Treating Chronic and Severe Mental Disorders: A Handbook of Empirically Supported Interventions / Edition 1

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Overview

While recent developments in psychopharmacology have been widely disseminated, equally important advances in psychological strategies for severe mental health problems have received less attention. Filling a crucial gap in the literature, this volume brings together leading clinical scientists to present evidence-based approaches for treating schizophrenia, mood disorders, substance use problems, and severe personality disorders. Cutting-edge modalities presented include behavioral and cognitive-behavioral therapies, dynamic therapies, interpersonal therapies, couple and family treatments, motivational interviewing, and more. Throughout, step-by-step clinical guidelines are accompanied by illustrative case examples and patient-therapist dialogues. Particular attention is given to strategies for integrating psychological and pharmacological interventions, as well as to gender and cultural issues in treatment.
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Editorial Reviews

From the Publisher

"This text fills a real void. There are few comprehensive texts re this subject matter."--Stacey Lambert, Psy.D.

"This compendium of clinical interventions described by highly skilled clinical researchers offers mental health practitioners very practical skills for effectively treating truly serious mental disorders. Especially useful is the mini-manual chapter format with case examples and clinical dialogue illustrating a wide range of cognitive-behavioral methods, interpersonal psychodynamic therapies, and family and systems interventions. This is an excellent choice as a text for advanced graduate students in all mental health disciplines."--Gail Steketee, PhD, Boston University School of Social Work

"This book is an important guide for psychiatrists, psychologists, social workers, and all health professionals who want to review new applications of tested treatments. Guidelines for the treatment of psychiatric disorders increasingly call for evidence of efficacy, making this a most timely publication. Empirical support is no less important in psychotherapy than it is in psychopharmacology."--Myrna M. Weissman, PhD, Department of Psychiatry, Columbia University College of Physicians & Surgeons

"For a long time, severe mental disorders have been treated for the most part with medication. This book fills a longstanding gap in clinical psychology with its sound collection of effective, empirically based psychological treatments for the most troubled populations. Featuring an impressive list of contributors who represent the leading figures in their respective fields, this is a valuable tool for mental health professionals in the United States and internationally. It is also an accessible text for graduate-level students. I highly recommend this book."--Kurt Hahlweg, PhD, Technical University of Braunschweig, Germany

Journal of Clinical Psychiatry

"Selects and presents evidence-based strategies from a veritable 'Who's Who' in psychological treatments....Individual chapters outline specific clinical strategies in a well-organized, readable fashion."--Journal of Clinical Psychiatry
The Clinical Psychologist

"For those readers who want an informed contemporary accounting of some of the most promising psychosocial treatments for disorders for which psychosocial treatments have not before been widely available, this would be an excellent choice."--The Clinical Psychologist
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Product Details

  • ISBN-13: 9781593850982
  • Publisher: Guilford Publications, Inc.
  • Publication date: 7/15/2004
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 430
  • Sales rank: 1,101,722
  • Product dimensions: 7.10 (w) x 9.76 (h) x 0.90 (d)

Meet the Author


Stefan G. Hofmann, PhD, is Associate Professor of Psychology at Boston University. His research, which has been funded by the National Institute of Mental Health and the National Alliance for Research on Schizophrenia and Depression, focuses on the treatment of anxiety disorders and schizophrenia. His publications include a coauthored book on social anxiety and social phobia.

Martha C. Tompson, PhD, is Assistant Professor of Psychology at Boston University. Her research interests include family processes among individuals with severe psychopathology, family-based treatment for mood disorders, and developmental psychopathology. She has received grants from the National Institute of Mental Health to develop a family-based treatment for preadolescents suffering from depression and to examine family factors in the development of depression vulnerability in youth.

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Read an Excerpt

Treating Chronic and Severe Mental Disorders

A Handbook of Empirically Supported Interventions

The Guilford Press

Copyright © 2004 The Guilford Press
All right reserved.

ISBN: 1-59385-098-0


Chapter One

Personal Therapy

A Practical Psychotherapy for the Stabilization of Schizophrenia

Gerard E. Hogarty

While psychotherapy continues to be the "cornerstone" of nonsomatic treatment for schizophrenia, little data had supported its efficacy until recently (Fenton, 2000). Decades of negative findings had in fact led to a recommended "moratorium" on dynamic forms of therapy (Mueser & Berenbaum, 1990), variously described as investigative, uncovering, analytical, or insight-oriented in nature. However, these uninspiring results could often be traced to various problems in the design of psychotherapy studies rather than to a lack of efficacy. Problems included the choice of controls, high attrition, therapist experience, equivocal diagnoses, small samples, a failure to access entitlements or control for medication, and more importantly, the conceptual relevance of the studied therapy to schizophrenia. Forms of brief therapy for an often chronic illness had tended to focus on the "crisis of the day" that typically characterized the early stages of recovery from an episode but were less relevant to the resumption of life roles.

In the modern era of psychopharmacology, only social skills training and aversion of cognitive-behavioral therapy for schizophrenia have held evidence-based credibility as individual psychosocial approaches for the patient with schizophrenia. While the advantages of these interventions are well described elsewhere in this volume, they tend by design to be problem-focused, usually on specific social deficits in the case of social skills training, or on medication refractory symptoms in the practice of cognitive-behavioral therapy. The patient populations most often targeted have been more seriously impaired, if not hospitalized. In all but a few studies, treatment exposure has been 9 months or less. Personal therapy (PT) incorporates selected social skills trainingtechniques that were found useful in an earlier study (Hogarty et al., 1986), but it has had little success with patients who remain medication refractory, thus indicatingan important, abiding role for cognitive-behavioral therapy. Today, the newer, atypical antipsychotic medications allow a majority of patients to achieve a better remission of positive symptoms than earlier medications. The need to maintain clinical stability, accomplish important life goals, and develop a management mastery of one's illness would likely fall to a longer term psychotherapeutic approach that could accommodate the spectrum of residual psychological, social, and neurobiological constraints imposed by schizophrenia.

In response to these issues, PT was conceived as a disorder-relevant intervention and tested between 1986 and 1995 in two, long-term (3-year) controlled trials involving 97 patients who lived with family, and 54 patients who lived on their own. Relapse was reduced to its practical limits amongpatients who lived with their families (13% relapsed on PT alone over 3 years), and the social adjustment of both PT cohorts greatly surpassed those of our previously tested interventions, includingour popular family psychoeducation approach (Hogarty, Greenwald, et al., 1997; Hogarty, Kornblith, et al., 1997). In the era of managed care and decreasing lengths of hospitalization for acute exacerbations of symptoms, the need for a more efficacious, comprehensive, and durable approach to the maintenance of clinical stability and recovery of interpersonal and instrumental role performance was addressed by PT.

OVERVIEW

PT seeks to achieve and maintain clinical stability usingboth appropriate pharmacotherapy and incremental acquisition of adaptive, self-regulating strategies. The latter are designed to counter the stress-induced, affective dysregulation that frequently precipitates an episode of psychosis. Given the well-established vulnerability of patients with schizophrenia to environmental stress, PT is intended to be applied in three distinct phases that accommodate the various stages of clinical recovery and reintegration following a psychotic episode. It is a collaborative intervention that utilizes the patient's own self-protective strategies, as well as a repertoire of well-tested techniques for prodromal management and the mastery of environmental stress.

In this brief chapter, only a summation of PT practice principles will be possible; the working manual itself is provided elsewhere (Hogarty, in press). The clinician will find that the manual is not a "cookbook" of clinical recipes that narrowly focus on a specific problem. Rather, it offers a number of flexible clinical approaches to the multiple problems that inevitably characterize individual patients. Patients learn to gain control over their schizophrenia and improve their quality of life in the context of potentially provocative interpersonal and vocational environments. When a patient appears not to profit from a specific technique, the systemic nature of PT offers a range of options within and across the three treatment phases that help to counter the therapeutic stalemate. In the following pages, I focus on describing the core principles themselves as they evolve across the various phases rather than a serial description of each PT phase, as is offered in the manual. With this change of emphasis, I hope the incremental nature of the core strategies can become better appreciated as a seamless set of exercises that accommodate patients' clinical state, strengths, and vulnerabilities as they recover from an episode and seek to maintain stability. Case material is not presented for many reasons, including the issues of confidentiality and the need to avoid inappropriate expectations for recovery (see Hogarty, in press, Chap. 1).

PREPARING FOR PERSONAL THERAPY

PT proceeds on the assumption that no psychosocial treatment can attain optimal efficacy unless the fundamentals of good care are firmly established. Foremost is the need for a very effective psychopharmacological regimen. While seemingly self-evident, no more than 29% of patients with schizophrenia are believed to be appropriately medicated (Lehman & Steinwachs, 1998). It has been my experience that many providers have an inappropriately high threshold for persistent symptoms. As PT and my former studies have shown, a high-contact, flexible, and persistent approach to medication management can achieve an optimal remission of symptoms for the vast majority of patients (Hogarty, in press). PT does not presume to address the cognitive or affective problems that are more appropriately and effectively managed with medication. Contemporary "atypical" antipsychotic medications now provide a better foundation for an optimal psychosocial treatment response. These medications, for example, rarely disable patients with extrapyramidal symptoms (particularly an assault on affect and volition), most often preclude the need for antiparkinsonian medications, thus minimizingthe well-known anticholinergic effect on short-term verbal memory, and generally manifest a better therapeutic profile across cognitive and affective symptoms.

In the context of rational pharmacotherapy, PT also relies on the established principles of psychological and material support. The former permeate each PT session and include attending to, observing, listening, and responding to the patient's personal accounts and descriptions of subjective state; a correct empathy; and the reinforcement, as well as encouragement, of the patient's own health-promoting efforts. The theoretical basis of this support is more interpersonal than intrapsychic or interpretive. Perhaps more troublesome to providers who remain ambivalent about the potential for dependency, PT nevertheless assumes an active role in assisting patients to access entitlement benefits for which they are eligible, primarily those administered by the Social Security Administration (Social Security disability insurance and supplemental security income) or the public welfare department. Otherwise, the case-management component of PT extends to facilitating the acquisition of needed (public) health insurance for the patient, supported housing, when indicated, and, as recovery improves, supported education and/or employment opportunities that are often administered through local rehabilitation agencies. The need to engage essential human services is paramount for patients who no longer have the support or resources of an available family. In fact, initiating the learning-based strategies of PT among such patients before residential stability, food, and clothing are secure has been shown to increase relapse in this vulnerable group of patients (Hogarty, Kornblith, et al., 1997), as I discuss later. The fundamentals of medication management, as well as psychological and material support, are described in detail in the working manual (Hogarty, in press, Chap. 3).

Insights gained from our study of integrated medication and psychosocial treatment over the previous 25 years also served to guide the application of PT. Among the more relevant insights was the reality that patients who suffered a relapse but were unequivocally faithful in taking medication almost always had experienced a severe and independent life event-an observation that held clear potential for prevention. Similarly, patients who remained withdrawn, disorganized, overly aroused, or who had little insight, could easily become dysregulated by a prematurely ambitious treatment plan. Otherwise, minor exacerbations could often be traced to environmental stress that could be negotiated by the therapist, rather than embark on a permanent increase in medication dose or type. (Often a short-term supplemental dose is helpful while attempts at environmental manipulation are being made.) It was also found that coping and other learned strategies should be introduced slowly, following the achievement of a stable dose of medication. The resolution of psychotic symptoms takes time, and patients often pass through months of inactivity, amotivation, and increased sleep before finding the energy to take on initiatives that could improve their quality of life. Once the treatment plan was initiated, we learned that one change at a time was also crucial. If a stable patient were beginning a job, finding a new residence, reestablishing or forming a new relationship, for example, this was not the time to change the medication dosage or try a new medication. (If the patient were to decompensate, one would never know what the precipitant might have been in the face of multiple changes.)

Regarding noncompliance, we also observed that patients should not be misled by the apparent "improvement" that follows discontinuation of antipsychotic medication. Side-effect reduction is most responsible for the increased feelings of well-being. Depolarization or receptor blockade can continue for days or weeks, dependingon the medication, and when symptoms eventually reappear, the relationship between noncompliance and relapse is often lost on the patient. Most important, low dose does not mean "no dose." Many patients do well on a low doses of certain antipsychotic medications (such as the typical neuroleptic medications), but the majority of these better functioning-patients will quickly decompensate if medication is discontinued (Hogarty, Ulrich, & Mussare, 1976). Once patients functionally recover, they might not need the intensity of weekly or biweekly sessions, but they do need the "safety net" of regular, often monthly, checkups. Booster sessions of the preferred psychosocial treatment are particularly necessary for stable patients, since these patients are most likely to initiate attempts to acquire or enhance social and vocational roles. While the interests and priorities of nonphysician therapists might understandably be focused on psychosocial issues, they need always to remain sensitive to potential medication problems as well. One cannot become passive about the question of treatment specificity for behavioral problems (i.e., whether the issue is better addressed by medication or psychosocial treatment). Finally, we learned that the therapist must be ever-vigilant about strongly held but potentially false assumptions, includingthe following incorrect beliefs: Persistent symptoms are an inevitable part of schizophrenia; supplemental medication will not work; one can "predict" how a patient will respond to an untried medication (e.g., with weight gain or other side effects); the diagnosis of early schizophrenia should be avoided (but at the price of mistreatment); one's knowledge of the patient is complete and further information from the patient, family, or a past provider is unnecessary. (Many patients will not spontaneously volunteer information on side effects, subjective state, or interpersonal problems in the absence of regular probing.)

Finally, in preparing for PT, compliance and success will depend a great deal on the strength of the therapeutic alliance. The task can be difficult when the clinician is faced with the fear, anxiety, blame, or denial that often accompany the first episode of schizophrenia, or with the demoralization and despair frequently associated with a recurrence of symptoms. PT strategies and goals can be presented as an opportunity for a more hopeful "new beginning," namely, that life stressors that might lead to a new episode can be identified, reduced, and controlled. In time, the patient's own social and vocational objectives can be increasingly pursued with confidence and safety. The treatment plan represents the blueprint for reaching these objectives and is driven by careful assessment of the patient's needs, strengths, personal goals, and coping strategies (particularly regarding the characteristic prodromes of a new episode), as well as existing supports and liabilities. "Therapy" is described for the patient as a series of progressive steps needed to maintain survival without psychosis; develop awareness and foresight regarding the relationship between relapse and the subjective cues of distress that arise internally or externally; acquire adaptive strategies designed to manage the sources of stress; and gradually resume expressive and instrumental roles. The plan also represents a collaborative agreement to work together to reach these goals. A time frame for treatment is established (e.g., up to 24 months for a symptomatically stable patient, but as long as 3 years for a recently hospitalized patient). Initially, weekly sessions will vary in length from 15 to 45 minutes, dependingon the patient's ability to concentrate and tolerate discussions. Once stabilization is secure, sessions are typically reduced to two or three per month.

Continues...


Excerpted from Treating Chronic and Severe Mental Disorders Copyright © 2004 by The Guilford Press. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents


I. Psychological Treatments for Schizophrenia
1. Cognitive-Behavioral Family and Educational Interventions for Schizophrenic Disorders, Ian R. H. Falloon
2. Social Skills Training for Schizophrenia,
Sarah Pratt and Kim T. Mueser
3. Personal Therapy: A Practical Psychotherapy for the Stabilization of Schizophrenia, Gerard E. Hogarty
4. Cognitive-Behavioral Therapy for Schizophrenia: A Case Formulation Approach, Nicholas Tarrier and Gillian Haddock
II. Psychological Treatments for Mood Disorders
5. Cognitive-Behavioral Therapy for Depression, Kate E. Hamilton and Keith S. Dobson
6. Cognitive-Behavioral Therapy for the Management of Bipolar Disorder, Michael W. Otto and Noreen Reilly-Harrington
7. Interpersonal Psychotherapy for Unipolar and Bipolar Disorders, Holly A. Swartz, John C. Markowitz, and Ellen Frank
8. Family-Focused Treatment for Bipolar Disorder, David J. Miklowitz
9. Treatment of Marital Discord and Coexisting Depression, K. Daniel O'Leary
10. Treatment of Suicidality: A Family Intervention for Adolescent Suicide Attempts, Mary Jane Rotheram-Borus, Alison M. Goldstein, and Amy S. Elkavich
III. Psychological Treatments for Substance Use and Abuse Disorders
11. Motivational Interviewing for Initiating Change in Problem Drinking and Drug Use, Nancy S. Handmaker and Scott T. Walters
12. Cognitive-Behavioral Therapy for Alcohol Addiction, Tracy A. O'Leary and Peter M. Monti
13. Twelve-Step Facilitation Therapy for Alcohol Problems, Joseph Nowinski
14. Couple Treatment for Alcohol Abuse: A Systemic Family-Consultation Model, Michael J. Rohrbaugh and Varda Shoham
15. Psychosocial Treatment of Cocaine Dependence: The Community Reinforcement plus Vouchers Approach, Stephen T. Higgins, Stacey C. Sigmon, and Alan J. Budney
IV. Psychological Treatments for Severe Personality Disorders
16. Dialectical Behavior Therapy for Borderline Personality Disorder, Kelly Koerner and Marsha M. Linehan
17. Multiple Family Group Treatment for Borderline Personality Disorder, Teresa Whitehurst, Maria Elena Ridolfi, and John Gunderson
18. Multisystemic Treatment of Antisocial Behavior in Adolescents, Elizabeth J. Letourneau, Phillippe B. Cunningham, and Scott W. Henggeler
19. Cognitive-Behavioral Therapy for Severe Personality Disorders, Arthur Freeman
20. Short-Term Dynamic Psychotherapy: Resolving Character Pathology by Treating Affect Phobias, Nathaniel S. Kuhn and Leigh McCullough
Concluding Remarks, Stefan G. Hofmann and Martha C. Tompson
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