The behavioral medicine unit: A new facility

The Behavioral Medicine Unit: A New Facility Charles D. Morgan,

M

OST

INPATIENT

that they

modate

types

that

are

problems. patients with

on the contrary,

specifically

manifesting

associated

The

we will such

such a facility

Often

patients

manifesting

infer,

however

erroneously.

problems tion

are viewed

of psychogenicity

treatment. tients

and,

known

psychogenic

for further

category

physicians

along

observations:

psychosomatic

disorders

implies

resent

that

theit

the perceived

asser-

or may actually

refuse

are often

undiagnosed

evaluation

disorders

approach

They

of

to treat

and phobias.

by the following and

and

in specialized

defined

pain.

are not cooperative

illnesses,

is incorrect

psychosomatic

chronic

psychologic.

hence,

organic

maladies

and

a psychiatric

practicing

to accom-

and treatment

treated

a precisely

psychophysiologic

Furthermore.

with

this assumption

was suggested

as purely

the assumption

to patients

such a unit that was designed

as anxiety.

that

under

approach

may be better

to treat

psychophysiologic

problems

need for

that

describe

Gaylor

into both assessment

disorders

designed

In this paper,

operate

in their

problems

of psychiatric

and Michael

facilities

enough

of psychiatric

We believe,

that certain units

psychiatric

can be flexible

a panoply

programs.

Edwin Kremer,

hesitant

to refer

complaints,

in a conventional

pa-

or presumed psychiatric

set-

ting. This is due primarily to concerns about the patient’s reaction when referred for “psychiatric” inpatient treatment or to concerns for the potential stigmatization facility that nosis

and

setting

of the patient. There is a need, therefore, for a health would aid community and subspecialist physicianc in the treatment

that

is more

of such closely

In 1975. an opportunity establish

a unit

psychological

whose

were

chophysiologic

either complaint.

to their

Medicine

facility.

employing

predominantly

in a medical

Comprehensive

setting.

with

physical

in nature Unit,

management usual

anxiety.

which

but

Center significant

whose

expressed

as an acute.

assessment

and psychological

1979

psy-

to call this short-term

and treatment component\

is to describe

to

with

We have chosen

Vol. 20, No. 1 (January/February),

in a

of practice.

had a circumscribed

we define

of this paper

problems

mode Medical

illnesses, or who

behavioral

both organic

The purpose

Psychiatry,

stress

be the care for patients

such as severe

a Behavioral patients

would

physical

facility

in treating

and

to the physicians’

arose at the Dartmouth-Hitchcock purpose

components

complaints

medical

related

care diag-

mode\ to illness

the principles

of

79

80

day to day operation years of operation.

MORGAN,

at the Dartmouth

KREMER, AND GAYLOR

Behavioral Medicine Program after two

THE UNIT The Behavioral Medicine Unit (BMU) is a IO-bed inpatient unit established in 1975 as a component of the Dartmouth Medical School Department of Psychiatry, which in turn is a section of the Dartmouth-Hitchcock Medical Center. The BMU has been located in a small general hospital immediately adjacent to Mary Hitchcock Memorial Hospital, a 400-bed, diversified, genera1 hospital; this fact has had relevance for the patients who have been referred to US and for the referring sub-specialty physicians. The physical facility itself was not modified in order to care for psychiatric patients, with the exception of minor changes undertaken to render one room more suitable for group activities. By design and intent, there is a distinctly medical atmosphere to the unit; patients sleep in hospital beds, physicians wear white coats, nurses wear traditional uniforms, meals are brought to the patients’ bedside. and the staff makes bedside rounds each morning. There is office space for staff, a “group room” on the unit, and an adjacent psychophysiologic laboratory. There are other nonbehavioral medicine inpatients on the ward who have a variety of medical and surgical disorders. The codirectors of the unit are a psychiatrist and a behaviorally trained clinical psychologist. A psychiatrically trained head nurse trained the hospital’s nursing staff, which had extensive experience in medical and surgical nursing. but, essentially, no experience in treating psychiatric patients. Four nurses from the general nursing staff became de facto behaviorally oriented psychiatric nurses and each developed a specialty in one of the treatment modalities to be discussed below. In addition to the co-directors and nurses, there is a psychiatric resident and three behavioral technicians, who are BA level graduates in experimental psychology given special training in behavioral therapy and biofeedback. Initially. an occupational therapist was responsible for various ward activities. This position has subsequently been eliminated with some benefit; the psychiatric connotations of the position probably detracted from the general medical atmosphere of the behavioral medicine unit and the tasks of the position were easily assimilated by various other members of the staff. Because considerable stress is placed on systematic evaluation of patients, as well as on research efforts, a clinical secretary/coordinator was trained to score various psychologic tests which are administered to patients. collect data from staff, and take care of routine clerical matters. Importantly, staffing of the unit and the manner of the staff adopts the traditional physician’s approach to the patients’ problems. It is our impression that the congruency of patient beliefs regarding symptoms and the overt treatment modality (e.g., physical symptoms are caused by organic factors that will be treated physicaliy in an environment where symbols of conventional medical culture are evident) promotes a beneficial therapeutic alliance. The approach is distinctly rehabilitative, and the patient treatment is highly individualized. One practical effect of this approach is to deemphasize the utilization of ward milieu as a major therapeutic modality.

BEHAVIORAL

MEDICINE

The theoretical of the medical

and practical model

symptomatology. methods

81

UNIT

orientation

of disease

is reflected

of the unit,

and the behavioral

in the assessment

incorporating

approach

elements

to psychological

techniaues

and the treatment

utilized.

Each

patient

requires

undergoes

4-5 days.

culminates

in a staffing

the assessment mental

that

status.

dardized

Nursing

There

oriented and

test completion

that

usually

and. at its completion. distinct

(A) Traditional

examination

interviews

psychological

assessment

are several

be enumerated:

(B) Behaviorally (D)

diagnostic

is done systematically

conference.

may

and physical

investigations: sessment:

an extensive

The assessment

components

psychiatric

supplemented

by medical

interview:

Psychophysiologic

(0

observations and record

laboratory

of behavior: keeping

to

history. as-

(E)

of baseline

Standata by

the patient. The assessment be comprehensive: of the

patient

protocol is designed to fulfill a number of objectives: It must that is. it must evaluate the psychiatric and medical status

as well

developed.

It must

temporally.

spatially,

as the

psychosocial

be meticulous

context

in which

in its elicitation

and emotionally

the illness

of circumstances

to the patient’s

has

related

symptomatology.

Fur-

thermore, because of the emphasis placed affect symptoms in a behavioral approach

on symptoms and the factors that to clinical problems, the data ob-

tained

For

very

in the assessment helpful

patient

must be reliable.

to err on the side of assessment

interviews

that

overlap

somewhat

Intc~rl*ic~~1~. The psychiatrist pose of obtaining examination

of the

behavioral history

pertaining

tionnaires

problems.

members

and instructs

on, and attitude other” unit.

toward,

the patient

students

Psychological

testing

in the completion

admission,

psychologic

tests,

contact the patient

the Minnesota

history, illness

process

that the patient is asked

of ques-

Desirability

Scale”.

All

patients

during hospitalization incentive value for

also

complete

the

as well as to involve

admission

a

Since the ward

by one of the two

clerkship. In addition has with

Personality

lo the extensive

staff in the first few of standardized

Inventory’.

the Rot-

ter Internal-External Scale’, the Rathus Assertiveness Scale:‘. a Mood tive Checklist’, the Zung Depression Scale”. and the Marlowe-Crowne goals have

of

learn of the family’s

to fill out a number

Multiphasic

points

staff interviews

at the outset.

after

in a psychiatric

the

elicits

his own assessment

of the nursing

~mi hrhn~~iorr~l htrsrlinc.

of interpersonal

days after

as possible

the patient

the patient’s

and

the psychologist

makes

is seen shortly

engaged

the medical

psychologist

as well

additional

it

for the pur-

technician

in the hospitalization

medical

amount

to obtain

interviews

staff

separately:

disorder

found

we employ

and completing

The

tests. A member

on admission

perspective is a teaching

of the

The behavioral

and psychological

history

patient.

we have in that

content.

one or more

the patient

to features

“significant senior

admitted

interview

intervention.

of the patient’s

in their

conducts

and psychiatric

newly

technician

behavioral

family

medical

this reason, “overkill.”

questionnaires

regarding

AdjecSocial theil

as well as interests. activities. and events which them. These tests are scored and the results ;~re

82

MORGAN,

KREMER, AND GAYLOA

considered in the overall assessment of the patient. If, based on the patient’s history, there appears to be a need for baseline measures of specific behaviors, e.g., intrusive thoughts, physical symptoms, and so forth, the patient is requested to do record keeping as “homework” on paper with scales provided to measure frequency and intensity of the problem or symptom. In addition, nurses have been trained to be systematic observers of patient behavior and provide a measure of the patient’s behavior independent of the patient’s statements or record keeping. Additionally, during this assessment period, the behavioral technician evaluates the patient’s behavioral capability to cope with a number of in vivo task situations. The patient might, for example, be presented with a reported anxiety-inducing situation. Observation of the patient’s behavior in these circumstances aids in determining the correspondence between the patient’s verbal reports of his behavioral repertoire and the actual events, thereby highlighting the patient’s defense mechanisms and revealing, in a less deniable manner, problems that the patient may be having in selected aspects of his interpersonal behavior. This also contributes to the important process whereby the patient becomes a more accurate observer of his own behavior. A further aspect of the behavioral assessment is a psychophysiological evaluation conducted by the behavioral technician. During this evaluation, frontalis electromyograph response (EMG), palmar skin potential response (SPR). digital skin temperature, and heart rate (HR) are recorded to presentation of standardized and idiosyncratic stress stimuli. Subsequently, reactive modalities for a given patient may be selected for use in therapeutic intervention. Specialist medical consultations are Specialist medical consultations. routinely obtained where indicated by medical concern of the staff or to allay the patient’s anxiety regarding the nature of his problem. The location of the unit in a general medical hospital setting and the ease of obtaining consultations foster the general medical atmosphere of the Behavior Medicine Unit. Treatment Psychiatric treatment afforded by the Behavioral Medicine Unit is eclectic and empirical, but the predominant theoretical orientation is behavioral, in the broad sense of the term7. Treatment modalities may be roughly divided into four categories: behavioral, medical, traditional psychotherapeutic, and other. Behavioral treatment. Behavioral treatment approaches may be further subdivided into four classifications: classical behavioral techniques, cognitive techniques, psychophysiologic techniques, and social skills acquisition therapy. Each of these will be discussed briefly. These involve the manipulation of (A) Classical Behavioral Techniques: response consequences to increase appropriate well behaviors and to decrease inappropriate or undesirable behaviors. Behavioral incentive contingencies, based on the data obtained during the assessment phase of the program, are made specific in the treatment plan and enforced by staff members as well as by other patients through the use of social feedback and attention. Other be-

BEHAVIORAL

havioral

MEDICINE

techniques,

terconditioning. (B) Cognitive

including

imagery

with

management

stopping

skills

in formulating

of anxiety,

intrusive

flooding. and cow

where appropriate. Cognitive self-regulatory

and self-instruction

of both

desensitization.

systematic

are employed Techniques:

of mental the

83

UNIT

frustration

or unwanted

involve

the use

due

thoughts,

to

task

and

deal

to

coping-strategies failure,

thought-

in elimination

of self-

derogating aspects of the patient’s cognitive behavior. (C) Psychophysiologic Techniques: Psychophysiologic

self-regulating

involve

and autonomic

con-

Biofeedback

tech-

trol

the

learning

skills

niques

to

of progressive

cope

with

muscular

muscular

have both general

and specific

deep muscle

the treatment

of migraine

headaches.

are used where

appropriate.

feedback portable

galvanic

during

social

cated

skin

self-regulatory

variety

of extra-hospital

periods

of time.

family

have

(D) classes.

Skills

behavioral

Acquisition

technician

phasis on the advantages the patient

actively

with problematic

tion

il

is

tokens

tient on his behavior, another’s

token”

chronic

Iongel

the patient

and the

of assertive

taught

as

skill teaching.

A

behaviors. behavioral

A second format group.

are generally

for social

class each day with

of beneficial

or, alternatively,

are designed

for social

with

token

A system

an em-

and he engages styles

useful

for

for social skills acquisiof exchanges

to compliment

to request

a change

ble to effect

behavior

a lasting

program

of paper another

specified

pii-

in writing

change

likely rights.

The paper tokens ities alone.

Medical

returning

when

aspects

A rational

the

the

effect

behavioral

arouses

mentally

in

response

patient

by virtue

contingenrather

contingency

antagonism.

This

emphasis

we did not take

by dint of their

use of pharmacotherapeutic

01

it is possi-

to be the result response

exchanges;

only;

is to be

retarded

Though

For this reason

privileges

values

use of tokens

settings. is likely

setting.

of token

as earned

had considerable

trrrrtment.

that

short-term

them

This

the use of behavioral

compliance

in a manner

in an acute,

on the interactional

patients’

effect

with

institutional

through mere

therapeutic

and have symbolic

or goods.

employed

in longer-term

economies.

is conducted

especially

reinforcement

for privileges economies

schizophrenics

cies as in token

placed

skills

can be individualized

are not exchangeable

contrasted

than

use in ;I

behavior.

Tokens they

of indi-

skill

for increasingly

skills

formats

an assertive

life situations. that

a

can be carried

to practice

visits,

Social

and techniques

developed

is assigned

the development

opportunities.

two coordinated

“communicational

was

that

as in

and EEG

task to complete.

in the role-playing

dealing

home

Therapy:

conducts

machine

is required

including

of choice

pressure

the patient

Following

each of these practice

We have employed

behavioral

feedback

patient

settings,

indicated,

skills

use may be adjunctivc

SPR. HR, blood

Where

(GSR)

During

a specific

Social

EMG,

situations.

the

their

or it may be the treatment

stress

skills,

anxiety.

applicability:

relaxation

response

or in vivo

and

tension

as in teaching

relaxation

is was

away

of reinforcement. transactional

qual-

techniques

is

employed on the unit. The primary indication for pharmacotherapy is to aid patients whose symptoms are of such a severity that they are relatively inac-

84

MORGAN,

KREMER, AND GAYLOR

cessible to behavioral intervention, such as. for example, a patient with frequent severe anxiety attacks. Secondly, evidence indicates that many patients with chronic psychophysiological disorders and chronic pain syndromes have a concomitant depressive illness, and if psychobiologic signs of depression accompany such a chronic problem an antidepressant will often be empirically prescribed, if there is no medical contraindication. Traditional psychotherapeutic techniques. The patient’s behavioral technician is responsible for elements of the behavioral assessment and implementing aspects of the behavioral treatment program. Each patient, however, is also assigned a primary therapist, an experienced psychotherapist who conducts therapy in a problem-oriented manner, commensurate with the patient’s verbal conceptualization of his psychosocial problems. The primary therapist is also responsible for conducting the family assessment and for continuing family therapy sessions, as needed, as well as aiding with discharge planning and follow-up. The patient is actively involved in a process of defining problem areas, goals, and solutions with his therapist. We have frequently had recourse to the expertise of a Other therapies. psychiatrist, particularly in treatment of chronic pain syndromes. Active collaboration between behavioral medicine and physical therapy has benefitted patients and has been gratifying to the staff of both departments. The full range of physical medicine diagnostic and treatment procedures has been available to us as required. We have worked regularly with orthopedists, anesthesiologists, and neurosurgeons based at the medical center, for mutual assistance with assessment and treatment of patients. Finally, hypnotherapy has been found to be useful in a number of conditions. The patients who benefit from hypnosis are taught self-hypnotic techniques. Patient Follow- Up Drrta We have contacted all patients treated at the Behavioral Medicine Unit to assess the long-term effects of our therapeutic efforts. This program is yet in its early stages but sufficient data have been collected to indicate clear trends. Selected statistics are presented in Table I. The table includes data from 81 former patients from a total mailing of 197 questionnaires. We are currently attempting to acquire data from the patients who failed to respond to our postal inquiry. Of the patients who did respond, it is clear that the far greater percentage reported subjective improvement in the problem that originally resulted in their hospitalization: relative to nonimproved patients, these improved patients indicated a significantly greater decrease in both frequency and intensity of their presenting complaint(s). Importantly, this apparent continued improvement does not appear to be confounded by differences between the groups in the length of time between discharge and follow-up. In fact, this interval was longer for improved patients than non-improved patients, though not reliably so. Moreover, there was no reliable difference between the groups in length of hospital admission, nor were there any obvious differences in distribution of presenting complaint represented in each group. These latter data are presented in Table 2. Observation of these data fail to indicate any pattern of presenting complaint that would easily differentiate improved and nonimproved patients.

BEHAVIORAL

Table

MEDICINE

85

UNIT

1. Selected Data From Patients Reporting improvement and Those Reporting Following Discharge From the Behavioral Medicine Unit

Nonimprovement

Patient Status Nonimproved

Improved

* Fisher studentized

t Critical ratio, p <

in Table

greater

for

though

5%’ 6%*

6.9 3.3

3.7x 3.3

94% 85%

72%t 44%t

t test, p < .Ol,

training

and progressive

1 show that training

improved

significantly

66% 84%

.03.

The data for assertiveness sented

patients

than

more improved

for

nonimproved

patients

difference

in the frequency

proved

employed

these

As with

all retrospective

sis of our follow-up findings.

However,

of assertive chosomatic plaints

that

skills patients

argue that proficient

skills.

with

improved

and nonim-

note made, long-term

which

use of assertive

with

this preliminary

in any interpretation the apparent

improvement

to theoretical

psychosocial

notions

variables.x

abuse

differential

(n = 63)

analyefficacy of psy-

of psychosomatic

In this

context,

skills so alters the psychosocial

improved

Back pain Headaches Migraine Tension Other Depression Alcoholism or substance Anorexia Dermatitis Insomnia Tics (including torticollis, muscle spasms) Cardiovascular

there

of these

in a variety

Table 2. Primary Complaint for Improved and Nonimproved

Anxiety (including vomiting fainting spells, weakness) Compulsive behaviors Pain

In contrast.

skills.

this cautionary

incorporate

patients.

pre-

reliably

relaxation

data and. in particular,

is congenial

relaxation

skills were

were taught

data, we must be conservative in promoting

muscular

in, and use of, assertive

was no reliable patients

207.8 19.0

284.7 22.4

Days post-discharge Length of hospitalization in days Percent remission Frequency of complaint Intensity of complaint Use of skills per week Assertiveness Progressive muscular relaxation Percentage of group trained Assertiveness Progressive muscular relaxation

one fabric

Patients

Nonimproved

14%(9)

17%(3)

3%(2)

0 (0)

5%(3)

6%(l)

3%(2) 16%(10) 6%(4) 27%(17) 17%(11) 2%(l) 2%(l) 2%(l) 3%(2)

0 (0) 17%(3) 17%(3) 17%(3) 11%(2) S%(l) 0 (0) 6%(l) cl (0) S%(l)

In

181

commight as to

66

MORGAN,

KREMER, AND GAYLOR

remove many erstwhile sources of stress. Prospective research is currently being planned in an attempt to elucidate the precise mechanism through which assertive skills effect their influence. Regardless of the mechanism, the data reported here are unambiguous in demonstrating the long-term efficacy of a behavioral medicine treatment for a variety of psychosomatic complaints. DISCUSSION

The Behavioral Medicine Unit is a short-term facility for the diagnosis and treatment of illness states where psychological factors or behavioral contingencies may be operating in maintaining or exacerbating the illness processes. There are two characteristics of the Behavioral Medicine Unit as a psychiatric facility that warrant special mention: the absence of the elements of a therapeutic community approach as a primary tool of treatment, and the integration of a broad range of behavioral techniques in an inpatient setting. As described above, the ward culture is medical, symbolized by white coats, traditional uniforms, and a general hospital setting. These symbols are complemented in the case of patients with physical complaints, whether or not an organic cause for a complaint has been specified, through the use of a linguistic strategy with the patient. This strategy acknowledges the validity of the complaint, with an explanation to the patient that, frequently, factors in one’s life such as events at home, job problems, fatigue, worries, etc..-all of which may be categorized under the rubric of stress-may make the symptom worse or even disabling, and that the staff is undertaking a detailed assessment of the patient’s physical condition and psychological state to determine the impact of such factors, if any exist, and to help correct the problem through a stress management program. This explanation is readily accepted by most patients, corresponding as it does to a common sense understanding of illness. Once the stress hypothesis has been accepted by a patient, this permits the introduction of overtly psychologic and behavioral assessment methods, because the patient understands the relevance of these investigations to the presenting complaint. The presence of the medical atmosphere permits patients to retain their conceptualization of themselves as medically ill, while at the same time the stress hypothesis communicated to them prevents, in large measure, the arousal of the denial of psychologic problems to which somaticizing patients are prone. In this manner, we attempt to keep patients’ hostility and defensiveness to a minimum. The efficacy of the Behavioral Medicine Unit as a unique, clinical effort relies on meeting two basic criteria. First, the Behavioral Medicine Unit must offer a unique form of therapeutic intervention and/or offer established modalities to a new patient population. We believe the unit described above satisfies both of these criteria. The treatment methods themselves employed on the Behavioral Medicine Unit are unique in respect to their application to the inpatient treatment of psychophysiologic disorders and in their conceptual organization into the patient’s treatment plan. Most inpatient psychiatric facilities employ pharmacotherapy where appropriate, and most facilities attempt to involve families and other significant individuals in the patient’s life in the treatment program.

a7

BEHAVIORAL MEDICINE UNIT Such treatment restructuring

of the

uniqueness various

the second

we

have

Many

in a coordinated

of our patients and.

hence,

responses.

with

tion

by

or

quently.

cases,

their

These

for

a patient

rooms

and office

procedures

by well-meaning

and

patient

continues

tration

both on the part of the patient

the major

purposes

of treatment

the patient

to incorporate

repertoire.

so that

future.

In the absence

the physician A further enduring

criterion

problems

systematically Thus.

it is often still

particular

mode

acquire

overall

measures

but

and sought

of treatment

of behavioral

his behavioral

Unit

whether

not

One of the

that

it does

not

procedures.

the patient frustrated

is fully with

that

or simply

has moved

has been organized

to provide

for each patient change

in the

the patient cycle.

has been

has become

is to aid

be avoided

neither

help elsewhere,

Medicine efficacy

into

the

One of

patient

of its various

fails to return.

complaint

The Behavioral

evaluation

effectiveness

if a patient

of treatment

system

as

in frus-

community.

is that it must be evaluative.

delivery

relative

has the same

to a new locale. on-line

unclear,

the

facility,

relief,

resulting

may

Fre-

services

to obtain

skills

behavior

at an

by inclina-

or diagnostic

to this interminable

efficacy

health

failing physicians.

for

significant

admission.

somaticizing

medicine

alternative

disease

care

surgical

medical

and either

therefore,

health

and coping

sickness

of program of the

other

and the local

of a behavioral

evaluate

recovered.

with

new behaviors

has a satisfying

pain. have

to provide

has numerous

of the chronically

inappropriate

chronic

psychiatric

and. after

odyssey

seriously

but are not suited such

care

an acute

been

evaluations

themselves,

utilizes

physicians.

his medical

find

physicians.

a conventional

visits

for

have

as anxiety. medical

often

extensively

emergency

often

has been unable

or surgical

symptomatology

such

health

at the time of

has been made of an organic

treatment patients

medical

such

extensive

of the patients

appropriate

be considered

patterns

with

of the patient.

incapacitated

normally

systemat-

of his illness.

that for many

no other

life

of these

based upon a

capabilities

noted

of symptoms

or surgical

relief.

impasse

not

their

or else a diagnosis

the medical

symptomatic

we have

might

In many

been nondiagnostic

manner,

and conceptualization

is literally

but

by the presence

phobic

from the utilization

are not psychiatrically

hospitalization,

disrupted

on an

the self-regulation

there

and cognitive outpatient basis. The

biofeedback.

usually

Unit derives

behavior

criterion.

treated,

admission

psychiatric

which

Medicine

modalities

training.

settings,

goal being to promote

Regarding facility.

in other

of the patient’s

the primary whom

as assertiveness

Behavioral

treatment

ic evaluation

their

modalities are available

as well

as to regularly

and behavioral

change

mainte-

nance. A standardized battery of psychological tests and psychophysiologic evaluations is administered on admission and discharge and gives a quantified measure

of the effectiveness

We believe

less extensive

of the hospitalization and systematic

in producing

evaluation

could

treatment modalities by casual impression of effectiveness: tive, however, to the difficulties inherent in establishing evaluation

program.

structuring

of individual

Of particular

responsibility

of obtaining,

staff

The

person.

“end

responsibility

importance

in our own

as regards

at the end of the day.

of the day”

was defined

change.

lead to utilizing

we are not insenaia comprehensive experience

data collection. the appropriate

with

was the the final

data from each

by the submission

of appro-

88

MORGAN,

KREMER, AND GAYLOR

priate data to the clinical coordinator and, in turn, the final daily responsibility of the clinical coordinator was to have a!! patients’ data current that day. Finally, a criterion against which the efficacy of the Behavioral Medicine Unit must be tested is demonstrable effectiveness of the program. Do patients continue to do we!! for any period of time following discharge from the Behavioral Medicine Unit? The data reported above provide clear evidence that a substantial percentage of patients maintain improvement over an g month follow-up period. The Behavioral Medicine concept described in the present article is congenial to the holistic-systems approach to psychosomatic medicine recently described by Leigh and Reiser.Y Whereas Leigh and Reiser define behavioral medicine or holistic psychiatry as an approach or an attitude toward comprehensive medical care, integr,ating consideration of factors from psychologic, physiologic. environmental, and sociocultura! levels of conceptualization and, therefore, equally applicable to al! patients regardless of their ailment, we would propose that the term “holistic medicine” be applied to such a broad conceptual scheme and would define behavioral medicine as follows: Behavioral medicine is an approach to illness states which utilizes assessment techniques to evaluate affective, cognitive, psychophysiologic, overtly behavioral (contextually respondent), and environmental aspects of illness; behavioral medicine utilizes treatment techniques which include, but are not necessarily restricted to, those described in this article, and is appropriately applied to those illness states in which a psychological/behavioral component is significant. In effect, behavioral medicine is a discipline utilizing defined methods ofassessment and treatment applied to a specific patient population and represents a clinical application of the holistic-systems approach to psychosomatic medicine. SUMMARY A new type of short-term, psychiatric, inpatient facility is described that utilizes predominantly behavioral techniques and is designed to treat patients manifesting symptoms of severe anxiety, phobias, chronic pain syndromes, and psychosomatic disorders. Salient aspects of its organization and conduct are discussed. This Behavioral Medicine Unit offers a unique program of therapy to a patient population that presently has no appropriate health care facility. It is designed, moreover, to be self-evaluative and, within its own treatment Behavioral schemes, optimizes conditions for long-term effectiveness. medicine as here defined is a systematic approach to illness involving a sequence of assessment and treatment directed towards a specific patient population and represents a clinical application of a holistic-systems approach to medicine. REFERENCES 1. Hathaway SR, McKinley JC: Minnesota Multiphasic Personality Inventory (Revised Manual). New York. Psychological Corporation, 1967

2. Rotter JB: Generalized expectancies for internal versus external control of reinforcement. Psychological Monograph. 1966, 80, (1, Whole No. 609).

BEHAVIORAL

3. Rathus assertive

MEDICINE

S: A ?&item

behavior.

89

UNIT

schedule

Behavior

for assessing

Therapy.

4:39X-

8. Backus

406 4. Nowli\ Farber.

V:

SM

Cwtrtiviry.

Wilson

Arch

Gen DP.

A

,4:349-x4.

of

(eds):

Cor~j;c,r

or/(/

depression

12:63-70.

1965

D: A new

of Consulting

scale of of

p5y-

Psychol-

MJ:

organic

York.

FI.

DL:

Trends

9. Leigh ing role

in

P teds):

chosomatic 239.

Dudley

factors

Oxford

and

Behavial

Ballinger.

of

relalionship

to

Z,

I).

their

Lipowski

and Clinical

Lipsit~ Medicine:

Application\

Press.

1977

Major

trend\

H. Reiser

MF:

medicine:

The psychiatrist’s Ann

1974

Observation\

Psychosomatic

University

in medicine.

1977

and

Mass.

dixase.

Current

Cognition

Cambridge,

psychosocial Whyborw

self-rating

independent 1960

in

1963

Marlowe

Journal

mood.

McGraw-Hill.

Psychiatry.

desirability

chopathology. ogy.

concept RHL

WWK:

6. Cruwne social

The

New York.

5. Zung scale.

7. Mahoney Modification.

Intern

Mrd

New in pr)evol\X7:273-