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Behavioral psychotherapy: Basic principles and case studies in an integrative clinical model
86
BOOK REVIEWS
Functional Gastrointestinal Disorders: A Behavioral Medicine Approach by PAUL Springer,
R. LATIMER
New York,
This brief monograph concerns one of the most common medical conditions, irritable bowel syndrome. This syndrome, which has gone by a number of labels over the years (mucous colitis, intestinal croup, functional diarrhea, etc.), is probably the most common disorder seen by gastroenterologists. As the author makes most clear, the condition cannot be adequately understood, and hence adequately treated, if it is conceptualized solely as a digestive disease. A wide range of non-gastrointestinal symptoms are seen in many cases of the syndrome which cannot be accounted for by a primary disturbance in intestinal physiology. Nor can irritable bowel syndrome simply be regarded as a psychiatric illness as most of these patients do not fulfil minimal criteria for a psychiatric diagnosis. A psychophysiological model is more adequate and is in keeping with the well-known and documented sensitivity of the gut to emotional influences. However, such a model will not account for the clinical features seen in many cases such as the patient who meets diagnostic criteria for the syndrome but who has physiological responses of the G.I. track not in fact more marked or aberrant than those of many persons without the syndrome. Dr. Latimer proposes a behavioral model in which irritable bowel syndrome is regarded as a problem of learned maladaptive behavior. The disordered behavior may be in any or all of three realms: verbal behavior (the patient complains of abdominal pain, reports abnormal stools, etc.), motoric behavior (e.g. illness behavior such as taking medications or making frequent trips to the toilet) or physiological behavior (e.g. excessive motility of the gut). The author argues quite convincingly that only such a multi-dimensional behavioral model of irritable bowel
1983, 174 pp.
syndrome can do justice to what is known about this multifaceted disorder. After describing this conceptual model, he discusses its implications for assessment, treatment and research. There is an outline of comprehensive behavioral assessment (behavioral analysis) and an excellent review of methods of treatment. As the model would suggest, important ingredients of the treatment in particular cases may be addressed at various levels, e.g. on the physiological level by the use of anti-spasmodic agents, on the behavioral level by selfmonitoring of pain and techniques of stress management and on the social level by contingency management. The latter may sometimes actively involve significant others. This book will be extremely useful to any clinician who treats patients with irritable bowl syndrome. However, the general approach developed by Dr. Latimer for the understanding and treatment of this one syndrome provides a model which is applicable to a large array of medical problems. The book makes the point convincingly that there is no single treatment, behavioral or otherwise, for irritable bowel syndrome. The treatment program must follow from a careful behavioral analysis of the individual case since any of a number of environmental and internal (physiological) factors may be maintaining the symptoms. Accordingly, this volume will prove to be invaluable for student and clinician alike interested in behavioral medicine.
Kenneth E. Appel Professor University of Pennsylvania Philadelphia, Pennsylvania,
JOHN PAUL of Psychiatry
BRADY
I/. S. A.
Behavioral Psychotherapy: Basic Principles and Case Studies in an Integrative Clinical Model Edited by HERBERT
FENSTERHEIM
Brunner/Mazel,
and HOWARD
New York, 1983,245
The purpose of this volume is 10 present an eclectic model of therapy integrating the behavioral and psychodynamic perspectives. The authors believe that neither perspective is wholly sufficient to understand or to treat patients. Consequently, they argue that the unique strength< of each should be melded into an approach they call “behavioral psychotherapy”. The book is divided into two major sections. The first, written entirely by Fensterheim, explicates the behavioral psychotherapy model. Fensterheim begins by discussing the putative strengths and weaknesses of Ihe two parent models. He holds that clinical problems arc best underrtood from a dynamic rather than a behavioral standpoint. On
I. GLAZER
pp.
the other hand, the behavioral model provides powerful techniques for identifying and changing target behaviors. Thus, he maintains, “both perspectives are necessary for complete and adequate treatment of patients” (p. 6). Fensterheim devotes the remaining chapters of the first section to describing his eclectic approach lo assessment and treatment planning. Although he uses nonbehavioral concepts at various points during the evaluation process, the end product is always a treatment plan based upon a behavioral formulation. These formulations involve the specification of target behavior5 and the selection of treatment procedures and are nor appreciably different tram conbenrional behavioral conceptualirations. Thus the
87
BOOK REVIEWS
training) with less emphasis on traditional techniques. So, despite their espousal of eclectism, the authors engage in few activities foreign to mainstream behavior therapy. This book is written for practitioners of all orientations. Although most behavior therapists are unlikely to find much new in this volume, therapists of other persuasions may find this a usefut introduction to a pragmatic, empirical approach to clinical intervention.
dynamic concepts seem to add relatively little to the overall strategy. The second part of the book comprises seven case studies, selected for their complexity, and designed to exemplify behavioral psychotherapy. The disorders include agoraschizophrenia, obsessive-compulsive checking, phobia, depression, erectile dysfunction, “psychogenic” vomiting and asthma. For the most part, the authortherapists assume a flexible, pragmatic and empirical stance toward these difficult cases. And, perhaps as a consequence of their empiricism, their approach is more behavioral than dynamic. The therapeutic tactics are drawn largely from behavior therapy (e.g. desensitization, assertiveness
RICHARD Temple University School of Medicine Philadelphia, Pennsylvania, U.S. A.
Self-Control and Self-Modification Edited by KIRK R. BLANKSTEIN Plenum
J. MCNALLY
of Emotional Behavior and JANET
POLIVY
Press, New York, 1983 programs for these problems. However, the outcome evaluation was not complete for the Type A behavior group, and no formal evaluation was conducted in the loneliness prevention group. There is little evidence that the individuals in the loneliness study comprised an at-risk group, and the gains made by the participants were modest at best. Given a burgeoning literature on the assessment and treatment of both Type A behavior and loneliness, it is hard to understand why the editors chose to include unevaluated programs. The Sobell’s chapter on alcoholism is well-written but outdated at the time of this review. Rosen’s chapter on self-help approaches airs important ethical and practical issues of concern to all professionals who either develop or recommend self-help programs. In conclusion, the quality of this volume is inconsistent. Some chapters contribute to a better understanding of complex issues; others seem neither well thought out nor particularly up to date. There is minimal discussion of current issues such as compliance and long-term maintenance. While the book provides occasional glimpses of insight into self-control issues, in general it does not reflect the current state of the art in the field of self-regulation.
This book purports to provide a contemporary crosssection of psychological theory and research on the title subject. Though it contains some noteworthy chapters, its focus is diffuse and its overall quality uneven. It is the seventh volume in the series, Advances in the Study of Communication and Affect, and it consists of nine chapters. In the introductory chapter, the editors provide definitions for some key concepts, a brief overview of theoretical approaches to self-regulation, and a preview of the remaining chapters. It would have been useful if they had made more effort to underscore the theoretical similarities and differences in the remaining papers and had given reasons for their selection. Chapters on the psychophysiology of emotions, alcoholism, Type A behavior, loneliness, aging, self-help, and a combined systems-learning theory approach to selfregulation are unintegrated. The topics are diffuse and seem directed at different audiences. Schulz’s chapter on “Emotionality and Aging” is the best this book has to offer. Well-written and wellorganized, it summarizes and integrates a large literature. Wilson’s chapter on alcoholism and anxiety reviews the importance of cognitive set in mediating the effects of alcohol; it provides a readable critique of the current state of the tension reduction theory of alcohol consumption. The chapters on Type A behavior and the prevention of loneliness offer good descriptions of clinical intervention
ELLEN
COSTELLO
Behavior Therapy Unif Temple University Medical School Philadelphia, PA 19129, U.S.A.
-
Directive Parental Counseling By CORNELIUS Midwest Professional
Publishing,
J. HOLLAND
Bloomfield
The number of parents trained to apply behavioral strategies to children has greatly increased over the past 10 yr period, as has the number of parent training manuals. Bernal and North (1978) have published a survey of 26
Hills, Michigan,
U.S.A.,
$49.95
commercially available manuals. These have enabled clinicians to adopt more standardized and systematic approaches. The Directive Parental Counseling program (DPC) is another such publication.
BOOK REVIEWS
Functional Gastrointestinal Disorders: A Behavioral Medicine Approach by PAUL Springer,
R. LATIMER
New York,
This brief monograph concerns one of the most common medical conditions, irritable bowel syndrome. This syndrome, which has gone by a number of labels over the years (mucous colitis, intestinal croup, functional diarrhea, etc.), is probably the most common disorder seen by gastroenterologists. As the author makes most clear, the condition cannot be adequately understood, and hence adequately treated, if it is conceptualized solely as a digestive disease. A wide range of non-gastrointestinal symptoms are seen in many cases of the syndrome which cannot be accounted for by a primary disturbance in intestinal physiology. Nor can irritable bowel syndrome simply be regarded as a psychiatric illness as most of these patients do not fulfil minimal criteria for a psychiatric diagnosis. A psychophysiological model is more adequate and is in keeping with the well-known and documented sensitivity of the gut to emotional influences. However, such a model will not account for the clinical features seen in many cases such as the patient who meets diagnostic criteria for the syndrome but who has physiological responses of the G.I. track not in fact more marked or aberrant than those of many persons without the syndrome. Dr. Latimer proposes a behavioral model in which irritable bowel syndrome is regarded as a problem of learned maladaptive behavior. The disordered behavior may be in any or all of three realms: verbal behavior (the patient complains of abdominal pain, reports abnormal stools, etc.), motoric behavior (e.g. illness behavior such as taking medications or making frequent trips to the toilet) or physiological behavior (e.g. excessive motility of the gut). The author argues quite convincingly that only such a multi-dimensional behavioral model of irritable bowel
1983, 174 pp.
syndrome can do justice to what is known about this multifaceted disorder. After describing this conceptual model, he discusses its implications for assessment, treatment and research. There is an outline of comprehensive behavioral assessment (behavioral analysis) and an excellent review of methods of treatment. As the model would suggest, important ingredients of the treatment in particular cases may be addressed at various levels, e.g. on the physiological level by the use of anti-spasmodic agents, on the behavioral level by selfmonitoring of pain and techniques of stress management and on the social level by contingency management. The latter may sometimes actively involve significant others. This book will be extremely useful to any clinician who treats patients with irritable bowl syndrome. However, the general approach developed by Dr. Latimer for the understanding and treatment of this one syndrome provides a model which is applicable to a large array of medical problems. The book makes the point convincingly that there is no single treatment, behavioral or otherwise, for irritable bowel syndrome. The treatment program must follow from a careful behavioral analysis of the individual case since any of a number of environmental and internal (physiological) factors may be maintaining the symptoms. Accordingly, this volume will prove to be invaluable for student and clinician alike interested in behavioral medicine.
Kenneth E. Appel Professor University of Pennsylvania Philadelphia, Pennsylvania,
JOHN PAUL of Psychiatry
BRADY
I/. S. A.
Behavioral Psychotherapy: Basic Principles and Case Studies in an Integrative Clinical Model Edited by HERBERT
FENSTERHEIM
Brunner/Mazel,
and HOWARD
New York, 1983,245
The purpose of this volume is 10 present an eclectic model of therapy integrating the behavioral and psychodynamic perspectives. The authors believe that neither perspective is wholly sufficient to understand or to treat patients. Consequently, they argue that the unique strength< of each should be melded into an approach they call “behavioral psychotherapy”. The book is divided into two major sections. The first, written entirely by Fensterheim, explicates the behavioral psychotherapy model. Fensterheim begins by discussing the putative strengths and weaknesses of Ihe two parent models. He holds that clinical problems arc best underrtood from a dynamic rather than a behavioral standpoint. On
I. GLAZER
pp.
the other hand, the behavioral model provides powerful techniques for identifying and changing target behaviors. Thus, he maintains, “both perspectives are necessary for complete and adequate treatment of patients” (p. 6). Fensterheim devotes the remaining chapters of the first section to describing his eclectic approach lo assessment and treatment planning. Although he uses nonbehavioral concepts at various points during the evaluation process, the end product is always a treatment plan based upon a behavioral formulation. These formulations involve the specification of target behavior5 and the selection of treatment procedures and are nor appreciably different tram conbenrional behavioral conceptualirations. Thus the
87
BOOK REVIEWS
training) with less emphasis on traditional techniques. So, despite their espousal of eclectism, the authors engage in few activities foreign to mainstream behavior therapy. This book is written for practitioners of all orientations. Although most behavior therapists are unlikely to find much new in this volume, therapists of other persuasions may find this a usefut introduction to a pragmatic, empirical approach to clinical intervention.
dynamic concepts seem to add relatively little to the overall strategy. The second part of the book comprises seven case studies, selected for their complexity, and designed to exemplify behavioral psychotherapy. The disorders include agoraschizophrenia, obsessive-compulsive checking, phobia, depression, erectile dysfunction, “psychogenic” vomiting and asthma. For the most part, the authortherapists assume a flexible, pragmatic and empirical stance toward these difficult cases. And, perhaps as a consequence of their empiricism, their approach is more behavioral than dynamic. The therapeutic tactics are drawn largely from behavior therapy (e.g. desensitization, assertiveness
RICHARD Temple University School of Medicine Philadelphia, Pennsylvania, U.S. A.
Self-Control and Self-Modification Edited by KIRK R. BLANKSTEIN Plenum
J. MCNALLY
of Emotional Behavior and JANET
POLIVY
Press, New York, 1983 programs for these problems. However, the outcome evaluation was not complete for the Type A behavior group, and no formal evaluation was conducted in the loneliness prevention group. There is little evidence that the individuals in the loneliness study comprised an at-risk group, and the gains made by the participants were modest at best. Given a burgeoning literature on the assessment and treatment of both Type A behavior and loneliness, it is hard to understand why the editors chose to include unevaluated programs. The Sobell’s chapter on alcoholism is well-written but outdated at the time of this review. Rosen’s chapter on self-help approaches airs important ethical and practical issues of concern to all professionals who either develop or recommend self-help programs. In conclusion, the quality of this volume is inconsistent. Some chapters contribute to a better understanding of complex issues; others seem neither well thought out nor particularly up to date. There is minimal discussion of current issues such as compliance and long-term maintenance. While the book provides occasional glimpses of insight into self-control issues, in general it does not reflect the current state of the art in the field of self-regulation.
This book purports to provide a contemporary crosssection of psychological theory and research on the title subject. Though it contains some noteworthy chapters, its focus is diffuse and its overall quality uneven. It is the seventh volume in the series, Advances in the Study of Communication and Affect, and it consists of nine chapters. In the introductory chapter, the editors provide definitions for some key concepts, a brief overview of theoretical approaches to self-regulation, and a preview of the remaining chapters. It would have been useful if they had made more effort to underscore the theoretical similarities and differences in the remaining papers and had given reasons for their selection. Chapters on the psychophysiology of emotions, alcoholism, Type A behavior, loneliness, aging, self-help, and a combined systems-learning theory approach to selfregulation are unintegrated. The topics are diffuse and seem directed at different audiences. Schulz’s chapter on “Emotionality and Aging” is the best this book has to offer. Well-written and wellorganized, it summarizes and integrates a large literature. Wilson’s chapter on alcoholism and anxiety reviews the importance of cognitive set in mediating the effects of alcohol; it provides a readable critique of the current state of the tension reduction theory of alcohol consumption. The chapters on Type A behavior and the prevention of loneliness offer good descriptions of clinical intervention
ELLEN
COSTELLO
Behavior Therapy Unif Temple University Medical School Philadelphia, PA 19129, U.S.A.
-
Directive Parental Counseling By CORNELIUS Midwest Professional
Publishing,
J. HOLLAND
Bloomfield
The number of parents trained to apply behavioral strategies to children has greatly increased over the past 10 yr period, as has the number of parent training manuals. Bernal and North (1978) have published a survey of 26
Hills, Michigan,
U.S.A.,
$49.95
commercially available manuals. These have enabled clinicians to adopt more standardized and systematic approaches. The Directive Parental Counseling program (DPC) is another such publication.