Comprehensive Treatment Model Research Articles

CHARACTERIZATION OF TRICHOTILLOMANIA: A Phenomenological Model with Clinical Relevance to Obsessive-Compulsive Spectrum Disorders

Multiple approaches to characterization of TTM have been developed, including categoric definitions and dimensional considerations. When TTM is viewed in the context of other disorders with common comorbidities and overlapping similar phenomenologies, such as OCD, body dysmorphic disorder, skin picking, TS, and olfactory reference syndrome, clinical approaches to assessment and differential diagnosis are more complex. This article presents a general overview of TTM included as a background for a heuristic clinical framework for assessing obsessive-compulsive spectrum disorders. A comprehensive behavioral model of TTM as a template is presented in the context of a broader, phenomenologic approach to assessment of several other disorders. These additional conditions were chosen on clinical grounds because they seem to share some phenomenologic characteristics with TTM. It is hoped that combining a phenomenologic approach to the differentiation of repetitive behaviors (as has been valuable in advancing the understanding of repetitive behaviors in TS and OCD), coupled with a paradigmatic comprehensive behavioral assessment and treatment model of TTM, may foster the validation of such approaches for other putative obsessive-compulsive spectrum disorders. Also, the relative intensity and frequency ascribed to the various behavioral and phenomenologic components of the conditions depicted represent clinical impressions, with varying degrees of empiric support, and require objective validation. This approach is meant to serve as a point of departure for clinical assessment of these complex, interesting, and sometimes incompletely diagnosed and inadequately treated conditions. It is hoped that empiric validation or refutation of this conceptualization will stimulate additional research and provide clinicians with a general framework for assessing patients suffering from these difficult conditions. For more information about trichotillomania, contact The Trichotillomania Learning Center (TLC), 1215 Mission Street, Santa Cruz, CA 95060 (831-457-1004; www.trich.org).

Dialectical behavior therapy: So far so soon.

While dialectical behavior therapy (DBT) has created widespread interest and has achieved a degree of popular acceptance, there is a relative paucity of research to support its effectiveness. However, even without strong empirical backing the model has already had an important positive influence on a wide range of interested clinicians. DBT is a comprehensive and well-defined treatment model that holds much promise. However, its enthusiastic acceptance by the professional community should not distract researchers from objectively examining both the process and outcome dimensions of the model.

A comprehensive model for behavioral treatment of trichotillomania

Trichotillomania is a disorder characterized by repetitive pulling out of one's hair. In this paper, we explore the essential elements for effective treatment and propose a comprehensive model for behavioral intervention. Individualized, focused treatment proceeds through four phases: First, a functional analysis is conducted that garners information about critical antecedents, behaviors, and consequences of hair pulling. Next, this information is organized into cognitive, affective, motoric, sensory, and environmental modalities. Then, specific treatment strategies are selected and implemented to target critical maintaining factors through relevant modalities. Finally, evaluation and modifications are made as necessary. The potential advantages of this approach are discussed, as are its limitations.

Short-term outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients

The aims of this study were to determine whether detection of major depression in primary care was associated with improved outcome, and to compare the 4.5 month outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients. Primary care patients with major depression were recruited from the practices of 50 family physicians in Southeastern Michigan using a two-stage selection procedure employing the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Structured Clinical Interview for DSM-III-R (SCID); clinician detection of depression was ascertained by response to a direct query on a rating form. Depressed patients seeking treatment in an outpatient psychiatric setting also received the CES-D and the SCID. Data on patient demographics and clinical characteristics were obtained for both primary care and psychiatric patients. Initial and 4.5 month scores on the Hamilton Depression Rating Scale (HAM-D) were obtained for 34 undetected and 25 detected depressed primary care and 55 depressed psychiatric patients. Improvement in depression over time was assessed by the change in HAM-D scores over the 4.5 months. The three groups did not differ in initial severity. Both psychiatric and undetected primary care patients showed significant improvement at 4.5 months, whereas detected primary care patients did not improve. At 4.5 months there were no differences in mean HAM-D scores between undetected, depressed primary care patients and depressed psychiatric outpatients. This result did not change after controlling for age and severity of depression at initial presentation, nor did it change after exclusion of cases of mild depression to control for a possible “floor effect.” However, differences among groups in the stage of depressive episodes may have affected this comparison. These findings suggest that an exclusive focus on increasing detection of depression in primary care patients is unlikely to improve outcomes, and that undetected depression among primary care patients does not necessarily represent poor quality of care. Although depressed psychiatric patients in this study had better outcomes than detected depressed primary care patients, the presence of unmeasured differences among groups in the stage of the depressive episode makes it impossible to determine whether treatment of depression by psychiatrists is superior to that provided by primary care physicians. These findings should stimulate efforts to examine a more comprehensive model for detection and treatment of depression in primary care.

Integrating individual and public health perspectives for treatment of tobacco dependence under managed health care: A combined stepped-care and matching model

There is an increasing momentum to integrate prevention into mainstream health care. Three decades of research on tobacco dependence can provide insights into the conceptual, clinical, economic, and service delivery challenges to such an integration. Biological sciences, cognitive-behavioral, clinical treatment outcome, and public health arenas are selectively reviewed. The key conceptual issues are explored relevant to the optimal delivery of quality smoking cessation treatments for the general population of adult smokers at reasonable cost. A comprehensive model for adult smoking cessation treatment is developed. The model consists of an overarching public health approach, focusing on enhancing motivational level from low motivation to quit to high motivation. A common outcome metric of overall impact is proposed to facilitate comparisons between clinical and public health interventions. Smokers are then assessed and triaged into one of three treatment steps of minimal, moderate, and maximal intensity and cost. Smoker individual differences at both the population and individual level are also taken into account as part of a tailoring or matching strategy within and across the stepped interventions. Smoker profiles include sociocultural, nicotine dependence, and comorbidity factors. The result is a hybrid stepped-care matching model. The model serves to illustrate some of the needs and challenges facing future tobacco dependence research and practice. Comparisons are made between tobacco control and other preventive medicine practices in terms of cost per quality adjusted life-year saved. The barriers and opportunities under managed care are explored. The conceptual principles identified here could be used as a guidepost for integrating other preventive medicine programs into the evolving managed health care system.

Issues in the treatment of depressed children

Basic research into the cognitive, behavioral, familial, and physiological disturbances associated with depressive disorders during childhood is reviewed. Implications for the development of a treatment program are discussed and a comprehensive treatment model is proposed. The proposed model includes intervention strategies for the child, parents, family, and school. The child component consists of intervention strategies for the affective, cognitive, behavioral, and physiological disturbances that are evident from the existing research. The parent training component is designed to address disturbances in parenting due to cognitive disturbances and skills deficits. The family therapy component emphasizes changing interaction patterns that communicate schema-consistent maladaptive interactions. A school consultation component is proposed in which school personnel support the skills training through prompting use of the skills and reinforcement of the use of the coping skills.

Themes and Variations among Seven Comprehensive Perinatal Drug and Alcohol Abuse Treatment Models

In recent years, the prevalence of perinatal chemical dependency has become widespread, .crossing all ethnic and racial lines and every socioeconomic group (Chasnoff, Landress, & Barrett, 1990). Its potential effect on the health of women, children, families, and society has prompted support at the state and federal levels for comprehensive perinatal drug and alcohol treatment models (California Legislature, 1990; Doshan & Bursch, 1982; Graham & Timney, 1990; Jessup & Green, 1987; Novick, 1990; Reed, 1987; U.S. General Accounting Office, 1990). In California, legislation was enacted that funded a novel interdepartmental partnership within the California Health and Welfare Agency. The four agencies involved in this collaborative effort, called Options for Recovery (OFR), were the departments of Alcohol and Drug Programs, Developmental Services, Health Services, and Social Services. The OFR program provided comprehensive perinatal services to more than 2,600 individual pregnant or parenting women at seven pilot sites in both urban and rural parts of the state. The primary OFR program services included case management, residential and intensive outpatient treatment, perinatal medical care, and foster care services. These services were provided in a women-focused, women-sensitive manner to an ethnically and culturally diverse client population. The OFR program also emphasized coordinated service linkages both to prevent service duplication and to ensure that potential service gaps were not left unfilled. A state interagency task force, composed of representatives from the four collaborating state agencies responsible for the OFR program, was established to develop a statewide strategy for addressing the substance abuse treatment needs of pregnant and parenting women and their children. At each of the seven pilot sites, a local lead agency, accountable to the state, was given primary responsibility for implementing the OFR program. The management teams of each pilot project, which at a minimum consisted of alcohol and drug treatment program representatives and case management staff, reported to the local lead agency. Line staff who had ongoing responsibility for providing services for clients included drug and alcohol counselors, case managers, child development specialists, child care workers, parent educators, foster parent recruiters and trainers, mental health workers, and any other service provider that was part of the pilot's OFR program. An evaluation of the OFR program was conducted from 1991 to 1993. On the basis of information obtained through interviews, surveys, and focus groups with OFR staff, clients, and foster parents at all seven pilot sites, as well as quantitative data, the author identified a number of similar treatment and service themes and variations across all seven sites. This article describes both the commonalities and the differences observed during the course of the three-year evaluation. METHODS Qualitative Staff Data In-person interviews were conducted with members of the OFR State Interagency Task Force, staff from both the California Department of Alcohol and Drug Programs and alcohol and drug treatment programs at the local pilot project level, staff from each pilot's local lead agency, managerial and program staff at all pilot sites, foster parent recruiters and trainers, and county social services agency administrators. Interview questions focused on descriptive program information, program philosophy, indicators of success, service provision, staffing, interagency coordination, and program implementation. Program personnel at all seven pilot projects were also surveyed via self-administered, semi-structured survey questionnaires. The survey questions addressed the same issues as the interview as well as professional training and time management. Focus groups were conducted at 18 randomly selected provider sites from the pool of 73 treatment providers that participated in the OFR program. …

Feeding Disorder and Failure to Thrive

A critical overview of failure to thrive and feeding disorder is followed by a presentation of the physiology of the feeding process in infants. The relationship between impaired feeding and behavioral and interactional difficulties is explored. A comprehensive assessment and treatment model is illustrated by a case presentation.

Outcome measures of clozapine treatment within a comprehensive treatment model

Outcome measures of clozapine treatment within a comprehensive treatment model

Impediments to comprehensive treatment models for substance-dependent women: treatment and research questions.

A number of factors need to be addressed in order to provide efficacious treatment for drug-dependent women, particularly those who are opioid dependent. If left unaddressed, these factors may reduce the effectiveness of treatment. In addition, evaluation research frequently overlooks the impact of these factors in methodological approaches examining treatment outcomes. This article discusses several of the problems brought to treatment settings by women, considers how these problems impact on current treatment models, examines alternative research approaches to evaluating treatment for women, and focuses on three critical factors regularly overlooked in treatment provision and in research related to women: (1) broader issues of dependency in women; (2) the impact of chaotic early interpersonal relationships on developmental levels; and (3) diagnostic criteria and treatment goals appropriate for women. It attempts to provide an understanding of the impact of these three elements on treatment and on research methodologies in order to provide and evaluate comprehensive and effective treatment for drug-dependent women.

A Comprehensive Approach to the Treatment of Gender Dysphoria

After a brief historical review of the clinical management of gender dysphoria, the authors argue for a comprehensive treatment model that recognizes a wide spectrum of gender identity disorders. This treatment model explores the meaning of a gender dysphoric individual's desire for sex reassignment in the context of the individual's biography and psychosociosexual adjustment. Unlike previous treatment approaches, this model makes no attempt to identify the 'true' transsexual. The model's treatment tasks are: assessment, management of comorbid psychiatric disorders, facilitation of identity formation, sexual identity management, and aftercare. The implications of this treatment model for classification and ethical standards of care are discussed.

Drug Use in Pregnancy: Mother and Child

The crack cocaine crisis has greatly increased the need for the health care practitioner to have an understanding of the identification and management of the substance-abusing mother and the approach to the follow-up of the drugexposed infant. The management of the substanceabusing mother includes evaluation of many factors: the complex interaction of drugs, including cigarettes and alcohol; often the lack of prenatal care; inadequate nutrition; mood disorders; and the possible involvement of sexually transmitted diseases. Care of a drugexposed infant requires diagnosis of the physical injury and sensitive follow-up techniques to monitor potential developmental delay. Drug Use in Pregnancy: Mother and Child introduces a comprehensive treatment model used at Northwestern University. Editor Ira Chasnoff, MD, has organized the 13 chapters around the Perinatal Services Project, a comprehensive treatment model for drug abuse during pregnancy. The 18 contributing authors describe the individual areas of risk, such as pharmacology, recognition, management, mother-infant

Neurobehavioral Treatment for Cocaine Dependency

Relapse prevention techniques have recently been incorporated into some nonpharmacologic models of chemical dependency treatment. The neurobehavioral model of cocaine dependency treatment establishes a clear timetable for recovery from cocaine dependency and focuses on four distinct areas of functioning. Strategies for addressing these areas of functioning include the use of relapse prevention methods and individual therapy procedures, family systems materials, 12-Step involvement, and urine testing. The model constructs a comprehensive framework for facilitating involvement in recovery activities that promote positive behavior change. The relapse prevention group component of the model is described, the use of a systematic relapse analysis procedure is presented, and an outline of plans for evaluating the model is discussed. The development of a comprehensive outpatient treatment model for treating cocaine dependency provides a standardized structure within which other treatment interventions (e.g., medication, acupuncture) could be evaluated.

'There ain't Nobody on My Side': A New Day Treatment Program for Black Urban Youth

Black, inner city, indigent youth present clinicians with an array of psychological, educational, social, economic, and behavioral problems that defy traditional treatment methods. City Lights is described as a comprehensive day treatment model that has the potential to succeed with high-risk youth. The program utilizes a self-paced computer-assisted education program within the context of a therapeutic community. Innovative strategies have been developed to accomplish both academic remediation and emotional development. Academic competence is seen as an essential component of psychological well-being.

Abused and Non-Abused Children's Perceptions of Their Mothers, Fathers and Siblings: Implications for a Comprehensive Family Treatment Plan

Utilizing the findings of a research project identifying family perceptions of abused children and their siblings, the author proposes a comprehensive treatment model for abusive families. Because the abuse affects all of the members of an abusive family, it is argued that the entire family system must be assessed and treated. A three-phase comprehensive assessment and treatment model is proposed that includes not only individual, marital, and sibling dynamics, but also family dynamics. This combination of treatment approaches culminates in conjoint family therapy and completes the comprehensive plan for working with abusive families.