroufe longitudinal data eg Egeland Carlson amp Sroufe 1993 reveal that manifestation of re silience is associated either with a history of positive experience and positive adaptation prior to the period of stress or maladaptation andor positive experience between the period of stress and recovery For example groups of malfunctioning 4yearolds who later were free of behavior problems at school more of ten had histories of early secure attachment and stable emotional support in the toddler period than did 4 yearolds who showed con tinuity of malfunctioning Sroufe et al 1990 Had the research started at age 4 the resil ience would have appeared mysterious and may have been attributed to some children simply having the right stuff From within the classic medical model the search for ante cedents of resilience with the exception of IQ or temperamental traits has had low priority Other research from our project shows that changes in parental stress and social support also account for differential improvement in children s functioning over time eg Ege land et al 1993 This graphically illustrates that resilience resides more in the develop mental system which of course includes the child s history of adaptation than in the child alone In a completely parallel manner under standing desistance of problem behavior will be enhanced em 10 in a developmental model Both adaptational history and current supports and challenges are needed to explain those whose disordered behavior improves Spontaneous recovery is just a term for cur rent ignorance left unexamined because of weddedness to a particular disease model of disorder Comorbidity The phenomenon to which comorbidity refers is the simple fact that children especially of ten show behaviors that fit two or more of the currently designated diagnostic categories see Caron amp Rutter 1991 for a discussion Saying that such joint occurrences are a re flection of comorbidity is no explanation Nothing in this observed fact suggests that children therefore often have concurrently Psychopathology as development two or more discrete disorders read dis eases But the term comorbidity based in the hidden assumptive network of the disease model suggests just that If a child manifests problems that fit two current categories it is concluded assumed that he or she has two conditions rather than even considering the alteniative that there is a failure of syndromic integrity for one or both categories The power of the hidden assumptions leads inves tigators to skip right over the challenge the basic observation poses to the classic medical model The disease model requires syndromic in tegrity If the disease model is apt for chil dren s behavioral and emotional problems children generally should manifest tight clus ters of symptoms with unique indicators of other syndromes being absent But in reality children commonly manifest problems that cut across established categories To be sure one disorder may potentiate another in medi cine as well Rutter 1996 but not nearly to the extent implied by the prevalence of co morbidity of childhood disturbances Descrip tions of disorders in the literature frequently begin by noting large percentages of overlap with other conditions eg Rutter Taylor amp Hersov 1994 For example Harrington 1994 reports that most children who meet criteria for depression also have been given another primary diagnosis Citing other work Anderson Williams McGee amp Silva 1987 he also reports that of 14 11yearolds with depression 11 qualified for at least one other diagnosis 8 of the 14 qualifying for anxiety disorder attention deficit disorder and con duct disorder Conduct problems and activity attention problems have been found to corre late quite highly eg 77 August MacDon ald Realmuto amp Skare 1996 Comorbidity is the rule not the exception Moreover broad classes of problems such as extenializing be haviors are predictive of a myriad of later conditions including depression and other conditions not typified by aggression or other hallmarks of extenializing Robins amp Price 1991 Number of problems rivals clustering of problems in predicting later dysfunction One might think the discovery that chil dren s problems often cut across the working 257 categories would have led to a questioning of the entire system not to a new medical term in our reference books Because of the power of the medical models the literature contains almost no discussion of concenis about basic tenets underlying the DSM classification sys tem itself for recent exceptions see Rich ters amp Cicchetti 1993 Wakefield 1992a 1992b Rather discussion focuses on cate gory changes alone Rutter et al 1994 If taken seriously the data on comorbidity could lead to revolutionary changes in classification of childhood psychological problems and per haps quite distinctive views of disturbance it self The way would be cleared for evolving classification schemes centered on pattenis of adaptation and developmental trajectories Designing and Interpreting Research The pervasiveness of the medical model not only has implications for conceptualization and treatment of childhood problems but also has a major impact on research It power fully guides the questions that are asked as well as how obtained findings are interpreted Much current research is focused on finding the pathogen for a given problemithe gene or the particular neuropathology assumed to underly all instances of a disturbance lt fol lows that this search commonly is localized in the person and the assumption is made that the pathogen by itself accounts for the origin onset and course of the problem disorder Nothing of course is wrong with neurophysi ologically oriented research At this stage of our knowledge of maladaptation research on numerous fronts is vital However singular devotion to the disease model with its hidden assumptions has the unfortunate consequence of limiting and narrowing the research en deavor When it is taken as a given that disor der derives from pathogens that are endoge nous to the individual there will be limited efforts to discover etiological factors lying outside of the child and to understand how these interact with endogenous factors or perhaps especially to understand what factors may bring the child back toward normal adap tation away from a disturbed patteni Examin ing factors that lead a child into or away from 258 maladaptation is not even a very meaningful issue if disorder is considered something an individual either has or does not have Within a developmental perspective the re search agenda changes dramatically from that inspired by the disease model and existing data frequently are seen in different light One moves away from the search for single patho gens conceptualized as linear causes ineluc tably producing their outcome toward the search for a complex of influences that initiate a developmental pathway which only probabi listically is associated with disturbance Cic chetti amp Tucker 1994 Sameroff amp Fiese 1989 Sroufe 1989 The etiology of disturb ance is conceptualized in terms of a combina tion of risk factors and protective factors of diverse sorts Moreover the possibility or even probability of later disturbance may be seen in early patterns of maladaptation that in and of themselves are not pathological and in aspects of the developmental context even prior to the appearance of child maladapta tion Second and equally important from this perspective is research on factors influencing continuity and change that is processes and mechanisms that maintain individuals on pathways once enjoined or deflect them to ward others This includes the search for fac tors that lead iridividuals away from disturb ance following its manifestation Disturbance is not a given it is supported Pathology is not something a child has it is a pattern of adaptation reflecting the totality of the devel opmental context to that point When disturbance is viewed as develop ment one asks numerous questions How do individual children get off track When going off track what deviating track is a particular child likely to take What influences in their pattern of adaptation and in the total develop mental context tend to maintain them on the track they are on and what would be required to bring them back to a more serviceable de velopmental pathway These are very differ ent than questions about which gene causes or what are the physiological correlates of a particular disorder which are inspired by the classic medical model and shed limited light on most childhood problems Two illustrations from the Minnesota lon Li A Sroufe gitudirial study of development from birth through adolescence eg Egelarid et al 1993 Carlson Jacobvitz amp Sroufe 1995 Sroufe Carlson amp Shulman 1993 can illus trate the heuristic value of this viewpoint and its distinctiveness from the disease model The first comes from a prospective longitudi nal investigation of children s attention and activity problems using criteria of ADHD in DSM 7R The second is based on an ado lescent outcome study of infariticaregiver at tachment problems A deVelopmental view of attention and activity problems The starting point for a developmental ap proach to psychopathology is always a con sideration of normal development Thus we began our investigation of attentionactivity problems by considering factors that normally support the development of the capacities to modulate arousal regulate affect control im pulses arid direct attention Basically a pro cess unfolds whereiri what begins as care giverorchestrated regulation becomes dyadic regulation with increasingly active participa tion by the infant Then progressively trans fer of the regulatory responsibility to the child occurs over the course of early childhood through a series of phases At each phase be iririin in the early months of life patterns of affective attentional and behavioral regula tion are constructed within the caregivirig sys tem Such developing patterns or prototypes are carried forward and interact with subse quent challenges to regulation as development continues see Sroufe 1989 for more detail Given this understanding we then asked what factors would be liabilities with respect to pursuing the normative pathway toward effec tive selfregulation What might lead some children to get off track The data set was comprehensive and a range of factors were considered We exam ined a number of early child variables that is variables commonly thought of as residing in the child These included premature birth nonoptimal newborn neurological status nurses ratings of fussiness soothability and other behaviors in the newborn nursery ob Psychopathology as development servational measures of infant activity level and irritability and parentbased temperament questionnaire data in infancy and at age 212 years While we believe that each of these variables is best thought of as reflecting a de velopmental process it is the case that most of them the exception being the parental re ports can be defined as child characteristics They are manifest in child behavior observ able even when the child is apart from the caregiver But in addition to these child characteris tics which along with environmental toxins often would exhaust variables in a study guided by a disease model of disorder we also examined aspects of the developmental context This included the immediate context of parenting behaviors pattenis of stimulating and regulating the child the broader context in which parenting was nested the stress sup port and general degree of stability in the par ent s life and more distal contextual factors such as marital status at birth No prior study had explored the origins of attention and ac tivity problems in this way though from a de velopmental perspective it is obvious to do so The results of this research based on fol lowing some 180 children from birth through sixth grade and using teacher Behavior Prob lem Checklist data as the outcome strongly supported the heuristic value of a develop mental perspective Jacobvitz amp Sroufe 1987 Carlson Jacobvitz amp Sroufe 1995 The more than 40 early child variables were consistently weak in terms of predictive power One variable from the Brazelton Neo natal Exam Motor lmmaturity showed mod est prediction of ADHD criteria in kindergar ten but not thereafter Observed or parent reported activity level or other dimensions of infant temperament were never significantly related to subsequent attention or activity problems In contrast measures of parental in trusiveness and overstimulation including the single measure of such parenting obtained when the infant was 6 months old were more predictive with some consistency across ages It is important to note that parental intrusive ness at 6 months was not predicted by any antecedent or concurrent child variable Thus we view this influence as initially lying out 259 side of the child Moreover the single best predictor of attention problems was mother s relationship status at birth children later showing attention and activity problems had single mothers Such a contextual feature can not be attributed to the child and shows the importance of casting a broad net in defining factors that place children on pathways to dis order With regard to the prediction of atten tional and hyperactivity problems in kinder garten we found that there was almost no overlap between those few cases that were predictable from newboni motor immaturity and the others that were predicted from the parentin and other contextual variables J a cobvitz amp Sroufe 1987 Thus multiple path ways to the same disturbed behavior are sug gested While nothing observable in the child dur ing the infancy period was found to predict later attentional and hyperactivity problems by age 312 this no longer was so Consistent with other literature eg Campbell 1990 our observationbased rating of distractibility was modestly related to ADHD criteria be haviors in early elementary school account ing for about 6 of the variance By the pre school period then one might say that some children are on the attentional problemhyper activity pathway even though enjoining this pathway the 312 year distractibility measure is predictable from contextual variables well before this time as is later criterial ADHD behavior itself Moreover a combination of distractibility and early and later contextual variables predicted elementary attention prob lems far more strongly than early distractibil ity alone up to 28 of the variance in Grade 173 problem behavior In the second phase of the research we showed that contextual variables accounted for change in ADHD criterial behaviors over time Changin support for caregivers and changing caregiver relationship status were the most consistent predictors of change in child problem behaviors As the rimary care giver s relationship stabilized or destabilized the child s manifestation of attentional and hyperactivity problems changed Thus in the current developmental terminology some children who were on the ADHD pathway at 260 ages 31 5 or 6 were apparently not on this pathway at a later age whereas others not manifesting such problems early had enjoined this pathway at a later age More detailed process data will be required to determine whether such change is mediated primarily by change in the caregiver s behavior toward the child as we would hypothesize A final result is relevant to the pathways model When cumulative attentional and hy peractivity problems up through third grade are considered very little change can be ac counted for thereafter This suggests that at least for these types of extenralizing prob lems change becomes increasingly difficult the longer the pathway is followed This also seems to be true for aggression Gottesman 1995 Loeber et al 1993 Moffitt 1993 Reactions to this work during conference discussions and in editorial review were inter esting with respect to the role of models in research evaluation The first reaction typi cally has been to ask how many of our sub jects really had ADHD This question steeped in the disease model presumes the distinct entity organically based nature of such problems Taken to extreme this would preclude scientific investigation If an organic variable is not predictive or if medication is ineffective long term then this is taken as evidence that the children in question did not have ADHD The altenrative of a continuum of problem behaviors is simply not taken as a viable position We found no evidence for discontinuity in the distribution univariate or bivariate of our variables nor is there a body of evidence suggesting the 8 DSM HLR or 6 DSMilV symptoms represent a qualita tive break point Jacobvitz Sroufe Stew art amp Leffert 1990 We obtained results par allel to those above looking at extreme cases and at the 12 children placed on stimulant medication which itself bore little relation to our objective assessment of behavior across timeia sad commentary on at least some clinical practice Other reactions suggested that the ques tions addressed by our work did not make sense or dealt with resolved or super uous is sues Environmental factors and even family factors in particular were said to require no Li A Sroufe further attention and citations were provided However environmental factors often re ferred to toxins such as lead Within a medical model of course these are the kind of envi ronmental factors that command attention rather than psychosocial stressors and other aspects of developmental context which might also be considered Moreover family vari ables it was argued had been shown to be irrelevant or to be effects not causes A cited example of the former was Goodman and Ste venson s 1989 twin study But their family data were based on contemporaneous parent interviews which not surprisingly yielded no predictability there was no observation of caregiver behavior antecedent or contempo rary Weak measures are quickly accepted when the null hypothesis follows from tacit assumptions about factors that are irrelevant Another example is a study by Schachar and Wachsmuth 1990 which could be cited as showing a lack of family influence on ADHD Taylor 1994 Schachar and Wachsmuth simply examined DSM diagnoses of parents finding no increment in disorders among par ents of ADHD cases compared to parents of controls though there was an increase for conduct disorder cases Such a family vari able follows from a medical model given a preoccupation with genetic causality How ever it is not parental psychiatric diagnosis but patterns of stimulation control and dy adic regulation that are critical within a devel opmental perspective These were not as sessed A study by Hinshaw and McHale 1991 was cited as an example of research showing that parenting differences are effects and not causes These authors reported that parent controllingness decreased when chil dren with attention problems were given stim ulant medication which as we will discuss below is not relevant to the question of etiol ogy Finally many reviewers and discussants of this work and researchers in general have argued that it has already been proven that at tentional problems are largely the result of neurological dysfunction eg Frick amp La hey 1991 Such a conclusion has been based on descriptions of the syndrome the pre sumed lack of evidence for parenting and other contextual influences shortterm re Psychopathology as development sponsiveness of the disorder to stimulant med ication and occasional neurophysiological correlates One highly acclaimed example of the latter is Zametkin s 1993 report of fron tal lobe blood flow differences in adults pre sumed to have been ADHD as children com pared to control subjects As will be discussed below such a correlation cannot be interpre ted as causal All of this re ects interpretation of information within a medical model with out consideration of compelling alteniatives When the medical model lens is removed and the literature on etiological factors in at tention problems is considered from within a developmental perspective very different in terpretations result With respect to parent be havior for example cause is not looked at in simple linear terms Of course maria ing a child with attention problems is extraordi narily difficult regardless of what is ulti mately understood regarding etiology It also would seem natural for parents to be control ling and even critical of a child having such problems and the literature contains such findings Taylor 1994 If with intervention child attention problems decrease one would expect controllingness to decline Ongoing mutual influence is the basic expectation within a developmental process model How ever such a finding in no way suggests that caregiving factors are irrelevant to etiology It would not be hypothesized that parental over control would lead to hyperactivity so the fact that overcontrol declines with diminished child problems is not germain to this issue Our prospective 39 quot re vealed no infant predictors of parental intru siveness or overstimulation At the same time these parenting pattenis predicted later atten tion and activity problems How child factors interact with such parenting variables has as yet been little explored Central nervous system correlates also would be expected within an integrative de velopmental framework First of all many of the data utilizing brain physiology or blood flow such as the findings of Zametkin 1993 are gathered during attentional tasks The measures therefore simply corroborate the at tention problem That lifelong attention prob lems would in adulthood be manifest both in 261 behavior and in CNS functioning is no sur prise given the integrated nature of human functioning However this in no way allows the conclusion of innate damage or even dys function in the sense of aberrant behaviori brain linkages Such measures thus have the status of markers but not necessarily causes The leap to equate correlation with cause is a reflection of a commitment to the medical model Moreover even were dysfunction in brain functioning shown to be antecedent to the emergence of attention and activity prob lems which certainly has not been done yet this still would be best interpreted within a broader causal framework The recent out pouring of evidence conceniing experience dependent brain development Cicchetti amp Tucker 1994 Greenough Black amp Wallace 1987 Kraemer 1992 Schore 1994 makes it clear that there are massive experiential influ ences on the development of the central ner vous system including the tuning of systems concerned with activation and regulation of affect and behavior Eclectic investigators will look for ongoing parenting influences on endogenous factors as well as endogenous in fluences on parenting Changes in behavior in response to stimu lant medication likewise do not allow etiolog ical interpretations Models of etiology and models of treatment bear no necessary rela tion to one another Frankly retarded young sters may be trained to perform certain cogni tive tasks but no one currently argues that their retardation was the result of insufficient 39 Those who argue that drug studies have etiological significance overlook the fact that stimulants also enhance the per formance of normal children and adults and show little evidence of improving the func tioning of attention disordered children in the long term see Jacobvitz et al 1990 Even were such results ever demonstrated and even if the effective drugs were those with more specific neurotransmitter actions in contrast to broadly acting methylphenidate this still would not prove inherent deficit due to the complex systemic nature of development Central nervous system dysfunction also is best viewed as developing within a complex causal framework 262 A deVelopmental view of infant attachment problems and later disturbanCe A second illustration of developmental re search on maladaptation concerns the relation of early anxious attachment relationships to later psychiatric problems Attachment re search provides an interesting case for devel opmental psychopathology because attach ment is a relationship construct not an individual trait construct Established assess ments of infant caregiver attachment eg the Strange Situation Procedure Ainsworth Blehar Waters amp Wall 1978 are assess ments of relationships not individuals This has been supported by ample research includ ing the findings that attachment patteni with each parent often is different with concor dance barely significant Fox Kimmerly amp Schafer 1991 and that attachment security with a given parent changes as a function of that parent s changing life stress eg Vaughn Egeland Waters amp Sroufe 1979 Clearly attachment security is not an endoge nous infant trait Still patterns of anxious attachment in in fancy are proposed to be risk factors for psy chopathology The quality of a particular at tachment relationship whether secure or anxious is based on the history of interaction within the pair When the caregiver is rou tinely responsive to the infant s signals the infant develops a confidence that reassurance tending assistance and other care will be available when needed Such confidence in support is precisely what is meant by secure attachment In contrast routinely unrespon sive or inconsistent care undermines security The patteniing of the early primary attach ment relationship is a prototype for subse quent development operating on numerous levels Sroufe Egeland amp Carlson in press In the secure attachment case having experi enced responsive care the child generalizes the expectation that others will be responsive and available that is the child develops gen erally positive and trusting attitudes toward others Along with this the child takes for ward a sense of his or her own effectance and personal worth Being able to effectively elicit responsiveness and care from the parent they Li A Sronfe expect to master challenges and to have power in the world They believe in them selves Likewise they value relating and have an intenialized template for empathy and reci procity in relationships Patterns evolved in the attachment rela tionship are taken forward at the behavioral level as well The child has been entrained into particular pattenis of reciprocity and af fective sharing as well as having evolved a sense of curiosity and a skill in exploration supported by the secure attachment Supporting the behavioral level are pat tenis of arousal regulation which allow the full range of emotional expression with suffi cient modulation such that organized behav ior can be maintained Such pattenis are readily established in the context of respon sive care because responsiveness entails ap propriate affective stimulation and interven tions to eep arousal within reasonable bounds Moreover recent evidence eg Schore 1994 suggests that a history of pat tenied responsive care actually is central in tuning and balancing excitatory and inhibitory systems in the central nervous system itself which would support emotional regulation and behavioral flexibility In addition to those attachment relation ships judged to be secure the clear majority in most samples there are three pattenis of anxious attachment each of which would compromise the developing capacities for selfregulation and social behavior Ains wort et al 1978 Main amp Hesse 1990 Sroufe 1988 Anxiousresistant attachment is characterized by difficulty settling with the caregiver when distressed often tinged with anger Such a pattern is associated with a his tory of inconsistent care andor neglect leav ing infants hyperaroused hypervigilant and uncertain regarding caregiver availability and their own effectiveness Anxiousavoidant at tachment involves explicitly failing to seek contact with the caregiver under conditions of stress eg following brief laboratory separa tions This pattern is associated with a history of chronic rebuff especially when the infant sought physical contact with the caregiver Such infants learn to cut off or truncate emo tional responses especially when tender needs Psychopathology as development are aroused Finally disorganizeddisoriented attachment re ects confusion about or even fear of caregivers who themselves have be haved in confused alarming or dissociated ways Such infants face an unresolveable par adox of having caregiver be both the source of alarm and the biologically expected source or reassurance Lapses in orientation and failures of integration of emotions cogni tions and behavior result We recently tested the hypothesis that pat tenis of anxious attachment represent risk fac tors for psychopathology across childhood and adolescence For example at age 17 we created an overall index of pathology based on the number duration and seriousness of diagnoses derived from the Schedule of Af fective Disorders and Schizophrenia Child Form clinical interview which was con ducted and coded completely independent of attachment history or other knowledge of the child The simple correlation of avoidant at tachment at 12718 months and the pathology index was 24 This is significant with 170 subjects though small in absolute terms The combination of disorganized attachment Main amp Hesse 1990 and avoidant attach ment raised the correlation to 41 modest but impressive over these many phases of devel opment and given the challenges of assessing such constructs The correlation increased still further into the high 50s when we also added measures of parenting and adaptation from the preschool and early adolescent peri ods see Carlson submitted The disorga nized attachment patteni was specifically re lated to dissociative symptoms in childhood and adolescence 40 as predicted by theory In accord with the developmental model avoidant and disorganized pattenis of attach ment may be thought of as initial develop mental variations probabilistically associated with later disturbance Such pattenis of anx ious attachment are not thought of as psychi atric disorders themselves Sroufe 1988 Again they are viewed as assessments of rela tionship qualities with a particular caregiver Avoidance and disorganizeddisoriented at tachment which show ittle concordance across parenting partners both are predictable from earlier pattenis of care by the particular 263 parent and show stability with each parent Carlson submitted Main amp Hesse 1990 Thus anxious attachment in infancy is better viewed as an initiating condition than as a characteristic of the infant Still as a mal adaptive relationships patteni it is probablisti cally linked to later psychological disorder Nor is anxious attachment viewed as causal of later disturbance in a simple sense After all as is true of most singular risk fac tors the majority of individuals showing early anxious attachment do not show serious dis turbance later Whether disturbance results depends on the successive combination of lia bilities and supports that maintain the individ ual on a pathway to pathology or bring them back toward positive adaptation Of course one of the liabilities or supports in the case of secure attachment is the prior adaptation including prototypical patteni of coping and affect regulation and expectations conceniing self other and relationships within which the person negotiates subsequence developmental p ases The manner in which attachment theory and research have been utilized within the dominant medical model was predictable Attachment disorders were added to the DSM APA 1987 1994 While the criterion of pathological care as the source of these problems marks a break from the traditional medical model approach and while the cases so designated may indeed have attachment problems Zeenah Mammen amp Lieberman 1994 the circumscribing of attachment prob lems to specific disorders reveals a failure to grasp the developmental significance of at tachment history and the potential power of a developmental approach to psychopathology in general What could become a model for approaching childhood disturbance of all kinds is sequestered into a circumscribed set of categories Various attachment problems seem to have implications for a range of disturbances cer tainly not all phenotypically similar to dyadic behavioral pattenis shown in infancy Blatt 1995 For example given the tendency of those in avoidant attachment relationships to turn from their caregivers when in need later social withdrawal and superficial relation 264 ships might be all that were expected based on linear predictions But the lack of empathic connection and the alienation inherent in these prototypic avoidant attachments also has been viewed as the basis for aggressiveness bully ing and conduct disorders predictions which have been confirmed Renken et al 1989 Troy amp Sroufe 1987 On the other hand re sistant attachment often is manifest in angry rejection of the caregiver when comfort is of fered to the distressed infant a pattenr which may be shown in batting away toys pushing away from contact squirming andor tarr truming Yet this pattenr is not associated with later Oppositional Defiant Disorder or other extenralizing problems It is uniquely related to Anxiety Disorder classifications as predicted from the chronic vigilance required to monitor an inconsistent caregiver Warren et al submitted Conclusion Future Directions The classic medical model as a framework for approaching behavioral and emotional prob lems in childhood has inherent limitations Childhood problems generally are not like diseases They show little evidence of a bounded discrete syndromic nature Often children qualifying for diagnosis are quantita tively not qualitatively different from other children Research often shows number of problems rather than tight syndromic coher ence to be predictive of later disorder Fur thermore most childhood problems are con text malleable to a degree that surpasses typical medical conditions especially during the years of onset All of is is much more consistent with the idea of development than the idea of disease Exceptions to this general case such as childhood autism actually further underscore the importance of a developmental viewpoint Autism is now classed as a Pervasive Devel opmental Disorder and properly so Such children are profoundly disturbed in all arenas of functioninggcognitive affective and so cial Hobson amp Patrick 1995 They are qual itatively different from other children in cluding those with behavior and emotional problems Children assigned diagnoses of at Li A Sroufe 7 u tention deficit hyperactivity disorder anxi ety disorder and so forth and children not fitting any DSM category are far more similar to each other than they are to children diag nosed as autistic The manifestation of most childhood disturbances but not autism is pro foundly influenced by context For example in our emotionally supportive wellstaffed one adult to four children activityoriented summer camps which include a good mix of competent 10yearolds and children with serious conduct problems aggression was al most nonexistent eg Elicker Englund amp Sroufe 1992 This is despite the fact that in school settings the troubled children were reli ably reported by both teachers and observers to engage in frequent bullying and other ag gressive behaviors Such contextual variation across time as well as situations is a hallmark of most childhood problems but not most medical conditions It is sometimes difficult to recognize that the medical model with its assumptive base is being applied broadly to problems of children and youth Its wide use partly derives from successes of the model with certain adult dis orders and with occasional childhood distur bances More general validity of the model is then simply taken for granted and not exam ined Moreover the classification of child hood problems currently in use has served certain purposes in research Categories such as ADHD promote communication to a de gree they summarize a set of behaviors in shorthand fashion and provide a starting point for research on etiology and treatment How ever the fact that the DSM system is being used cannot be taken as support for its valid ity There are children who are impulsive ag gressive anxious and so forth with frequen cies of behavioral manifestation showing notable stability in childhood But this is not evidence of syndromic integrity and not evi dence of endogenous pathogens as primary causes More research is needed that examines the integrity of existing diagnostic categories and that seeks to uncover new coherent groupings of problems Especially important will be re search that begins by defining early pattenrs of adaptation and then follows individuals Psychopathology as development showing such patterns to observed families of outcomes This contrasts sharply with the cur rent dominant approach of simply assuming the validity of existing categories and then seeking antecedents When these two ap proaches converge one would of course have considerable confidence in the meaning fulness of the taxa in question At the same time further efforts to group developmental trajectories meaningfully should be given high priority by both researchers and funding agencies The distinction between adolescent limited and developmentally persistent con duct problems Moffitt 1993 is an excellent example The problems of these groups of children are more appropriately distinguished rather than being lumped into the same cate gory It seems likely that developmental anal ysis will reveal similar distinctions among those who at some time show depression and other problems as well In general what is needed is a fresh examination of the whole issue of classification in child psychopathol ogy based on developmental research A serious consequence of the current dom inance of the medical model has been its con straining effect on the conduct of research and interpretation of findings This is highlighted when it is contrasted to a developmental model Under the aegis of the medical model environment is defined narrowly as toxins precursors are seen as pathogens or simply early forms of the disorder and course is viewed as linear Too often problems are con sidered conditions that children have Thus the role of experience is relatively neglected in research on childhood problems and there is a preoccupation with finding the gene that causes disorder or the locus of neuropathol ogy Little research is conducted on experien tial risk factors early adaptation or processes of change Treatment is viewed narrowly as symptom management and few guides for early intervention or primary prevention are uncovered More extensive and encompassing research is needed on risk factors for disorder As Rut ter 1996 has recently stated the understand ing of environmental risk factors in both de pressive and even more so anxiety disorders in children and adolescents is decidedly lim 265 ited p 224 This statement can be extended to most childhood disorders if one broadens environment to include experiential factors rather than simply demographic variables and aspects of the physical environment Espe cially important is longitudinal research be ginning prior to the onset of disorder Such research not only is necessary for untangling causal mechanisms and processes it is the key to resolving the classification problems dis cussed above Currently for example much discussion centers around ADHD with and without con duct disorders eg Rutter 1996 Outcomes for children so diagnosed are very different but it is not clear what the implications are for classification Such discussion would be enlightened enormously by antecedent data Are there distinctive origins of the comorbid patteni or is it simply a combination of the precursors of ADHD and CD7 Are the ante cedents of CD alone or ADHD alone dis tinctive from antecedents of those showing the combined patteni see Loeber Brin thaupt amp Green 1990 Is the comorbid pat teni itself in fact heterogeneous Such ques tions must be approached developmentally It is not enough to examine selective correlates of already manifest disorder In addition to having a broad net of theoretically derived potentially differentiating variables it is nec essary to examine the relationships between predictors and problem behaviors over time and across ages Some variables may have stronger differential links with onset of prob lems while others may be more tied to persis tence or desistance August et al 1996 Only longitudinal research can resolve these issues Lastly much more research is needed on processes of continuity and change again with renewed emphasis on experiential factors eg changing support and guidance of the child With regard to desistance both early experiential antecedents which may provide a foundation for resiliency and contemporary supports command study In general there has been far too little investigation of the interac tion between prior adaptation and current risks or changing support In conclusion within a developmental ap proach problems are viewed as adaptations 266 They may be compromising of development to be sure but as adaptations they are subject to change as well as forces for continuity This is especially true as challenges to adapta tion are changed Understanding pathways of adaptation has promise for both effective pre vention and broadened approaches to later in References Ainsworth M Blehar M Waters E amp Wall S 1978 Patterns of ttachment Hillsdale NJ Erlr b aum American Psychiatric Association 1987 Diagnostic and statistical manual of mental disorders 3rd ed rev Washington DC Author American Psychiatric Association 1994 Diagnostic and statistical manual of mental disorders 4th ed Washington DC Author 39 39 s McGee R amp Silva P 1987 SM III disorders in preadolescent children Prevalence in a large sample from the general popular tion Archives of General Psychiatry 44 69776 August G MacDonald A Realmuto G amp Skare S 1996 Hyperactive and aggressive pathways Effects of demographic family and child characteristics on children39s adaptive functioning Journal of Clinical Child Psychology 25 3417351 Blatt S 1995 Representational structures in psychor pathology In D Cicchetti amp S Toth Eds Rochesr ter symposium on developmental psychopathology Vol 6 Emotion cognition and representation pp Campbell S 1990 The socialization and social develr opment of hyperactive children In M Lewis amp S Miller Eds Handbook of developmental psychor pathology pp 77792 New York Plenum Carlson E A longitudinal study ofattachment disorganir zation Manuscript submitted for publication Carlson E Jacobvitz amp Sroufe L A 1995 A develr opmental study of inattentiveness and hyperactivity Child Development 66 37754 Caron C amp Rutter M 1991 Comorbidity in child psychopathology Concepts issues and research strategies Journal of Child Psychology and Psychiar try 32 106371079 Cicchetti D 1984 T e emergence of developmental psychopathology Child Development 55 177 Cicche i D amp Rogosch F Eds 1996 Developmental pathways Diversity in process and outcome Speci Issue Development and Psychopathology 8 5977600 Cicchetti D amp Sroufe L A 1976 The relationship between affective d co nitive development in Down39s syndrome infants Child Development 47 9207929 Cicchetti D amp Tucker D 1994 Development and selfrregulatory structures of the mind Development and Psychopathology 6 5337549 Cohen J amp Stewart I 1994 The collapse of chaos W York Penguin Books Crick N amp Dodge K 1994 A review and reformular tion of social informationrprocessing mechanisms in children39s social adjustment Psychological Bulletin 115 747101 L A Sroufe tervention As with resilience coping capac ity and personality in general maladaptation and ultimately disorder may also be pre sumed to develop The same laws that goveni normal development goveni the pathological as well Cicchetti 1984 Cicchetti amp Sroufe 1976 Loevinger 1976 Egeland B Carlson E amp Sroufe L A 1993 Resilr 39 process Development and Psychopathology 5177528 Eisenberg L 1977 Development as a unifying concept in psychiatry British Journal of Psychiatry 131 2257237 Elicker J Englund M amp Sroufe L A 1992 Predictr 39 and peer relationships in child hood from early parent4hild relationships In R Ladd Eds Familyipeer relationships Modes ofl39nkage pp 777106 Hillsdale NJ Erlr u a m Fox N Kimmerly N amp Schafer W 1991 Attachr ment to motherattachment to father A metaranalysis Child Development 62 2107225 Frick P amp Lahey B 1991 The nature and characterisr tics of attentionideficit hyperactivity disorder School Psychology Review 20 1637173 Goodman R amp Stevenson J 1989 A twin study of hyperactivity Journal of Child Psychology and Psyr chiatry 30 6917709 Gottesman N 1995 Environmental and familial ante cedents of sixth grade aggression Unpublished docr tora1 dissertation University of Minnesota Gottlieb G 1991 Experiential canalization of behave iora1 development Theory Developmental Psycholr ogy 27 4713 Greenough W Black J amp Wallace C 1987 Experir ence and brain development Child Development 58 7 9 Harrington R 1994 Affective disorders In M Rutter E Taylor amp L Hersov Eds Child and adolescent psychiatry pp 3307350 London Blackwell Hinshaw S amp McHale J 1991 Stimulant medications and the social interactions of hyperactive children In D Gilbert amp J Connolly Eds Personality social skills and psychopathology pp 2297253 New York Plenum Hobson R P amp Patrick M 1995 Emotion cognition and representation The interpersonal domain In D Cicchetti amp S Toth Eds Rochester symposium on developmental psychopathology Vol 6 Emotion cognition and representation pp 1677190 Roc es ter NY University of Rochester Press Jacobvitz D Sroufe L A Stewart M amp Leffert N Treatment of attentional and hyperactivity problems in children with sympathomimetic drugs A comprehensive review Journal of the American Academy of Child Psychiatry 29 6777688 Jacobvitz D amp Sroufe L A 1987 The early carer giver4hild relationship and attention de cit disorder with hyperactivity in kindergarten Child Develop ment 58 148871495 Kraemer G 1992 A psychobiological theory of attachr ment Behavioral and Brain Sciences 15 4937511 Psychopathology as development Lazare A 1973 Hidden conceptual models in clinical psychiatry New England Journal of Medicine 288 3 7 50 Loeber R 1991 Questions and advances in the study 39 39 amp S Toth Eds Rochester symposium on developmental psyr chopathology Vol 3 pp 977115 Rochester NY Rochester Universit Press Loeber R Brinthaupt V amp Green S 1990 Attention deficits impulsivity and hyperactivity with or with out conduct problems Relationships to delinquency and unique contextual factors In R McMahon amp R Peters Eds Behavior disorders ofadolescence Re search intervention a policy in clinical and school settings pp 39761 New York Plenum Lo Keenan K Giroux B Stour thameriLoeber M anKammen W amp Maughan B 1993 Developmental pathways in disru tive child behaviors Development and Psychopathology 3713 Loevinger J 1976 Ego development San Francisco 7 ass Main M amp Hesse E 1990 Parents39 unresolved traur matic experiences are related to infant disorganized attachment status In M Greenberg D Cicchetti amp E Cummings ds Attachment in the preschool years pp 1617182 Chicago University of Chicago Press Masten A amp Coatsworth J D 1995 Competence rer silience and psychopathology In D Cicchetti amp D Cohen Eds Developmental Psychopathology Vol 2 pp 7157752 New York Wiley Moffitt T 1993 Adolescencerlimited and lifercourse persistent antisocial behavior A developmental taxi onomy Psychological Review 100 6747701 aryshe B amp Ramsey E 1989 A developmental perspective on antisocial behavior tary school Journal ofPersonality 57 2577281 Richters J amp Cicchetti D 1993 Mark Twain meets MrllliR Conduct disorder development and the concept of harmful dysfunction Development and Psychopathology 5 5729 Rieder C amp Cicchetti D 1989 Organizational per spective on cognitive control functioning and cognir tiveraffective balance in maltreated children Develr opmental Psychology 25 3827393 Robins L amp Price R 1991 Adult disorders predicted by childhood conduct problems Psychiatry 54 1167 132 Rogosc F Cicchetti D amp Aber L 1995 The role of child maltreatment in early deviations in cogni 39ve and affective processing abilities and later peer relay tionships Development and Psychopathology 7 5917 61 Rutter M 1980 Introduction In M Rutter Ed Scir enti c foundations of developmental psychiatry Lonr do Heineman Rutter M 1996 Developmental psychopathology Concepts and prospects In M Lenzenweger amp J Havgaard Eds Frontiers ofdevelopmental psychor pathology pp 2097237 New York Oxford Univerr sity Press Rutter Taylor E amp Hersov L 1994 Child and adolescent psychiatry London Blackwell 267 Sameroff A amp Fiese B 1989 Transactional regular tion and early intervention In S J Meisels amp J Shonkoff Eds Early intervention A handbook of theory practice and analysis New York Cambridge Un1v Santostefano S 1978 A biodevelopmental approach to 39 ical child psychology New York Wiley Schachar R amp Wachsmuth R 1990 Hyperactivity and parental psychopathology Journal of Child Psyi o and Psychiatry 31 3817392 Schore A 1994 A ect regulation and the origin ofthe self Hillsdale NJ Erlbaum Sroufe L A 1988 The role of infantxaregiver attachr ment in development In Belsk amp T Nez orski Eds Clinical implications ofattachment pp 187 38 Hillsdale NJ Erlbaum Sroufe L A 1989 Pathways to adaptation and malady aptation Psychopathology as developmental deviar 39on In D Cicchetti Ed Rochester symposium on development psychopathology Vol 1 pp 13410 Hillsdale NJ Erlbaum Sroufe L A 1990 An organizational perspective on the self In D Cicchetti amp M Beeghly Eds Transir tions from infancy to childhood The self pp 2817 307 Chicago The University of Chicago Press Sroufe L A Carlson E amp Shulman S 1993 Individr uals in relationships Development from infancy through adolescence In D Funder R Parke C Tomi linsoniKeasey amp K Widman Eds Studying lives through time Personality and development pp 3157 342 Washington DC American Psychological Asr sociation Sroufe L A Egeland B amp Carlson E in press One social world In W A Collins amp B Laursen Eds Relationships as developmental contexts The Minnei sota symposia on child psychology Vol 29 Hills dale NJ Erlbaum Sroufe L A amp Egeland B 1991 Illustrations of per izati nd measurement of organismienvironment interaction pp 68784 Washington DC American Psychological Association Sroufe L A Egeland B amp Kreutzer T 1990 The fate of early experience following developmental change Longitudinal approaches to individual adapr tation in childhood Child Development 61 13637 37 3 Sroufe L A amp Rutter M 1984 The domain of develr opmental psychopathology Child Development 55 17729 Suess G J Grossmann K E amp Sroufe L A 1992 Effects of infant attachment to mother and father on quality of adaptation in preschool From dyadic to in dividual organization of self International Journal of havioral Development 15 43766 Taylor E 1994 Syndromes of attention deficit and overactivity In M Rutter E Taylor amp L Hersov Eds Child and adolescent psychiatry pp 2857 7 London Blackwell Thelen E 1990 Dynamical systems and the generation of individual differences In J Colombo amp J Fagan Eds Individual dijferences in infancy pp 19413 Hillsdale NJ Erlbaum Troy M amp Sroufe L A 1987 Victimization among preschoolers The role of attachment relationship his tory Journa o the American Academy of Child and Adolescent Psychiatry 26 166 232012 31800 PM Research Design Nomothetic research that sees to determine general lawsprinciples 0 Groups 0 Represents most research Idiographic focuses intently on the individual 0 Clinical situations Epidemiology study of the frequency and distribution of disorders within a population 0 Prevalence proportion of population that has a disorder at the same point in time Incidence rate of new cases of disorder in given period Risk factor condition variable which if present increases the likelihood of the disorder Protective factor condition variable which if present decreases the likelihood of the disorder Naturalistic observation observing a subject in hisher natural environment 0 Doesn t show cause and effect Survey methods 0 Random sample every member of population has equal chance of being chosen 0 Stratified sample collected so that it accurately represents population of interest Correlation method examines extent to which 0 Positive as one increases the other decreases Negative as one increases the other decreases Magnitude Between 1 and 1 Can t prove causation but causation can not be proven with out correlation Bidirectionality can not determine ifA caused B or B caused A Third variable problem unknown variable C may be causing both A and B Case study 0 O O O O O O O Models 0 O O 0 Can be used when working with rare phenomena Can generate hypothesis for Can be used by practicing clinicians to contribute to literature Doesn t show cause and effect Experimental methods 0 0 Single subject design ReversalwithdrawalABAB Design Multiple Baseline Group design random assignment to conditions and applying treatment A vs treatment B or no treatment DiathesisStressBiopsychosocial Model 0 Diathesis predisposition toward disorder Heredity early experiences etc Stress current environmental factors that combine with diathesis to influence likelihood of developing a disorder Biology psychology and sociology all play a part in likelihood of developing a disorder Sroufe s Pathways Model 0 O O 0 Path A continuity of maladaptation culminating in disorder Path 8 continuity of positive adaptation Path C initial maladaptation followed by positive change Path D initial positive adaptation followed by negative change Five Points Disorder is deviation over time Multiple pathways lead to similar outcomes equifinality Different outcomes can occur from same pathway multifinality Change is possible Change is constrained by prior adaptations Kelleher et al Article 0 MCS Study 1979 Asked pediatricians to record if they believed a child to have a possible disorder Identified 68 0 CBS Study 1996 Asked same question in same county 15 years later Identified 187 0 Found that certain risk factors such as single family homes and something else also increased Diagnostic Statistical Manuel of American Psychiatric Assoc DSMIVTR Potential benefits of classification 0 Provides description of problem which facilitates communication among professionals 0 May lead to discovery of causes of particular disorder 0 Can improve clinicians ability to predict outcome prognosis 0 Can lead to guidelines for selecting treatment Potential problems of classification 0 Labeling o Reliabilityagreement 0 Research in constantly changing Validity usefulness o Etiological classification may reveal cause Past 0 Concurrent two measurements agree Present 0 Predicted what can be expected in the future Future General types 0 Categorical have or don t have ie boy or girl 0 Continuousdimensional scale ie height Five Axes 0 Clinical disorders 0 Personality disorders andor mental retardation 0 General medical conditions 0 Psychological and environmental factors 0 Global Assessment of Functioning Comorbidity having more than one disorder 0 Very common with DSMIV O 232012 31800 PM Mental Health Professionals o Psychiatrists 0 Have MD and can prescribe medication o Psychologists 0 Some involved in mental healthcare Clinical counseling or school psychologists 0 May have PhD Doctorate of philosophy Research oriented 0 May have psyD Doctorate of psychology 0 May have EdD Doctorate of education Counseling oriented o Social Workers 0 MSW Masters of Social Work 0 DSW Doctorate of Social Work o Counselors Therapists and Psychotherapists 0 General ambiguous terms Study by Langer and Abelson o Showed two types of mental health professional a video of a person being interviewed o Behavioral psychologists When told it was a job applicant rated mental health to be high When told it was a mental health patient rate of metal health was high 0 Psychoanylical psychologists When told it was a job applicant rate of mental health was high When told it was a mental health patient rate of mental health was low a Background predisposed them to see more pathology theory makes a difference FreudPsychoanalysis o Psychosexual stages of development 0 Biological emphasis 0 Early stages are most important o Structure of mind Id present at birth impulsedriven pleasureprinciple Ego makes plansdecisions logical realityprinciple Superego learned from parentssociety moralprinciple Depicted as iceburg Unconscious mind below water greatest portion Conscious mind above water Preconscious mind along water line a Has potential to become part of consciousness o Defense Mechanisms 0 Function is to protect ego from anxiety Can be useful or restrictive 0 Projection ie paranoia attribute your own unacceptable urges or impulses to other people 0 displacement redirecting an urgeimpulse from a move to a less threatening personobject o Techniques Dream analysisinterpretation Free Association talking with out usual editing found in conversational speech ie firstthingthatcomestomind Transference client acts toward therapists in unconscious way as if they are an important person in their past ie authoritative motherfather Interpretation therapist shares theorythoughts with client Will hopefully bring insight to client Resistance therapist notes instances of when client avoids unpleasant but important content Carl RogersHumanistic Theory o Client centered o Foundational belief if people are given the right conditions they will become the person they are meant to be 0 Le unconditioned loveacceptance o goal insight create conditions necessary for growth by therapists characteristics 0 O O O O O O O o genuineness unconditional positive regard empathetic understanding EriksonPsychosocial o Social oriented o Stages of crisis 0 Prepotency stages build on one another 0 Stages 14 in book 0 Stage 5 ego identity vs role diffusion Resolution develop good sense of who you are 0 Stage 6 intimacy vs isolation Resolution 0 Stage 7 generativity vs stagnation Resolution being productive concerning the wellbeing of others midlife crisis ppl attempt to come to terms with the fact that they aren t going to accomplish everything they wanted in their lives emptynest syndrome feelings of emptiness that parents feel when the last child leaves home 0 Stage 8 integrity vs despair Resolution looking over life and being content Maslow o Hierarchy of Needs 0 Selfactualization o Esteem o Belonging 0 Safety 0 Physiological 232012 31800 PM Behavior Psychology Classical conditioning Pavlov o Unconditioned stimulus with no prior learning capable of eliciting an unconditioned response 0 Conditioned stimulus an originally neutral stimulus which through association with US elicited UR Learned response can be cognitive emotional or physiological Generalization stimuli similar to CS will elicit to some degree the CR with no additional learning 0 Discrimination presenting US only after specific CS which decreases generalization Extinction presenting the CS without the US leads to a gradual lessoning of CR 0 Spontaneous recovery increase in CR to CS following extinction without any additional learning Operant Conditioning Skinner 0 Positive behavior results in something being added following behavior 0 Negative behavior results in something being taken away following behavior 0 Reinforcement increase in behavior because of consequences behavior brought about 0 Punishment decrease in behavior because of consequences behavior brought about Stimulus control 0 O O 0 Functional analysis of behavior 0 Antecedent comes before behavior prompting occurrence 0 Behavior 0 Consequence comes after behavior influences likelihood Increasing behavior 0 Shaping breaking a complex task into its component parts task analysis and teaching each step in sequence 0 Modeling way of teaching complex behaviors not easily taught through shaping involves a model and an imitator Decreasing behavior o Extinction with holding reinforcers for a previously reinforced behavior Extinction burst increase in behavior at beginning of extinction program 0 Differential reinforcement of other behavior BRO reinforcement of a behavior that prevents the undesirable behavior 0 Time out from reinforcement o Reprimandingpunishing o Cognitive Behavior Theory 0 Ellis developed Rational Emotive Therapy Assumption that if irrational beliefs responsible for emotional issues are identified and correvyed rational beliefs will promote better emotional responses 0 Beck developed Cognitive Behavior Therapy After identifying maladaptive automatic thoughts validity of thoughts are challenged through Collborative Imperiasism o Maintenance and generalization 0 Maintenance behavior change continues once therapy has ceased o Generalization behavior is performed in nontraining enviorments o Ways to maintain behavior 0 Introduction to natural communities of reinforcement reinforcement trap Intermittent reinforcement schedule More resistant to extinction 0 Program common stimuli 0 Eliminate secondary gainreinforcement for misbehavior Does therapy work o Efficacy therapy produces significant effects in controlled research investigations 0 Necessary but not sufficient to demonstrate effectiveness o Effectiveness therapytreatment is useful in typical clinical studies 0 Memtall HeathJim January 17 2012 Mental Health Professionals Psychiatrist MD can prescribe medicine conduct therapy Psychologist PhD PsyD EdD clinical counseling school gt all involved in mental health 0 PhD Doctor of Philosophy university setting research oriented o PsyD Doctor of Psychology freestanding program business not usually in a university setting Social workers MSW DSW Counselors therapists psychotherapists generic terms that do not tell you much people working with human behavior is common characteristic of all of them Scientistpractitioner orientation science informs practice practice informs science both go back and forth and support each other llt is theory that decides what we can observequot Einstein Theory can be good but can be blinding it is hard for people to see outside their theories Study by Langer and Abelson Behavioral psychologists told that person was a job applicant Psychoanalytic psychologists told that person was a job applicant Behavioral psychologists told that person was a mental patient Psychoanalytic psychologists told that person was a mental patient High PA 13 PA Low Told a Job applicant patient Told a mental Two groups of doctors behavioral psychologists and psychoanalytic psychologists 15 minute video ofa person being interviewed told half the doctors that the person was a job applicant and the other half that he was a mental health patient told to rate the mental health of the person highlow PA rated mental health of person lower when told they were a mental patient saw something that wasn t there background affects what you see PA saw more pathology than B and interpreted it differently theoryparadigm makes a difference in what you see and how you interpret it Freud Psychoanalysis 0 39 39 u I p Li I g H u39i emphasized earlyageearlyyears not much later on 0 Structure ofthe mind 2 ways 1 Id present at birth only interested in gratification uses the pleasure principle Ego plans uses strategies makes decisions uses reality principl Superego uses moral principle incorporates the quotoughtsquot and quotshouldsquot of society difference between goodbad and wrongright Iceberg portrayal Most ofthe mind is unconscious Preconscious has potential to bring into conscious Goal of psychoanalysis is to make the unconscious conscious insightoriented therapy Defense mechanisms protect the ego from anxiety 0 Projection classic example is a paranoid person attribute to other people your unacceptable urges or impulses 0 Displacement transferring or redirecting an urge or impulse from a more to a less reatening person Techniques of psychoanalysis ream analysis and interpretation royal road to the unconscious dreams supposedly contain symbolic content 0 Free association talking without the usual editing that goes on in conversational speech 0 Transference client acts toward the therapist unconsciously as if the therapist was some important person in the clients 0 Instances of resistances client may exit room when subject is brought up change topic start an argument therapist notes when client avoids unpleasant but important content 0 Interpretation therapist will behin to share their theory with client about how they may be thinking Carl Ro er c Cl nt entered Thera 0 Foundational belief If people are given the right conditions they will develop into the person they are meant to be unconditional love and acceptance 0 Goals 0 Insight o Create conditions necessary for growth done by therapist characteristics more than techniques I Genuineness beinga real person ratherthan playinga role 39 Unconditionai positive regard no conditions of worth very accepting 39 Engage in empnatic understanding tnerapist refiects ciients words in orderfor them to understand 0 Not used as much anymore but has been integrated into other scnoois oftnougnt sSta es Psycnosociai stages of deveiopment 8 stages framed in terms of crises botn promise and perii Prepotency one stage buiids on the other successfui resoiution ofan eariy stage predisposes person to resoiution of higher stages Stage 5 adoiescence egoidentity vs roie diffusion or negative identity many possibie identities during this stage deveioping a sense of who you are is successfui resoiution vs not knowing or not iiilting who you are Stage 6 eariy 20 s intimacy vs isoiation entering into reiationsnips not necessary but wiii demand ofa person vs not being in any reiationsnips and choosing to be independentaione January 19 2012 Stage 7 generativity vs stagnation middieage being productive in one s iift work and concerned about and promoting the weiibeing of others vs being concerned about oniy yourseif o Midiife crisis wnen peopie attempt to come to grips by reaiizingtney are not goingto accompiisn everything they wanted intneir iives i eiings 39 39 Ha can uccui ueume iast o mptyi yi cniid ieaves home 0 Sta integrity vs despair oider age iooilting back over iife and being oilt witnit or not being ge 8 ok with it Maslow s H rarchy of Needs doesn t have to go in order seifactuaiization achieving your unique potentia Behavioral Psychology 0 Came from the lab working with animals 0 Two main branches 1 ClassicalConditioning US gt UR salivation meat powder CR salivation I Pavlov worked with dogs I US unconditioned stimulus stimulus which with no prior learning required is capable of eliciting an unconditioned response I UR unconditioned response response elicited by US I CS conditioned stimulus an originally neutral stimulus which through association with the US comes to elicit a close approximation of the UR I CR conditioned response response elicited by CS I Generalization other stimuli to the extent they resemble the CS will elicit some degree of the CR bellshaped curve I Discrimination other stimuli to the extent they resemble the CS will not elicit some degree of the CR curve I Extinction removing the US and repeatedly presenting the CS after an already welllearned response I Spontaneous recovery an increase in the CR to the CS following extinction which is due only to the passage of time 2 Operant Conditioning Positive Positive 39 Reinforcement Punishment I Negative Negative I Reinforcement Punishment I Positive behavior results in something being added following the behavior I Negative behavior results in something being taken away following the behavior I Reinforcement increase in behavior because of the consequences behavior brought about I Punishment decrease in behavior because of the consequences behavior brought about I Examples 0 PR treat following a good grade on a test EBSCOhost Discovery Service Loading Revised Date 072011 Accessibility Information and Tips Bad 1 articles will be saved The link information below provides a persistent link to the article you39ve requested Persistent link to this record Following the link below will bring you to the start of the article or citation Cut and Paste To place article links in an external web document simply copy and paste the HTML below starting with quotlta hrefquot To continue in Internet Explorer select FILE then SAVE AS from your browser39s toolbar above Be sure to save as a plain text file txt or a 39Web Page HTML only39 le html In FireFox select FILE then SAVE FILE AS from your browser39s toolbar above In Chrome select right click with your mouse on this page and select SAVE AS Record 1 Title Increasing Identification of Psychosocial Problems 19791996 Authors Kelleher Kelly J McInerny Thomas K Gardner William P Childs George E Wasserman Richard C Source Pediatrics Jun2000 Vol 105 Issue 6 p1313 9p 1 Graph Document Type Article Subject Terms PEDIATRICS Psychosomatic aspects CHILDREN Diseases Diagnosis Abstract ABSTRACT Objective To examine the changes in identi cation of pediatric psychosocial problems from 1979 to 1996 Research Design Comparison of clinicianidentified psychosocial problems and related risk factors among large primary care pediatric cohorts from 1979 Monroe County Study and 1996 Child Behavior Study Data were collected from clinician visit questionnaires developed originally for the 1979 study Setting Private practice offices of 425 communitybased pediatricians and family practitioners across both studies Patients We enrolled all children from 4 to 15 years of age who presented for nonemergent services in primary care of ces The 1979 study included 9612 children seen by 30 clinicians and the 1996 study included 21 065 children seen by 395 clinicians Selection Procedure Each clinician enrolled consecutive eligible patients for both studies Measurements and Results From 1979 to 1996 clinicianidenti ed psychosocial problems increased from 68 to 187 of all pediatric visits among 4 to 15yearolds We found increases in all categories of psychosocial problems except for mental retardation Attentional problems showed the greatest absolute increase 1492 and emotional problems showed the greatest relative increase 236 The use of psychotropic medications counseling and referral also increased substantially In particular the percentage of children with Attention deficithyperactivity problems receiving medications increased from 32 to 78 These increases in psychosocial problems were associated with increases in the proportions of singleparent families and Medicaid enrollment from 1979 to 1996 Changes in clinician characteristics did not appear to be the source of increases in clinician diagnoses of psychosocial problems Conclusions Substantial increases in the identi cation of psychosocial problems in primary care paralleled demographic changes in children presenting to primary care offices and in the l ABSTRACT FROM AUTHOR Copyright of Pediatrics is the property of American Academy of Pediatrics and its content may not be fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service copied or emailed to multiple sites or posted to a listsen without the copyright holder39s express written permission However users may print download or email articles for individual use This abstract may be abridged No warranty is given about the accuracy of the copy Users should refer to the original published version of the material for the full abstract Copyright applies to all Abstracts Full Text Word Count 7528 SSN 00314005 Accession Number 3183698 Persistent link to this record Permalink I I IIA I gel I Igl Ill directtrueampdba9hampAN3183698ampsiteedslive Cut and Paste ltA hrefquothttpproxyremotegalibugaeduloginurlhttpsearchebscohostcomloginaspx directtrueampdba9hampAN3183698ampsiteedslivequotgtIncreasing Identi cation of Psychosocial Problems 19791996ltAgt Database Academic Search Complete INCREASING IDENTIFICATION OF PSYCHOSOCIAL PROBLEMS 19791996 ABSTRACT Objective To examine the changes in identification of pediatric psychosocial problems from 1979 to 1996 Research Design Comparison of clinicianidentified psychosocial problems and related risk factors among large primary care pediatric cohorts from 1979 Monroe County Study and 1996 Child Behavior Study Data were collected from clinician visit questionnaires developed originally for the 1979 study Setting Private practice of ces of 425 communitybased pediatricians and family practitioners across both studies Patients We enrolled all children from 4 to 15 years of age who presented for nonemergent services in primary care offices The 1979 study included 9612 children seen by 30 clinicians and the 1996 study included 21 065 children seen by 395 clinicians Selection Procedure Each clinician enrolled consecutive eligible patients for both studies Measurements and Results From 1979 to 1996 clinician identi ed psychosocial problems increased from 68 to 187 of all pediatric visits among 4 to 15yearolds We found increases in all categories of psychosocial problems except for mental retardation Attentional problems showed the greatest absolute increase 1492 and emotional problems showed the greatest relative increase 236 The use of psychotropic medications counseling and referral also increased substantially In particular the percentage of children with Attention de cithyperactivity problems receiving medications increased from 32 to 78 These increases in psychosocial problems were associated with increases in the proportions of singleparent families and Medicaid enrollment from 1979 to 1996 Changes in clinician characteristics did not appear to be the source of increases in clinician diagnoses of psychosocial problems Conclusions Substantial increases in the identi cation of psychosocial problems in primary care paralleled demographic changes in children presenting to primary care offices and in the larger population Pediatrics 2000 10513131321 psychosocial problems pediatrics family medicine primary care fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service ABBREVIATIONS MCS Monroe County Study CBS Child Behavior Study PROS Pediatric Research in Of ce Settings network ASPN Ambulatory Sentinel Practice Network AAP American Academy of Pediatrics AHPs Attention de cithyperactivity problems Community studies of adult populations have reported a gradually rising prevalence of mental disorders especially depression Q Q The growing prevalence of adult mental disorders has greatly affected primary care practice because persons with these disorders are often treated in primary care settings In addition persons with mental disorders use more general medical services than persons without these disorders We lack similar data on changes in the prevalence of child mental disorders speci cally or pediatric psychosocial problems defined more generally However community epidemiology studies suggest that both child mental disorders and psychosocial problems are common g Some investigators report mental disorder prevalence rates of 17 to 20 in community samples Similarly primary care clinicians state that 15 to 20 of children in their practices have psychosocial problems that require intervention or monitoring These estimates of the prevalence of childhood psychosocial problems are greater than those obtained in the rst large study of clinicianidentified child psychosocial problems The Monroe County Study MCS Q of 1979 reported data on the prevalence of psychosocial problems and management for 18 000 children from 30 pediatric of ces in and around Rochester New York At that time clinicians identi ed psychosocial problems in only 68 of all visits for children 4 to 15 years old Since the MCS only 2 major studies have examined the identification of psychosocial problems in primary care settings for schoolaged children what Haggerty 18 described as the quotnew morbidityquot Costello et al examined rates of clinician identification of child mental disorders in a metropolitan health maintenance organization in Western Pennsylvania in 1986 Horwitz et al n1O conducted a study using a cohort of pediatricians around Yale University in 1990 Both studies compared clinician assessment of psychosocial problems with psychiatric diagnostic instruments and behavior checklists Costello et al reported only on pediatric identi cation of psychiatric disorders and found that pediatricians identified mental disorders in 4 of visits for patients 8 to 16 years old In contrast Horwitz et al M employed a broad definition of psychosocial problems and found that clinicians identified approximately 20 of all children 8 to 16 years old with psychosocial problems These studies were important descriptions of clinician identi cation of psychosocial problems However the differences in study design between Costello39s study on the one hand and the MCS Q on the other mean that one cannot compare the identi cation and management of psychosocial problems by Costello Q with those obtained in the MCS performed almost 20 years ago In contrast Horwitz39s study m used a de nition of psychosocial problems similar to the MCS but found a much higher rate of psychosocial problems Whether the discrepant findings are attributable to different instruments the use of single cities in each study clinician characteristics or to actual changes in the occurrence of psychosocial problems over time is not certain Therefore we designed an assessment of a national sample of primary care office visits to examine changes in clinician identification and management of child psychosocial problems since 1979 Our design was closely modeled on the MCS of 1979 We hoped to learn a if rates of psychosocial problem identification and treatment had increased over time and b if they had increased what portions of these increases might be associated with patient or clinician factors We hypothesized that psychosocial problem identification and treatment rates would be higher in our sample than in the MCS We also predicted that the prevalence of singleparent and Medicaid households would be much higher in our sample Finally we collected data on clinicians in the Child Behavior Study CBS sample to examine whether provider training attitude and age were associated with interphysician variation in identification or treatment rates MEILODS We obtained the original data from the MCS 1979 Q from the University of Rochester and combined it with data from the CBS 116 The CBS was supported by NIMH and conducted in the Pediatric Research in fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service Of ce Settings network PROS and the Ambulatory Sentinel Practice Network ASPN during 1995 1996 and the first part of 1997 MCS Setting The MCS was conducted in Rochester New York and surrounding towns In 1979 approximately 730 000 persons lived in this area including approximately 210 000 children Seventyfour pediatricians practiced in the Monroe County Study area The MCS researchers believed that these pediatricians provided gt80 of all pediatric care in 1979 The MCS stratified the primary care pediatricians by practice type solo group health center from which systematic samples every third in each category were selected for participation Only 7 3 of 41 of the physicians asked to participate refused because of lack of interest in the study with the other 8 not participating attributable to either staff changeover or previous participation in the study by another clinician in their own practice Overall 30 of the 74 Monroe County clinicians participated in the study Sample Each participating clinician reported on all consecutive eligible children enrolled over a 2month period Eligible children and adolescents included those from 0 to 18 years presenting to the clinician39s office for nonemergent care with a parent or guardian Overall the 30 clinicians provided data on gt21 000 visits by gt18 000 children For comparability we report only the data on the first visits by the 9612 children 4 to 15 years old because the CBS did not reenroll children for subsequent visits once they had participated in the study Procedu res Physicians were recruited into the MCS through the University of Rochester with the endorsement of the Monroe County Pediatric Society Participating physicians and their office coordinators received instruction either directly during a seminar with the consultant psychiatrist and study staff 16 clinicians or a videotape of this seminar 14 clinicians Clinicians lled out the Physician Visit Record with information on Medicaid status the reason for the visit diagnosis and management of psychosocial problems The office coordinators usually provided the demographic information CBS Setting The CBS was conducted in PROS 1111 and ASPN 1112 2 large practicebased primary care research networks PROS is a pediatric network that was established in 1986 and currently comprises gt1500 clinicians from gt480 practices in all 50 states and the Commonwealth of Puerto Rico ASPN is a family medicine network that was established in 1978 and currently consists of 148 practices with approximately 750 clinicians from 43 states and 6 Canadian provinces Eightynine percent of PROS clinicians are pediatricians 10 are nurse practitioners and 1 are physician assistants Eightyfive percent of ASPN clinicians are family physicians 7 are nurse practitioners and 8 are physician assistants ASPN also collaborated with 2 regional networks to expand the number of participating family physicians The characteristics of the Wisconsin Research Network and the Minnesota Academy of Family Physicians Research Network are similar to those of ASPN and contributed 38 and 24 participating clinicians respectively Recruitment of clinicians into the study has been described fully elsewhere Clinicians were recruited from network practices that a had previously completed PROS or ASPN research studies b were not participating simultaneously in other major studies or c expressed an interest in this study This study included 395 clinicians representing 204 practices in 44 states the Commonwealth of fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service Puerto Rico and 4 provinces in Canada Participating clinicians were 43 years of age on average 50 female and completed their training 16 years before participating in the study Pediatricians were 66 of the clinicians while family practice physicians made up 26 The other clinicians 7 were physician assistants and nurse practitioners Previous research from both ASPN and PROS con rms the similarity of patients clinicians practices and clinical behaviors of physicians participating in primary care network studies with those identified in national samples n13n16 A survey conducted as part of the CBS m showed no difference in demographic factors or practice characteristics among participating pediatricians and a random sample of primary care pediatricians from the American Academy of Pediatrics AAP AAP pediatricians however had minimally higher rates of patients with either private insurance or no insurance As expected both the MCS and CBS samples were representative of patients seen in private practice settings Thus minority and innercity populations are underrepresented as compared with the US population Sample Each participating clinician reported on a consecutive sample of approximately 55 children 4 to 15 years old presenting for nonemergent visits in the presence of a parent or caregiver Children were enrolled only once Ninetyone percent of eligible children across all sites participated We compared participating with nonparticipating children and detected no differences in age or gender Children in the western United States however were slightly more likely to participate We obtained results on 22 059 visits Among those visits 994 45 had inadequate or missing data suf cient to preclude further analyses resulting in a study sample of 21 065 visits Procedu res Network coordinators and staff recruited clinicians Practices received training materials for the study including videotaped and written instructions Clinicians completed the Clinician Visit Questionnaire with information on insurance status reason for the visit diagnosis and management of psychosocial problems MCS and CBS Measures Clinician Identification In the MCS clinicians indicated identification of a psychosocial problem by answering quotyesquot to this question quotRegardless of the purpose of this visit in your opinion does this patient currently have a behavioral emotional or school problem treated or untreatedquot For the CBS a focus group of clinicians in 1994 modi ed this question Clinicians identified psychosocial problems by responding positively to the question quotIs there a new ongoing or recurrent psychosocial problem presentquot We defined psychosocial problems as any mental disorders psychological symptoms or social situations warranting clinical attention or intervention Because clinicians in the later study may have included family or social problems we examined the number of children with only family problems noted The number was extremely small and did not change the overall results of the study Clinicians in both studies coded severity as mild moderate or severe For both studies clinicians identified the type of psychosocial problems present using the World Health Organization classification scheme M On the recommendation of our clinician advisors we changed the category quotHyperkinesisquot to quotAttention de cithyperactivity problemsquot AHPs Clinicians could and often did check more than one category of problems for both studies Visit Characteristics Clinicians in the MCS and the CBS reported on the reason for the visit acute or chronic medical concerns psychosocial concerns or wellchild care and preventive services and whether the patient was their primary care patient or a patient in their practice typically followed by another clinician fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service Patient Demographics For the MCS physicians or staff members provided all of the patient demographic information from their records including household structure race gender and patient date of birth In the CBS patient race and household structure were reported by parents or guardians on the Parent Questionnaire Parents reported both on race and ethnicity Household structure was classi ed using the methods used in the MCS Data Management and Analyses Dr Klaus Roghmann the original statistician for the MCS helped us obtain the MCS data tapes from the University of Rochester All CBS data were sealed and submitted without identi ers to data entry sites where forms were visually inspected Data were doubleentered and transmitted to the University of Pittsburgh for analyses We calculated proportions of visits for identification impairment and treatment for all patient visits among youth 4 to 15 years old and calculated Chi2 tests to compare proportions We estimated mixed logistic regression equations with random effects for the practices to calculate the distribution of risk factors predicting clinician identi cation We included a random effect for the practices because of the sampling technique used for both studies The term mixed refers to the use of both random and fixed effects in the regression equations In these regressions the xed effects are the variables such as age and season of visit We used the GLIMMIX SAS Institute Cary NC procedure in SAS Version 7 to estimate the random effect Classical regression techniques assume that selected samples are uncorrelated as well as being representative of the population being studied Due to the fact that patients were recruited from clinician offices this assumption is not valid because we expect that identification and treatment decisions are correlated within the same practice but varied among practices This variation tends to understate the signi cance levels of statistical tests for regression coefficients leading to toofrequent rejections of null hypotheses of no effect RESALE Did Clinicians Identify More Psychosocial Problems in 1996 Than in 1979 Table 1 reports a substantial difference in clinicianidenti ed psychosocial problems from 1979 to 1996 The overall identi cation rate more than doubled 68187 and a similar increase can be seen in each of the problem categories except mental retardation The largest absolute percentage change was in AHPs called hyperkinetic in the MCS which increased from 14 in 1979 to 85 in 1996 The change in emotional problems from 2 to 32 represented the largest relative increase There are several possible explanations for this marked increase in clinician identi cation of psychosocial problems The comparison of identification rates in Table 1 rests on the generalizability of the findings from the primary care offices in the MCS to other primary care offices in the United States in 1979 If Monroe County was similar enough to the rest of the United States with respect to primary care in 1979 then the results in Table 1 suggest that there has been a substantial increase in the identification of psychosocial problems in the United States in the intervening years We considered several possible explanations for the increase using the available data H Is the higher rate of identification attributable to CBS clinicians knowing their patients better than MCS clinicians Were the MCS clinicians different from the clinicians who participated in the CBS in a way that would have lead them to identify fewer children with psychosocial problems in 1979 Could this difference be related to changes in training or geographic location Can the increase in clinician identi cation of psychosocial problems be attributed to differences in patient demographic and risk factors between the MCS patients and the patients in the CBS Is the higher identi cation rate attributable to a basic change in the acceptance of treatment for AHPs by clinicians parents and teachers N 00 fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service Did CBS Clinicians Know Their Patients Better Than MCS Clinicians There was a substantial change in familiarity between pediatric patients and their clinicians from 1979 to 1996 More than 94 of children in both studies were seen in their usual practice However 43 of the CBS children were seen by a clinician other than their primary care provider whereas only 12 of the MCS children were seen by someone other than their primary care provider Previous work by Horwitz et al M and Kelleher et al showed that if the patient was not one of the clinician39s usual patients the probability that the clinician would recognize a psychosocial problem was diminished Had the CBS clinicians been as familiar with their patients as the MCS clinicians appeared to be the identification rate for the CBS might have been even higher We note however that seeing their own primary care provider in the MCS did not have a statistically significant effect on identification after controlling for patient risk factors Were the MCS Clinicians Different From Clinicians Participating in the CBS We considered 2 possible differences between the 2 sets of clinicians that could have resulted in fewer children being identified as having psychosocial problems in 1979 The first was that clinician training might have been different for clinicians in the CBS when compared with the MCS Because we did not have data on the training of the MCS clinicians we compared identification rates within the CBS sample to assess whether any possible changes in clinician training may have been important We hypothesized that if changes in training mattered younger clinicians and those with more residency or school training in behavioral or psychiatric issues would have higher identi cation rates We found few differences in identification across clinician characteristics Clinician gender region and amount of specialty training had no detectable effect on identification in the CBS Nor were there an systematic differences in identification rates among clinicians who nished training in different decades The highest rates were for those who had trained in the 1970s followed by those who had trained before 1970 We conjectured that older clinicians in this sample tended to have slightly older patients who in turn were more likely to have psychosocial problems However the correlation between clinician age and patient age was only 04 Alternatively older clinicians may have been more adept at identifying or discussing psychosocial issues Second we considered that the MCS clinicians may have been different either in attitude toward treating psychosocial problems or in some other way that was not measured Kelleher et al using preliminary data from the CBS alone found that physician beliefs about treatment effectiveness had no impact on the identification of psychosocial problems after controlling for patient demographics and problem severity Could there be some other unmeasured difference between the MCS and the CBS clinicians We note that some of the clinicians who participated in the MCS also participated in the CBS 17 years later however the MCS sampled gt40 of all the pediatricians in Monroe County and the CBS sampled only 15 of all Monroe County pediatricians We repeated our analyses between the MCS and the CBS using only Monroe County samples from both studies The different identification rates of Monroe County clinicians in 1979 and 1996 are shown in Table 1 The differences between identi cation rates among Monroe County clinicians in the 2 time periods were virtually as large as those between all CBS clinicians and the MCS clinicians The small apparent difference in identification of psychosocial problems between Monroe County clinicians in 1996 and other CBS clinicians was not statistically signi cant in an Ftest P 22 which adjusted for the correlation among patients even without controlling for patient risk factors that are discussed next Did Patient Demographic and Risk Factors Differ Between the MCS and the CBS Again we examined 2 possible categories of differences between 1979 and 1996 which may have had an impact on the identification rate of psychosocial problems Of primary concern was the possibility of a divergence in demographic structure between Monroe County and the rest of the country To evaluate the fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service extent to which this could be possible we conducted a number of comparisons First we considered whether Monroe County was demographically comparable to the nation as a whole in 1979 The population figures for 4 to 15yearold children from the 1980 Census indicate that there was little or no difference between Monroe County and the United States with respect to gender or the percentages of EuropeanAmericans and AfricanAmericans The Hispanic population was underrepresented in Monroe County relative to the United States Although the percent of singleparent families with children lt18 years old was 168 in the United States versus 187 in Monroe County the percent of these families below the poverty line was a little lower in Monroe County relative to the United States 380 vs 403 This comparability to national demographic gures persists today with Monroe County showing comparable increases in the proportion of residents living in poverty and lt18 years old Although Monroe County had slightly fewer minority residents than the country as a whole this number increased over the past decade Next we considered the possibility that children in the CBS were at greater risk of being identi ed as having a psychosocial problem than the children in the MCS Based on the Chi2 tests summarized in Table 2 children were more likely to be recognized as having a psychosocial problem if they were male older enrolled in Medicaid or not living with both parents From 1979 to 1996 the proportion of children seen for primary care visits who were not living with both parents increased from 15 to 25 These results were identical to increases reported in US Census Bureau data 11193122 In both studies children not living with both parents were more likely to have a psychosocial problem In addition the percentage of children enrolled in Medicaid almost tripled during the interval between the 2 studies Mitigating these more adverse conditions in 1996 were the small differences in age and gender between the MCS and the CBS Children in the CBS were slightly more likely to be female and younger despite the identical age ranges chosen for comparability between the studies This potential bias means that the identification rates in the CBS are somewhat lower compared with the MCS than they would have been had these 2 factors been the same in the 2 samples We also examined Chi2 tests for each sample separately to see whether the predictors of clinician identification differed between the MCS and the CBS The only results that differed between the studies were the effects of different seasons and whether the patient saw his or her primary care clinician which was noted previously We used a mixed logistic regression analysis with both the common and divergent sets of patient risk factors described above to summarize their effect on the chance of being identified with a psychosocial problem We included separate regressors for the MCS and the CBS for each of the divergent factors by crossing them with 01 indicators for participation in each of the studies The divergent factors included the different seasons whether or not the clinician reported the child as their patient and whether or not the visit was reported by the clinician as a wellchild visit The remaining common factors that have 1 coefficient for both studies were not living with both parents Medicaid enrollment age sex and minority status The regression results are reported in the first half of Table 3 The most important demographic factors appeared to be Medicaid enrollment and male sex which increased the likelihood of identification followed by cohabitation with both parents which decreased it Provider familiarity with patient was a factor for the CBS patients but not for those in the MCS Patient age and minority status also appeared to have small effects on clinician identification The one source of comparison that we did not have but would certainly have had an independent impact on the results was the parents39 perception of whether or not there was a problem This information was not a part of the MCS We combined these various risk factors in a summary score that was the estimated probability of being identified based on the mixed logistic regression For example a child with a risk score of 20 would have had a combination of risk factors leading to a 1 in 5 chance of being identified with a psychosocial problem Figure 1 illustrates how the distribution of risk factors has changed from 1979 to 1996 by presenting separate estimated distributions for each of the studies using these summary risk scores The dark area fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service under the MCS curve contains the MCS children who have the highest risk scores those in the 95th percentile or above The MCS children at this 95th percentile of risk scores had more than a 1 in 6 or 17 chance of being identified as having a psychosocial problem The hatched area under the CBS curve represents the proportion of children in the CBS who fell above the risk score that defined the 95th percentile in the MCS This risk score was reached by the 60th percentile and above in the CBS sample Put another way if we de ned high risk in terms of the prevalence of risk factors in 1979 there was an eightfold increase in the percentage of children at high risk between 1979 and 1996 Thus Fig 1 indeed shows that risk factors were more prevalent in 1996 ie the mean risk score for the CBS of 19 is higher than the MCS 7 However the separate distributions also indicate that based on the highrisk standard of 1979 many more children in the CBS would have been considered at high risk for being identified by clinicians as having a psychosocial problem Can the Differences Be Explained by AHPs If there was a fundamental shift in the awareness and acceptance of treatment for AHPs by clinicians parents and teachers then it is possible that clinicians identified more psychosocial problems in children because parents were more willing to bring children with AHPs to primary care clinicians for treatment This is after all one of the possible causes for the increased resource use by children with psychosocial problems in primary care Evidence of such a shift can be found in the different percentages of children with AHPs who received medications during the 2 separate periods Nearly 78 of children with AHPs in the CBS received psychotropic drugs whereas only 32 of MCS children with AHPs received them An assessment of psychosocial problems independent of the clinicians such as the parentreported reason for the visit or a behavior inventory would have afforded us a more careful test of this hypothesis but no such information was collected for the MCS We can shed some light on the question by considering the likelihood of identification for the rest of the sample excluding those identi ed as having AHPs The second set of columns in Table 3 shows the results of a regression similar to the one performed on the full sample from both studies In this regression children with AHPs in the CBS and the MCS have been removed The results are not changed dramatically for the risk factors in the regression except for male sex some seasonal variations and well visits all of which could be expected considering the drop of AHPs from the regression sample and a reduction in the importance of the clinician39s familiarity with the patient Clearly the increase in AHPs in primary care had a significant impact on the overall increase in the identification of psychosocial problems between 1979 and 1996 Without AHPs the rate of identification among CBS patients was nearly double that of MCS patients instead of almost triple for all psychosocial problems DISCUSSION The rapid growth of clinicianidenti ed psychosocial problems among children and adolescents presenting for primary care visits is consistent with the increase in parentreported behavior problems in national surveys n28 Data from communitybased studies of the prevalence of psychiatric disorders using structured diagnostic interviews also indicate a trend toward increased rates of emotional and behavioral disorders in children g This broad range of evidence suggests that behavioral and emotional problems have increased among children in the United States during the past 18 years Some portion of the increase in clinicianidenti ed psychosocial problems might be related to changes in clinicians39 perceptions of psychosocial problems Clearly clinician training has changed markedly for both pediatricians and family practitioners since the MCS Primary care residency programs now include more ambulatory training and more psychiatric and behavioral pediatric and developmental training However neither our own studies n6 nor others mg have found associations between enhanced training at these gross levels and better identification of psychosocial problems in primary care Patient and family characteristics have changed dramatically since 1979 Demographers have noted a marked increase in the number of children living in poverty during these years both in numbers and as a fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service share of their population Only 16 104 million of children lt18 years old were living in poverty in 1979 whereas 21 146 million were so situated in 1996 11193122 Poverty is a known risk factor for the development of behavior problems and emotional and behavioral disorders in childhood although we do not fully understand the speci c mechanisms by which poverty affects children and their development For example how these demographic changes relate to the increased prevalence of parental substance abuse parental depression and residential instabilityall risk factors for psychosocial problems among youthis not fully elucidated n1 n2 n31n33 The increase in singleparent households from 1979 to 1996 was associated with the increased rate of clinicianidenti ed psychosocial problems Children from singleparent households are more likely to develop behavior problems In both the MCS and the CBS children from singleparent households were roughly twice as likely to be identified with psychosocial problems although some component of this may reflect additional attentiveness by clinicians to children at risk Limits of This Report Caution is advised in the interpretation of our study findings because of several design limitations First the studies had slightly different data collection procedures The principal differences were the sampling of clinicians for participation and the number of patients enrolled per clinician Both studies included volunteer clinicians engaged in of cebased primary care practice However the early study MCS used a stratified sampling scheme while the later study CBS included all clinicians eligible from a large national primary care research network The early study MCS also used an enrollment strategy that included many patients per clinician during a 2month period while the later study CBS enrolled a smaller target number of patients per clinician over an unspecified time period but many more clinicians There was also a minor difference between the studies in the wording of the question regarding the identi cation of a psychosocial problem Some of the clinicians M in the early study were trained in a seminar while the remainder n14 and all of the clinicians in the later study were trained by videotape Besides these design characteristics some variables could only be assessed superficially in studies that gather data from clinician reports For example only 1 indicator of socioeconomic status Medicaid enrollment was common to both studies and eligibility for this program expanded in the late 1980s through 1996 to include families with somewhat higher income Finally because clinician report was the sole data source for the early study no verifying information on parent or child perceptions of psychosocial problems was available IMPLICATIONS Our finding of a dramatic increase in the rates of clinicianidentified childhood psychosocial problems over the last 2 decades raises questions about a decline in the wellbeing of some children in the United States The apparent association of this trend with parallel adverse changes in childhood poverty and the proportion of singleparent households suggests that the means to prevent childhood psychosocial morbidity lies beyond the primary health care system and hence beyond the scope of this article Even though clinicians have no direct influence over the socioeconomic status of their patients our ndings suggest a need to restructure outpatient primary care for children and adolescents Clinicians in 1996 reported that almost 19 of all pediatric visits involved a child or adolescent with psychosocial problems requiring attention or intervention As predicted by Haggerty n 25 years ago psychosocial problems are the most common chronic condition for pediatric visits eclipsing asthma and heart disease Moreover they are among the most disabling of pediatric conditions with mental health symptoms accounting for fully onethird of all school days missed by adolescents n34 Psychosocial problems are becoming the centerpiece of pediatric primary care for schoolaged children and pediatrician surveys suggest that they are among the most timeconsuming and frustrating problems to deal with in routine practice The use of brief and rare office visits to clinicians for schoolaged children has not been documented to be effective in preventing or managing psychosocial problems Instead primary care clinicians should forge partnerships with mental health professionals for direct initial assessments and management of psychosocial fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service problems as described by Pincus The use of parent advocates and home visitors for partial support and behavioral interventions may also be more effective than current practices 1132 Group well care and related support groups may allow better exchange of parenting information and social interventions that have longer lasting effects Recent efforts to develop primary carefriendly classi cation systems for psychosocial problems and related training materials may help if incorporated into ongoing education and payment systems m Although these novel approaches to improving mental health services in primary care are laudable several trends in the organization and nancing of care pose a threat to greater integration of medical and mental health services 1330 In particular managed care incentives that encourage clinicians to see greater numbers of patients per day or patients to change clinicians more often will decrease recognition and treatment in primary care 116 Similarly the increasing use of behavioral health carveouts may diminish the willingness of mental health providers to work creatively with primary care clinicians We discuss these changes elsewhere Clearly prevention and treatment of mental health problems of children must involve the multidisciplinary efforts of medical mental health social service and education professions and even insurers because the roots of children39s emotional problems are multifactorial Attempts to solve these problems solely in the medical sector have not been successful nor could they be A coordination of efforts of all those interested in the wellbeing of children is essential to reverse this disturbing trend Although the specific choice of treatment structure and process will be related to the capabilities of clinicians and facilities as well as the needs of a given population the need to change can no longer be denied nor solutions delayed ACKNOWLEDGEMENTS This study was supported by a grant from the National Institute of Mental Health Grant No MH50629 Principal Investigator Kelleher and the Health Resources and Services Administration Maternal and Child Health Bureau Grant No MCJ177022 and the Staunton Farm Foundation of Pittsburgh We wish to acknowledge the contributions of the Monroe County Study Investigators including Irving D Goldberg MPH Klaus J Roghmann PhD Thomas K McInerny MD and Jack D Burke Jr MD MPH Dr Roghmann was especially helpful in obtaining the 1979 data TABLE 1 Comparison of Identification and Treatment Rates Between Child Behavior and Monroe CounQL Studiesm Legend for Chart B Monroe County Pediatricians 1979 N 9612 C CBS Monroe County Pediatricians 1996 N 1387 D CBS All Clinicians 1996 N 21 065 A B C D Clinicianidentified problem 6 8 161 18 7 Adaptationadjustment reaction 23 39 44 ttention deficithyperactivity disorder 14 76 92 Specific developmental delaysA 15 35 21 Behavioralconduct pro 10 44 75 Childhood psychosis 0 0 2 Physical manifestationsB 1 29 39 Mental retardation 11 2 4 Emotional problemsC 2 20 36 OtherD 0 19 39 Impairment Severe problem 7 13 18 Moderate problem 28 70 90 Treatment Counseling in the office today 56 71 96 Medications present and past 8 63 8 1 Referral present an past 35 69 76 fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service Figures are percentages for the respective samples A Includes learning disabilities speech and language delays B Includes psychosomatic disorders anorexia C Includes anxiety sadness personality disorder neurotic disorder D Drugalcohol abuse family dysfunction unspecified others TABLE 2 Comparison of Patient Demographics and Clinician Identification of Psychosocial Problems E H E S Legend for Chart B MCS Children N 9612 of Sample C CBS Children N 065 of Sample D Combined Samples N 30 677 Psychosocial Problem n A B C D Gender Male 52 5O 19 2969 Raceethnicity White nonHispanic 89 82 15 3786 t AfricanAmerican 8 6 17 361 t Hispanic 3 8 17 325 t Asian American 1 2 8 40 t Native AmericanAlaskan 0 1 19 33 Total minority 11 18 17 798 t Living with both parents No 15 22 24 1437 Medicaid patient Yes 6 18 28 1194 Clinician relationship to patient Not in practice 6 3 JF Not mine but in practice 6 41 13 1219 t My patient 8 t Legend for Chart B All Visits N C All Visits N 3 D NonAHP Visits Only E NonAHP Visits Only N 30 675 Odds Ratio 0 675 P a e N 28 592 Odds Ratio 28 592 P Value A B C D E Common variables Medicaid 220 0001 214 0001 Male 210 0001 130 0001 ge 107 0001 104 0001 Minority 72 0001 74 0001 Living with both parents 59 0001 57 0001 MCSspecific variables My patient 86 2522 91 4934 Well visit 101 9484 92 3886 Seasonal factors Summer 32 0001 51 0100 fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service Autumn 56 0083 94 7737 Winter 69 0877 111 6338 Spring 76 2308 101 9662 CBSspecific variables My patient 185 0001 162 0001 Wellvisit 103 4376 142 0001 Seasonal factors Autumn 107 2439 101 9457 Winter 101 8777 90 2018 Spring 103 6552 100 9753 R2 08 all visits and 03 nonAHP visits deviance 22 241 all visits and 15 312 nonAHP visits practice variation 7 37 all visits and 33 nonAHP visitsL extra dispersion parameter 97 all visits and 94 nonAHP visits Odds ratios represent approximate relative risk of clinician identification for those patients close to the mean risk score relative to patients in the referent category The referent categories includeMedicaid commercially insured and uninsured children male female children minority nonHispanic EuropeansAmericans living with both parents children living with only one parent or a guardian my patient patients identified by the clinician as not their patient Wellvisit visits not identified by the clinician as wellvisits seasonal factors visits during the summer of the CBS Fig 1 Change in distribution of risk factors 19791996 REFERENCES Cal Weissman J5 Stern RS Epstein AM The impact of patient socioeconomic status and other social factors on readmission a prospective study in four Massachusetts hospitals Inquiry 199431163172 Luz Hagnell 0 Repeated incidence and prevalence studies of mental disorders in a total population followed during 25 years The Lundby Study Sweden Acta Psychiatr Scand 1989796178 n32 Hankin JR Steinwachs DM Regier DA Burns BJ Goldberg ID Hoeper EW Use of general medical care services by persons with mental disorders Arch Gen Psychiatry 198239225231 n42 Kessler LG Steinwachs DM Hankin JR Episodes of psychiatric care and medical utilization Med Care 19822012091221 n52 Costello E7 Developments in child psychiatric epidemiology J Am Acad Child Adolesc Psychiatry 1 98928836 841 m6 Kelleher KJ Childs GE Wasserman RC McInerny TK Nutting PA Gardner WP Insurance status and recognition of psychosocial problems a report from PROS and ASPN Arch Pediatr Adolesc Med 199715111091115 n22 Goldberg ID Roghmann KJ McInerny TK Burke JD Mental health problems among children seen in pediatric practice Pediatrics 198373278293 n82 Haggerty RJ Roghmann KJ Pless IB Child Health and the Community New York NY John Wiley and Sons 1975 mg Costello E7 Edelbrock C Costello AJ Dulcan MK Burns BJ Brent D Psychopathology in pediatric primary care the new hidden morbidity Pediatrics 198882415424 chm Horwitz SM Leaf PJ Leventhal JM Forsyth B Speechley KN Identi cation and management of psychosocial and developmental problems in communitybased primary care pediatric practices Pediatrics fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service 199289480485 Wasserman RC Slora E7 Bocian AB et al Pediatric Research in Of ce Settings PROS a national practicebased research network to improve children 395 health care Pediatrics 199810213501357 n121 Green LA Wood M Becker L The Ambulatory Sentinel Practice Network purpose methods 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1990 Census of Population Publication No CP211990 5125 US Bureau of the Census Social and Economic Characteristics New York Washington DC 1990 Census of Population Publication No CP2 341990 n271 LamisonWhite L Poverty in the United States 1996 Current Population Reports Series P60198 Washington DC US Government Printing Of ce 1997 n2812ill N Rogers C Recent trends in the wellbeing of children in the United States and their implications for public policy In Cherlin AJ ed The Changing American Family and Public Policy The Changing Domestic Priorities Series Washington DC Urban Institute Press 198831115 fileCConverterInputbzifbfeugfhtm582012 81542 AM EBSCOhost Discovery Service Ln29 Coiro MJ Zill N Bloom B Health of our nation39s children National Center for Health Statistics Vital Health Stat 199410 Ln30 McLeod JD Shanahan MJ Trajectories of poverty and children39s mental health J Health Soc Behav 1 99637207 220 L031 Garnefski N Diekstra RF Adolescents from one parent stepparent and intact families emotional problems and suicide attempts J Adolesc 199720201208 L032 Watson JE Kirby RS Kelleher KJ Bradley RH The effects of poverty on home environment an analysis of three year outcome data for low birth weight premature infants J Pediatr Psychol 199621419 431 Ln33 Bailey V Graham P Boniface D How much child psychiatry does a general practitioner do J R Coll Gen Pract Occas Pap 197828621626 Ln34 Newacheck PW Taylor WR Childhood chronic illness prevalence severity and impact Am J Public Health 199282364371 L035 Fritz GK Bergman AS Child psychiatrists seen through pediatricians39 eyes results of a national survey J Am Acad Child Psychiatry 1985248186 L036 Pincus HA Linking general health and mental health systems of care conceptual models of implementation Am J Psychiatry 1980137315320 0321 Hardy JB Streett R Family support and parenting education in the home an effective extension of clinicbased preventive health care service for poor children J Pediatr 1989115927 931 Ln38 Taylor JA Davis RL Kemper KJ Health care utilization and health status in highrisk children randomized to receive group or individual well child care Pediatrics 19971003 URL E I Z j I 22 3 L032 Kelleher KJ Wolraich ML Diagnosing psychosocial problems Pediatrics 199697899 901 Ln40 Kelleher KJ Scholle SH Children with chronic medical conditions II Managed care opportunities and threats Ambulatory Child Health 19951139146 0amp1 Kelleher KJ Scholle SH Feldman HM Nace D A fork in the road decision time for behavioral pediatrics J Dev Behav Pediatr 199920181186 Received for publication Jul 28 1998 accepted Jul 13 1999 Reprint requests to KJK 3510 Fifth Ave Suite 100 Pittsburgh PA 15213 Email kelleherkjatmsxupmcedu W Training physicians to handle uncertainty as they carry out their preventive diagnostic therapeutic and prognostic work in medical practice is and should be a primary goal of medical education Ludmerer KM Time to Heal American Medical Education From the Turn of the Century to the Era of Managed Care New York NY Oxford University Press 1999 Submitted by Student NNNNNNNN By Kelly J Kelleher MD MPH From the University of Pittsburgh School of Medicine Pittsburgh fileCConverterInputbzifbfeugfhtm582012 81542 AM BEHAVIOR THERAPY 35 205 230 2004 Toward a Unified Treatment for Emotional Disorders DAVID H BARLOW LAURA B ALLEN MOLLY L CHOATE Boston University Over 40 years of development of cognitive behavioral approaches to treating anxiety and related emotional disorders have left us with highly ef cacious treatments that are increasingly widely accepted Nevertheless these manualized protocols have become numerous and somewhat complex restricting effective training and dissem ination Deepening understanding of the nature of emotional disorders reveals that commonalities in etiology and latent structure among these disorders supercedes dif ferences This suggests the possibility of distilling a set of psychological procedures that would comprise a uni ed intervention for emotional disorders Based on theory and data emerging from the elds of learning emotional development and regula tion and cognitive science we identify three fundamental therapeutic components relevant to the treatment of emotional disorders generally These three components in clude a altering antecedent cognitive reappraisals b preventing emotional avoid ance and c facilitating action tendencies not associated with the emotion that is dysregulated This treatment takes place in the context of provoking emotional ex pression emotional exposure through situational internal and somatic interocep tive cues as well as through standard moodinduction exercises and differs from patient to patient only in the situational cues and exercises utilized Theory and ra tionale supporting this new approach are described along with some preliminary ex perience with the protocol This uni ed treatment may represent a more ef cient and possibly a more effective strategy in treating emotional disorders pending further evaluation EDITOR S N OTE Dr Barlow was invited to contribute an article about his research program on the occasion of his receiving an award for Outstanding Contribution by an Individual for Research Activities at the 2001 convention of the Association for Advancement of Behavior Therapy The following article by Barlow Allen and Choate was received in response to this request It underwent a modi ed editorial review process similar to the one used for AABT presidential address articles The Editor and Associate Editors congratulate Dr Barlow on his richly deserved award I This work was supported in part by NIMH Award 5 R01 MH45965 Treatment of Panic Disorder LongTerm Strategies Address correspondence to David H Barlow PhD Director Center for Anxiety and Related Disorders 648 Beacon Street 6th oor Boston MA 02215 email dhbarlowbuedu 205 0057894040205 02301000 Copyright 2004 by Association for Advancement of Behavior Therapy All rights for reproduction in any form reserved 206 BARLOW ET AL In the 1960s cognitive behavioral approaches to treating emotional dis orders such as anxiety and mood disorders began to emanate from basic psy chological science speci cally theories and data pertaining to learning emo tional development and regulation and somewhat later cognitive science To justify a relatively radical new and uni ed psychological approach to treating emotional disorders it is important to provide some background In the late 19508 and early 19605 treatments began to deviate from a com mon general psychotherapeutic approach by directly targeting speci c psycho pathology such as phobias These treatments represented the beginnings of behavior therapy This trend is probably best represented by Wolpe s system atic desensitization as well as the development of situational exposure for phobic behavior Agras Leitenberg amp Barlow 1968 Marks 1971 Wolpe 1958 Wolpe s development of systematic desensitization intrigued many particularly those who foresaw the promise of translational research from basic behavioral science to the clinic Furthermore his descriptions of sys tematic desensitization operationalized as they were provided a large boost to attempts to demonstrate its ef cacy empirically This allowed investigators to begin the task of refocusing psychotherapy research from an emphasis largely on process to one on outcomes Barlow amp Hersen 1984 Hersen amp Barlow 1976 Unfortunately systematic desensitization had only limited ef cacy in the clinic in contrast to its success with college sophomores with snake fears and then only for some types of speci c phobia Attempts to apply systematic desensitization to more complex clinical conditions such as agoraphobia were unsuccessful Barlow 1988 1994 In the mid19605 we began experimenting with some different therapeutic strategies in which we encouraged individuals with what we would now call panic disorder with agoraphobia PDA to expose themselves to real life frightening situations eg Agras et al 1968 At the same time Isaac Marks in London was experimenting with similar procedures eg Marks 1971 This approach was innovative at the time because conventional wisdom held that experiencing anything more than small doses of anxiety might result in some harm to the patient an idea based on prevailing theories Gradually through the 19705 programmatic research revealed that situational exposure did not require the various trappings that were then associated with it eg relaxation contingent social reinforcement and that it could be implemented relatively rapidly By the 1980s it was clear that we had an effective treatment for phobic behavior but it was at best a blunt instrument Best estimates of outcomes by the 1980s suggested that 60 to 75 of people receiving exposure based treatments for PDA showed some clinical bene t However in a review of 24 studies it was clear that as many as 35 of those entering treatment received little or no bene t Jansson amp Ost 1982 Furthermore of those receiving some bene t only 10 to 20 could be said to approach normal function ing The remainder continued to suffer from anxiety panic and residual avoidance UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 207 During this period of time several important developments occurred in the treatment of anxiety and related emotional disorders First investigators began to focus on mechanisms of action and theories of behavior change In considering exposure procedures it was clear that exposure was simply a dry theoretical description of a process with no heuristic value Various theo ries of fear reduction began to be investigated including habituation extinc tion and more cognitively based theories such as changes in selfef cacy Bandura 1977 modifying cognitive schemas Beck et al 1985 and emo tional processing accounts Foa amp Kozak 1986 Lang 1979 Rachman 1980 Second we learned a great deal about the nature of emotional dis orders from ongoing studies of psychopathology These theories of behavior change and increased knowledge of psychopathology led directly to new interventions In addition to exposurebased procedures cognitive therapy rst developed to treat depression became a staple of treatments for anxiety dis orders Beck 1972 Beck et al 1985 In addition to situational exposure we developed interoceptive exposure initially targeting PDA recognizing that the context of anxiety and fear was internal as well as external Barlow 1988 Yet another important development was the beginnings of research on outcomes of individual cognitive behavioral therapy CBT protocols targeting speci c anxiety or other disorders e g Barlow Hayes amp Nelson 1984 An impor tant consequence was the growing realization that meaningful research on outcomes required the generation of detailed individual therapeutic manuals so that subsequent clinical research efforts could attempt to replicate the thera peutic procedures As a result psychological treatments were increasingly characterized by individual protocols that contained speci c strategies such as cognitive restructuring coping skills and where necessary situational and interoceptive exposure procedures targeted to speci c forms of psychopathol ogy These treatments were then tested empirically in a variety of formats uses and settings Current Status of Treatment Early evidence on the ef cacy of these CBT protocols led directly to large scale clinical trials often conducted across several sites in order to include a large N and control for allegiance effects For example one large clinical trial tested the effectiveness of CBT medication and their combination as treat ments for panic disorder Barlow Gorman Shear amp Woods 2000 A second study tested the effectiveness of cognitive behavioral group therapy CBGT compared tO medication and several placebo groups including a psychologi cal placebo for social phobia Heimberg et al 1998 Liebowitz et al 1999 A third study looked at the separate and combined effects of a psychological treatment medication and their combination for chronic major depressive disorder MDD Keller et al 2000 In this large study patients received either nefazodone a CBT constructed speci cally for chronically depressed patients or their combination In yet another large recently completed multi 208 BARLOW ET AL center trial the effects of clomipramine intensive behavior therapy consist ing of exposure and response prevention and a combination were compared for the treatment of obsessivecompulsive disorder OCD Kozak Liebowitz amp Foa 2000 It is not our intention within the scope of this review to provide detailed outcomes from each individual protocol for speci c disorders Nevertheless some general conclusions flow from the reports mentioned above and other studies at least for adults Barlow 2001 Nathan amp Gorman 2002 Approxi mately 50 to 80 of patients undergoing treatment for one or more of the emo tional disorders achieve responder status with the de nition of responder necessarily differing somewhat from study to study In most of these cases the individual has made a clinically signi cant improvement although they may not be cured symptomfree These outcomes are typically better than a credible alternative psychological treatment or placebo in every anxiety disorder with information on this issue less certain for the mood disorders Thus these results indicate that common factors of positive expectancies remoralization and a strong therapeutic alliance while contributory to out comes are substantially enhanced by the addition of psychological treatments at least for the anxiety disorders Barlow 2001 Nathan amp Gorman 2002 Finally it seems clear from the multisite studies mentioned above that psy chological and pharmacological treatments achieve approximately equal ef cacy immediately after treatment is concluded except possibly for OCD where the psychological treatment seems more ef cacious but that psycho logical treatments are more enduring after treatment is discontinued The evi dence also suggests that in those disorders where the question has been eval uated simultaneously combining drug and psychological treatments does not confer a substantial advantage with the possible exception of MDD Sequential combinations of treatments on the other hand are more promising Barlow 2002 Nathan amp Gorman 2002 Nevertheless a number of signi cant limitations to current treatments exist Obviously there are still a considerable number of patients who do not respond well to this type of remedy and the reasons for their lack of response are not yet known Thus although treatment is effective for many people there is plenty of room for improvement Another problem that has become apparent with manualized treatments is that there are simply too many of them Clinicians must use separate handbooks workbooks and protocols for each disorder Not only can this be quite costly but it can take a signi cant amount of training to become adequately familiar with each of the distinct protocols Finally because the protocols are somewhat complex dissemina tion of treatment to providers becomes an obstacle Barlow Levitt amp Bufka 1999 For example in the area of depression a recent NIMH task force speci ed as a priority for treatment development the need for more user friendly protocols Hollon et al 2002 Unless these treatments become more userfriendly as recommended it is unlikely that most nonresearch UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 209 clinicians will have a suf cient understanding of or access to these empiri cally supported techniques for the emotional disorders The Nature of Emotional Disorders and Negative Affect Syndrome One argument for a uni ed treatment approach to emotional disorders is the facilitation of dissemination and training focused on a single set of thera peutic principles rather than diverse protocols A second more fundamental argument concerns emerging research and theory based on conceptions of the major emotional disorders that emphasize their commonalities rather than their differences These arguments point to major developments in the areas of phenomenology and nosology with a particular focus on comorbidity all suggesting considerable overlap among disorders Additionally the observed effects of current psychological treatments on comorbid conditions and the nonspeci city of treatment response support this overlap Equally important is emerging research on the latent structure of dimensional features of emo tional disorders Finally a body of evidence supports commonalities in the eti ology of emotional disorders which has been summarized recently in the form of a new model referred to as triple vulnerabilities Barlow 1991 2000 2002 Each of these will be brie y reviewed in turn For purposes here the focus will be on anxiety and unipolar mood disorders MDD and dysthymia However we envision that the principles elucidated may be applicable more broadly to psychopathology in which negative affect plays a functional role including bipolar somatoform dissociative and angerrelated disorders as well as eating disorders Overlap Among Disorders Currently the evidence strongly suggests considerable overlap among the various anxiety and mood disorders At the diagnostic level this is most evi dent in the high rates of current and lifetime comorbidity e g Brown Camp bell Lehman Grisham amp Mancill 2001 Kessler et al 1996 1998 We have collected data on the percentages of additional diagnoses in patients who have been diagnosed with a principal anxiety or mood disorder Brown et al 2001 These data were derived from a large sample 1127 patients who were carefully diagnosed with the Anxiety Disorders Interview Schedule for DSM IV Lifetime Version ADISIV L Di Nardo Brown amp Barlow 1994 As noted in that article these summaries are most likely conservative due to limits in generalizability such as the nature of inclusionexclusion cri teria used Overall results indicate that 55 of patients with a principal anxi ety or mood disorder had at least one additional anxiety or depressive dis order at the time of assessment and this rate increases to 76 when additional diagnoses occurring at any time during the patient s life including currently ie lifetime diagnoses are considered To take one example Of patients diagnosed with PDA 60 out of 324 patients were determined to meet criteria 210 BARLOW ET AL for an additional anxiety or mood disorder breaking down to 47 with an additional anxiety disorder and 33 with an additional mood disorder When lifetime diagnoses are considered the percentages rise to 77 experiencing any anxiety or mood disorder breaking down to 56 for any anxiety disorder and 60 for any mood disorder The principal diagnostic categories of post traumatic stress disorder PTSD MDD dysthymia and generalized anxiety disorder GAD were associated with the highest comorbidity rates For speci c patterns of comorbidity associated with each diagnoses see Brown et a1 2001 Further evidence of the conservative nature of this estimate is present in ndings on the comorbidity of GAD and mood disorders This is due to hier archical exclusions remaining in the DSMIV For instance when adhering strictly to DSM I V diagnostic rules the comorbidity of dysthymia and GAD was 5 However when the hierarchical rule that GAD should not be assigned when occurring exclusively during a course of a mood disorder was suspended the comorbidity estimate increases to 90 These data also ignore the presence of subthreshold symptoms that did not meet diagnostic thresh olds for one disorder or another There are several possible explanations for these high rates of comorbidity that we have reviewed extensively elsewhere Brown amp Barlow 2002 Among these are trivial problems with overlapping de nitional criteria arti factual reasons such as differential base rates of occurrence in our setting and the possibility that disorders are sequentially related and that the features of one disorder act as risk factors for another disorder For example depres sion seems to follow PDA and panic disorder seems to follow PTSD But another more intriguing explanation is that this pattern of comorbidity argues for the existence of what has been called a general neurotic syndrome Andrews 1990 1996 Tyrer 1989 Under this conceptualization hetero geneity in the expression of emotional disorder symptoms eg individual differences in the prominence of social anxiety panic attacks anhedonia etc is regarded as trivial variation in the manifestation of a broader syn drome This in turn is consistent with models we have developed that anxi ety and mood disorders emerge from shared psychosocial and biological genetic diatheses If this is the case then a uni ed treatment protocol cutting across current diagnostic categories to address core features of the emotional disorders could be a more parsimonious and perhaps powerful option The E ects of Psychological Treatments 0n Comorbid Disorders and Nonspeci city of Treatment Response Other ndings supporting our contention of a general neurotic syndrome or negative affect syndrome NAS as we prefer to call it include the ob servation that psychological treatments for a given anxiety disorder produce signi cant improvement in additional comorbid anxiety or mood disorders that are not speci cally addressed in treatment Borkovec Abel amp Newman 1995 Brown Antony amp Barlow 1995 For example we examined the course of additional diagnoses in a sample of 126 patients who were being treated UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 211 for PDA at our center At pretreatment 26 had an additional diagnosis of GAD but the rate of comorbid GAD declined signi cantly at posttreatment to 9 and remained at this level at a 2 year follow up Whether this repre sents the generalization of elements of treatment to independent facets of both disorders or a way of effectively addressing core features of emo tional disorders is not signi cant to our purpose here In both cases the ef ciency of a uni ed treatment protocol is suggested The fact that a wide range of emotional disorders eg MDD dysthymia OCD and PDA respond ap proximately equivalently to antidepressant medications has also been inter preted as indicating a shared pathophysiology among these symptoms eg Hudson amp Pope 1990 Also Tyrer et a1 1988 treated 210 outpatients with GAD PDA or dysthymia with either drug placebo CBT or a selfhelp pro gram Although some differences were noted at posttreatment as a function of treatment condition eg some drugs were less effective than other drugs and psychological treatments no diagnostic group differences were observed This suggested to Tyrer et a1 1988 that the differential diagnosis of anxiety and mood disorders does not provide a sound basis for treatment prescription It should be noted of course that these data are only suggestive because the current generation of more powerful psychological treatments was not uti lized But it does appear to offer support for the above conceptions Latent Structure of the Emotional Disorders There is wide agreement that DSMI V represents the zenith of a splitting approach to nosology with the obtained advantage of high rates of diagnos tic reliability But there is growing suspicion that this achievement has come at the expense of diagnostic validity and that the current system as suggested above may be erroneously distinguishing categories that are minor variations of broader underlying syndromes This would not imply a return to a non empirical system of classi cation based on theories of etiology Rather this thinking points to a quantitative approach using structural equation modeling to examine the full range of anxiety and mood disorders without the con straints of arti cial categories given their strong relationship and potential overlap Brown Chorpita amp Barlow 1998 Chorpita Albano amp Barlow 1998 Clark amp Watson 1991 Watson Clark amp Harkness 1994 We have been studying this question for the last 10 years eg Brown et a1 1998 Zinbarg amp Barlow 1996 and have con rmed with some modifications the tripartite model of emotional disorders rst proposed by Clark and Watson 1991 Some of our ndings are presented in Figure 1 One of the intriguing and important ndings from this line of research is that mood disorders show greater overlap with certain anxiety disorders such as GAD than do other anxiety disorders supporting and reinforcing the commonalities of depression and anxiety at a phenomenological level Brown et a1 1998 Clark Steer amp Beck 1994 Mineka Watson amp Clark 1998 The ndings from Brown et a1 1998 using a sample of 350 patients with DSMIV anxiety and mood dis orders con rmed a hierarchical structure In this structure negative affect and 212 BARLOW ET AL PA positive affect NA negative affect DEP mood disorders GAD generalized anxiety disorder PDA panic disorder with 39 39 39 0CD quotbe quot4 39 disorder SOC social phobia AA autonomic arousal plt01 a r v r FiG 1 Structural model of interrelationships of DSM I V disorder constructs and negative affect positive affect and automatic arousal From Structural Relationships Among Dimen sions of the DSMI V Anxiety and Mood Disorders and Dimensions of Negative Affect Positive Affect and Autonomic Arousal by T A Brown B F Chorpita amp D H Barlow 1998 Jour nal of Abnormal Psychology 107 pp 179 192 Copyright 1998 by the American Psychologi cal Association Reprinted with permission positive affect emerged as higherorder factors to the DSMIV disorder fac tors with signi cant paths from negative affect to each of the ve DSMIV factors and signi cant paths from positive affect to the mood disorders and social phobia factor only In this model autonomic arousal which we con sider to represent the phenomenon of panic emerges as a lowerorder factor with signi cant paths from FDA and GAD where the relationship was nega tive These ndings indicate that the key features of the DSM anxiety and mood disorders cannot be collapsed indiscriminately into an NAS But it seems safe to conclude that what is common outweighs what is not DSMIV factors Our view then is that DSMIV emotional disorder categories do not qualify in any sense as real entities Kendell 1975 but do seem to be useful concepts or constructs that emerge as blips on a general background of NAS It also appears increasingly likely for a variety of reasons including the ndings from genetics eg Kendler 1996 Kendler Heath Martin amp Eaves 1987 that DSM V will turn to a more dimensional description of these phe nomena that would reinforce conceptions of common underlying compo nents Kupfer First amp Regier 2002 UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 213 Etiology Elsewhere we have elaborated on an interacting set of vulnerabilities or di atheses relevant to the development of anxiety anxiety disorders and related emotional disorders This triple vulnerabilities theory encompasses a gen eralized biological vulnerability a generalized psychological vulnerability and a speci c psychological vulnerability emerging from early learning Barlow 2000 2002 A generalized biological vulnerability involves nonspeci c genetic contributions to the development of anxiety and negative affect Much of the research on this generalized biological vulnerability has focused on tempera ments labeled anxiety neuroticism negative affect or behavioral inhi bition Although the relationships among these closely related traits and tem peraments have yet to be fully worked out it is likely that each partially represents a common theme associated with a biological vulnerability to de velop emotional disorders generally Barlow 2000 2002 Additionally early life experiences under certain conditions contribute to a generalized psycho logical vulnerability or diathesis to experience anxiety and related negative affective states Chorpita amp Barlow 1998 It is this set of experiences that produces a sense of uncontrollability that seems to be at the core of negative affect and derivative states of anxiety and depression If these two vulnerabil ities happen to line up and are potentiated by the in uence of life stress the likely result are the clinical syndromes of GAD andor depressive disorders as outlined in Figure 2 Notice that false alarms panic attacks may occur as a function of stressful life events facilitated by high levels of baseline anxi ety and emerging as a function of these synergistic generalized vulnerabili ties But these false alarms are not in themselves necessarily implicated in a clinical disorder For that to occur an additional layer of a more speci c psy chological vulnerability must be considered In this conception certain learn ing experiences seem to focus anxiety on speci c life circumstances that is Synergistic Vulnerabilities F Biological Vulnerabilities J Generalized PsychologicalVulnerability I False Alarms Panic Generalized Anxiety Depression FIG 2 Diathesisstress model of the development of generalized anxiety and depression From Unraveling the Mysteries of Anxiety and its Disorders From the Perspective of Emotion Theory by D H Barlow 2000 American Psychologist 55 pp 1247 1263 Copyright 2000 by the American Psychological Association Reprinted with permission 214 BARLOW ET AL Synergistic Vulnerabilities Biological Vulnerabilities Generalized Psychological Vulnerability W J Speci c Psychological Vulnerability Focus of anxiety eg physical sensations are dangerons social evaluation is dangerous bad thoughts are dangerous i 1 Stress False Alarms Panic Disorder PaniC Social Phobia 0CD FIG 3 Triple vulnerabilities model in the development of certain anxiety disorders From Unraveling the Mysteries of Anxiety and its Disorders From the Perspective of Emotion The ory by D H Barlow 2000 American Psychologist 55 pp 1247 1263 Copyright 2000 by the American Psychological Association Reprinted with permission these circumstances or events become imbued with a heightened sense of threat or danger For example speci c early learning experiences seem to de termine whether individuals may View somatic sensations intrusive thoughts or social evaluation as speci cally dangerous Barlow 2002 Bouton Mineka amp Barlow 2001 It is this speci c psychological vulnerability that when co ordinated with the generalized biological and psychological vulnerabilities mentioned above seems to contribute to the development of discrete anxiety disorders such as social phobia 0CD panic disorder and speci c phobias as represented in Figure 3 Evidence for this model has been reviewed in detail elsewhere Barlow 2000 2002 Bouton et al 2001 Chorpita amp Barlow 1998 While future research will determine the validity of this model it is consistent with the emerging phenomenological evidence reviewed above on the overriding importance of common factors in the genesis and presentation of emotional disorders Implications for Treatment Growing evidence on the unifying principles of emotional disorders Barlow 1991 2002 with a focus on common underlying mechanisms suggests the possibility of distilling a set of psychological procedures that would comprise a uni ed intervention for emotional disorders In 1988 one of us proposed fol lowing the emotion theorists eg Izard 1971 that a coherent and consistent therapeutic approach to emotional disorders would ultimately be based on emotion theory and evolving knowledge of the modi cation of emotional states Following Lang 1968 Rachman 1981 and Wilson 1982 whose UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 215 TABLE 1 COMPONENTS OF ANY AFFECTIVE THERAPY A Essential targets for change 1 Action tendencies 2 A sense of uncontrollability unpredictability 3 Selffocused attention It Helpful but not essential targets for change Hot apprehensive cognitions Hypervalent cognitive schemata and attention narrowing Coping skills and social support Elevated physiological responding and altered neurobiological functions bl UJN Note From Anxiety and Its Disorders The Nature and Treatment of Anxiety and Panic by D H Barlow 1988 New York The Guilford Press Copyright 1988 by The Guilford Press Reprinted by permission early speculations were in uential components of any affective therapy were outlined see Table 1 Based on theoretical and empirical work at that time and a lineage of knowledge dating back to Darwin 1872 there seems no quicker or more powerful way to change emotional expression than to modify action tendencies associated with a speci c emotion Other essential targets for change included increasing a fundamental sense of controllability and pre dictability over events in one s environment and decreasing the powerful avoidant strategy of focusing attention on nontaskrelated consequences of excessive emotional activity neurotic selfpreoccupation Other targets for change that were speculated as being insuf cient but perhaps helpful in as much as they facilitated change in the essential targets included focusing directly on emotional cognitions coping skills social support networks and height ened arousal Evidence for these assertions was reviewed in Barlow 1988 Development of these ideas was for the most part put aside during the 1990s as we concentrated on DSM I V large clinical trials and other tasks but these ideas were not entirely ignored by others For example Marsha Line han brought the concept of modifying action tendencies opposite action ten dencies to good use in her development of dialectical behavior therapy DBT Linehan 1993 For the past 18 months we have turned our attention once again to these fundamental themes taking advantage of substantial progress in a number of related areas over the past decade This progress has occurred in the context of developments in modern learning theory and cognitive neuro science as well as our greatly increased knowledge of naturally occurring processes in the regulation of emotional expression We will brie y touch on developments in each of these areas Modern Learning Theory and Cognitive Neuroscience In an article exploring theoretical conceptualizations of the etiology of anxiety disorders Bouton et al 2001 suggest that early panic attacks result 216 BARLOW ET AL in conditioned associations between the attack and a variety of interoceptive and exteroceptive cues When some of these cues are elicited in a nonpanic situation a constellation of behavioral and physiological responses arise which we collectively call anxiety As such anxiety is a state of relatively lowlevel arousal preparing us for possible future danger Panic on the other hand is associated with a surge in autonomic arousal enabling immediate action ght ight These mechanisms are not necessarily mutually exclu sive In fact modern learning theory suggests that anxiety may initiate panic because anxiety too can become a conditioned stimulus It seems that small physiological behavioral and emotional changes can become associated with an extreme fear reaction such as panic with or without conscious knowl edge of the cues These conditioned events can begin to in uence behavior at a subconscious level such that strengthening of the association between physi cal and emotional cues and panic begins to occur LeDoux 1996 Brain imaging techniques have offered support for this interpretation even indicat ing differences in the neurobiological bases of conscious and unconscious conditioning processes Ohman 1999 Future work in understanding the actual functional brain changes in emotional disorders continues and researchers are now using imaging strategies to examine changes in brain function following cognitivebehavioral treatments for anxiety eg Furmark et al 2002 Thus the future investigation of emotional disorders and their treatment will involve a comprehensive study of the psychological emotional and neurobiological correlates of emotionbased conditioning procedures Work in this area has already in uenced our knowledge of emotional cues from a variety of external and internal contexts that must be considered in treatment to maximize effects Emotion Regulation A particularly important concept for understanding emotional disorders is that of emotion regulation Brenner amp Salovey 1997 Mayer amp Salovey 1997 By this we are referring to the strategies individuals use to influence the occurrence experience intensity and expression of a wide range of emo tions Frijda 1986 Masters 1991 Richards amp Gross 2000 Emotion regu lation and dysregulation seem to play an important role in emotional dis orders and other psychopathology and levels of positive and negative emotions as well as their functional relationships often differ depending on the particular disorder Gross amp Levenson 1997 Rottenberg amp Gross 2003 Thayer 2000 Emotional disorders seem characterized to some degree by at tempts to control both positive and negative emotions in a variety of contexts as outlined below Individuals concerned about the expression and experience of their feelings may attempt to suppress hide or ignore them with unin tended consequences Gross amp Levenson 1997 Pennebaker 1997 This is because excessive attempts to control emotional experience lead to an in crease in the very feelings the individuals are attempting to regulate as dem onstrated by attempts to control emotions after initial panic attacks Craske UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 217 Miller Rotunda amp Barlow 1990 Furthermore the degree to which one attempts to control emotions is somewhat related to the degree of intensity to which an individual experiences negative emotions which can quickly be come overwhelming Lynch Robins Morse amp Krause 2001 These over powering experiences Often lead to attempts at thought suppression as a con venient and accessible way to reduce emotional responsiveness It is this pattern that may erupt in a vicious cycle Of increased physiological and emo tional arousal leading to more unsuccessful attempts at suppression which in turn contributes to growing psychological distress Thus it is clear that future treatments for emotional disorders must focus on this issue and develop treat ments speci cally targeting emotion dysregulation A Unified Treatment Based on theory and practice described above over the past year we have distilled three fundamental therapeutic components that currently comprise our uni ed treatment approach to emotional disorders Following a standard psychoeducational phase common to all psychotherapeutic approaches these three components include a altering antecedent cognitive reappraisals an intensive emotion regulation procedure that directly facilitates the next two steps in treatment b preventing emotional avoidance a broadbased effort that goes well beyond traditional attempts to prevent behavioral avoidance in phobic disorders by targeting cognitive behavioral and somatic experiential avoidance and c facilitating action tendencies not associated with the emo tion that is disordered This treatment takes place in the context of provoking emotional expression emotion exposure through situational internal and somatic interoceptive cues as well as through standard moodinduction exercises and differs from patient tO patient only in the situational cues and exercises utilized Notice also that exposure is not conceptualized as a mechanism of action Rather successfully provoking emotions is considered a setting condition in order tO implement the essential treatment components Of course we recognize that the mereexposure paradigm Zajonc 2001 has some emotion regulating properties itself in terms of producing positive affect even if the exposure is subliminal most likely due to classical condi tioning These mechanisms may apply to emotion exposure as well Antecedent Cognitive Reappraisal Since the 1970s and under the enormous in uence of cognitive therapy as innovated by Aaron T Beck Beck 1972 Beck Rush Shaw amp Emery 1979 clinicians have focused on the appraisals and judgments that individu als with emotional disorders make regarding external events as well as their own ef cacy in coping with these events This approach was rst developed in the context of depression In this context Beck outlined the wellknown cognitive triad in which individuals maintained negative beliefs about their own self the world and the future Subsequently this notion was extended to 218 BARLOW ET AL anxiety disorders Beck et a1 1985 It wasn t long before the importance of appraisals focused on internal events such as physical sensations and emo tions began to be recognized In panic disorder this was rst suggested by Goldstein and Chambless 1978 who outlined a fear of fear model of panic disorder In this model conscious negative appraisals of somatic and affective manifestations of the experience of fear as dangerous became an important focal point Subsequently the concept of interoceptive condition ing originally developed by Razran 1961 was applied to anxiety disorders to describe a relatively less conscious process by which internal cues often generated by emotional activation could trigger anxiety and panic with the implication that direct exposure to emotion associated internal somatic cues would be an important part of treatment Barlow 1988 The notion of ap praising internal cognitive and emotional states in a negative way was ex tended to other anxiety disorders such as OCD Steketee 1993 and GAD Craske Rapee Jackel amp Barlow 1989 Wells et al 1995 Cognitive therapy focuses on evaluating the rationality of these negative appraisals and substituting more realistic evidencebased appraisals in their place On one level this may seem very much as an attempt to eliminate or suppress negative thoughts and immediately replace them with more adaptive or realistic appraisals and it has been used in this way as lucidly noted by Hayes Strosahl and Wilson 1999 But in fact this process can be concep tualized from an emotionregulation perspective as altering antecedent re appraisals of threat and negativity Support for this subtle but Clucial recon ceptualization emerges from the emotionregulation literature where evidence clearly exists that reappraisal of both internal and external threat and danger before the fact that is before heightened levels of negative emotion are pro voked has a salutory effect on the later expression of negative emotion as noted above Gross 1998 Richards amp Gross 2000 Thayer 2000 The im portance of antecedent reappraisal versus more reactive strategies was rst outlined in 1991 by Masters 1991 In a program of research Gross 1998 has found that antecedent cognitive reappraisal does in fact reduce subjective experience of negative emotion For individuals with emotional disorders we rst demonstrated this phe nomenon in 1989 Sanderson Rapee amp Barlow 1989 in the context of manip ulating antecedent appraisals of control over a threatening situation In this experiment patients with PDA were told that they would be able to control in a C02 inhalation paradigm the ow of C02 by turning a dial when a light was illuminated For half of the patients the light was never illuminated leading them to believe they had no control over the sensation For the other half the light did come on indicating that the dial was operative and leading them to believe that they had some control over the situation In fact the dial had no bearing on C02 ow and thus provided only an illusion of control perceived control Nor did patients ever really attempt to use the dial Nevertheless patients in the perceived control condition reported signi cantly fewer panic attacks and less emotion in general than those in the no UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 219 control group despite receiving the same amount of C02 More recently Telch and colleagues have demonstrated this principle For example patients with speci c phobias who were instructed to focus on their identi ed core threats and who received brief guidance on threat reappraisal evaluation did signi cantly better than those simply receiving exposure exercises without reappraisal Kamphuis amp Telch 200039 Sloan amp Telch 2002 In our hands we have adapted cognitive interventions to focus on two fundamental ante cedent misappraisals rst the probability of a negative event happening probability overestimation and second the consequences Of that negative event if it did happen catastrophizing Barlow amp Craske 2000 Craske Bar low amp O Leary 1992 We have now extended these concepts to the full range Of emotional disorders Now Hariri and colleagues Hariri Bookheimer amp Mazziotta 2000 Hariri Mattay Tessitore Fera amp Weinberger 2003 building on work by Damasio and colleagues Bechara Damasio Damasio amp Lee 1999 Damasio 1994 have begun to elucidate the neural circuits underlying this process using functional magnetic resonance imaging fMRI They demonstrated that acti vation of the right prefrontal and anterior cingulate cortices during conscious evaluation and appraisal of emotional stimuli modulates and regulates bilat eral amygdala responding These ndings also suggest that implementing antecedent cognitive reappraisal strategies is an important step in altering emotional responding Emotional Avoidance There is also evidence that many emotional disorders are related to attempts to downregulate avoid excessive unexpected emotional experiences Examples of this process in the context of depression anger and excitement mania as well as fear are provided in Barlow 2002 Preliminary data also exist on the prevalence of the occurrence of unexpected and sometimes distressing emo tions in the nonclinical population Craske Brown Meadows amp Barlow 1995 Speci cally over 300 undergraduates were surveyed with a question naire to determine the prevalence of both cued and uncued panic attacks anger outbursts episodes Of sadness and surges Of excitement as well as the degree of worry or distress over the recurrence of each type of emotional ex perience While fully 32 of the sample reported no uncued emotional expe riences the fact that 68 of this sample reported experiencing at least one uncued emotion in the previous 3 month interval was surprising It is also noteworthy that while 10 of the population experienced uncued panic which is consistent with other surveys as many as 34 of the sample re ported uncued depressive episodes and many found these episodes very dis tressing The fact that distress was associated with a substantial proportion of these unexpected episodes implies attempts to regulate these emotional expe riences through suppression although this was not speci cally tested with resulting consequences These results of course are consistent with observations of emotional 220 BARLOW ET AL avoidance in other disorders For example Roemer Litz Orsillo and Wagner 2001 reported that veterans with PTSD were more likely to report intention ally withholding their emotions both positive and negative than were veter ans without PTSD In a related study of rape related PTSD Orsillo Roemer and Litz 2001 found that women with PTSD described their sexual assault experiences with fewer fear words than did women without PTSD although women with PT SD displayed higher levels of arousal Evidence on the dele terious use of avoidant techniques extends to calming procedures so much a part of our own earlier protocols for treating anxiety and panic Barlow amp Cemy 1988 Speci cally when calming techniques such as relaxation and breathing control are conceptualized to the patient as a speci c strategy for reducing negative emotions and distress in which the focus is to cope with the emotions and distress rather than as a noncontingent calming exercise the results seem counterproductive For example Schmidt et al 2000 con cluded that breathing retraining did not add any clear bene ts to a treatment package consisting of education cognitive restructuring and exposure based techniques for patients with panic disorder In fact a trend in the data indi cated that patients who received breathing retraining showed lower end state functioning on both selfreport and clinicianrated measures Similar results have been obtained from our prior work evaluating distraction strategies Craske Street amp Barlow 1989 Craske Street Jayaraman amp Barlow 1991 Kamphuis amp Telch 2000 And of course the deleterious effects of down regulating avoiding emotion through reliance on talismen or safety signals have been conclusively demonstrated Salkovskis Clark Hackman Wells amp Gelder 1999 Sloan amp Telch 2002 Wells et al 1995 Finally laboratory studies are directly demonstrating the effects of avoiding or suppressing emo tion For example Feldner Zvolensky Eifert and Spira 2003 divided non clinical subjects into high or low emotional avoiders and subjected them to 4 breaths of 20 Cog enriched air Half in each group were instructed to inhibit negative emotional reactions the other half to simply observe their emotional response High emotional avoiders reported greater distress and anxiety Whether suppressing or not compared to low avoiders In our labora tory Levitt Brown Orsillo and Barlow in press divided 60 patients with PDA into three groups each of whom listened to a 10 minute audiotape describing one of two emotionregulation strategies acceptance or suppression or a neutral narrative Patients then underwent a 15minute 55 C02 challenge Following this challenge they were asked to participate in a second chal lenge The acceptance group was signi cantly less anxious and less avoidant than either the suppression or control groups in terms of subjective anxiety during the C02 challenge and willingness to participate in a second challenge Now we have also developed some direct evidence of the maladaptive use of emotion regulation strategies in patients with a wide range of emotional disorders CampbellSills Barlow Brown amp Hofmann 2003 In this study 60 patients who met diagnostic criteria for an anxiety or mood disorder and 30 individuals with no history of emotional disorders experienced an induction UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 221 of a negative emotion by watching an emotional lm In Study 1 the sponta neous emotion appraisals and emotional regulation strategies were Observed in both the clinical sample and the control sample The patients in the clinical sample reported signi cantly different emotional appraisals and emotional regulation strategies than nonclinical participants Consistent with data reported above clinical participants reported greater anxiety focused on the occur rence of emotions as well as less emotional clarity They also endorsed more reliance on maladaptive emotion regulation strategies eg suppression cog nitive rehearsal The patients also rated their resulting emotions as less ac ceptable and engaged in more emotional suppression Higher levels of sup pression were associated in turn with elevated heart rate during the emotion induction as well as inhibited recovery from subjective distress skin conduc tance and nger temperature changes after the induction In the second study patients were instructed to engage in either emotion suppression activities during the emotional induction exercise or emotion ac ceptance activities Suppression participants failed to recover from subjective distress after the induction and they manifested a different heart rate pattern than acceptance participants Speci cally when patients were instructed to suppress their emotions once again heart rate actually increased from antici pation to termination of the lm while heart rate in the acceptance group de creased during this period Thus patients with emotional disorders endorsed more negative emotion appraisals and utilized counterproductive emotion regulation strategies compared to individuals without disorders Modifying Emotional Action Tendencies As Izard pointed out in 1971 theories and evidence from emotion theory indicate that the most ef cient and generalized principles and techniques for emotion control are focused on the neuromuscular component of emotion striate muscle action can initiate amplify attenuate or inhibit an emotion p 415 In other words the individual learns tO act his way into a new way of feeling p 410 As I suggested in 1988 it is possible that the crucial function of exposure in the treatment of phobic disorders is to prevent the action tendencies associated with fear and anxiety and facilitate different action tendencies Barlow 1988 For example Fridlund Hat eld Cottam and Fowler 1986 determined that physiological elevation during anxiety did not represent generalized arousal but rather speci c action tendencies associ ated with anxiety I also speculated Barlow 1988 that it is possible that attention to action tendencies forms an important part Of the treatment of other emotional disorders For example Beck Rush Shaw and Emery 1979 and others eg Lewinsohn amp Lee 1981 spent a considerable amount of time countering the tendencies Of their depressed patients to behave in a pas sive retarded and apathetic manner p 312 More recently behavioral acti vation has become a central and de ning principle in some new treatments for depression that show considerable promise Jacobson Martell amp Dimid jian 2001 222 BARLOW ET AL In fact these strategies have a long history Laughter humor and associ ated facial expression induced during successful paradoxical intention tech niques Frankl 1960 a technique successfully used to counteract fear and anxiety in previous decades e g Ascher 1980 may be effective not because of the induction of cognitive changes as was often assumed but rather be cause of the prevention of behavioral responses including facial expressions and the substitution of action tendencies associated with alternative emotions As noted above Linehan 1993 has adapted this strategy creatively and with good effect to patients with borderline personality disorder which with its core feature of the avoidance and intolerability of negative affect may be fundamentally a severe emotional disorder Also Hayes in his creative con ceptualization of acceptance and commitment therapy ACT Hayes et al 1999 has underscored the importance of encouraging action as an alter native coping strategy with the purpose of instituting a sense of control as opposed to focusing on decreasing unwanted internal events Applications to Emotional Disorders As reviewed above it is our contention that these three basic therapeutic principles can be applied with relatively minor modi cations to each of the emotional disorders Antecedent cognitive reappraisal in each of the emo tional disorders is easily categorized into overestimating the probability of a negative event happening probability overestimation and exaggerating the consequences of that negative effect if it did happen catastrophizing These concepts are relatively wellknown by cognitive behavioral therapists and need no further elaboration as applied to individual disorders Tables 2 and 3 provide some examples of both the general implementation of strategies for preventing emotional avoidance and modifying action tendencies across emotional disorders as well as some speci c adaptations of these strategies that seem useful when dealing with individual emotional disorders We have reviewed evidence above on the variety of cognitive and behav ioral avoidance strategies including cognitive rituals distraction emotion suppression etc as noted in Table 2 that cut across emotional disorders Providing examples across some speci c emotional disorders it is clear that the lives of individuals with PDA revolve around avoiding intense emotions particularly fear and associated somatic sensations This also extends to con texts or situations that produce strong emotional and somatic responding We have referred elsewhere to this pattern of avoidance as interoceptive avoid ance and have developed a questionnaire to assess the extent of its presence Brown White Forsyth amp Barlow 2004 Rapee Craske amp Barlow 1994 1995 Cognitive and behavioral rituals have long been recognized as avoidant strategies in OCD More recently we have recognized similar features associ ated with GAD in the form of worry behaviors which are fundamentally checking rituals Craske et al 1992 as well as the behavioral pattern of per fectionism particularly negativemaladaptive perfectionism This behavioral UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 223 TABLE 2 PREVENTING AVOIDANCE General Speci c Water bottles PDA Avoidance of somatic sensations emotional experiences Safety Signals Cell phones Social phobia Avoidance of performanceinteractions Medications Speci c phobia Avoidance of object situation Cognitive rituals 0CD Behavioral rituals Distraction GAD Perfectionism worryworry behaviors Rationalization PTSD Avoidance of strong affect trauma cues Emotion suppression MDD Withdrawal Worryruminationrehearsal Note PDA panic disorder with agoraphobia 0CD obsessive compulsive disorder GAD generalized anxiety disorder PTSD posttraumatic stress disorder MDD major depressive disorder pattern seems tO re ect a tendency to impose control over perceived uncon trollable daily events in one s life thereby reducing distress and negative affect Frost Heimberg Holt Mattia amp Neubauer 1993 Scott amp Cervone 2002 Similarly for MDD behavioral tendencies toward withdrawal seem clearly associated with avoiding interactions and contexts that may provoke negative affect In modifying the behavioral action tendencies driven by fundamental emo tions the rst step is to provoke the emotions in so far as possible usually through emotioninducing exposure based procedures see Table 3 Adopting strategies that encourage experience of the emotion without engaging in the associated action tendencies accepting the emotion is a very basic strategy TABLE 3 MODIFYING ACTION TENDENCIES General Speci c Emotion exposure GAD emotional arousal Emotion recognition MDD behavioral activation increased coping behavior Facilitate emotion experiencing and PDA approach behavior activation Of fear related acceptance somatic sensations Note GAD generalized anxiety disorder MDD major depressive disorder PDA panic disorder with agoraphobia 224 BARLOW ET AL in this regard When applied to speci c disorders emotional and behavioral activation especially in situational context becomes a particularly powerful tool Modifying action tendencies often but not always coincides with and complements techniques to prevent avoidance of emotional expression In fact preventing avoidance in some emotional contexts such as anxiety and fear is one way to modify action tendencies Thus for most phobic situations it is clear that encouraging approach behavior in place of avoidance is an im portant step But this strategy of modifying action tendencies also might in volve provoking a different emotion or facial expression with its associated action tendencies in the phobic context eg laughter or humor as in para doxical intention In GAD implementing this strategy might involve ac tively prescribing nonperfect behavior at home or in the workplace Passiv ity and detachment may be more appropriate actions in the context of anger or more positive active coping skills to counter withdrawal in depression It is also clear that individuals may initiate different action tendencies eg ap proach during emotion induction while simultaneously engaging in substan tial avoidance behavior eg distraction Thus attention to both strategies is essential At present we are in the beginning process of evaluating the ef cacy and feasibility of this protocol Thus far we have collected data from several groups of 6 to 8 patients with heterogeneous emotional disorders including such disparate principal diagnoses as PTSD MDD GAD and a variety of phobic disorders While nal results await more systematic data collection and experimentation patients in these groups are doing as well as or a bit better than patients in more homogeneous groups More importantly patients express their understanding of the fundamental similarities in their experi ences despite different diagnoses and somewhat different presenting symp toms Con rming this impression through systematic and rigorous experi mentation is the next step as well as further elucidating mechanisms of therapeutic action In conclusion it is of interest to note that the rst author had the good for tune to be present at the creation of behavior therapy at least as a student at a time when the concept of neuroses was in ascendance and long term depth psychotherapy was the uni ed approach to these problems Now the junior authors are beginning their careers with concepts of negative affect syndrome and a proposed uni ed psychological approach While ironic on the face of it the fundamental differences in these two seemingly similar conceptions represent in a very real way the revolution of the last 40 years For now we have a broader and deeper understanding of the psychopathology of emotional disorders that is based on the slow but inexorable process of sci ence And now we have successful and effective ways empirically derived but also rmly grounded in theory to address the suffering occasioned by negative affect in its many manifestations The ability to submit the many and varied hypotheses generated over the years to the scienti c method as well as the fact that those generating the hypotheses were often proven wrong along UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 225 the way resulting in mid course corrections has brought us to where we are today Most of us going down this road will be wrong again in the future and it is possible that many of the ideas presented in this article will not be sustained But we will all be better off nding that out and in a fundamental sense this is the ful lled promise of CBT that differentiates us from our 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psychotherapy on comorbid con ditions in generalized anxiety disorder Journal of Consulting and Clinical Psychology 63 479 483 Bouton M E Mineka S amp Barlow D H 2001 A modern learning theory perspective on the etiology of panic disorder Psychological Review 108 4 32 Brenner E M amp Salovey P 1997 Emotion regulation during childhood Developmental interpersonal and individual considerations In P Salovey amp D J Sluyter Eds Emo tional dc r and 39 39 quot390 r Educational implications pp 168 195 New York Basic Books Brown T A Antony M M amp Barlow D H 1995 Diagnostic comorbidity in panic dis order Effect on treatment outcome and courSe of comorbid diagnoses following treatment Journal ofConsulting and Clinical Psychology 63 408 4I 8 Brown T A amp Barlow D H 2002 Classi cation of anxiety and mood disorders In D H Barlow Ed Anxiety and its disorders The nature and treatment of anxiety and panic 2nd ed New York The Guilford Press Brown T A Campbell L A Lehman C L Grisham J R amp Mancill R B 2001 Current and lifetime comorbidity of the DSM IV anxiety and mood disorders in a large clinical sample Journal ofAbnormal Psychology 110 49 58 Brown T A Chorpita B E amp Barlow D H 1998 Structural relationships among dimen sions of the DSM IV anxiety and mood disorders and dimensions of negative affect posi tive affect and autonomic arousal Journal of Abnormal Psychology 107 179 192 Brown T A White K S Forsyth J P amp Barlow D H 2004 The structure of perceived emotional control Psychometric properties of a revised anxiety control questionnaire Behaviour Therapy 35 75 99 Campbell Sills L Barlow D H Brown T A amp Hofmann S G 2003 The relevance of emotion regulatory processes to arm39er and mood disorder Manuscript submitted for publication Chorpita B F Albano A M amp Barlow D H 1998 The structure of negative emotions in a clinical sample of children and adolescents Journal of Abnormal Child Psychology 107 7485 Chorpita B F amp Barlow D H 1998 The development of anxiety The role of control in the early environment Psychological Bulletin 124 321 Clark D A Steer R A amp Beck A T 1994 Common and speci c dimensions of self reported anxiety and depression Implications for the cognitive and tripartite models Jour nal ofAbnormal Psychology 103 645654 Clark L A amp Watson D 1991 Tripartite model of anxiety and depression Psychometric evidence and taxonomic implications Journal of Abnormal Psychology 103 103 1 16 Craske M G Barlow D H amp O Leary T 1992 Mastery ofyour anxiety and worry San Antonio TX GraywindPsychological Corporation Craske M G Brown T A Meadows E A amp Barlow D H 1995 Uncued and cued emo tions and associated distress in a college sample Journal of Anxiety Disorders 9 125 137 Craske M G Miller P P Rotunda R amp Barlow D H 1990 A descriptive report of fea tures of initial unexpected panic attacks in minimal and extensive avoiders Behaviour Research and Therapy 28 395 400 Craske M G Rupee R M Jackel L amp Barlow D H 1989 Qualitative dimensions of worry in DSM IIl R generalized anxiety disorder subjects and nonanxious controls Behaviour Research and Therapy 27 397 402 UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 227 Craske M G Street L L amp Barlow D H 1989 Instructions to focus upon or distract from internal cues during exposure treatment of agoraphobic avoidance Behaviour Research and Therapy 27 663672 Craske M G Street L L Jayaraman J amp Barlow D H 1991 Attention versus distraction during in vivo exposure Snake and spider phobias Journal of Anxiety Disorders 5 199 211 Damasio A R 1994 Descartes error New York GrossetPutnam Darwin C R 1872 The expression of the emotions in man and animals London John Murray Di Nardo P A Brown T A amp Barlow D H 1994 Anxiety Disorders Interview Schedule for DSMI V Lifetime Version ADISIVL San Antonio TX Psychological Corporation Feldner M T Zvolensky M J Eifeit G H amp Spira A P 2003 Emotional avoidance An experimental test of individual differences and response suppression using biological chal lenge Behaviour Research and Therapy 41 403 41 1 Foa E B amp Kozak M J 1986 Emotional processing of fear Exposure to corrective infor mation Psychological Bulletin 99 20 35 Frankl V E 1960 Parodoxical intention A logotherapeutic technique American Journal of Psychotherapy 14 520535 FridlundA J Hat eld M E Cottam G L amp Fowler J C 1986 Anxiety and striate muscle activation Evidence from electromyographic pattern analysis Journal of Abnormal Psy chology 95 228 236 Frijda N H 1986 The emotions Cambridge UK Cambridge University Press Frost R 0 Heimberg R G Holt C S Mattia J 1 amp NeubauerA L 1993 A comparison of two measures of perfectionism Personality and Individual Di erences 14 119 126 Furmark T Tillfors M Marteinsdottir I Fischer H Pissiota A Langstrom B amp Fredrik son M 2002 Common changes in cerebral blood ow in patients with social phobia treated with citalopram or cognitivebehavioral therapy Archives of General Psychiatry 59 425 433 Goldstein A J amp Chambless D L 1978 A reanalysis of agoraphobia Behavior Therapy 9 47 59 Gross J J 1998 Antecedent and responsefocused emotion regulation Divergent conse quences for experience expression and physiology Journal of Personality and Social Psychology 74 224 237 Gross J J amp Levenson R W 1997 The acute effects of inhibiting negative and positive emotion Journal of Abnormal Psychology 1 06 95 103 Hariri A R Bookheimer S Y amp Mazziotta J C 2000 Modulating emotional responses Effects of a neocortical network on the limbic system Neuroreport 11 43 48 Hariri A R Mattay V S Tessitore A Fera F amp Weinberger D R 2003 Neocortical modulation of the amygdala response to fearful stimuli Biological Psychiatry 53 494 501 Hayes S C Strosahl K D amp Wilson K G 1999 Acceptance and commitment therapy An experiential approach to behavior change New York The Guilford Press Heimberg R G Liebowitz M R Hope D A Schneier F R Holt C S Welkowitz L A Juster H R Campeas R Bruch M A Cloitre M Fallon B amp Klein D F 1998 Cognitive behavioral group therapy vs phenelzine therapy for social phobia 12week out come Archives of General Psychiatry 55 1 133 1141 Hersen M amp Barlow D H 1976 Single case experimental designs Strategies for studying behavior change New York Pergamon Press Hollon S D Munoz R F Barlow D H Beardslee W R Bell C C Guillermo B Clark G N Francois L P Kazdin A E Kohn L Linehan M M Markowitz J C Milko Witz D J Persons J B Niederehe G amp Somers D 2002 Psychosocial intervention development for the prevention and treatment of depression Promoting innovation and increasing access Biological Psychiatry 526 610 630 228 BARLOW ET AL Hudson J 1 amp Pope H G 1990 Affective spectrum disorder Does antidepressant response identify a family of disorders with a common pathophysiology American Journal of Psy chiatry 147 552 564 Izard C E Ed 1971 The face of emotion New York AppletonCenturyCrofts Jacobson N 5 Martell C R amp Dimidjian S 2001 Behavioral activation treatment for depression Returning to contextual roots Clinical Psychology Science and Practice 8 255 270 Jansson L amp Ost LG 1982 Behavioral treatments for agoraphobia An evaluative review Clinical Psychology Review 2 311 336 Kamphuis J H amp Telch M J 2000 Effects of distraction and guided threat reappraisal on fear reduction during exposure based treatments for speci c fears Behaviour Research and Therapy 38 1163 1181 Keller M B McCullough J R Klein D N Amow B Dunner D L Gelenberg A J Markowitz J CNemeroff C B Russell J M Thase M ETrivediM H amp Zajecka J 2000 A comparison of nefazodone the cognitive behavioralanalysis system of psycho therapy and their combination for the treatment of chronic depression New England Jour nal ofMedicine 342 1462 1470 Kendell R E 1975 The role of diagnosis in psychiatry Oxford Blackwell Kendler K S 1996 Major depression and generalized anxiety disorder Same genes partly different environments revisited British Journal of Psychiatry 168Suppl 30 68 75 Kendier K 8 Heath A C Martin N G amp Eaves L J 1987 Symptoms of anxiety and symptoms of depression Same genes different environments Archives of General Psychi atry 44 451 457 Kessler R C Nelson C B McGonagle K A Lui J Swartz M amp Blazer D G 1996 Comorbidity of DSM IIIR major depressive disorder in the general population Results from the National Comorbidity Survey British Journal of Psychiatry 168 1730 Kessler R C Stang P E Wittchen H U Ustan T B RoyByrne P P amp Walters E E 1998 Lifetime panic depression comorbidity in the National Comorbidity Survey Archives of General Psychiatry 55 801 808 Kozak M J Liebowitz M R amp Foa E B 2000 Cognitive behavior therapy and pharmaco therapy for 0CD The NIMH sponsored collaborative study In W K Goodman M V Rudorfer amp J D Maser Eds Obsessive compulsive disorder Contemporary issues in treatment Mahwah NJ Erlbaum Associates Kupfer D 1 First M B amp Regier D A Eds 2002 Research agenda for DSM V Wash ington DC American Psychiatric Press Lang P J 1968 Fear reduction and fear behavior Problems in treating a construct In J M Shlien Ed Research in psychotherapy Vol 3 Washington DC American Psychologi cal Association Lang P J 1979 A bioinformational theory of emotional imagery Psychophysiology 16 495512 LeDoux J E 1996 The emotional brain The mysterious underpinnings of emotional life New York Simon amp Schuster Levitt J T Brown T A Orsillo S M amp Barlow D H in press The effects of acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide challenge in patients with panic disorder Behavior Therapy Lewinsohn P M amp Lee W M L 1981 Assessment of affective disorders In D H Barlow Ed Behavioral assessment of adult disorders New York The Guilford Press Liebowitz M R Heimberg R G Schneier F R Hope D A Davies S Holt C S Goetz D Juster H R Lin S H Bruch M A Marshall R D amp Klein D F 1999 Cognitive behavioral group therapy versus phenelzine in social phobia Long term outcome Depres sion and Anxiety 10 89 98 UNIFIED TREATMENT FOR EMOTIONAL DISORDERS 229 Linehan M 1993 Skills training manual for cognitive behavioral treatment of borderline personality disorder New York The Guilford Press Lynch T R Robins C J Morse J 0 amp Krause E D 2001 A mediational model relating affect intensity emotion inhibition and psychological distress Behavior Therapy 32 519 536 Marks 1 M 1971 Phobic disorders four years after treatment A prospective followup Brit ish Journal of Psychiatry 129 362 371 Masters J C 1991 Strategies and mechanisms for the personal and social control of emotion In J Garber amp K Dodge Eds The development of emotion regulation and dysregulation Cambridge studies in social and emotional development pp 182 207 New York Cam bridge University Press Mayer J D amp Salovey P 1997 What is emotional intelligence In P Salovey amp D J Sluyter Eds Emotional development and emotional intelligence Educational implica tions pp 3 34 New York Basic Books Mineka 8 Watson D amp Clark L A 1998 Comorbidity of anxiety and unipolar mood dis orders Annual Review of Psychology 49 377 412 Nathan P E amp Gorman J M Eds 2002 A guide to treatments that work London Oxford University Press Ohman A 1999 Distinguishing unconscious from conscious emotional processes Method ological considerations and theoretical implication In T Dalgleish amp M Power Eds Handbook of cognition and emotion Chichester England Wiley Orsillo S M Roemer L amp Litz B T 2001 Narrative analysis of emotional processing in PTSD Manuscript submitted for publication Pennebaker J W 1997 Therapeutic process Psychological Science 8 162 166 Rachman S J 1980 Emotional processing Behaviour Research and Therapy I 8 51 60 Rachman S J 1981 The primacy of affect Some theoretical implications Behaviour Research and Therapy I 9 279 290 Rapee R M Craske M G amp Barlow D H l9941995 Assessment instrument for panic disorder that includes fear of sensation producing activities The Albany Panic and Phobia Questionnaire Anxiety 1 114 122 Razran G 1961 The observable unconscious and the inferable conscious in current Soviet psychophysiology Interoceptive conditioning semantic conditioning and the orienting re ex Psychological Review 68 81 150 Richards J M amp Gross J J 2000 Emotion regulation and memory The cognitive costs of keeping one s cool Journal of Personality and Social Psychology 79 410 424 Roemer L Litz B T Orsillo S M amp Wagner A W 2001 A preliminary investigation of the role of strategic withholding of emotions in PTSD Journal of Traumatic Stress 14 143 150 Rottenberg J amp Gross J J 2003 When emotion goes wrong Realizing the promise of affective science Clinical Psychology Science and Practice 10 227 232 Salkovskis P M Clark D M Hackman A Wells A amp Gelder M G 1999 An experi mental investigation of the role of safetyseeking behaviours in the maintenance of panic disorder with agoraphobia Behaviour Research and Therapy 37 559 574 Sanderson W C Rapee R M amp Barlow D H 1989 The in uence Of an illusion of control on panic attacks induced via inhalation of 55 carbon dioxide enriched air Archives of General Psychiatry 46 157 164 Schmidt N B WoolawayBickel K Trakowski J Santiago H Storey J Koselka M amp Cook J 2000 Dismantling cognitivebehavioral treatment for panic disorder Question ing the utility of breathing retraining Journal of Consulting and Clinical Psychology 68 417 424 Scott W D amp Cervone D 2002 The impact of negative affect on performance standards Evidence for an affectas information mechanism Cognitive Therapy and Research 26 19 37 Langer and Abelson what do these results mean Paradigms matter what you see and how you see it In this case one paradigm was not as useful as the other This investigation doesn t speak to the validity of the two paradigms in general The behavioral perspective was more valid in this case but mainly it proved that paradigms matter psychoanalysis Freud the rst who undertook the theory of behavior a formidable task we are all psychoanalytic in our orientation at least a little bit psychanalysisunconcious motivators for our behavior importance of early learning defense mechanisms symbolic meaning ofthings PA is both theory of developement and an approach to therapy aned theory stages of developement successful progression or if conflicts at those stages can become fixated or regress when under stress fixated stuck with issues at those stages worse regress partially resolved but under pressure regress back to an earlier stage Psychosexual stages biologically driven via maturation also in uenced by those around us oral first 18 months nursing being cared for nutrients having physical needs taken care of anal 18 mos to 3 yrs toilet training problems with training neatness anal retentive is someone who needed to be neat at this early stage phallic 35 yrs discover genitals oedipal and electra complex successful resolution is to identify with the same sexunderstanding appropriate relationship latency 5 years to adolescence not much happening genital adolescence through adulthood final stage productive in life s activities criticized because of too little focus on post adolescent development controversial hard to verify scientifically structure of mind 2 ways to view 1 unconcious concious preconcious like an iceberg goal of PA is to get unconcious to concious awareness unconcious causes the problems that need to be resolved insight orientated therapygaining concious awareness of whats motivating behavior 2 Id ego superego id most primitive present at birth interested in grati cation pleasure libido is energy force someone with depression has low libido gtlow sexual drive operates on pleasure principleiust go for it ego develops during rst year of life consciousness emerges execute plan strategize to get what s wanted operates on reality principle has to plan and use strategy instead ofgoing for it id says go for it ego says nah don t want to mess things up superego develops through childhood incorporates right and wrong from family and society concsious from latin meaning to know together or joint knowledge with others can be overly strict or permissive operates on morality principle defense mechanisms function protect ego from anxiety displacement redirects an emotional impulse from a more to a less threatening object rationalization conceals true motivation by giving elaborate or socially acceptable reasons for behavior projection take your own unacceptable urges or impulses and attribute them to someone else paranoid people project by acting paranoid because they want to hurt someone reaction formation subsitutes thoughts feelings or behaviors opposite oftrue feelings an antiporn activist might actually really enjoy porn sublimation generally healthy directs potentially maladaptive thoughts feelings or behavior into socially acceptable behaviors cancer sufferers who get involved with organizations for cancer patients PA Therapy too cost inefficient to be long term an insight oriented therapy make unconscious concsious if insight is gained for reasons of behavior the person should be able to change it working through therapy takes years Focus on early experiences and unconcsious motivations taht play themselves out in current behavior Current behavior not the main focus Techniques of PA free association person talks about whatever comes up without usual sensoring that occurs in conversations therapist tries to make connections about the themes the person discusses resistance person tries to avoid important but unpleasant emotional content person answers brie y then changes subject sarcasm make a joke start an argument fidget etc transference patient acts toward therapists as ifthe therapist were an important person in patients past ie concerned about iftherapist likes him what he thinks about them reveals how patient related to parents and others countertransference not a good technique therapist acts toward patient as if patient is an important person in therapists past therapists have to undergo psychotherapy themselves to make sure their pasts don t interfere must guard against them dream analysis examine symbolic content within dreams interpretation having gathered info and formed hypotheses therapist shares insight with patient timing is important therapists may be correct but patient might not be prepared can lead to patient insight which will help them to work through their issues PA is best suited for fairly highfunctioning neurotic or anxious patient ie Woody Allen wouldn t be suited for schizophrenic patients those with less grounding in reality likely to be counterproductive Iatrogenic effects treatment makes problem worse hippocratic oath above all do no harm very little data of PA effectiveness mostly uncontrolled case studies working with someone long term unsuccessful case often not published Humanist Client Centered Therapy Rogerian Therapy Carl Rogers little theory a philosophical stance people will develop well ifthey are given unconditional love unconditional positive regard taken on when given love and adopt that view about themselves conditional love loved when I do X but not loved when I do Y A distorting reality about self so that you seem loveableacceptable B denyignore undesirable parts of yourself little growth this way Therapy is more a set of characteristics ratherthan techniques Rogerian Triad or Therapeutic Triad Genuineness acting warmly and openly with an individual idea that around genuine people one feels saferto be themselves aroundungenuine people one feels more guarded unconditional positive regard love accepting patient for who they are not what they do accurate emphatic understanding gt listening skill of reflections presenting back what patient has said evaluation of clientcentered therapy


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