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The importance of walking on “Infirm or swampy ground”
R e s p o n s e : Infirm a n d S w a m p y G r o u n d
Response Paper
s u p p o r t f o r C a r r i e f r o m o t h e r p a t i e n t s m a y have b e e n a useful a d j u n c t to b e h a v i o r a l t r e a t m e n t if it w e r e available. I n summary, t h e a u t h o r s ' w o r k in this a r e a is a d m i r a ble a n d t h e y h a v e u t i l i z e d e m p i r i c a l l y s u p p o r t e d p r o c e d u r e s very well. It is suggested, however, t h a t a b r o a d e r b e h a v i o r a l a p p r o a c h to c o n c e p t u a l i z a t i o n a n d t r e a t m e n t m a y have o p t i m i z e d m o t i v a t i o n a n d t r e a t m e n t r e s p o n s e in this case.
The Importance of Walking on "Infirm or Swampy Ground" W e n d y K. S i l v e r m a n
Florida I n t e r n a t i o n a l University I provide comments to Roblek, Detweileg, Fearing, and Albano's (1999) presentation of child and adolescent cases of trichotillomania in this case conference series. I focus particularly on the authors' attitude when it comes to conceptualizing and treatment planning, and I present an alternative attitude, a pragmatic attitude. A pragmatic attitude begins with concrete problems of specific human beings in particular contexts, and in beginning with concrete problems of specific human beings in particular contexts the pragmatist recognizes the myriad of problems that might arise, and perhaps even more importantly, that different problems may require different solutions. I then illustrate how a pragmatic therapist might have considered the need to consider various contextual factors, including developmental factors, which would have led to modifying the behavioral conceptualization and treatment when working with an adolescent.
References Azrin, N. H., & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. BehaviourResearch and Therapy, 12, 619-628. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hail~ pulling (trichodltomania) : A comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and ExperimentaIPsychiatry, 11, 13-20. Mansueto, C. S., Stemberger, R. M. T., McCombs, A., & Golomb, R. G. (1997). TrichotiUomania: A comprehensive behavioral model. Clinical Psycholog)Review, 1Z 567-577. Roblek, T. L., Detweiler, M. E, Fearing, T., & Albano, A. M. (1999). Cognitive behavioral treatment of trichodllomania in youth: What went right and what went wrong? Cognitive and Behavioral Practice, 6, 154-161. Rothbaum, B. O. (1992). The behavioral treatment of trichodllomania. BehavioralPsychotherapy, 20, 85-90. Stanley, M. A., Borden, J. w., Mouton, S. G., & Breckenridge, J. K. (1995). Nonclinical hairpulling: Affective correlates and comparison with clinical samples. BehaviourResearchand Therapy, 33, 179186. Address correspondence to Melinda A. Stanley, Ph.D., Department of Psychiatry and Behavioral Sciences, University of Texas, Houston Health Science Center, 1306 Moursund Ave., MSI, Houston, TX 77030-3497.
Received: December1, 1998 Accepted: December1, 1998
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T WAS A PLEASURE tO r e a d Roblek, Detweiler, F e a r i n g , a n d M b a n o s (1999) p r e s e n t a t i o n o f t h e i r c h i l d a n d a d o l e s c e n t cases o f t r i c h o t i l l o m a n i a , a n d I a p p r e c i a t e t h e o p p o r t u n i t y to c o m m e n t o n t h e i r p r e s e n t a t i o n in this case c o n f e r e n c e series o f Cognitive and Behavioral Practice. T h e r e is m u c h t h a t is l a u d a b l e a b o u t the ways in w h i c h A1b a n o a n d h e r c o l l e a g u e s assessed a n d t r e a t e d t h e two cases d e s c r i b e d in t h e i r article. I n t e r m s o f assessment, f o r e x a m p l e , in b o t h cases, s t r u c t u r e d d i a g n o s t i c interviewing p r o c e d u r e s w e r e u s e d to e n s u r e a c c u r a t e differential diagnoses. Q u e s t i o n n a i r e s w e r e a d m i n i s t e r e d so that treatment progress and outcome could be gauged. Steps w e r e t a k e n to s e e k o u t a n d to use a n i n d e x specific to t r i c h o t i l l o m a n i a , namely, the Psychiatric I n s t i t u t e T r i c h o t i l l o m a n i a Scale (PITS), w h i c h p r o v i d e d d e t a i l e d i n f o r m a t i o n a b o u t various facets o f t h e p r o b l e m behavior. T h e r e is also a g r e a t d e a l t h a t is l a u d a b l e a b o u t t h e description of the treatment, including the authors' s e a r c h i n g t h r o u g h t h e clinical r e s e a r c h l i t e r a t u r e to h e l p i d e n t i f y e m p i r i c a l l y b a s e d t r e a t m e n t s . T h i s l e d to t h e i r i d e n t i f i c a t i o n a n d utilization o f A z r i n a n d N u n n ' s (1973) h a b i t reversal t e c h n i q u e s . D e s p i t e t h e a b o v e m e n t i o n e d positive aspects o f t h e
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Cognitive and Behavioral Practice 6, 1 6 3 - 1 6 7 , 1999 1077-7229/99/163-16751.00/0 Copyright © 1999 by Association for Advancement of Behavior Therapy. MI rights of reproduction in any form reserved.
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Silverman assessment a n d t r e a t m e n t a p p r o a c h e s used in the two cases, things a p p a r e n t l y went "right" in the case o f 7-yearo l d Ethan b u t "wrong" in the case o f 15-year-old Carrie. In the section "Conclusions a n d Questions for the Experts," the authors highlighted several factors they thought might be worthy of consideration in future attempts to imp l e m e n t the treatment described in their paper. Specifically, the authors m e n t i o n e d (1) the motivational level o f the client, (2) the age of the client, (3) familial a n d individual historical information, a n d (4) the child a n d parent(s)' belief in the integrity o f t r e a t m e n t and the model. T h e authors t h e n raised four specific questions that they asked the discussants to consider, including (1) how to improve compliance when motivation is low, (2) how to manage the complexities involved in working with b l e n d e d families, (3) how to h a n d l e n o n a d h e r e n c e to monitoring, a n d (4) how to engage clients who have p r e c o n ceived notions of the process a n d p r o c e d u r e s of therapy. It is e x p e c t e d that, as a discussant, I will now d e l i n e a t e specific answers to each o f these four excellent questions. Rather t h a n d o i n g this, however, my p r e f e r e n c e is to begin a bit m o r e at the beginning! For me, the b e g i n n i n g is with the authors' conceptualization or theoretical frame of t r i c h o t i l l o m a n i a a n d its treatment. More specifically, I focus on the authors' attitude r e g a r d i n g conceptualizing a n d t r e a t m e n t planning. I will t h e n p r e s e n t an alternative attitude, a pragmatic attitude, which is m o r e like "walking on infirm or swampy g r o u n d " - - a phrase I b o r r o w from Charles Sanders Peirce, the A m e r i c a n logician a n d phil o s o p h e r o f science who or~iginally c o i n e d the term "pragmatism." In presenting this alternative attitude, I touch on several o f the questions raised by the authors. T h e authors explain in the b e g i n n i n g o f their introd u c t i o n that: D e p e n d i n g on the theoretical explanation used to define trichotillomania, different treatments have b e e n i m p l e m e n t e d . Psychodynamic therapy, pharmacotherapy, a n d behavior modification are rep o r t e d with varying levels o f effectiveness. However, the only t r e a t m e n t that has b e e n systematically investigated has b e e n the behavior modification techniques. F r o m a behavioral perspective, trichotillomania is the exaggeration in frequency a n d severity o f a n o r m a l behavioral p a t t e r n (i.e., r e a c h i n g h a n d to h e a d ) . It is t h e o r i z e d that this e x a g g e r a t i o n occurs in response to anxiety e x p e r i e n c e d after an event s u c h as a physical injury, c h a n g e in family functioni n g , o r psychological trauma, a l t h o u g h n o empirical evidence supports any specific etiological trigger. As the behavioral p a t t e r n increases in frequency, its form is also altered such that hair pulling occurs, a n d with r e p e t i t i o n the behavioral sequence can be classified as a nervous habit.
F r o m this conceptualization came Azrin a n d N u n n ' s habit reversal t r e a t m e n t in which "The clie n t should learn to be aware o f every o c c u r r e n c e o f the habit by i n t e r r u p t i n g the h a b i t m o v e m e n t so that it is n o l o n g e r p a r t o f a chain o f n o r m a l movements. A physically c o m p e t i n g response s h o u l d be established to interfere with the habit, a n d social r e i n f o r c e m e n t should be reversed or e l i m i n a t e d (from Azrin a n d N u n n , 1973, p. 620)" (Roblek et al., 1999, pp. 154-161). However, as the authors p o i n t o u t in their article, there has b e e n only o n e c o n t r o l l e d study on Azrin a n d N u n n ' s treatment, a n d this study has follow-ups o f only 3 and 4 months. (Though in Azrin, Nunn, and Frantz [1980] in which h a b i t reversal was c o m p a r e d to negative practice training, the f o r m e r was f o u n d to be s u p e r i o r over the latter a n d follow-ups were as long as 22 months.) Further, the studies c o n d u c t e d by Azrin a n d colleagues were all d o n e with adults, n o t children. So even less is known a b o u t w h e t h e r h a b i t reversal works with child a n d adolescent populations. In light o f the above, my m a i n reaction to the treatm e n t cases described in this article is not that it was necessarily a mistake to a t t e m p t to use Azrin a n d N u n n ' s h a b i t reversal technique. O n the contrary, given the absence o f o t h e r d o c u m e n t e d treatments that have b e e n systematically evaluated, e x p l o r i n g the utility o f Azrin a n d N u n n ' s h a b i t reversal t e c h n i q u e with c h i l d r e n makes a lot o f sense. It is only t h r o u g h such activities that knowledge will be i n c r e m e n t e d with respect to the clinical effectiveness o f various treatments. Having said this, howevel; I think it is i m p o r t a n t that when we try relatively "new" p r o c e d u r e s with "new" populations (e.g., children, adolescents), we n e e d a certain type o f attitude: We n e e d an attitude that is o p e n to the idea that the t r e a t m e n t either (a) may n o t work, a n d that o t h e r treatments m i g h t work j u s t as well o r better, o r (b) may require modifications in light o f the p o p u l a t i o n , context, etc., with which we are working. This type o f attitude I refer to as pragmatic (described f u r t h e r below). In r e a d i n g over the a c c o u n t o f the cases, I d i d n o t pick u p that the authors h a d a p r a g m a t i c attitude. Rather, the attitude I picked u p on was that the authors h a d a very strong belief or conviction in their behavioral conceptualization o f a n d t r e a t m e n t for trichotillomania. F o r example, in discussing Carrie's m o t h e r ' s reactions to the behavioral t r e a t m e n t that they were trying to i m p l e m e n t with Carrie, they indicate that because o f the m o t h e r ' s own involvement with psychodynamic therapy, the m o t h e r h a d d e v e l o p e d a psychodynamic conceptualization a b o u t h e r d a u g h t e r ' s hair-pulling behavior. T h e authors indicate: "At this p o i n t we did n o t want to summarily dismiss the m o t h e r ' s conceptualization for risk o f alienating h e r fully. However, given o u r strong behavioral b a c k g r o u n d
Response: Infirm and S w a m p y Ground a n d a p p r o a c h to psychopathology, we d i d find this form u l a t i o n b o t h a m u s i n g a n d at the same time destructive to the child's t r e a t m e n t p r o g r a m . It was evident that the m o t h e r d i d n o t agree with o u r t r e a t m e n t rational o r approach, as it was drastically different from h e r own therapy experience" (p. 157). A p r a g m a t i c attitude is o n e that does n o t instinctually r e s p o n d to alternative ways o f viewing things by a desire to "summarily dismiss" it a n d to view any alternative form u l a t i o n t h a n o n e ' s own as "amusing." This would n o t be a p r a g m a t i c attitude because in fact t h e r e is an absence o f the "best" type o f evidence n e e d e d in this c o n t e x t (i.e., the c o n t e x t of evaluating psychotherapy), n a m e l y empirical evidence. T h a t is, t h e r e is an absence o f empirical evi d e n c e for the behavioral conceptualization o f trichotill o m a n i a a n d t h e r e is an absence o f clinical trims on behavioral t r e a t m e n t of trichotillomania with either child r e n or adolescents. Because t h e r e is an absence o f evidence, a pragmatist would r e m a i n o p e n to the possibility that p e r h a p s t h e r e are alternative conceptualizations a n d / o r treatments for trichotillomania in youth. At a m i n i m u m , a p r a g m a t i c attitude would be o p e n to the possibility that a particular c o n c e p t u a l i z a t i o n / t r e a t m e n t (e.g., behavioral) m i g h t n e e d to b e m o d i f i e d when working with c h i l d r e n a n d adolescents ( a n d m o d i f i e d differently for c h i l d r e n t h a n for adolescents). In o t h e r writings, my colleague William Kurtines a n d I have written a b o u t how d e v e l o p m e n t s that have o c c u r r e d within psychology (e.g., eclecticism, integrationism) as well as outside o f psychology (e.g., p o s t m o d e r n i s m ) pose serious challenges to the n o t i o n o f having "a theory" o f child p s y c h o t h e r a p y (see, for example, Silverman a n d Kurtines, 1996a, 1996b, 1997; in press). We have discussed in detail how we view "pragmatism" in b o t h practice a n d research as a reasonable response to these developments. (The interested r e a d e r m i g h t consult those writings for f u r t h e r details a b o u t these developments.) We have discussed how we view p r a g m a t i s m as a reasonable response mainly because it does not l e a d us down eit h e r o n e of the following two paths: It does n o t lead us down the m o d e r n i s t p a t h of essentialist or f o u n d a t i o n a l pursuits (Amundson, 1996). T h a t is, it does n o t lead us to pursue the "truth" a b o u t theory in child psychotherapy practice o r research as we are n o t g u i d e d by the h o p e (or o n e may even say the delusion) that eventually we will get it '~just right." It also does n o t lead us down the p o s t m o d ernist p a t h o f relativism or nihilism (a f r e q u e n t charge l a u n c h e d against p o s t m o d e r n i s m ; McSwite, 1997). T h a t is, it does n o t lead us to view all ideas as b e i n g as "good" o r as "bad" as another, o r that "nothing really matters, a n d if it did, so what?!" If the p r a g m a t i c tradition does n o t l e a d us down the p a t h o f e s s e n t i a l i s t / f o u n d a t i o n a l pursuits or down the p a t h of relativism/nihilism pursuits, t h e n what p a t h does
it take us down? Basically, it puts us on a p a t h o f constantly searching for finding ways to m a k e things work in ways that can be useful to h u m a n beings. In o t h e r words, it puts us on a path that is always searching for a n d seeking o u t new a n d b e t t e r ideas a n d ways o f d o i n g things, i n c l u d i n g ideas a n d ways of c o n d u c t i n g child psychotherapy: To quote Charles Sanders Pierce (from w h o m I b o r r o w this article's title) m o r e fully now: "I fear it will always b e as if we are walking o n infirm or swampy g r o u n d a n d this is g o o d because if the g r o u n d were firm, w e ' d have no reason to go anywhere" (Collected Papers, 1962, p. 317; as cited in A m u n d s o n , 1996). Why does the pragmatist p r e f e r this infirm o r swampy g r o u n d for p u r s u i n g knowledge? Because the pragmatist begins with concrete p r o b l e m s o f specific h u m a n beings in particular contexts, a n d in b e g i n n i n g with c o n c r e t e p r o b l e m s o f specific h u m a n beings in particular contexts the pragmatist recognizes the myriad o f p r o b l e m s that m i g h t arise, a n d p e r h a p s even m o r e importantly, that diff e r e n t p r o b l e m s may.require different solutions. Given this type o f problem-solving orientation, the p r a g m a t i s t thus adopts an a p p r o a c h to p r o b l e m solving that is contextual as well as pragmatic. T h e pragmatist, for e x a m p l e , thinks that the solution to p r o b l e m s c a n n o t be s e p a r a t e d from the practical effects or c o n s e q u e n c e s o f the solutions o n particular h u m a n beings in specific contexts because what is a successful solution in o n e context may b e a m o r e o r less successful solution in a n o t h e r context. In o t h e r words, the p r a g m a t i s t recognizes the contextual n a t u r e o f knowledge; that is, that what is "known" o r what is a "fact" d e p e n d s on c h a n g i n g circumstances, c h a n g i n g times, c h a n g i n g contingencies, a n d so on (Rorty, 1992). Moreover, in using this t e r m "contingency," the pragmatist is showing a p p r e c i a t i o n n o t j u s t for the "known" b u t for the "unknown" or for the mysteries a n d s e r e n d i p i t o u s n a t u r e o f circumstances a n d o f life itself. In treating trichotillomania, then, what the above means is that the p r a g m a t i c therapist would recognize that a l t h o u g h a particular way o f treating trichotiltomania m i g h t work with o n e particular case, it may n o t work with a n o t h e r given the different circumstances s u r r o u n d ing that case, t h e different t e m p o r a l c o n t e x t in which o n e is working, the different populations, a n d / o r because different circumstances o r events m i g h t "pop up" which thereby m a k e it necessary to conceptualize the case differently o r to use different strategies for treating that case, etc. It m e a n s r e m a i n i n g o p e n to the possibilities for seeing ( a n d u n d e r s t a n d i n g ) things differently a b o u t t h e m by c h a n g i n g o u r lens. In c h a n g i n g o u r lens we t h e r e b y r e m a i n o p e n to the possibility that t h e r e m i g h t b e different p r o c e d u r e s a n d m e t h o d s (and, yes, sometimes even different theories a n d constructs) from which we can draw. In d e c i d i n g o n which p r o c e d u r e s a n d
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Silverman m e t h o d s , theories, a n d constructs to draw u p o n o r to use, we have only p r a g m a t i c c o n s t r a i n t - - n a m e l y , that is: We use what is useful and what works.
So o f course o n e thing the p r e c e d i n g p a r a g r a p h m e a n s is that a p r a g m a t i c therapist would n o t have this attitude that only o n e way exists for working with trichotillomania. It also does n o t mean, however, that a pragmatic therapist would j u m p on b o a r d a n d j o i n the m o t h e r ' s conceptualization. But certainly the therapist would a p p r e c i a t e the diversity o f views/theories that the families with w h o m we work m i g h t have. (Just as h o p e fully we a p p r e c i a t e their diversity when it comes to ethnicity, race, religion, a n d lifestyle.) To be a bit m o r e c o n c r e t e now with respect to these cases, what would a p r a g m a t i c therapist have d o n e differently? First, as a p r a g m a t i c therapist, I also would have b e g u n with the behavioral conceptualization o f trichotillomania. I would have b e g u n with the behavioral conceptualization because, as I m e n t i o n e d already before, when it comes to d o i n g therapy, b e i n g p r a g m a t i c means taking the evidence that is "best" in terms o f showing what works. In the c o n t e x t o f evaluating therapy, the consensus is that the best evidence is empirical evidence. H e n c e , a l t h o u g h sparse, t h e r e still is m o r e empirical evidence for the behavioral conceptualization a n d t r e a t m e n t of tricho t i l l o m a n i a than t h e r e is for o t h e r conceptualizations a n d treatments. However, b e i n g pragmatic, I also would first think a b o u t the behavioral conceptualization a n d behavioral t r e a t m e n t (e.g., "the client s h o u l d learn to be aware o f every o c c u r r e n c e o f the h a b i t by i n t e r r u p t i n g the h a b i t m o v e m e n t so that it is n o l o n g e r p a r t o f a chain o f n o r m a l movements"), a n d because the empirical supp o r t for the conceptualization a n d t r e a t m e n t still is n e e d e d with respect to the p o p u l a t i o n o f youth, I would think a b o u t w h e t h e r the particulars o f each case may require the conceptualization a n d / o r t r e a t m e n t to be m o d ified in some way. By the particulars, I m e a n all the various contextual factors s u r r o u n d i n g each case, the d e v e l o p m e n t a l factors o f each cases, the circumstances that p r o m p t e d the therapy, w h e t h e r there are e x t r a n e o u s circumstances that m i g h t arise that m i g h t require yet further alteration in the conceptualization, etc. I would t h i n k a b o u t all o f these things before initiating the treatm e n t itself. So, for e x a m p l e , let's take the i d e a that the client should learn to be aware of every o c c u r r e n c e o f the habit. I would question, before starting the treatment, how clients' motivation o r willingness to l e a r n this m i g h t vary d e p e n d i n g on d e v e l o p m e n t . I m i g h t hypothesize that adolescents would have m u c h m o r e difficulty in l e a r n i n g this than c h i l d r e n because adolescents m i g h t be m o r e sensitive to revealing their shortcomings in appearance o r in self-control a n d in having these shortcomings c o m e so m u c h to the f o r e f r o n t with an a d u l t therapist. I
m i g h t think that having adolescents focus on what is quite an embarrassing set o f behaviors, t h r o u g h monitoring, awareness training, etc., would be difficult for them. I would have t h e r e f o r e initiated a discussion with the adolescent treated in the first case, Carrie, before beginning such a treatment, a b o u t these issues. I would have e x p l a i n e d what the t r e a t m e n t would entail a n d assess w h e t h e r she m i g h t e x p e r i e n c e the above types o f aversive, negative reactions, if she were to try to be t a u g h t to be m a d e aware. I would t h e n have tried to h e l p h e r sort t h r o u g h these feelings a b o u t the treatment, to try to h e l p h e r feel m o r e c o m f o r t a b l e a b o u t it, a n d to share with h e r my u n d e r s t a n d i n g that she m i g h t feel embarrassed, ashamed, maybe even h u m i l i a t e d at times. I would try to see t h o u g h w h e t h e r this is s o m e t h i n g she is at least willing to give "a go," a n d as she went a b o u t the treatment, we would have discussions a b o u t h e r feelings t h r o u g h o u t the process. This contrasts t h e n to what is m e n t i o n e d by the authors, where they indicate that d u r i n g Carrie's awareness training "the client b e c a m e quite a m u s e d a n d would start giggling. This behavior was i g n o r e d a n d d i d decrease in frequency" (Roblek et al., 1999, p. 157). In addition, any p r o b l e m a t i c c h i l d / a d o l e s c e n t behavior frequently b e c o m e s a source o f conflict a n d tension within the family, a n d this certainly would be true for trichotillomania. T h e e x t e n t to which the hair p u l l i n g could be a source of conflict a n d tension is also likely to vary with d e v e l o p m e n t . F o r e x a m p l e , it m i g h t b e even worse with adolescents as the behavior m i g h t also b e c o m e intertwined with o t h e r d e v e l o p m e n t a l challenges that adolescents face: b e c o m i n g a u t o n o m o u s , having control, develo p i n g an identity, etc. Thus, I would have wanted to know m u c h m o r e a b o u t how the p a r e n t s o f Carrie a n d Ethan view the hair-pulling behaviors a n d how this behavior has b e e n h a n d l e d vis-ft-vis o t h e r age-related issues such as identity f o r m a t i o n a n d d e v e l o p i n g a u t o n o m y a n d control. I would t h e r e f o r e have wanted tO i n q u i r e m o r e a b o u t the role o r the function o f the hair-pulling behavior within the familial context. To the e x t e n t that the hair pulling is a source o f conflict a n d tension, I m i g h t think a b o u t ways to remove the behavior from the c e n t e r o f p a r e n t conflict. This m i g h t have m e a n t having a m u c h m o r e child-focused t r e a t m e n t a n d a limit on p a r e n t involvement when working with Carrie. T h e fact that Carrie was an identical twin makes this issue even m o r e intriguing. F o r example, what role d i d the hair p u l l i n g play in relation to Carrie's g r a p p l i n g with identity a n d a u t o n o m y issues, particularly within the c o n t e x t o f b e i n g an identical twin? In summary, I would have viewed the behavior m u c h m o r e within the c o n t e x t in which it was occurring (e.g., d e v e l o p m e n t , familial, etc.) a n d I would have t h o u g h t a b o u t the n e e d to alter my conceptualization a n d / o r t r e a t m e n t in relation to the context. T h a t is what it m e a n s
Response: CBT of Trichoti|lomania
Response Paper
to be pragmatic: to recognize the c h a n g i n g contexts (i.e., "the infirm or swampy ground") a n d the i m p o r t a n c e therefore of c h a n g i n g o u r ideas a n d m e t h o d s accordingly so that we can effectively solve that p r o b l e m in varying contexts.
Cognitive Behavioral Treatment of Trichotiilomania T h o m a s H . O l l e n d i c k a n d J a c k W. F i n n e y Virginia Polytechnic Institute & State University
References Amundson, J. (1996). Why pragmatics is probably enough for now. Family Process,35, 473-486. Azrin, N. H., & Nunn, R. G. (1973). Habit reversal:A method of eliminating nervous habits and tics. BehaviourResearchand Therapy, 12, 619-628. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hairpulling (trichotillomania): A comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and ExperimentalPsyehiatry, 11, 13-20. McSwite, O. C. (1997). Postmodernismand public administration's identity crisis. PublicAdministration Review, 55, 174-181. Roblek, T. L., Detweiler, M. E, Fearing, T., & Albano, A. M. (1999). Cognitive behavioral treatment of trichotillomania in youth: What went right and what went wrong? Cognitive and Behavioral Practice, 6, 154-161. Rorty, R. (1992). Consequencesof pragmatism: Essays 1972-1980. Minneapolis: Universityof Minnesota Press. Silverman,W. K., & Kurtines, W. M. (1996a). Anxiety and phobic disorders:A pragmaticapproach.New York: Plenum Press. Silverman,W. K., & Kurtines,W. M. (1996b). Transfer of contro]: A psychosocial intervention model for internalizing disorders in youth. In E. D. Hibbs & E S.Jensen (Eds.),Psychosocialtreatmentof child and adoles~t disorders:Empirically basedstrategiesfor clinicalpractice(pp. 63-82). Washington,DC: American PsychologicalAssociation. Silverman,W. K., & Kurtines, W. M. (1997). Theory in child psy-chosocial treatment research: Have it or had it? A pragmatic alternative. Journal of Abnormal Child Psychology,25, 359-367. Silverman,W. K., & Kurtines,W. M. (in press). A pragmatic perspective toward treating children with phobia and anxiety problems. In S.W. Russ & T. H. Ollendick (Eds.), Handbook ofpsychotherapies with children and families. Address correspondence to Wendy K. Silverman, Child and Family Psychosocial Research Center, Department of Psychology, Florida International University,University Park, Miami, FL 33199; e-mail: [email protected] Received: February15, 1999 Accepted: February15, 1999
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In this brief commentary, we suggest that the cognitivebehavioral treatment of trichotillomania is a complex but rewarding venture. We review the two case studies of hair pulling presented by Robtek, Detweileg, Fearing, and Atbano (1999) and comment on an individualized, prescriptive approach to assessment, conceptualization, and treatment. A clinical and functional analysis that is informed by the context in which the hair-pulling behavior occurs is espoused.
Presenting Problems WO CASE STUDIES of trichotillomania (TT) in youth are presented by Roblek, Detweiler, Fearing, a n d Albano (1999). T h e first, a 15-year-old Caucasian female (Carrie) in the 8th grade, p r e s e n t e d with a relatively brief history of hair pulling. According to her mother, a single p a r e n t at the time of referral, she b e g a n to display syrup. toms of T T d u r i n g the s u m m e r m o n t h s prior to e n t e r i n g the 8th grade at a new private school. Carrie h a d a n identical twin sister who reportedly was "brighter" t h a n Carrie a n d who was a b o u t to attend a public m a g n e t school (for gifted students?). Apparently, the twins attended the same e l e m e n t a r y school prior to this p o i n t in time. Little detail a b o u t the relationship between the twin sisters or their relationships with their m o t h e r or father (who lived in the same city b u t who h a d i n f r e q u e n t contact) was provided. Carrie p r e s e n t e d with "severe hair loss o n both sides of the head above h e r temples" (Roblek et al., p. 155). She reportedly d e n i e d hair loss in other bodily areas (e.g., eyebrows, arms). Exact d u r a t i o n of hair-pulling was n o t reported; however, it presumably was for several m o n t h s ( b e g i n n i n g d u r i n g the s u m m e r m o n t h s p r i o r to the 8th grade a n d lasting sometime into the 8th grade d u r i n g which t r e a t m e n t began). In addition to TT, Carrie presented with n o c t u r n a l e n u r e s i s - - " C a r r i e h a d never b e e n fully dry at night, a n d had b e e n wearing adolescent diapers for as long as she could r e m e m b e r " (Roblek et al., p. 156). Finally, a diagnosis of generalized anxiety diso r d e r was d e t e r m i n e d to be p r e s e n t following completion of a structured diagnostic interview (ADIS-C/P).
T
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Response Paper
s u p p o r t f o r C a r r i e f r o m o t h e r p a t i e n t s m a y have b e e n a useful a d j u n c t to b e h a v i o r a l t r e a t m e n t if it w e r e available. I n summary, t h e a u t h o r s ' w o r k in this a r e a is a d m i r a ble a n d t h e y h a v e u t i l i z e d e m p i r i c a l l y s u p p o r t e d p r o c e d u r e s very well. It is suggested, however, t h a t a b r o a d e r b e h a v i o r a l a p p r o a c h to c o n c e p t u a l i z a t i o n a n d t r e a t m e n t m a y have o p t i m i z e d m o t i v a t i o n a n d t r e a t m e n t r e s p o n s e in this case.
The Importance of Walking on "Infirm or Swampy Ground" W e n d y K. S i l v e r m a n
Florida I n t e r n a t i o n a l University I provide comments to Roblek, Detweileg, Fearing, and Albano's (1999) presentation of child and adolescent cases of trichotillomania in this case conference series. I focus particularly on the authors' attitude when it comes to conceptualizing and treatment planning, and I present an alternative attitude, a pragmatic attitude. A pragmatic attitude begins with concrete problems of specific human beings in particular contexts, and in beginning with concrete problems of specific human beings in particular contexts the pragmatist recognizes the myriad of problems that might arise, and perhaps even more importantly, that different problems may require different solutions. I then illustrate how a pragmatic therapist might have considered the need to consider various contextual factors, including developmental factors, which would have led to modifying the behavioral conceptualization and treatment when working with an adolescent.
References Azrin, N. H., & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. BehaviourResearch and Therapy, 12, 619-628. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hail~ pulling (trichodltomania) : A comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and ExperimentaIPsychiatry, 11, 13-20. Mansueto, C. S., Stemberger, R. M. T., McCombs, A., & Golomb, R. G. (1997). TrichotiUomania: A comprehensive behavioral model. Clinical Psycholog)Review, 1Z 567-577. Roblek, T. L., Detweiler, M. E, Fearing, T., & Albano, A. M. (1999). Cognitive behavioral treatment of trichodllomania in youth: What went right and what went wrong? Cognitive and Behavioral Practice, 6, 154-161. Rothbaum, B. O. (1992). The behavioral treatment of trichodllomania. BehavioralPsychotherapy, 20, 85-90. Stanley, M. A., Borden, J. w., Mouton, S. G., & Breckenridge, J. K. (1995). Nonclinical hairpulling: Affective correlates and comparison with clinical samples. BehaviourResearchand Therapy, 33, 179186. Address correspondence to Melinda A. Stanley, Ph.D., Department of Psychiatry and Behavioral Sciences, University of Texas, Houston Health Science Center, 1306 Moursund Ave., MSI, Houston, TX 77030-3497.
Received: December1, 1998 Accepted: December1, 1998
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T WAS A PLEASURE tO r e a d Roblek, Detweiler, F e a r i n g , a n d M b a n o s (1999) p r e s e n t a t i o n o f t h e i r c h i l d a n d a d o l e s c e n t cases o f t r i c h o t i l l o m a n i a , a n d I a p p r e c i a t e t h e o p p o r t u n i t y to c o m m e n t o n t h e i r p r e s e n t a t i o n in this case c o n f e r e n c e series o f Cognitive and Behavioral Practice. T h e r e is m u c h t h a t is l a u d a b l e a b o u t the ways in w h i c h A1b a n o a n d h e r c o l l e a g u e s assessed a n d t r e a t e d t h e two cases d e s c r i b e d in t h e i r article. I n t e r m s o f assessment, f o r e x a m p l e , in b o t h cases, s t r u c t u r e d d i a g n o s t i c interviewing p r o c e d u r e s w e r e u s e d to e n s u r e a c c u r a t e differential diagnoses. Q u e s t i o n n a i r e s w e r e a d m i n i s t e r e d so that treatment progress and outcome could be gauged. Steps w e r e t a k e n to s e e k o u t a n d to use a n i n d e x specific to t r i c h o t i l l o m a n i a , namely, the Psychiatric I n s t i t u t e T r i c h o t i l l o m a n i a Scale (PITS), w h i c h p r o v i d e d d e t a i l e d i n f o r m a t i o n a b o u t various facets o f t h e p r o b l e m behavior. T h e r e is also a g r e a t d e a l t h a t is l a u d a b l e a b o u t t h e description of the treatment, including the authors' s e a r c h i n g t h r o u g h t h e clinical r e s e a r c h l i t e r a t u r e to h e l p i d e n t i f y e m p i r i c a l l y b a s e d t r e a t m e n t s . T h i s l e d to t h e i r i d e n t i f i c a t i o n a n d utilization o f A z r i n a n d N u n n ' s (1973) h a b i t reversal t e c h n i q u e s . D e s p i t e t h e a b o v e m e n t i o n e d positive aspects o f t h e
I
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Silverman assessment a n d t r e a t m e n t a p p r o a c h e s used in the two cases, things a p p a r e n t l y went "right" in the case o f 7-yearo l d Ethan b u t "wrong" in the case o f 15-year-old Carrie. In the section "Conclusions a n d Questions for the Experts," the authors highlighted several factors they thought might be worthy of consideration in future attempts to imp l e m e n t the treatment described in their paper. Specifically, the authors m e n t i o n e d (1) the motivational level o f the client, (2) the age of the client, (3) familial a n d individual historical information, a n d (4) the child a n d parent(s)' belief in the integrity o f t r e a t m e n t and the model. T h e authors t h e n raised four specific questions that they asked the discussants to consider, including (1) how to improve compliance when motivation is low, (2) how to manage the complexities involved in working with b l e n d e d families, (3) how to h a n d l e n o n a d h e r e n c e to monitoring, a n d (4) how to engage clients who have p r e c o n ceived notions of the process a n d p r o c e d u r e s of therapy. It is e x p e c t e d that, as a discussant, I will now d e l i n e a t e specific answers to each o f these four excellent questions. Rather t h a n d o i n g this, however, my p r e f e r e n c e is to begin a bit m o r e at the beginning! For me, the b e g i n n i n g is with the authors' conceptualization or theoretical frame of t r i c h o t i l l o m a n i a a n d its treatment. More specifically, I focus on the authors' attitude r e g a r d i n g conceptualizing a n d t r e a t m e n t planning. I will t h e n p r e s e n t an alternative attitude, a pragmatic attitude, which is m o r e like "walking on infirm or swampy g r o u n d " - - a phrase I b o r r o w from Charles Sanders Peirce, the A m e r i c a n logician a n d phil o s o p h e r o f science who or~iginally c o i n e d the term "pragmatism." In presenting this alternative attitude, I touch on several o f the questions raised by the authors. T h e authors explain in the b e g i n n i n g o f their introd u c t i o n that: D e p e n d i n g on the theoretical explanation used to define trichotillomania, different treatments have b e e n i m p l e m e n t e d . Psychodynamic therapy, pharmacotherapy, a n d behavior modification are rep o r t e d with varying levels o f effectiveness. However, the only t r e a t m e n t that has b e e n systematically investigated has b e e n the behavior modification techniques. F r o m a behavioral perspective, trichotillomania is the exaggeration in frequency a n d severity o f a n o r m a l behavioral p a t t e r n (i.e., r e a c h i n g h a n d to h e a d ) . It is t h e o r i z e d that this e x a g g e r a t i o n occurs in response to anxiety e x p e r i e n c e d after an event s u c h as a physical injury, c h a n g e in family functioni n g , o r psychological trauma, a l t h o u g h n o empirical evidence supports any specific etiological trigger. As the behavioral p a t t e r n increases in frequency, its form is also altered such that hair pulling occurs, a n d with r e p e t i t i o n the behavioral sequence can be classified as a nervous habit.
F r o m this conceptualization came Azrin a n d N u n n ' s habit reversal t r e a t m e n t in which "The clie n t should learn to be aware o f every o c c u r r e n c e o f the habit by i n t e r r u p t i n g the h a b i t m o v e m e n t so that it is n o l o n g e r p a r t o f a chain o f n o r m a l movements. A physically c o m p e t i n g response s h o u l d be established to interfere with the habit, a n d social r e i n f o r c e m e n t should be reversed or e l i m i n a t e d (from Azrin a n d N u n n , 1973, p. 620)" (Roblek et al., 1999, pp. 154-161). However, as the authors p o i n t o u t in their article, there has b e e n only o n e c o n t r o l l e d study on Azrin a n d N u n n ' s treatment, a n d this study has follow-ups o f only 3 and 4 months. (Though in Azrin, Nunn, and Frantz [1980] in which h a b i t reversal was c o m p a r e d to negative practice training, the f o r m e r was f o u n d to be s u p e r i o r over the latter a n d follow-ups were as long as 22 months.) Further, the studies c o n d u c t e d by Azrin a n d colleagues were all d o n e with adults, n o t children. So even less is known a b o u t w h e t h e r h a b i t reversal works with child a n d adolescent populations. In light o f the above, my m a i n reaction to the treatm e n t cases described in this article is not that it was necessarily a mistake to a t t e m p t to use Azrin a n d N u n n ' s h a b i t reversal technique. O n the contrary, given the absence o f o t h e r d o c u m e n t e d treatments that have b e e n systematically evaluated, e x p l o r i n g the utility o f Azrin a n d N u n n ' s h a b i t reversal t e c h n i q u e with c h i l d r e n makes a lot o f sense. It is only t h r o u g h such activities that knowledge will be i n c r e m e n t e d with respect to the clinical effectiveness o f various treatments. Having said this, howevel; I think it is i m p o r t a n t that when we try relatively "new" p r o c e d u r e s with "new" populations (e.g., children, adolescents), we n e e d a certain type o f attitude: We n e e d an attitude that is o p e n to the idea that the t r e a t m e n t either (a) may n o t work, a n d that o t h e r treatments m i g h t work j u s t as well o r better, o r (b) may require modifications in light o f the p o p u l a t i o n , context, etc., with which we are working. This type o f attitude I refer to as pragmatic (described f u r t h e r below). In r e a d i n g over the a c c o u n t o f the cases, I d i d n o t pick u p that the authors h a d a p r a g m a t i c attitude. Rather, the attitude I picked u p on was that the authors h a d a very strong belief or conviction in their behavioral conceptualization o f a n d t r e a t m e n t for trichotillomania. F o r example, in discussing Carrie's m o t h e r ' s reactions to the behavioral t r e a t m e n t that they were trying to i m p l e m e n t with Carrie, they indicate that because o f the m o t h e r ' s own involvement with psychodynamic therapy, the m o t h e r h a d d e v e l o p e d a psychodynamic conceptualization a b o u t h e r d a u g h t e r ' s hair-pulling behavior. T h e authors indicate: "At this p o i n t we did n o t want to summarily dismiss the m o t h e r ' s conceptualization for risk o f alienating h e r fully. However, given o u r strong behavioral b a c k g r o u n d
Response: Infirm and S w a m p y Ground a n d a p p r o a c h to psychopathology, we d i d find this form u l a t i o n b o t h a m u s i n g a n d at the same time destructive to the child's t r e a t m e n t p r o g r a m . It was evident that the m o t h e r d i d n o t agree with o u r t r e a t m e n t rational o r approach, as it was drastically different from h e r own therapy experience" (p. 157). A p r a g m a t i c attitude is o n e that does n o t instinctually r e s p o n d to alternative ways o f viewing things by a desire to "summarily dismiss" it a n d to view any alternative form u l a t i o n t h a n o n e ' s own as "amusing." This would n o t be a p r a g m a t i c attitude because in fact t h e r e is an absence o f the "best" type o f evidence n e e d e d in this c o n t e x t (i.e., the c o n t e x t of evaluating psychotherapy), n a m e l y empirical evidence. T h a t is, t h e r e is an absence o f empirical evi d e n c e for the behavioral conceptualization o f trichotill o m a n i a a n d t h e r e is an absence o f clinical trims on behavioral t r e a t m e n t of trichotillomania with either child r e n or adolescents. Because t h e r e is an absence o f evidence, a pragmatist would r e m a i n o p e n to the possibility that p e r h a p s t h e r e are alternative conceptualizations a n d / o r treatments for trichotillomania in youth. At a m i n i m u m , a p r a g m a t i c attitude would be o p e n to the possibility that a particular c o n c e p t u a l i z a t i o n / t r e a t m e n t (e.g., behavioral) m i g h t n e e d to b e m o d i f i e d when working with c h i l d r e n a n d adolescents ( a n d m o d i f i e d differently for c h i l d r e n t h a n for adolescents). In o t h e r writings, my colleague William Kurtines a n d I have written a b o u t how d e v e l o p m e n t s that have o c c u r r e d within psychology (e.g., eclecticism, integrationism) as well as outside o f psychology (e.g., p o s t m o d e r n i s m ) pose serious challenges to the n o t i o n o f having "a theory" o f child p s y c h o t h e r a p y (see, for example, Silverman a n d Kurtines, 1996a, 1996b, 1997; in press). We have discussed in detail how we view "pragmatism" in b o t h practice a n d research as a reasonable response to these developments. (The interested r e a d e r m i g h t consult those writings for f u r t h e r details a b o u t these developments.) We have discussed how we view p r a g m a t i s m as a reasonable response mainly because it does not l e a d us down eit h e r o n e of the following two paths: It does n o t lead us down the m o d e r n i s t p a t h of essentialist or f o u n d a t i o n a l pursuits (Amundson, 1996). T h a t is, it does n o t lead us to pursue the "truth" a b o u t theory in child psychotherapy practice o r research as we are n o t g u i d e d by the h o p e (or o n e may even say the delusion) that eventually we will get it '~just right." It also does n o t lead us down the p o s t m o d ernist p a t h o f relativism or nihilism (a f r e q u e n t charge l a u n c h e d against p o s t m o d e r n i s m ; McSwite, 1997). T h a t is, it does n o t lead us to view all ideas as b e i n g as "good" o r as "bad" as another, o r that "nothing really matters, a n d if it did, so what?!" If the p r a g m a t i c tradition does n o t l e a d us down the p a t h o f e s s e n t i a l i s t / f o u n d a t i o n a l pursuits or down the p a t h of relativism/nihilism pursuits, t h e n what p a t h does
it take us down? Basically, it puts us on a p a t h o f constantly searching for finding ways to m a k e things work in ways that can be useful to h u m a n beings. In o t h e r words, it puts us on a path that is always searching for a n d seeking o u t new a n d b e t t e r ideas a n d ways o f d o i n g things, i n c l u d i n g ideas a n d ways of c o n d u c t i n g child psychotherapy: To quote Charles Sanders Pierce (from w h o m I b o r r o w this article's title) m o r e fully now: "I fear it will always b e as if we are walking o n infirm or swampy g r o u n d a n d this is g o o d because if the g r o u n d were firm, w e ' d have no reason to go anywhere" (Collected Papers, 1962, p. 317; as cited in A m u n d s o n , 1996). Why does the pragmatist p r e f e r this infirm o r swampy g r o u n d for p u r s u i n g knowledge? Because the pragmatist begins with concrete p r o b l e m s o f specific h u m a n beings in particular contexts, a n d in b e g i n n i n g with c o n c r e t e p r o b l e m s o f specific h u m a n beings in particular contexts the pragmatist recognizes the myriad o f p r o b l e m s that m i g h t arise, a n d p e r h a p s even m o r e importantly, that diff e r e n t p r o b l e m s may.require different solutions. Given this type o f problem-solving orientation, the p r a g m a t i s t thus adopts an a p p r o a c h to p r o b l e m solving that is contextual as well as pragmatic. T h e pragmatist, for e x a m p l e , thinks that the solution to p r o b l e m s c a n n o t be s e p a r a t e d from the practical effects or c o n s e q u e n c e s o f the solutions o n particular h u m a n beings in specific contexts because what is a successful solution in o n e context may b e a m o r e o r less successful solution in a n o t h e r context. In o t h e r words, the p r a g m a t i s t recognizes the contextual n a t u r e o f knowledge; that is, that what is "known" o r what is a "fact" d e p e n d s on c h a n g i n g circumstances, c h a n g i n g times, c h a n g i n g contingencies, a n d so on (Rorty, 1992). Moreover, in using this t e r m "contingency," the pragmatist is showing a p p r e c i a t i o n n o t j u s t for the "known" b u t for the "unknown" or for the mysteries a n d s e r e n d i p i t o u s n a t u r e o f circumstances a n d o f life itself. In treating trichotillomania, then, what the above means is that the p r a g m a t i c therapist would recognize that a l t h o u g h a particular way o f treating trichotiltomania m i g h t work with o n e particular case, it may n o t work with a n o t h e r given the different circumstances s u r r o u n d ing that case, t h e different t e m p o r a l c o n t e x t in which o n e is working, the different populations, a n d / o r because different circumstances o r events m i g h t "pop up" which thereby m a k e it necessary to conceptualize the case differently o r to use different strategies for treating that case, etc. It m e a n s r e m a i n i n g o p e n to the possibilities for seeing ( a n d u n d e r s t a n d i n g ) things differently a b o u t t h e m by c h a n g i n g o u r lens. In c h a n g i n g o u r lens we t h e r e b y r e m a i n o p e n to the possibility that t h e r e m i g h t b e different p r o c e d u r e s a n d m e t h o d s (and, yes, sometimes even different theories a n d constructs) from which we can draw. In d e c i d i n g o n which p r o c e d u r e s a n d
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Silverman m e t h o d s , theories, a n d constructs to draw u p o n o r to use, we have only p r a g m a t i c c o n s t r a i n t - - n a m e l y , that is: We use what is useful and what works.
So o f course o n e thing the p r e c e d i n g p a r a g r a p h m e a n s is that a p r a g m a t i c therapist would n o t have this attitude that only o n e way exists for working with trichotillomania. It also does n o t mean, however, that a pragmatic therapist would j u m p on b o a r d a n d j o i n the m o t h e r ' s conceptualization. But certainly the therapist would a p p r e c i a t e the diversity o f views/theories that the families with w h o m we work m i g h t have. (Just as h o p e fully we a p p r e c i a t e their diversity when it comes to ethnicity, race, religion, a n d lifestyle.) To be a bit m o r e c o n c r e t e now with respect to these cases, what would a p r a g m a t i c therapist have d o n e differently? First, as a p r a g m a t i c therapist, I also would have b e g u n with the behavioral conceptualization o f trichotillomania. I would have b e g u n with the behavioral conceptualization because, as I m e n t i o n e d already before, when it comes to d o i n g therapy, b e i n g p r a g m a t i c means taking the evidence that is "best" in terms o f showing what works. In the c o n t e x t o f evaluating therapy, the consensus is that the best evidence is empirical evidence. H e n c e , a l t h o u g h sparse, t h e r e still is m o r e empirical evidence for the behavioral conceptualization a n d t r e a t m e n t of tricho t i l l o m a n i a than t h e r e is for o t h e r conceptualizations a n d treatments. However, b e i n g pragmatic, I also would first think a b o u t the behavioral conceptualization a n d behavioral t r e a t m e n t (e.g., "the client s h o u l d learn to be aware o f every o c c u r r e n c e o f the h a b i t by i n t e r r u p t i n g the h a b i t m o v e m e n t so that it is n o l o n g e r p a r t o f a chain o f n o r m a l movements"), a n d because the empirical supp o r t for the conceptualization a n d t r e a t m e n t still is n e e d e d with respect to the p o p u l a t i o n o f youth, I would think a b o u t w h e t h e r the particulars o f each case may require the conceptualization a n d / o r t r e a t m e n t to be m o d ified in some way. By the particulars, I m e a n all the various contextual factors s u r r o u n d i n g each case, the d e v e l o p m e n t a l factors o f each cases, the circumstances that p r o m p t e d the therapy, w h e t h e r there are e x t r a n e o u s circumstances that m i g h t arise that m i g h t require yet further alteration in the conceptualization, etc. I would t h i n k a b o u t all o f these things before initiating the treatm e n t itself. So, for e x a m p l e , let's take the i d e a that the client should learn to be aware of every o c c u r r e n c e o f the habit. I would question, before starting the treatment, how clients' motivation o r willingness to l e a r n this m i g h t vary d e p e n d i n g on d e v e l o p m e n t . I m i g h t hypothesize that adolescents would have m u c h m o r e difficulty in l e a r n i n g this than c h i l d r e n because adolescents m i g h t be m o r e sensitive to revealing their shortcomings in appearance o r in self-control a n d in having these shortcomings c o m e so m u c h to the f o r e f r o n t with an a d u l t therapist. I
m i g h t think that having adolescents focus on what is quite an embarrassing set o f behaviors, t h r o u g h monitoring, awareness training, etc., would be difficult for them. I would have t h e r e f o r e initiated a discussion with the adolescent treated in the first case, Carrie, before beginning such a treatment, a b o u t these issues. I would have e x p l a i n e d what the t r e a t m e n t would entail a n d assess w h e t h e r she m i g h t e x p e r i e n c e the above types o f aversive, negative reactions, if she were to try to be t a u g h t to be m a d e aware. I would t h e n have tried to h e l p h e r sort t h r o u g h these feelings a b o u t the treatment, to try to h e l p h e r feel m o r e c o m f o r t a b l e a b o u t it, a n d to share with h e r my u n d e r s t a n d i n g that she m i g h t feel embarrassed, ashamed, maybe even h u m i l i a t e d at times. I would try to see t h o u g h w h e t h e r this is s o m e t h i n g she is at least willing to give "a go," a n d as she went a b o u t the treatment, we would have discussions a b o u t h e r feelings t h r o u g h o u t the process. This contrasts t h e n to what is m e n t i o n e d by the authors, where they indicate that d u r i n g Carrie's awareness training "the client b e c a m e quite a m u s e d a n d would start giggling. This behavior was i g n o r e d a n d d i d decrease in frequency" (Roblek et al., 1999, p. 157). In addition, any p r o b l e m a t i c c h i l d / a d o l e s c e n t behavior frequently b e c o m e s a source o f conflict a n d tension within the family, a n d this certainly would be true for trichotillomania. T h e e x t e n t to which the hair p u l l i n g could be a source of conflict a n d tension is also likely to vary with d e v e l o p m e n t . F o r e x a m p l e , it m i g h t b e even worse with adolescents as the behavior m i g h t also b e c o m e intertwined with o t h e r d e v e l o p m e n t a l challenges that adolescents face: b e c o m i n g a u t o n o m o u s , having control, develo p i n g an identity, etc. Thus, I would have wanted to know m u c h m o r e a b o u t how the p a r e n t s o f Carrie a n d Ethan view the hair-pulling behaviors a n d how this behavior has b e e n h a n d l e d vis-ft-vis o t h e r age-related issues such as identity f o r m a t i o n a n d d e v e l o p i n g a u t o n o m y a n d control. I would t h e r e f o r e have wanted tO i n q u i r e m o r e a b o u t the role o r the function o f the hair-pulling behavior within the familial context. To the e x t e n t that the hair pulling is a source o f conflict a n d tension, I m i g h t think a b o u t ways to remove the behavior from the c e n t e r o f p a r e n t conflict. This m i g h t have m e a n t having a m u c h m o r e child-focused t r e a t m e n t a n d a limit on p a r e n t involvement when working with Carrie. T h e fact that Carrie was an identical twin makes this issue even m o r e intriguing. F o r example, what role d i d the hair p u l l i n g play in relation to Carrie's g r a p p l i n g with identity a n d a u t o n o m y issues, particularly within the c o n t e x t o f b e i n g an identical twin? In summary, I would have viewed the behavior m u c h m o r e within the c o n t e x t in which it was occurring (e.g., d e v e l o p m e n t , familial, etc.) a n d I would have t h o u g h t a b o u t the n e e d to alter my conceptualization a n d / o r t r e a t m e n t in relation to the context. T h a t is what it m e a n s
Response: CBT of Trichoti|lomania
Response Paper
to be pragmatic: to recognize the c h a n g i n g contexts (i.e., "the infirm or swampy ground") a n d the i m p o r t a n c e therefore of c h a n g i n g o u r ideas a n d m e t h o d s accordingly so that we can effectively solve that p r o b l e m in varying contexts.
Cognitive Behavioral Treatment of Trichotiilomania T h o m a s H . O l l e n d i c k a n d J a c k W. F i n n e y Virginia Polytechnic Institute & State University
References Amundson, J. (1996). Why pragmatics is probably enough for now. Family Process,35, 473-486. Azrin, N. H., & Nunn, R. G. (1973). Habit reversal:A method of eliminating nervous habits and tics. BehaviourResearchand Therapy, 12, 619-628. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hairpulling (trichotillomania): A comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and ExperimentalPsyehiatry, 11, 13-20. McSwite, O. C. (1997). Postmodernismand public administration's identity crisis. PublicAdministration Review, 55, 174-181. Roblek, T. L., Detweiler, M. E, Fearing, T., & Albano, A. M. (1999). Cognitive behavioral treatment of trichotillomania in youth: What went right and what went wrong? Cognitive and Behavioral Practice, 6, 154-161. Rorty, R. (1992). Consequencesof pragmatism: Essays 1972-1980. Minneapolis: Universityof Minnesota Press. Silverman,W. K., & Kurtines, W. M. (1996a). Anxiety and phobic disorders:A pragmaticapproach.New York: Plenum Press. Silverman,W. K., & Kurtines,W. M. (1996b). Transfer of contro]: A psychosocial intervention model for internalizing disorders in youth. In E. D. Hibbs & E S.Jensen (Eds.),Psychosocialtreatmentof child and adoles~t disorders:Empirically basedstrategiesfor clinicalpractice(pp. 63-82). Washington,DC: American PsychologicalAssociation. Silverman,W. K., & Kurtines, W. M. (1997). Theory in child psy-chosocial treatment research: Have it or had it? A pragmatic alternative. Journal of Abnormal Child Psychology,25, 359-367. Silverman,W. K., & Kurtines,W. M. (in press). A pragmatic perspective toward treating children with phobia and anxiety problems. In S.W. Russ & T. H. Ollendick (Eds.), Handbook ofpsychotherapies with children and families. Address correspondence to Wendy K. Silverman, Child and Family Psychosocial Research Center, Department of Psychology, Florida International University,University Park, Miami, FL 33199; e-mail: [email protected] Received: February15, 1999 Accepted: February15, 1999
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In this brief commentary, we suggest that the cognitivebehavioral treatment of trichotillomania is a complex but rewarding venture. We review the two case studies of hair pulling presented by Robtek, Detweileg, Fearing, and Atbano (1999) and comment on an individualized, prescriptive approach to assessment, conceptualization, and treatment. A clinical and functional analysis that is informed by the context in which the hair-pulling behavior occurs is espoused.
Presenting Problems WO CASE STUDIES of trichotillomania (TT) in youth are presented by Roblek, Detweiler, Fearing, a n d Albano (1999). T h e first, a 15-year-old Caucasian female (Carrie) in the 8th grade, p r e s e n t e d with a relatively brief history of hair pulling. According to her mother, a single p a r e n t at the time of referral, she b e g a n to display syrup. toms of T T d u r i n g the s u m m e r m o n t h s prior to e n t e r i n g the 8th grade at a new private school. Carrie h a d a n identical twin sister who reportedly was "brighter" t h a n Carrie a n d who was a b o u t to attend a public m a g n e t school (for gifted students?). Apparently, the twins attended the same e l e m e n t a r y school prior to this p o i n t in time. Little detail a b o u t the relationship between the twin sisters or their relationships with their m o t h e r or father (who lived in the same city b u t who h a d i n f r e q u e n t contact) was provided. Carrie p r e s e n t e d with "severe hair loss o n both sides of the head above h e r temples" (Roblek et al., p. 155). She reportedly d e n i e d hair loss in other bodily areas (e.g., eyebrows, arms). Exact d u r a t i o n of hair-pulling was n o t reported; however, it presumably was for several m o n t h s ( b e g i n n i n g d u r i n g the s u m m e r m o n t h s p r i o r to the 8th grade a n d lasting sometime into the 8th grade d u r i n g which t r e a t m e n t began). In addition to TT, Carrie presented with n o c t u r n a l e n u r e s i s - - " C a r r i e h a d never b e e n fully dry at night, a n d had b e e n wearing adolescent diapers for as long as she could r e m e m b e r " (Roblek et al., p. 156). Finally, a diagnosis of generalized anxiety diso r d e r was d e t e r m i n e d to be p r e s e n t following completion of a structured diagnostic interview (ADIS-C/P).
T
Cognitive and Behavioral Practice 6, 167-173, 1999 1077-7229/99/167-17351.00/0 Copyright © 1999 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.