Save Your Marriage

Save The Marriage

Lee Baucom, Ph. D. shows couples with marriage troubles a new way to save their marriage that is far more effective than any marriage counselor in this marriage course. In 4 easy-to-read modules, Dr. Baucom shows the step by step way to save a marriage that is in danger of ending any day. These show the top 5 mistakes that most people make in marriage, the REAL secrets to a happy marriage, why marriage counseling can actually HURT your marriage more, and how to move beyond your emotions into action. This module can actually have you saving your marriage in less than an hour, sometimes even 10 minutes. This book also comes with 4 bonus gifts free: Coping With a Midlife Marriage Crisis, Recovering from an Affair, 5 Rules for Fighting Fair, and an eBook written by a couple who was on the edge of divorce and the methods they used to get a happy marriage back. Marriage can be hard, but divorce is harder, on you and your children. Why risk it? Read more...

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I usually find books written on this category hard to understand and full of jargon. But the author was capable of presenting advanced techniques in an extremely easy to understand language.

Overall my first impression of this ebook is good. I think it was sincerely written and looks to be very helpful.

Behavioural marital therapy

Behavioural marital therapy produces better outcomes of drinking and marital relations than individual counselling or similar control conditions. The superior effects last for 24 months after treatment. Outcome at 1 year is better if sessions of behavioural marital therapy continue after the end of treatment to reinforce what has been learnt and rehearse relapse prevention plans.(38) This has been reviewed by Miller et al.'(1.9

Couple counselling and couple therapy

The concept of couple counselling dates from the 1920s when in the United States the American Association for Marital Counselling was formed in the United Kingdom the Marriage Guidance Council (later called Relate) was founded in 1938. Counselling mainly took the form of giving advice on practical issues, but in more recent years Relate counselling has been orientated more towards psychodynamic approaches, and favours a more long-term involvement with the couple. Couple counselling continues in both countries, and the great majority of couples seeking help with their problems are seen by couple counsellors, rather than any other types of therapist. The distinction between couple counselling and couple therapy is not an easy one, because many of the interventions are similar. In a simplistic sense therapy attempts to make a more radical difference to the couple's functioning than counselling, and many forms of couple therapy are based on a theoretical formulation which is derived from...

Psychoanalyticpsychodynamic couple therapy

Couple therapy using a psychodynamic model began in the United Kingdom in 1948, when Dicks and his colleagues founded the Institute of Marital Studies. The theories and techniques involved have been ably reviewed by Daniell(4) and Clulow.(5) The central concept used is that the inner (unconscious) world of the two partners determines their interaction and their response to changing circumstances. It is as though each partner has an internal blueprint, both of themselves and each other, formed partly by observation but also partly by the influence of earlier experiences of intimate relationships with parents, siblings, or friends. As a result, there may be projections which lead one partner to attribute motives such as hostility or sadism to the other, whereas in fact this is a split-off and denied characteristic of the first partner. Other consequences of this unconscious process may be the actual choice of partner, and the system of shared fantasies and defences which builds up as...

Behavioural couple therapy

The behavioural approach, in contrast, makes no assumptions about internal conflicts or underlying mechanisms in the individuals. The approach was initiated in 1969 to 1970 by Stuart(8) and Liberman(9) as behavioural marital therapy. They worked from the principles of operant conditioning and made the assumption that couples who were having difficulties were either giving each other very low levels of positive reinforcement or were using punishment or negative reinforcement to coerce each other into behaving differently. The remedy that they proposed for this situation was to help the partners to increase their abilities to persuade each other to conform to the desired pattern of behaviour by the use of prompting and positive reinforcement. Behavioural marital therapy relies on the observation of the couple's behaviour in the session and on the reported problems from the previous week or equivalent timespan. There are two types of therapeutic activity in behavioural marital therapy....

Cognitivebehavioural and rationalemotive couple therapy

Aaron Beck,( 9 in his cognitive-behavioural approach to couple therapy, identifies in the communication of disturbed couples many of the problems found in the thinking of depressed patients, and attempts to correct these. Thus, he tackles misunderstandings, generalizations, untested assumptions, and automatic negative thoughts by challenging assumptions, reducing expectations, relaxing absolute rules, and focusing on the positive rather than the negative.

Contraindications for family therapy

Family equilibrium is so precarious that the inevitable turbulence (32) arising from family therapy is likely to lead to decompensation of one or more members for example, a sexually abused adult may do better in individual therapy than by confronting the abusing relative. 5. The patient is too incapacitated to withstand the demands of family therapy. The person in the midst of a psychotic episode or someone buffeted by severe melancholia is too affected by the illness to engage in family work.

Role of the family therapist

Beels and Ferber,(34) among the first observers to consider various roles for family therapists, divided them into 'conductors' and 'reactors' this differentiation remains useful since it transcends schools. The therapist as conductor is represented in the work of practitioners like Satir, Bowen, and Minuchin. Satir (35) is a good illustration. With her emphasis on communication, she espoused the notion that the family therapist is a teacher who shares expertise in optimal communication by setting goals and the direction of treatment. In her case, she guided the family to adopt a new form of language to resolve communication problems, which she saw as the root of their troubles. Additionally, the therapist instils confidence, promotes hope for change, and makes them feel comfortable in the process. In Satir and fellow conductors, the therapist is an explicit authority, who intervenes actively in implementing change.

Specific techniques in behaviouralsystems couple therapy

The remedy proposed by behavioural marital therapy is that each partner should state their complaints, but that these complaints should then be translated into wishes for an alternative way of behaving which is more acceptable, and, as a second stage, into tasks. It is very useful to concentrate on practical, domestic issues for these tasks, as these are easily grasped, frequently repeated, and more likely to be remembered than more abstract tasks. In principle the tasks for each partner should be linked and reciprocal, but if this is not possible a 'bank account' approach can be used in which each partner builds up a fund of good behaviour and they work out at the end of a period of time whether it has been mutually acceptable. In moving from complaints to tasks one also moves from past to future, and this is one of the most characteristic features of reciprocity negotiation. The therapist is thus more interested in what will happen next week than in what happened last week or last...

The behaviouralsystems approach to couple therapy

Behavioural-systems couple therapy is the approach that will be described in detail in the present chapter, and is the method developed at the Maudsley Hospital Couple Therapy Clinic. It has been expounded at greater length by Crowe and Ridley (1) and like some of the other eclectic models mentioned above it combines two different approaches, behavioural marital therapy and systems family therapy. The behavioural dimension, similarly to that described by Jacobson and Margolin, (19) consists of the relatively straightforward methods of reciprocity negotiation and communication training. The systems dimension is more complicated, and involves systems thinking, structural moves during the session, tasks and timetables for the couple between sessions, and the use of paradox. The method was developed in a predominantly psychiatric setting, and has been found to be particularly suitable for those couples where one or both partners has psychiatric problems in addition to their relationship...

Research in family therapy

In appraising the present state of adult family therapy research, the choice is to see the glass as either half full or half empty. We opt for the more optimistic scenario. We need to remind ourselves that adult psychiatry family therapy is a mere toddler, dating only from the I970s. During this time, immense strides have been made, particularly in the development of theoretical concepts. Pioneers in the field were chiefly therapists working with families and were tantalized by the nature of the process rather than its effectiveness. In hindsight, this makes sense. Models were completely lacking the 'how to' conduct treatment crying out for creative ideas. As can be seen in the theoretical part of the chapter, many have emerged, and continue to do so. The result is a rich array of therapeutic approaches including several comprehensive theoretical contributions.(42) The growth has occurred at a dizzy pace with an inevitable consequence of overload. How can we make sense of the many...

Efficacy of couple therapy

The efficacy of couple therapy is not an easy topic to discuss. Problems arise as to how one should assess efficacy, and while most authors would agree that a measurable improvement in marital adjustment is a valid measure of improvement, some authors dismiss that as being too subjective or too superficial. On the other hand, to use divorce as an outcome variable might be seen as being too strict on the therapy, since divorce happens for many reasons, and it might not actually be a bad outcome in some relationships. A review of efficacy in couple therapy has been carried out by Baucom et al.'(2 r) They did a very thorough search of the literature, and made some far-reaching and challenging observations. They comment that the untreated improvement rate is very low in couple problems. They conclude that behavioural marital therapy, comparing mean effect size over a series of 17 independent controlled outcome studies, is an efficacious and specific intervention for marital distress. The...

Family therapy

Family therapy is the main treatment which has been evaluated in anorexia nervosa. A controlled trial of family therapy was undertaken at the Maudsley Hospital on a series of 57 patients.(121) The principles of the family therapy have been incorporated in the Maudsley model. (i9 One assumption is that the family is ineffective in helping the patient eliminate her symptoms, or might contribute to their maintenance. It was also considered essential to correct the patient's starvation by assisting the parents to take control jointly of their child's eating until her weight had returned to normal. The effects of the family therapy were compared with a control individual therapy. In order to reduce any ethical objections to the random allocation to two different treatments, the risks were minimized by first ensuring that the patients' weight loss had been corrected by admission to the Eating Disorders Unit. The trial was of outpatient family therapy administered for 1 year. The patients...

Preface to the First Edition

The authors came to an interest in philosophical problems in psychology and psychiatry by different routes. Before training as a clinical psychologist D.B. read philosophy and researched on Wittgenstein. J.H. read natural sciences before training in medicine, psychiatry, and family therapy. We published papers independently about ten years ago which overlapped in subject-matter meanings, reasons, and causes and conclusions, whence came our idea of co-writing a book. The book as a whole is co-written, though some chapters were written mainly by one or other of us. Chapters 1 to 4 were written mainly by D.B., 5 and 7 mainly by J.H., while 6, 8, and 9 have been co-written.

Concepts of disablement

The description of social and interpersonal relationships is in principle included in comprehensive schemas such as the ICIDH and that of Nagi, but many separate instruments that cover relationships in great detail have been devised over the years by psychotherapists, family therapists, and others. (29,30 and 3

Social Functioning In Depression

Depressed individuals are characterized by a wide range of social deficits (see Barnett & Gotlib, 1988 Segrin, 2000, for reviews). It is noteworthy that there is no single cohesive theory to account for the origins of these social difficulties. Instead, relatively isolated bodies of empirical research (for example, studies examining the associations between depression and stressful life events, social networks, marital functioning, etc.) have implicated different aspects of interpersonal functioning as being important in understanding the etiology and maintenance of depression, as well as relapse of this disorder. Given recent reviews of the social functioning of depressed persons (e.g., Hirschfield et al., 2000 Segrin, 2000), we will not attempt to present an exhaustive review of this research in this chapter. Rather, we will organize our discussion of the social functioning of depressed persons by describing two main types of social deficit in MDD those that involve problems with...

Psychological processes and treatment implications

A number of other therapies have also been shown to be effective, particularly in the alcohol field, including self-control training, self-help groups, marital and family therapy, coping and social skills training, anxiety and stress management, aversion therapies, and brief intervention strategies. (2 25)

Coping With Msrelated Changes In Sexual Response

Restore the special nature of your relationship by showing your partner how important he or she is to you. Loving gestures are often forgotten under the pressure of coping with MS and other stresses. when you treat your partner as a special person, you set the stage for increased intimacy, which can sometimes stimulate libido. Read books and watch educational videos with your partner. Set aside time to talk about what you are learning, whether or not it applies to your relationship. Make regular dates, free from the responsibilities of work, caregiving, and childrearing, to rediscover your partner. Try to recreate the feeling of romance that characterized your relationship before it was swept away by the burdens of career, parenthood, and MS.

Advice about management

Psychiatrist together with collaboration with the family practitioner and social workers improve the long-term prognosis. If resources allow, psychotherapy by a trained practionioner, behavioural therapy, or family therapy may be combined with a low-dose pharmacotherapy.

Impairment in social and familial relationships

The relationship between marital disturbance and affective disorder has received increased attention over the two past decades. First, descriptive studies have suggested that marital conflict correlates highly with concomitant depression,(65) and marital therapy has been found to be effective in reducing the symptoms of depression, alone(66) as well as in combination with pharmacotherapy 67) Further, previous research found dysfunctional patterns of communication in couples with a depressed spouse. Specifically, compared with their non-depressed counterparts, depressed couples have been found to exhibit more friction, lack of affection, lower levels of constructive problem solving, mutual self-disclosure, and reciprocal support. (Z6,69 The lack of a confiding and intimate relationships leaves individuals vulnerable to depression 7,7 Z1) Finally, marital distress may also exacerbate difficulties experienced in extramarital relationships, (72) thereby increasing introverted behaviour...

Other psychotherapies

Few high-quality studies exist on marital and family models of psychotherapy. It is clear that cognitive therapy, interpersonal therapy, and brief dynamic psychotherapy can be applied to families, groups or couples, but the only published randomized controlled trials on marital therapy mainly draw on behavioural approaches. For example, O'Leary and Beach70 demonstrated that behavioural marital therapy or cognitive therapy were both more effective than waiting-list controls in treating women with depression or dysthymia. Furthermore, Jacobson et al.(71) demonstrated an advantage for behavioural marital therapy over cognitive therapy in depressed individuals with marital discord.

Continuation and maintenance trials

Psychotherapy for bipolar disorders has not been systematically studied. No studies are available on psychological interventions in acute mania. Reviews by Scott (55 and by Roth and Fonagy(57 highlight that psychosocial interventions undertaken during other phases of bipolar disorder all resulted in greater symptomatic improvement and social adjustment than treatment with medication alone. However, the studies were poorly designed and the data are weak. The only controlled trial published(83) randomly assigned a small sample of 28 subjects to either six sessions of compliance-oriented cognitive therapy or standard clinic care. In the next 6 months lithium compliance appeared to be enhanced in the cognitive-behavioural therapy group, who also showed fewer hospitalizations. The most promising approaches to bipolar disorders appear to be cognitive therapy, interpersonal therapy-social rhythms therapy, and family therapy, and large-scale controlled trials of these therapies are now...

Management General aspects

Most patients with affective disorders are treated in primary care or general medical settings. Cases seen by specialist mental health services are usually referred because the disorder is more severe, chronic, treatment resistant, or because other difficulties, such as alcohol misuse or marital difficulties, complicate the clinical picture. In these situations it may be necessary to use combinations of drugs and psychosocial approaches. The rest of this section gives an overview of physical and psychological treatments. Although these approaches are described separately, the treatment of affective disorders rarely involves simply prescribing medication. Education and support of a depressed patient and his or her family are important aspects of any clinical management package.

Nonresponse and resistant depression

Are there perpetuating factors in personality, family environment, or the social setting It is common where depression has been long term that secondary role loss (including work) and family adaptations to a non-functioning member mean there are no roles or relationships for the patient to return to and remission cannot occur, or is transient, unless psychotherapy, family therapy, and rehabilitation are employed to change the situation.

Psychological treatments

Formal psychotherapy may be offered as the only treatment to individuals with milder depressions or in combination with medication in those with moderate and severe disorders. More than 20 per cent of couples report marital discord in association with depressive disorders and so marital or family approaches should always be considered as an alternative to individual therapy. Individual treatments, such as cognitive therapy, may particularly benefit milder depressions. There are a number of features that identify potentially effective psychological approaches to depression. (56) The therapy should be highly structured and based on a coherent model. It should provide the patient with a clear rationale for the interventions made and the therapy should promote independent use of the skills learned. Change should be attributed to the individual's rather than the therapist's skillfulness and the therapy should enhance the individual's sense of self-efficacy. Clearly cognitive therapy,...

Chapter References

O'Leary, K. and Beach, S. (1990). Marital therapy a viable treatment for depression and marital discord. American Journal of Psychiatry, 147, 183-6. 71. Jacobson, N., Dobson, K., Furzzetti, A., and Schmaling, K. (1991). Marital therapy as a treatment for depression. Journal of Consulting Clinical Psychology, 59, 547-57.

Psychotherapy and counselling

Treatment of AD initially focuses on psychotherapeutic and counselling interventions to reduce the stressor, enhance the capacity to cope with a stressor that cannot be reduced or removed, and establish a system of support to maximize adaptation. The patient needs to be made aware of the significant dysfunction that the stressor has caused and consider strategies to manage the disability. Some stressors, for example taking on more responsibility than can be managed by the individual, or putting oneself at risk (e.g. unprotected sex with an unknown partner), can be avoided or minimized. Other stressors may elicit an over-reaction on the part of the patient (e.g. abandonment by a lover). The patient may attempt suicide or become reclusive, damaging his or her source of income. In this situation, the therapist would assist the patient to verbalize his or her disappointed feelings and rage rather than behaving destructively. The role of verbalization in minimizing the discomfort of the...

Comparison of outpatient treatments and hospital admission

Outpatient treatment combining individual and family therapy over the course of 12 sessions spanning several months The patients' progress was re-evaluated at the end of 1 year. The clearest finding was that patients allocated to any one of the three active treatment options fared better than those allocated to the one-off evaluation session. There were fewer clear-cut differences between the patients in the three different treatment groups. The inpatients tended to achieve a more rapid and higher weight gain towards the end of their admission, but at the 1-year follow-up the weights were similar in all three treatment groups. The patients' improvement in their socio-economic status was greatest in the individual-family therapy group.

The Psychodynamic Perspective

This is a principal reason that dependents are often so completely devastated when relationships end. In effect, abandonment becomes the final verdict of someone whose opinion they have previously accepted as unquestioned truth. Should the marriage fail, Sharon may experience the divorce as not only a break from Tom but also an abandonment by everything Tom symbolizes, including her father. In effect, she is being abandoned by an introjected ideal that forms an important cornerstone of her identity. If she cannot succeed in therapy in drawing a distinction between Tom and this internalized image, the future may prove particularly crushing. Another way of coping with a problematic, hostile world is simply to deny that it is hostile at all. Although introjection creates soothing feelings of being allied or fused with a powerful other, it cannot eliminate all sources of anxiety. Accordingly, dependents make extensive use of denial to damp down whatever feelings of doom or apprehension...

Respiratory disorders Asthma

Asthma is one of the classic 'psychosomatic diseases'. Emotional arousal causes changes in airway tone. The severity of an asthma attack is highly correlated with presence of major depressive disorder, panic attacks, and level of fear. Psycho-education, relaxation, biofeedback, and family therapy have each shown efficacy in the management of asthma 31 Particularly important in the management of asthma is education about the adverse effects of antiasthma medications, which include jitteriness, palpitations, and insomnia. These side-effects may require treatment with behavioural and or psychopharmacological therapies.

Relationship problems

A positive cervical smear test result can result in the woman feeling differently about her body and about sex. (29) A study of hypertension screening found decreased marital satisfaction in those with a high-risk result. (33 After a high-risk result for Huntington's disease, some people's personal relationships have broken down, (17) although others have reported improvements 23 Genetic testing, unlike other types of testing, may have health implications for the person's relatives, and problems may arise in these relationships. After a positive HIV diagnosis there are additional issues regarding possible infection of the person's sexual partner. The HIV-positive person may have to deal with the death of a sexual partner and friends, and bereaved reactions to AIDS-related deaths appear most severe among people who are themselves infected. Telling friends or relatives about the positive test result may also involve difficult communication about previously undisclosed sexual preferences.

The advantages of the systematic approach

Systematic reviews can provide clear information to clinicians, policy makers, and recipients of care, and so help inform the decision-making process. For example, a systematic review of family therapy suggests that this educational, psychosocial package can help those with schizophrenia avoid or postpone relapse. (1Z) This finding is very much in line with the suggestions of traditional reviews.(1,8) However, the systematic review is able to illustrate how seven families have to undergo regular therapy, for up to a year, in order for a single relapse to be postponed. Such data, of course, mean different things to different people. Clinicians may find this an acceptable degree of effort, whereas managers of services, or even families of those with schizophrenia, may not. Although the findings may not decrease controversy, at least debate can be informed.

The Primary Care Physician as a Member of the Bariatric Team

Patients need to understand that surgery changes the stomach but does not change the mind. Eating behaviors, attitude towards food, perceptions as to how much food should be eaten at one setting must change. Bariatric surgery does not provide the patient with an automatic long-term weight reduction guarantee. Even after dramatic weight loss, weight regain through engaging in old eating behaviors can occur if emotional, mental, and social issues are not addressed before and after surgery. At present, psychologists, dieticians, and the surgeon address the patient's mental, emotional, and medical needs. As a member of the bariatric team, the primary care physician can continue this care indefinitely because of the long-term relationship with the patient. For instance, patients who have had bariatric surgery, especially those with restrictive-malabsorptive procedures, have special medical needs for the rest of their lives. Patients must be vigilant in preventing iron deficiencies, B12...

Epidemiology and Demographics

Psychological testing on women with vulvar vestibulitis has found higher rates of introversion, somatization, and interference with sexual function. Overall levels of psychological distress, negative feelings toward sex, self-esteem, and marital satisfaction are conflicted in the literature with some studies showing no difference from matched controls and others finding opposite results. Furthermore, the order of causation remains unclear, with many authors suggesting a circular relationship of the physical condition and psychological changes.8-10

Primary care guidelines

The extensive clinical practice guidelines for antidepressant treatment in primary care comprise four volumes. (8) Both the physician and patient guides list IPT, cognitive-behavioural therapy (CBT), behavioural, brief dynamic, and marital therapy as treatments for depression. IPT is recommended as an acute treatment for non-psychotic depression, to remove symptoms, prevent relapse and recurrence, correct causal psychological problems with secondary symptom resolution, and correct secondary consequences of depression. The guidelines state that medication alone may suffice to prevent relapse or recurrence, and to maintain remitted patients with recurrent depression.(1, 11)

Introduction and background

There is at present a crisis in the institution of marriage, at least in Western cultures. There has for some time been a tendency to idealize marriage, and at the same time social forces are operating which tend to undermine it. (1) These influences have probably made a contribution to the increasing divorce rate, as well as the tendency for fewer couples to marry, and have probably also led to an increase in the numbers of couples seeking help with their relationships. Couple therapy must be able to take account of these factors, and whilst much of what is contained in this chapter will relate to heterosexual married British couples living with their biological children, it should be understood that there are many other types of relationship which can be helped in a similar way with appropriate changes of emphasis.

Mixed or eclectic approaches

The first is the psychodynamic-behavioural approach of Segraves et al.(15) In this, the basic underlying cause of marital disturbance is assumed to be the partners' conflicting internal and unconscious projections, and their interactions. The therapy, however, is not only directed at helping them to understand these (as in psychodynamic therapy) but also to increase their negotiating and communicating skills (as in behavioural marital therapy). The third eclectic approach is that of Spinks and Birchler.(17) This is called behavioural-systems marital therapy, and makes use of behavioural marital therapy as the main form of intervention, moving into the systems mode when 'resistance' emerges. There are many similarities between this form of treatment and the one described in the main part of this chapter, but our 'behavioural-systems approach' is more integrated as between the two components of the method.

Assessment and selection

This is not an easy process, because there is a dearth of information about the types of couple problem presenting for treatment and on the outcome of treatment itself. In practice we select on the basis of the referral letter, resulting in allocation either to the couple therapy clinic, to an individual psychiatric clinic, or to a sexual dysfunction clinic. Some patients seem after perhaps one session to have been misallocated, and it is then possible to move them within the system to another clinic. However, this is a process which many patients find difficult to accept, and we try to do it as infrequently as possible.

The process of therapy beginning and continuing

Behavioural-systems couple therapy is essentially a short-term therapy involving about five to I0 sessions of 75 minutes each, over a period of 3 to 6 months. Although the therapy was developed in a room with a one-way screen, it is quite possible to use behavioural-systems couple therapy in any conventional consulting room without a team or live supervision. Before the first session the therapist and the team (which may include students as well as experienced colleagues) read the referral letter and the biographical questionnaires which the couple will have completed, and discuss the case with a view to formulating the problem from an interactional point of view. This may involve, for example, thinking about the couple's stage in the 'family lifecycle' (e.g. birth of the first child or the 'empty nest'), any recent event such as a bereavement or a new relationship, or the diagnosis of a serious illness. Hypotheses about the possible causation of the recent problems are not...

The course of therapy

Given the plethora of 'schools' of family therapy, as described earlier, it would be laborious to map out the course of treatment associated with each. Instead, we shall focus on the approach pioneered by the Milan group,(12) but we should stress that it has undergone much elaboration and refinement over 20 years. Our account below tends to highlight the original core features. First, we need to comment briefly on the different roles the therapist may assume.

Problems encountered in therapy

Missed appointments may punctuate the course of therapy, often linked to turbulent experiences between sessions or apprehension about what a forthcoming session may reveal. Like any psychotherapy, drop-out is possible. On occasion, this is appropriate in that the indication for family therapy was misconstrued. In other circumstances, drop-out is tantamount to failure and may derive from such factors as therapist ineptitude, unearthing of family conflict which they cannot tolerate, and inappropriate selection of family therapy based on faulty assessment. Finally, part of the family may harbour a secret that threatens the principle of open communication between members. The therapist may be inveigled into a subgroup, although it was stressed at the outset that keeping secrets is not conducive to the therapeutic process. For example, a wife calls the therapist to say she is having an affair and that she will not tell her husband, or children impose a burden on both therapist and the...

How Viruses Replicate

Some viruses do not cause lysis and ultimate destruction of their host cells which they infect. These viruses are called lysogenic phages or temporate phages. These bacteriophages establish a stable, long-term relationship with their host called lysogeny. The bacterial cells infected by these phages are called lysogenic cells.

American practice patterns

Presently, many work within the private not-for-profit and for-profit sector, predominantly as care managers and counsellors psychotherapists, rather than in the public sector. The move to private practice occurred during the 1970s and 1980s. It was seen as desirable for the purpose of professional autonomy and to enable the worker to be engaged in counselling and family therapy, at a time when less and less counselling was on offer within the public sector.

S Evidence statement

Trials compared the efficacy of kava extract (a herbal treatment) to placebo. All the trials showed superiority of kava extract, with any adverse effects being mild and transient.419 However, it should be noted that kava extract has been voluntarily withdrawn from the market because of fears of liver toxicity. A more permanent ban of kava extract is currently being considered by the MCA. The last review compared the effectiveness of group therapy, individual therapy, couple therapy and relaxation therapy in patients with a diagnosis of cancer who were at risk of developing anxiety. The results indicated that all the four treatments were superior to placebo, with psycho-education and group therapy being the most effective.*420

Integrating the components

During the intermediate phase of IPSRT, the therapist uses the IPT strategies discussed in Chapter 9 to resolve the interpersonal problem identified in the case formulation. In addition to helping the patient see connections between the problem area and mood, the therapist explores the impact of the interpersonal problem area on social rhythm stability and medication adherence. For instance, if the selected problem area is a role dispute with a spouse, the therapist will ask the patient about the marital conflict over the past week. If the patient reveals that his wife now insists that he drop the children off at school early in the morning (this had previously been the wife's responsibility), the therapist will explore both the impact of the new schedule on the patient's daily rhythms (Will he have to get up earlier Should he go to bed earlier Will this interfere with his morning dose of lithium ), as well as the interpersonal meaning of the event (How does the patient feel about the...

Family systems theories

The theories that we have considered thus far take as their starting point that disruption of function has taken place, and that this is the individual's problem. Family therapy has in some respects proposed that this is a case of mistaken identity. We say 'in some respects' because currently there is a wide diversity of emphases in family therapy and some will not be captured in this brief overview. A major influence on the analysis of psychological problems has come from systems theory and the work of Gregory Bateson (1971). It is agreed that disruption of function is a key issue, but that the disruption is only apparent. By analogy with the physician who may ascribe a tachycardia to the effects of altitude, systems theory and family therapy have led therapists to examine further sources of intentionality within a person's context. For instance a person may suffer from depression and there may be no apparent precipitants in the form of life events that involve loss or threat. We may...

Effects on parenting and the family

Mothers of children with mental retardation (learning disability) and severe sleep problems have been reported to be more irritable, concerned about their own health, and less affectionate towards their children, with less control and increased use of punishment than mothers of such children without sleep problems. (7) Similar associations have also been suggested between sleeplessness in toddlers in the general population and family problems, including marital discord and possibly physical abuse of the child.(8)

Parental physical illness

Parental cancer is likely to be associated with depression and marital difficulties, both risk factors for the child's problems. The balance of evidence indicates that their children are at increased risk of developing psychological disturbance (60) and lower self-esteem 61.) The impact of parental cancer on family communication and child outcomes may vary according to the child's developmental level, their gender, the presence of disability in the child, and the parent's level of psychological distress and marital discord 62,63)

Family interventions in the schoolaged years

There are several examples of comprehensive school-aged programmes, including the FAST Track programme (Families and Schools Together) (22 and the LIFT intervention programme (Linking the Interests of Families and Teachers). (23 The FAST Track programme targets children in early elementary school who are at risk of developing later conduct disorder and delinquent behavioural problems. Children and families receive a multifocused intervention package, targeting development across multiple domains, including peers, the school environment, academic achievement, and the family context. The family intervention integrates successful approaches to parent training with issues relevant to the development of school-aged children, including parent-school involvement and early reading. l22 Parents meet in groups weekly during the first school year and every other week in the second year. In addition, an hour of parent-child learning activity is also provided, which emphasizes positive...

Business Considerations

An outsourcing relationship for commercial manufacturing requires that when a sponsor decides to bring the product to an outsource organization, a long-term relationship is anticipated. The fate of the product is literally in the hands of the outsource organization. Once the outsource plant site is registered with the FDA in an NDA or ANDA, it is very difficult, disruptive, and costly to relocate the product. Because of this, both parties should anticipate a long-term business relationship. The financial strength of a contract manufacture is crucial. A review of the company's annual report will reveal the financial strength of the company. If the company is not publicly traded but is owned by a parent company, then the parent's financial strength should be reviewed. If the parent company is also not publicly traded a report on the company from a financial institution such as Dunn and Bradstreet (D&B) can be obtained. Other sources of financial viability are the company's bank and...

Clinical problems to be anticipated

In these and other presentations the visiting school psychiatrist will often find his or her work needs to combine individual counselling or therapy in privacy with liaison with others, for example key teachers or tutors, psychologists undertaking educational vocational assessment, or psychological therapies. A varying amount of work with the young person's family will be needed, either at the level of advice and the exchange of information, or as family therapy. In all this work an important skill is to determine how much psychiatric intervention is needed, and how much of another type of experience and skill (e.g. that of a tutor) will be helpful. Agreeing who is in the best position to do which part of the work is an important function of consultative work. (6,12,28

Parentcarer involvement

Parents and carers should be involved as partners in the management plan to avoid alienation of the family and to facilitate compliance with treatment. (73) Parent education and counselling regarding the nature of the mental retardation and associated emotional and behavioural problems may encourage the parents to cope with their grief, co-operate with management, and develop their own adaptive responses. Involvement of teachers and other carers also facilitates management. More specific family therapy exploring communication and patterns of interaction, conflict resolution, and beliefs may be helpful however, outcome research is required. (74 Parent involvement in the delivery of speech and physiotherapy and behaviour-modification programmes is indispensable. (75)

Sexual relationships marriage and parenthood

Long-term relationships and parenting children (at some stage) are generally considered to be an integral part of being an adult. In adolescence, emotional and sexual interest and needs develop, and it is at this stage that most young people start to have sexual relationships. However, in spite of a policy of normalization, people with mental retardation are seldom encouraged to develop intimate sexual relationships. Parents tend not to want it to happen, (1.8 and service managers and care staff, though they may not necessarily actively discourage it, often provide little opportunity, or privacy, to enable it to happen.

Family factors Childrearing

Other studies also show a link between delinquency and parental supervision, discipline, and attitude. In a Birmingham survey, Wilson ( .S followed up nearly 400 boys in 120 large intact families, and concluded that the most important correlate of convictions, cautions, and self-reported delinquency was lax parental supervision at the age of 10 years. In their English national survey of juveniles aged 14 to 15 years and their mothers, Riley and Shaw ( 5) found that poor parental supervision was the most important correlate of self-reported delinquency for girls, and that it was the second most important for boys (after delinquent friends). Also, in their follow-up of nearly 700 Nottingham children in intact families, Newson et al.( 6) reported that physical punishment by parents at the ages of 7 and 11 years predicted later convictions.

Parental conflict and separations

Many studies show that broken homes or disrupted families predict offending. In the Newcastle 1000-Family Study, marital disruption (divorce or separation) in a boy's first 5 years predicted his later convictions up to the age of 32 years. Similarly, in the Dunedin study in New Zealand, (21) children who were exposed to parental discord and many changes of the primary caretaker tended to become antisocial and delinquent. The same study showed that single-parent families disproportionally tended to have convicted sons 28 per cent of violent offenders were from single-parent families, compared with 17 per cent of non-violent offenders and 9 per cent of unconvicted boys.

Management of anorexia nervosa

The patient should be weighed at each visit. In individuals not previously overweight, weight loss of more than 25 of the previous body weight requires referral to a structured refeeding program in an inpatient or day treatment program. Outpatient psychological management is indicated for lesser degrees of weight loss. In amenorrheic patients, bone mass should be protected with hormonal replacement therapy. Psychological intervention may include a structured outpatient refeeding program, cognitive-behavioral therapy, individual psychotherapy, and or group or family therapy. Support groups may also be helpful.

Psychiatric treatment of young offenders

Research has shown mixed results from intervention by the justice or the social welfare system, or by mental health services. This has induced a negative academic discourse, to the effect that 'nothing works'. (37,81 This attitude is not justified by a careful reading of the literature. As Gordon et al.(82) point out it is not surprising that when a single approach is applied to a heterogeneous group of offenders the results are unimpressive. The judgement of Goldstein et al.(83) that almost everything works but only for certain youngsters is a more generous and probably appropriate reading of the literature. Cognitive and behavioural treatment models have been beneficial with juvenile delinquents in general though less is known about treatment of the subpopulation of serious offenders. (7 8 85 and 86) Individual therapy based on psychodynamic principles had a vogue, but such interpretive approaches tend now to be regarded as less effective than predominantly supportive therapeutic...

Mechanisms of Viral Pathogenesis

The mechanisms of viral pathogenesis are somewhat different than those observed in the interaction between bacteria and their hosts. First, viruses live only within the context of a cell. All viruses are parasites, according to our earlier definitions. However, we are seeing clear evidence that some viruses, endogenous retroviruses for example, have very long term relationships with their hosts even across generations. Thus, viral pathogenesis is more a matter of degree than it is with bacteria. The virus must recognize its host, enter the cell, find a way to utilize or subvert the physiological processes of the cell for replication, keep the host from recognizing and destroying the infected cell during viral replication, and then move to new cells or hosts. In carrying out these functions, many viruses damage host cells and induce inflammatory responses, causing the signs and symptoms of disease.

Challenges to Overcome for Long Term Success

The second challenge for an obese patient is the need to obtain social support or at least to understand how lack of social support can hamper the patient's weight loss success. How will significant persons in the patient's life respond to a thinner, typically more energetic, and frequently more attractive individual in place of the person who was obese, especially if the significant other person is obese as well It is not unusual for an obese spouse or key family member to become jealous or envious of the person who lost a large amount of weight. The significant person may be threatened by the patient's increase in self-esteem or the way others respond to that person as they lose weight. Either consciously or unconsciously, an individual may try to sabotage the patient's weight loss efforts. Statements like, I loved you just the way you were, or buying the patient foods high in calories as an expression of caring might be sending a message that change is threatening to the key...

Looking at Significant Stressors What Else Can Account for Somatic Symptomatology

Sometimes, distortions of reality are corroborated by two or more individuals because of the personality dynamics of their relationship. A narcissistic member of a couple may damn his masochistic counterpart for her failings, while the masochist sits in agreement. To an interviewer focused only on verbal report, the masochist is the problem and, therefore, the proper focus of treatment. Functionally, however, the masochist is what family therapists refer to as the identified patient, the scapegoat whose symptoms help a pathological system limp along. Both subjects distort reality at a level below conscious awareness. The influence of personality style factors in limiting the validity of information, then, extends across both the patient and other informants.

Genetics Of Sensation Seeking

Biometric studies of the genetics of personality and intelligence have used several methods including studies comparing identical and fraternal twins, adoption studies comparing children with biological and adoptive parents and siblings, and family studies of first degree relatives from intact families. The methodology for these studies is aptly described in the most recent edition of Behavioral Genetics (Plomin, DeFries, McClearn, & Rutter, 1997). The SSS V was given to the separated twins in the Minnesota study. The correlation for the identical twins separated during their formative years (Table 1) was .54 and that for separated fraternal twins was .32. The correlation of the identicals was not very different for those found in the Fulker et al. study of twins from intact families. Since the correlation between separated identical twins is the heritability it is 54 for the purely genetic factor. Because fraternal twins

Changing family patterns

Recent decades have seen massive changes in the pattern of many children's family lives. The most obvious markers are the dramatic increases in rates of ivorce, single parenthood, and step-family formation.(9) In the years immediately after the Second World War, just 6 per cent of British couples divorced within 20 years of marriage. By the mid-1960s that figure had increased fourfold recent estimates suggest that almost 40 per cent of all marriages begun in the 1990s will eventually end in divorce. On these projections, approaching a fifth of all 10-year-olds, and over a quarter of 16-year-olds, will experience the breakdown of their parents' marriage in childhood or adolescence. For most, this will be followed by a period in a single-parent household for a substantial minority, further family transitions will mean that they become part of a step family. In the early 1990s, almost one in five children in the United Kingdom lived with a separated single parent or in a step family. In...

Indications and contraindications

If there is a relationship problem identified by either the couple or their advisers, and the couple are willing to discuss and work on it, then in most cases they are suitable for behavioural-systems couple therapy. The breadth of the therapeutic approach, the fact that the behavioural techniques are of proven efficacy (see below), and the fact that the systemic interventions are suitable for those with more psychiatric symptoms or similar problem behaviours, all give the therapy a wide range of positive indications. Clearly those with relationship problems such as arguments and tensions are highly suitable for couple therapy. Another related indication is those relationships in which one partner (who might be attending a counsellor or psychiatrist alone) spends much time complaining about the absent partner's behaviour. A third indication is where the health of one partner suffers following the other partner's individual therapy. Many problems with sexual function would be suitable...

Conjoint IPT for depressed patients with marital disputes IPTCM

It is well established that marital conflict, separation, and divorce can precipitate or complicate depressive episodes (Rounsaville et al., 1979). Some clinicians have feared that individual psychotherapy for depressed patients in marital disputes can lead to premature rupture of marriages (Gurman & Kniskern, 1978). To test and address these concerns, Kler-man and Weissman developed an IPT manual for conjoint therapy of depressed patients with marital disputes (Klerman & Weissman, 1993). Both spouses participate in all sessions, and treatment focuses on the current marital dispute. Eighteen patients with major depression linked to the onset or exacerbation of marital disputes were randomly assigned to 16 weeks of either individual IPT or IPT-CM. Patients in both treatments showed similar improvement in depressive symptoms, but patients receiving IPT-CM reported significantly better marital adjustment, marital affection, and sexual relations than did individual IPT patients (Foley et...

The Case of Lenore Borderline Personality Disorder

Their parents had developed a strong relationship pattern over the more than 12 years of their marriage. The pattern was dysfunctional but comfortably familiar. Lenore's father was tough and distant, having poor regard for women. While always holding a job, he was a weekend drunk, becoming more argumentative and nasty as the weekend progressed. Most of his ire was taken out on his wife, but as the girls got older, they were included as objects of his frustration and rage. Lenore's mother would tolerate her husband's abuse, knowing that by Monday morning he would clean up and fly right again. She tried intermittently to protect the girls, but mostly she modeled helplessness and despair. On a few occasions when Lenore's father got especially out of control and the physical violence escalated, their mother took the twins to a cousin's house nearby for a day or two until the situation at home cooled off, at which point they would return home. The tacit rule was that no one would speak...

Systems therapy for couple problems

The systems approach to couple therapy derives partly from concepts developed by Minuchin ( 2) and Haley,(13) and partly from the work of Selvini Palazzoli et al.(14) All these pioneers worked predominantly with families rather than couples, but many of their ideas and techniques are relevant to the treatment of couples. Although the systems approach to therapy has broadened and deepened since the 1980s, many of the early concepts are still very useful.

The Case of the Cantankerous Couple How Does Personality Affect Couples

As part of her prepracticum class, Jenna observed an experienced psychologist interview a middle-age couple, who wanted to discuss their relationship and consider the possibility of divorce. The wife felt that she had no separate identity. She wanted to get a college degree and start her own career. Whenever she discussed it, however, she noticed that her husband became overcontrolling, long an issue in their marriage. Inevitably, any discussion of her attending school led to hostile argument, followed by long periods of uncomfortable silence, and an enduring irritability on both sides. After a stressful promotion at work that added to his duties, she noticed that her husband had become even more controlling than usual, which led to even more frequent arguments. His most frequently used interpersonal strategy was now the only one he could apply to their relationship.

Proliferation of schools

Things took a different turn in the United States. There, Ackerman(3) had introduced the idea of working with the nuclear family of a disturbed child using the methods of interpretive psychodynamic therapy. An interest in working with the family, including two or more generations, arose concurrently in several psychiatric centres during the 1950s. Most of the pioneers of so-called 'transgenerational family therapy' were analysts who used many of the concepts of object-relations theory which they recast into their own idiosyncratic language. Working with delinquent youths in New York, Salvador Minuchin and his colleagues recognized the relevance of systems-thinking to their interventions. The youngsters often came from financially impoverished, emotionally deprived families, headed by a demoralized single parent (most often the mother) who alternated between excessive discipline and helpless delegation of executive family responsibilities to a child or to her own disapproving parent....

The Interpersonal Perspective

As with all of the personality patterns, not all narcissists exhibit flagrant, obvious hallmarks of the disorder. At this point in your study of personality patterns, you are likely realizing that there is not a singular pattern for each disorder, but many admixtures likewise, the intensity of a disordered pattern ranges from muted to highly brazen. Our next case (see Case 10.3) concerns familial imbalance. Chase clearly demonstrates many aspects of narcissistic personality disorder and could be diagnosable as such, but he also is much less grandiose than Gerald or Leonardo. Chase and his wife are in family therapy because everything in their lives revolves around him. His wife admits that he is talented and imaginative, characteristics to which she was probably attracted from the very beginning. Now, however, she has realized that despite his good qualities, Chase is simply not emotionally available to her and takes her for granted in the relationship. This problem extends to the...

The Case of Toby Dependent Personality Disorder

Toby L.'s husband called the psychologist to schedule an appointment. I don't know if you want to see us together or just my wife. She's driving me absolutely crazy. I love her, but I'm really at the end of my rope here. She's crying in the next room even while I'm calling you. An appointment was set for the couple to come in. The clinician intended to meet with them together to identify if this would become a couples therapy case or an individual case, and, if so, who would be the identified patient. The couple therapy should be interspersed with the individual therapy, to direct and support positive changes. Their strengths as a couple would be validated and valued. Toby would need to be reassured that should she become less dependent (or more independent), she would not risk her husband's disapproval and thereby increase her fear of his abandonment (equated with less attention and less protection). As she is so concerned about his health and well-being (to ensure his availability),...

Alpf Medical Research Personality Disorders

Many of Benjamin's (1996) suggestions are rooted in the paradoxical approach to therapy, dividing the pathology against itself. By painting grandiosity as a need, it becomes incongruent with a self-image of strength and self-determination. The tendency of the narcissistic personality to externalize blame, according to Benjamin, can be countered by the therapist's taking responsibility for small errors. The narcissist thus sees a status person who is comfortable with his or her own human imperfections, with no need to project blame onto others. The therapist's model allows narcissists an avenue for escape from their early learning history, in which most were unconditionally praised for perfection and feel like utter failures if seen as lacking perfection. Other interpersonal strategies may also be effective. Couple and family therapy provide an opportunity for guided negotiation with significant others to help break patterns that support narcissistic behavior, leading to new and more...

Measurement and meanings

The original version of the Life Events and Difficulties Schedule was developed to study schizophrenic episodes (29,,30) and there has since been a large amount of research dealing with psychotic patients.(31) An early achievement was to make clear that the amount of change in activity as such brought about by a life event appears to be irrelevant and that the impact of events results from their meaning. (32 It has also been clear that some attention needs also to be given to ongoing difficulties that can either be brought about by an event (e.g. the death of husband leading to financial problems), or lead to an event (e.g. a marital difficulty eventually ending in a separation).

Major depression

Few disorders illustrate the interaction between genetics and environment more clearly than major depression. In Kendler's study of twins (21) he followed 2164 members of female-female twin pairs. Recent stressful events were the single most powerful risk factor for an episode of major depression. Genetic factors were substantial, but not overwhelming. He followed this cohort of subjects for 17.3 months. During that time 14 per cent of them had major depressive episodes. He found that the four most powerful predictors of a major depression in the month of the occurrence were death of a close relative, serious marital problems, assault, and


Outcome in opiate dependence is not unitary. It is a dynamic process with bio-psychosocial facets. Outcome parameters may include the individual's level of alcohol and drug use, his or her personal and social functioning, and the impact upon public health and safety. Figures will depend on the particular population of users that is followed up and on the level of intervention they received. Regarding treatment contact samples, what is clear is that longer treatment contacts are associated with better outcomes.(33 It is thought that methadone treatment has to continue for at least 2 years for significant gains to be made, although earlier health benefits may be seen. Generally, the greater the range of treatment services provided (health care, family therapy, cognitive-behavioural therapy, etc.), the better is the outcome. (34) Abstinence rates following treatment vary widely, but 10 to 40 per cent of treated patients would still be drug free at 6 months. (35) The majority of those who...

Letter 9 To C Lyell

I have no doubt that your father did rightly in persuading you to stay at Shrewsbury , but we were much disappointed in not seeing you before our start for a year's absence. I cannot tell you how often since your long illness I have missed the friendly intercourse which we had so frequently before, and on which I built more than ever after your marriage. It will not happen easily that twice in one's life, even in the large world of

Family environment

It is likely, however, that family environment also plays an important role in continuities. Some kinds of family adversity, such as marital discord, can be highly persistent (Richman et al., 1982 Rutter & Quinton, 1984), and there is growing evidence of the relevance of these factors to continuities of depressive disorders in young people. For example, Hammen and colleagues found a close temporal relationship between episodes of depression in children and episodes of depression in the mother (Hammen et al., 1991). Fergusson et al. (1995) reported that maternal depression was only associated with depressive symptoms in adolescent offspring insofar as maternal depression was associated with social disadvantage or family adversity. Depression in parents is associated with many problems that could lead to depression in offspring, including impaired child management practices, insecure attachment, poor marital functioning, and hostility towards the child (Cummings & Davies, 1994). Indeed,...


Suffering is invariably associated with pain, but suffering and pain are distinct and may occur independently. Suffering includes disruption of mood, thoughts, plans, and sense of well being. There may be economic distress, family marital problems, and various losses resulting from the impact of pain on the patient's life. Disruption of the sleeping cycle, anger, anxiety, helplessness, and the side-effects of medication may add to demoralization and increased suffering. To some extent the degree of suffering is related to the adequacy of the patient's coping skills. Patients who 'catastrophize' about their pain tend to suffer more than those who do not.


A symbiosis (siM-bie-OH-sis) is a close, long-term relationship between two organisms. Three examples of symbiotic relationships include parasitism, mutualism, and commensalism. Parasitism (PAR-uh-SIET-IZ-UHM) is a relationship in which one individual is harmed while the other individual benefits. Mutualism (MYOO-choo-uhl-iZ-uhm) is a relationship in which both organisms derive some benefit. In commensalism (kuh-MEN-suhl-iZ-uhm), one organism benefits, but the other organism is neither helped nor harmed.

Family factors

Two influential groups of family therapists (Minuchin at the Philadelphia Child Guidance Clinic and Selvini Palazzoli in Milan) have devised family models to explain the genesis of anorexia nervosa. Selvini Palazzoli(48 also identified abnormal patterns of communication within these families and in addition described abnormal relationships between the family members. She assumed that anorexia nervosa amounted to a logical adjustment to an illogical interpersonal system. But it remains uncertain whether these abnormal interactions are to blame for the illness or develop as a response by parents faced with a starving child. Careful therapists take pains to reassure parents at the commencement of family therapy ' we always find it useful to spend some time discussing the nature of the illness, stressing in particular that we do not see the family as the origin of the problem'.(49) Bruch(25) described girls who developed anorexia nervosa as 'good girls', who previously had a profound...

Family treatments

Family therapy and family counselling have already been discussed, but additional practical advice will now be given. Family therapy As in family therapy the parents are given direct advice on how to manage their daughter's eating problem. The patient herself is provided with individual educative therapy. The therapist provides counselling about abnormal attitudes to weight and emphasizes the weight issue until steady progress has been made. (123) This method is often preferred by the patient and her parents, largely because it is almost devoid of overt confrontation. It is also easier to gain access to the patient's fears and conflicts.


The person whose gambling has become pathological and the spouse partner should be encouraged to review their social relationships. In doing so, the involvement of a social worker can be helpful. This is especially so if there have been serious marital problems that predated the pathological gambling. In particular, the couple need to consider how they spend their spare time, what friends they cultivate, and what interests they pursue. It is often within specific settings that incitement to gambling has occurred in the past, and the couple need to make very careful arrangements to avoid such situations or, at least, to be prepared for them. They may be helped in achieving their objective if they draw up a joint contract, which spells out in detail those types of behaviour to be avoided as well as those to be encouraged. This needs to be reviewed regularly.

Postwar period

Based at the Maudsley Hospital after the Second World War, Foulkes gathered about him a small group of clinicians and others who developed his ideas and practices. Drawing on the ideas of Trigant Burrows, they called it group analysis and later established the Group-Analytic Society. Generations of clinicians went on to work or train with him at the Maudsley and elsewhere. His first book written in the heat of the Northfield experience, outlined the basics of his approach. A later text, written with James Anthony, has been in continuous publication ever since and remains one of the most widely read in the field. (33) Other publications followed and, with one of this paper's authors (MP) and other colleagues, training courses were established which lead to the founding of the Institutes of Group Analysis and Family Therapy, the Association of Family Therapists, and the Association of Therapeutic Communities. (34) There are now training courses in group analysis in many centres in the...

Couples groups

The group-analytic approach to marital problems in couples groups has been well developed over many years and was first described by Foulkes. ( 39) These groups cater for people in stable but troubled relationships in which there is some form of pernicious collusion. The approach can provide symptom relief and personality change in even severe difficulties with relationships that last but do not work. The husband of an anorexic or depressive, or the wife of an alcoholic or violent man, is often 'part of the problem'. As the symptom improves the relationship may deteriorate, and to 'protect' the relationship the symptom may be aggravated. Family therapy is concerned with the systemic function served by such symptoms. Psychoanalysis is concerned with the origins of these compulsions to repeat unsatisfying object relationships. Group analysis provides a bridge between these paradigms, helping therapists find a point of intervention between marital and object relationships.(l4 ) In a...

The family interview

The interview concludes with a summary of what has emerged. The clinician may wish to continue the assessment or may recommend family therapy at this point. If the latter, an explanation of its aim and rationale is then given. Arrangements are made for a follow-up session, purportedly the launch of the family therapy perse, but in essence a continuation of the 'work' already in progress.


In both these approaches, clinicians and policy-makers want to be able to identify individuals in a population, children in this case, who have a clinically important disorder. This necessitates the setting of a threshold or cut-off point above which children are said to have a disorder, and below which they do not. Thresholds, in the categorical approach, can be affected by factors such as changing the symptoms criteria for a disorder or changing the impairment criteria that must be fulfilled. The setting and justification of a threshold for the presence or absence of psychiatric disorder are critical issues in child psychiatry. Changing the threshold even slightly will have a noticeable effect not only on prevalence of disorders but on patterns of comorbidity and associated features. (Z 8 It is hoped that whatever threshold is set can be justified. Figure.2 illustrates the different patterns of the relationship between an associated feature (for example, marital discord or level of...


AD-HKD is associated with serious social, academic, and psychological difficulties at each stage of development. The quality of the social relationships of children with AD-HKD with their siblings, peers, parents, and other adults is poor as a result of their verbal and physical aggressiveness, inattention to social cues, and bias toward attributing hostile motives to others. (31 As a result, children with AD-HKD are rejected by others and treated in a controlling and negative fashion by their peers, teachers, and parents.(3233 Their families experience considerable stress, feelings of incompetence, and marital discord because of these behavioural problems. These children's parents tend to use coercive parenting strategies. Children with AD-HKD are more likely than their unaffected peers to live in families whose lives are disrupted by poverty, marital separation, and parental psychopathology. (3 35 and 36

Multimodal treatment

Recently, a large multisite treatment study in the United States compared drug treatment (mostly methylphenidate), drug treatment combined with an intensive psychosocial intervention (a combination of family therapy, social skills training, and classroom management), psychosocial intervention alone, and a typical community-based intervention in 576 school-aged children with AD-HKD. (160) All subjects received the same assessment, but those in the community-based intervention were referred to their family physicians for appropriate treatment. The results of this study demonstrated little evidence of an incremental effect of combined treatment over medication alone. The effects of psychosocial treatment, when administered without medication, were generally equivalent to those of a community-based treatment. Many children in the community-based intervention received medication, but they did not seem to progress as well as those who received medication managed by the study personnel. This...

Involving parents

The extent of parental involvement depends on the problem that is presented. There is a long history of parental involvement in the treatment of behavioural problems, where it may be crucial in ensuring that skills are transferred to the home. A typical programme is as follows. (38) Parents participate initially in educational sessions about the disorder and about its management. They then take part in group or family sessions about how to model and reinforce the skills that the young person is learning. The cognitions of the parents may then be examined. Parental beliefs about parenthood and attitudes towards the child may be crucial in determining the outcome of treatment. It seems, for example, that parents' models of their own parenting relationships predict the attachment that they will have to their children.(39) Negative attitudes towards the child, as shown by high levels of hostility and criticism, are highly predictive of outcome. (4Q It may be possible to work with the...

The Editors

The third section is concerned with psychological treatment. The main approaches to treatment are described here with chapters on counselling, cognitive-behaviour therapy, interpersonal psychotherapy, dynamic psychotherapy and psychoanalysis, large- and small-group therapy, couple therapy, and family therapy. There are so many methods of psychological treatment that it has been necessary to make some selection. For example, we have not included a chapter on hypnosis, which is used infrequently. Also the reader will not find sex therapy in this section it is described instead in Ch pteLl.11.2, along with the disorders of sexual function.


A number of systematic public education campaigns have been launched in recent years specifically to improve public perceptions and combat stigmatization in the mental health field. In the United Kingdom, the Royal Colleges of Psychiatrists and of General Practitioners launched a Defeat Depression Campaign in 1992 which aimed to increase public and professional awareness of depression and its treatment. (35) At the outset of the campaign, research had shown that most members of the public did not know what depression was. Many felt that physical illness was easier to sympathize with as it was easier to see. Most considered counselling the best way to treat depression and certain life events, such as bereavement, marital breakdown, and loss of a job, as most likely to cause it. Antidepressants were not clearly understood, and were clearly confused with tranquillizers and regarded as seriously addictive. Yet the survey did show that some 90 per cent of the public polled agreed that...

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