Crisis Intervention - Theory An - Aguilera, Donna C

CRISIS.
NAM SAYING WO)

Theory and Methodology
Eighth Edition
CONTENTS
1. Historical Development of Crisis Intervention Methodology, 1

2. Differentiation Among Psychotherapeutic Techniques, 13
5. Problem-Solving Approach to Crisis Intervention, 26
4. Legal and Ethical Issues in Psychotherapy, 43
> Posttraumatic Stress Disorder and Acute Stress Disorder, 62
6 . Violence in Our Society, 76

7 . The Psychological Trauma of Infertility, 122
8 . Situational Crises, 138
2 . Life Cycle Stressors, 186
10. Substance Abuse, 221
11. Persons With AIDS/HIV, 240
12. Burnout Syndrome, 265
Postscriptum, 283
APPENDIX A
Disciplinary Key, 285
APPENDIX B
Descriptive Terms Applicable to a Mental Status
Examination, 287
APPENDIX C
Infertility Resources, 289
APPENDIX D
Completed Case Study Paradigms, 293
APPENDIX E
Authors Quoted in This Book, 315
CRISIS
INTERVENTION
INL
v
- ABOUT THE COVER

The Chinese pictograms shown on the cover
symbolize crisis, through the juxtaposition of figures
that traditionally represent danger and opportunity.
They were graciously supplied by Peter Berton,
Professor Emeritus, University of Southern Califor-
nia School of International Relations, and member
of the Far Eastern Society of Southern California.
CRISIS
INTERVENTION
DONNA C. AGUILERA, PHD, FAAN, FIAEP

Disaster Mental Health Services, American Red Cross
Consultant and Private Practice
Beverly Hills and Sherman Oaks, California
Eighth Edition
with 57 illustrations
NA Mosby
An Affiliate of Elsevier
135407
NA Mosby
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Associate Developmental Editor: Jeff Downing
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Cover Art: Jacob Shapiro
Pe ¢c
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FOREWORD
Biological evolution has prepared humans to survive even in the most challenging
of life’s threats and traumas, both physical and psychological. We have learned,
however, that the alarm reaction, first described in full detail by Hans Selye during
the 1940s, is associated with trauma and threats of trauma by the flow of stress
hormones and neurotransmitters and also with other rapidly changing bodily
physiology that, if unmodulated, can produce illness (physical or emotional) from
overreaction to trauma. We also now know that trauma and threat of trauma can lead
to changes in the immune system, which may operate against survival if such changes
are unmodulated. Oftentimes, the threat of trauma can be more devastating than the
actual trauma itself, especially in the cases of children (for example, in the witnessing
of home violence) and anyone else who is helpless and is without well-timed social
and psychological support when the trauma threat occurs.
Humankind’s physical and psychic survival require both physical and emotional
supports from others in the environment. This modulating influence from the
environment is a part of our biological and social heritage. Humans are social
mammals and are predisposed toward social responses to others and integrated joint
activity, ensuring survival of the species. This social predisposition toward shared
experience in humans makes it possible for an individual suffering pain, trauma or
distress, or threats of these traumas to be understood and acknowledged directly or
intuitively by another person. Thus one person’s pain and trauma or threat becomes
a shared threat or a shared trauma for others in the community.
Even before the days of technically equipped emergency services, “911,” the
lines and
paramedics, mountain rescue teams, as well as the crisis intervention hot
professional societies mobilized to respond to massive trauma in the community
saved
(referred to in this volume), the lives of many men, women, and children were
noticed and responded to them and provided a safe haven and a
because someone
before
protective environment for the person in trouble or threat. What was provided
ed methods of life-saving technology was primarily psycho-
our more sophisticat
by our
logical, together with warmth and protection. Such support provided
now know why it
unsophisticated ancestors worked then and still works now. We
environment
works, which is because a supportive psychological and physical
and the mind to a
actually does modulate the overreactive responses of the body
and does not escalate
trauma or threat; thus the feeling of helplessness is diminished
example, during a
into an exaggerated, nonadaptive ilIness-producing response. For
was stung on the finger
recent backpacking trip to the high Sierras, one of our party
dying and not
by a wasp. Her whole hand began to swell, and she was frightened of
were applied
easily reassured, even after she received some Benadryl and cold packs
who had also been
to the hand. Luckily, we met a pleasant, uniformed forest ranger
viii Foreword
attacked by a swarm of wasps when he inadvertently disturbed their nest on the forest
floor. He told us of his experience and of his recovery and reaffirmed the correctness
of the treatment given and indicated further that the danger period for more
complicated events had now passed.
Appropriate response to a crisis in the present helps individuals clearly distinguish
between a minor stress and an impending catastrophe in the future. Learning to make
this distinction is extremely important for each individual and can be helped by an
understanding person who is knowledgeable and helpful to a person who has been
traumatized. Making this distinction then prepares the person to truly emerge from
the present situation with knowledge and understanding, such that the anxiety signal
that alerts the person to a danger then also brings to mind the appropriate response
to the danger, taking into account its magnitude. Not all dangers are of equal
magnitude. A modulated response is required.
The helping professions must have and must be able to convey to others their
presence and emotional availability in a timely fashion to the person in crisis.
The professional must be able to understand the peculiar nature of each individual
in crisis and out of such understanding must be, able to help the patient gain
hope and increased confidence in being able to survive the crisis. Another important
asset of the professional is the capacity to understand that the person himself
contains the forces that can lead to recovery. The implication is that the helping
person helps the traumatized individual see and understand how to make use of
his most strongly developed coping capacities. Well-timed warmth, caring, love,
information leading to understanding, good communication, and the capacity of
the injured party to distinguish between a minor transient incident and a more
serious long-term incapacity provide a powerful holding environment that allows
the individual to recover, even though temporarily overwhelmed with feelings of
helplessness.
Many people have gone through traumatic experiences during their formative
years without remembering such experiences. Overreactions later on to a faintly
similar experience can be understood as a maladaptive response to the actual present
reality, including the tendency to provoke and repeat the traumatic experience.
Unrecognized posttraumatic effects coming late on the heels of earlier trauma are
sources of considerable pain, suffering, and maladaptation in adolescent and adult
life. They are the result of poorly resolved early traumatic experience, inadequately
responded to by the environment, and with an inadequate convalescence of the
person from the traumatic experience. Convalescence after any illness or trauma is
the most important variable that determines whether the illness becomes chronic or
whether it becomes fully resolved. It is worth pointing out here that life is full
of
eu traumas (health-producing traumas), which were fully incorporated in Selye’s
theory of adaptation in the fifties. A recent well-controlled study by Andrews
and
others (1993) shows that students going to foreign countries under AFS International
Exchange programs show a long-term decline in vulnerability to neurotic symptoms
as compared with a well-matched control group. Parmalee (1993) has
written on the
importance of helping families of young acute and chronically ill
children adapt to
situations such as being in the hospital, experiencing crisis, and
preparing for
potentially traumatic surgeries, emphasizing that successfully traversing
these rather
Foreword ix
common potentially traumatic situations in childhood actually leaves the child and
family in a stronger, more resilient psychological state.
Human beings inherently strive to attain new understanding and new meaning in
every life experience. New meaning is critical for recovery from trauma and helps
prevent the long-term consequences of repressed traumatic experience. Many cases
of posttraumatic stress disorder have been hidden by this repression for many years.
This book will be a valuable resource for those who help or who want to help.
It will soon be learned and acknowledged by anyone in the field, however, that
helping is not as simple as it might seem on the surface. Sometimes “help” can add
to distress and trauma rather than lead to a resolution of it. The complexity of both
conscious and unconscious motivations of the persons providing help should be
required as part of the training of anyone espousing skills in helping others. This book
will help individuals achieve that kind of understanding. Insight, however, is a long,
hard, and difficult road. The working through of insight in the helping professions
requires constant vigilance and continuing psychological work.
Justin D. Call, MD
Newport Beach, California
University of California, Irvine
REFERENCES
Andrews G, Page AC, Neilson M: Sending your teenagers away: controlled stress decreases
neurotic vulnerability, Arch Gen Psychiatr 50:585, 1993.
Parmalee AH: Children’s illnesses and normal behavioral development: the role of care giver,
Zero to Three 13(4):1, 1993.
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PREFACE
The eighth edition of this text acknowledges the fact that crisis intervention is being
widely used by those in the helping professions. Individuals from all walks of life
and age groups and with diverse problems and varying cultural backgrounds have
responded to the skilled use of crisis intervention. It is being used by professionals
and nonprofessionals with a wide range of skills.
It was felt that there was still a need for an overview and a guide to crisis
intervention, from its historical development to its present utilization. The techni-
ques and skills of a therapist must be learned and practiced under professional
supervision. However, it is believed that an awareness of the basic theory and
principles of crisis intervention will be valuable to all who are involved in the
helping professions. This book should be a particularly meaningful mode of
intervention for those who have constant and intimate contact with individuals
and families in stressful situations (those who seek help because they are unable to
cope alone and situations that may be biological, sociolcgical, or psychological in
origin).
Chapter 1 presents the historical development of crisis intervention methodology.
Its intent is to create an awareness of the broad base of knowledge incorporated in
its present practice. Looking to the future, a discussion of potential crises that may
result from society’s technological advances is new to this edition.
Chapter 2 deals with the differences between psychotherapeutic techniques of
psychoanalysis and psychoanalytic psychotherapy and between brief psychotherapy
and crisis intervention methodology. It presents the major goals of these methods of
treatment, foci, activities of the therapist, indications for treatment, average length
of treatment, and the approximate cost to the individual. New to this chapter is the
introduction of cognitive therapy and its utilization in crisis intervention with
depressed patients.
Chapter 3 introduces the paradigms and illustrates their utilization in case studies.
It focuses on the problem-solving process and introduces the reader to basic termi-
nology used in this method of treatment. The paradigm clarifies the sequential steps
of crisis development. Two case studies, with paradigms, illustrate its application as a
guide to the case studies that are presented in subsequent chapters. New to this
chapter is a discussion of the biophysiological components of stress, since individuals
in crisis are under stress.
Also new to this edition are blank paradigms for the reader to complete for each
case study in the text. The reader can then compare that paradigm with completed
paradigms that are presented in Appendix D to evaluate his knowledge of crisis
and
intervention. It is hoped that this interactive method will prove useful in learning
applying knowledge about the crisis intervention process.
xi
xii Preface
Chapter 4 discusses the legal and ethical issues inherent in psychotherapy.

Discussed are the legal aspects of malpractice. Sexual harassment is presented as it
is related to psychotherapy and the relationship between the therapist and patient.
A case study is presented that demonstrates the use of crisis intervention techniques
in a case of sexual harassment. The first paradigm for the reader to complete
accompanies this case study.
Chapter 5 presents posttraumatic stress disorder and, new to this edition, acute
stress disorder. The American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV) criteria places these two disorders in separate
categories. They are presented here to clarify and distinguish between them. A case
study is included with a paradigm for the reader to complete.
Chapter 6, Violence in Our Society, is a new chapter that discusses concerns that
individuals and therapists are confronted with daily: child abuse and neglect, violence
in the home, violence in schools, and elder abuse and neglect. Case studies and
paradigms are presented for each issue discussed.
Chapter 7, the Psychological Trauma of Infertility, is also a new chapter.
Individuals are reluctant to discuss this topic with those who have had one or several
spontaneous abortions (“‘miscarriages’’). Infertility is presented as a life crisis.
A case study and paradigm are included.
Chapter 8 deals with stressful events that could precipitate a crisis in individuals
regardless of socioeconomic or sociocultural status. These events include role and
status changes, rape, physical illness, Alzheimer’s disease, and suicide. Case studies
based on factual experience are presented to illustrate the techniques used by
therapists in crisis intervention. Theoretical material preceding each case study is
presented as an overview to the crisis situation.
Chapter 9, Life Cycle Stressors, presents stressors that occur during concomitant
physiological and social transitions: prepuberty, adolescence, adulthood, and old age.
Case studies are included with appropriate theoretical material.
Chapter 10 is a new chapter that is devoted to substance abuse. It includes the older
and better known substances such as marijuana, heroin, and cocaine, as well as the
newer “designer” drugs that are cheap and easy to obtain or manufacture but that
can be deadly. A case study is presented. There is also a section that addresses the
abuse and misuse of prescription drugs by the elderly and its consequences.
Chapter 11 delineates the concerns of the public toward individuals who are
HIV-positive or who have AIDS and emphasizes the increase of this disease in youth,
women, and those who do not use drugs. Two case studies are presented.
Chapter 12 is devoted to the burnout syndrome that occurs frequently in
high-stress work situations. Theoretical material is presented, as well as a case
study
about a nurse who works in a hospice.
Postscriptum. According to Webster’s dictionary: “A postscript is a note...
appended to a completed letter, book or the like.” The postscript
in this text is for
me, as the author, to share with you, the reader, my thoughts, feelings,
and beliefs
regarding the future of patients and mental health professionals as
we approach the
twenty-first century.
Five appendixes have been added to this edition to provide key
information that
supplements text content. Appendix A is a key of terms used
in legal disciplinary
Preface xiii
hearings. Appendix B contains terms associated with the mental status examination.
Appendix C is a detailed list of organizations and other resources for couples dealing
with infertility. Appendix D provides completed paradigms for each case study that
the reader may consult after filling out the blank paradigm in each chapter. Appendix
E is a register of authors quoted in this book.
Acknowledgments
I am greatly indebted to many individuals who have been of direct and indirect
assistance in writing this edition. I wish to specifically thank the following
individuals for their roles in bringing this manuscript to fruition:
My editors, Jeff Burnham, for his enthusiasm and encouragement, and
Linda Caldwell, for her patience and understanding.
Cheryl Abbott Bozzay, Production Editor, and Jeff Downing, Associate Devel-
opmental Editor, for their expertise, wisdom, and knowledge.
Yael Kats, Designer, for creating such original artwork and a wonderful cover.
Dorothy and Norman Karasick (well-known writers), two very special friends
who were always there when I needed them. They gave me advice about
content, grammar, and my Macintosh.
Leslie Moffett, who typed the rough and completed drafts and edited as
needed. If not for her, this manuscript would not have been completed.
Laurel Stine, my research assistant, for all her efforts and the help she
provided.
Peter Berton, for providing me with the Chinese pictographs to use on the
cover of the book.
Janice Messick, former co-author, especially for her moral support and contin-
ued friendship.
Justin D. Call, MD, well-known and famous child psychiatrist. (It is a particu-
lar honor to have him write the foreword. Our collegial friendship goes
back many happy years.)
To my family, who are still my kindest critics and strongest supporters, for letting
me take time away from them to write, I owe a very special debt—my eternal love.
Donna Conant Aguilera
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CONTENTS
1. Historical Development of Crisis Intervention

Methodology, 1
Historical development, 2
Evolution of community psychiatry, 5
Crises related to technological advances, 8
Signs of an on-line addict, 9
2. Differentiation Among Psychotherapeutic

Techniques, 13
Psychoanalysis and psychoanalytic psychotherapy, 13
Brief psychotherapy, 16
Crisis intervention, 18
Methodology, 18
Steps in crisis intervention, 20
Use of cognitive therapy in crisis intervention, 21
Summary, 23
3. Problem-Solving Approach to Crisis Intervention, 26

Factors affecting the problem-solving process, 27
Problem solving in crisis intervention, 29
Assessment of the individual and the problem, 29
Planning therapeutic intervention, 31
Intervention, 31
Anticipatory planning, 32
Paradigm of intervention, 32
Balancing factors affecting equilibrium, 35
Perception of the event, 35
Situational supports, 36
Coping mechanisms, 37
4. Legal and Ethical Issues in Psychotherapy, 43

Therapeutic jurisprudence, 44
Limits of therapeutic jurisprudence, 45
Alliance of mental health law and care, 46
Legal and ethical defined, 47
Legal issues, 48
xv
xvi Contents
Duty to warn, 49
Legal and ethical consequences of therapist malfeasance, 50
Sexual harassment, 52
Case study: therapist-patient involvement, 55
. Posttraumatic Stress Disorder and Acute

Stress Disorder, 62
Posttraumatic stress disorder, 62
Symptoms of PTSD, 63
Special needs of children with PTSD, 65
Acute stress disorder, 66
Treatment of stress disorders, 68
Physiological reactions, 70
Case study: posttraumatic stress disorder, 71
_ Violence in Our Society, 76

Child abuse and neglect, 77
Incidence and prevalence of child abuse and neglect, 78
Dynamics of child abuse and neglect, 79
Case study: child abuse, 85
Violence in the home, 93
Violence in “new” families, 95
Dynamics of violence in the home, 96
Case study: battered spouse, 97
Violence in the schools, 102
Discipline as an exercise of power, 103
Alternative approaches to school violence prevention, 105
Case study: violence at school, 106
Elder abuse and neglect, 109
Types of elder abuse and neglect, 109
Documentation of elder abuse and neglect, 111
Characteristics of abusive caregivers, 111
Case study: elder abuse, 115
. The Psychological Trauma of Infertility, 122

Infertility as a life crisis, 123
The emotional state of the infertile couple, 123
The affective stages of infertility, 124
Miscarriage and stillbirth, 126
Psychotherapy and infertility, 128
Psychosocial therapy, 129
Determining the cause of infertility, 131
When someone you know miscarries, 131
Case study: infertility, 132
Contents xvii
8. Situational Crises, 138

Defining situational crises, 138
Status and role changes, 139
Case study: status and role changes, 141
Rape, 144
Rape defined, 146
Fear and anxiety, 147
Depression, 147
Case study: rape, 148
Addendum, 151
Physical illness, 152
Case study: physical illness, 157
Alzheimer’s disease, 161
Case study: Alzheimer’s disease, 167
Suicide, 172
Suicide in adolescence, 172
Suicide in midlife, 174
Related factors, 175
Case study: suicide, 179
. Life Cycle Stressors, 186

Prepuberty, 187
Case study: prepuberty, 188
Adolescence, 193
Case study: adolescence, 196
Adulthood, 199
Case study: adulthood (motherhood), 202
Case study: adulthood (menopause), 207
Old age, 211
Case study: old age, 214
LO: Substance Abuse, 221

Marijuana, 222
Heroin, 223
Methamphetamine, 224
Designer drugs, 225
Rohypnol, 225
Gamma hydroxybutyric acid (“‘scoop” or GHB), 226
Inhalants (the silent epidemic), 226
Substance abuse in the elderly, 227
Cocaine, 228
Case study: substance abuse, 235
xviii Contents
Ee Persons With AIDS/HIV, 240

Historical background, 241
Antibody testing, 242
AIDS and HIV counseling, 242
Role of the therapist in AIDS counseling, 243
Boundaries of the therapist, 243
Family systems, 244
Isolation, 245
Death, 246
AIDS in the United States, 247
The Americans With Disabilities Act of 1990, 250
Impact of AIDS on the healthcare system, 250
Sexual transmission of AIDS, 251
Vaginal and anal intercourse, 252
Case study: AIDS (heterosexual female), 252
AIDS/HIV in adolescence, 254
Case study: AIDS (adolescent), 256
Common questions about AIDS, 259
What is AIDS?, 259
What causes AIDS?, 259
How is AIDS spread?, 259
What are the symptoms of AIDS?, 260
How is AIDS diagnosed?, 260
How can people avoid getting AIDS?, 260
Should mothers exposed to the AIDS virus breastfeed their infants?, 261
Is there a test available to determine if a person has been exposed to
AIDS?, 261
Who should be tested for antibodies to AIDS?, 261
What is the risk of getting AIDS by donating blood?, 262
How is AIDS treated?, 262
What can one do?, 262
1 Burnout Syndrome, 265

Burnout and the work environment, 266
Stressors in hospice and AIDS care, 267
Hospice care, 267
AIDS care, 268
Indicators of burnout, 269
Burnout progression, 269
Stages of disillusionment, 270
Avoiding burnout, 274
Intervention, 275
Case study: burnout, 276
Contents xix
Postscriptum, 283
Appendix A, 285
Appendix B, 287
Appendix C, 289
Appendix D, 293
Appendix E, 315
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CRISIS
INTERVENTION
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psychological crisis refers to an individual’s inability to solve a problem. We

all exist in a state of emotional equilibrium, a state of balance, or homeostasis.
When something that is different (either positive or negative), a change, or a loss that
creates a state of disequilibrium occurs, we strive to regain and maintain our previous
level of equilibrium. A person in crisis is at a turning point. He* faces a problem that
he cannot readily solve by using the coping mechanisms that have worked before.
As a result, his tension and anxiety increase, and he becomes less able to find a
solution. A person in this situation feels helpless—he is caught in a state of great
emotional upset and feels unable to take action on his own to solve the problem.
In a 1959 address John F. Kennedy stated, ‘““When written in Chinese the word
crisis is composed of two characters—one represents danger and the other represents
opportunity.”
Crisis is a danger because it threatens to overwhelm the individual or his family,
and it may result in suicide or a psychotic break. It is also an opportunity because
during times of crisis individuals are more receptive to therapeutic influence. Prompt
and skillful intervention may not only prevent the development of a serious long-term
disability but may also allow new coping patterns to emerge that can help the
individual function at a higher level of equilibrium than before the crisis.
Crisis intervention can offer the immediate help that a person in crisis needs to
reestablish equilibrium. It is an inexpensive, short-term therapy that focuses on
solving the immediate problem. Increasing awareness of sociocultural factors that
could precipitate crisis situations has led to the rapid evolution of crisis intervention
methodology.
men
except where the name of
*For the sake of clarity, male pronouns have been used throughout this book
the patient or therapist denotes female gender.
2 Crisis Intervention: Theory and Methodology
Historical Development
The origin of modern crisis intervention dates back to the work of Eric Lindemann
and his colleagues after the Coconut Grove fire in Boston on November 28, 1942.
In what was at that time the worst single-building fire in the country’s history,
493 people perished when flames swept through the crowded nightclub. Lindemann
and others from the Massachusetts General Hospital played an active role in helping
survivors who had lost loved ones in the disaster. His clinical report (Lindemann,
1944) on the psychological symptoms of the survivors became the cornerstone for
subsequent theorizing on the grief process, a series of stages through which a
mourner progresses on the way toward accepting and resolving loss. Lindemann
came to believe that clergy and other community caretakers could play a critical role
in helping bereaved people through the mourning process and thereby head off later
psychological difficulties. This concept was further operationalized with the
establishment of the Wellesley Human Relations Service (Boston) in 1948, one of
the first community mental health services noted for its focus on short-term therapy
in the context of preventive psychiatry.
Lindemann’s (1956) initial concern was to develop approaches that might
contribute to the maintenance of good mental health and the prevention of emotional
disorganization on a community-wide level. He chose to study bereavement reactions
in his search for social events or situations that would predictably be followed by
emotional disturbances in a considerable portion of the population. In his study of
bereavement reactions among the survivors of those killed in the Coconut Grove
nightclub fire, he described both brief and abnormally prolonged reactions occurring
in different individuals as a result of the loss of a significant person in their lives.
In his experiences working with grief reactions, Lindemann concluded that a
frame of reference constructed around the concept of an emotional crisis, as
exemplified by bereavement reactions, might be worthy of investigation and useful
for the development of preventive efforts. Certain inevitable events in the course
of
the life cycle of every individual can be described as hazardous situations, for
example, bereavement, the birth of a child, and marriage. He postulated that in each
of these situations emotional strain would be generated, stress would be experienced
,
and a series of adaptive mechanisms would occur that could lead either to
mastery
of the new situation or to failure with more or less lasting impairment
to function.
Although such situations create stress for all people who are exposed
to them, they
become crises for those individuals who because of personality, previous
experience,
or other factors are especially vulnerable to this stress and whose
emotional resources
are taxed beyond their usual adaptive resources.
Lindemann’s theoretical frame of reference led to the develo
pment of crisis
intervention techniques, and in 1946 he and Caplan
established a community-wide
mental health program in the Harvard area, known as the
Wellesley Project.
According to Caplan (1961), the most important aspects
of mental health are the
state of the ego, the stage of its maturity, and the quality
of its structure. Assessment
of the ego’s state is based on three main areas:
1. The capacity of the person to withstand stress and
anxiety and to maintain
ego equilibrium
Chapter 1: Historical Development of Crisis Intervention Methodology 3
2. The degree of reality recognized and faced in solving problems

3. The repertoire of effective coping mechanisms the person can employ in
maintaining a balance in his biopsychosocial field
Sigmund Freud was the first to demonstrate and apply the principle of causality
as it relates to psychic determinism (Bellak and Small, 1965). Simply put, this
principle states that every act of human behavior has its cause, or source, in the
history and experience of the individual. It follows that causality is operative,
whether the individual is aware of the reason for the behavior. Psychic determinism
is the theoretical foundation of psychotherapy and psychoanalysis. The free
association technique, dream interpretation, and assignment of meaning to symbols
are based on the assumption that causal connections operate unconsciously.
A particularly important outcome of Freud’s deterministic position was his
construction of a developmental or “genetic” psychology (Ford and Urban, 1963).
Present behavior is understandable in terms of the life history or experience of the
individual; the crucial foundations for all future behavior are laid down in infancy
and early childhood. The most significant determinants of present behavior are the
“residues” of past experiences (learned responses, particularly those developed
during the earliest years to reduce biological tensions).
Freud assumed that a reservoir of energy that exists in the individual initiates all
behavior. Events function as guiding influences, but they do not initiate behavior;
they serve to help mold behavior only in certain directions.
Since the end of the nineteenth century, the concept of determinism and the
scientific bases from which Freud formulated his ideas have undergone many
changes. Although the ego-analytic theorists have tended to subscribe to much of the
Freudian position, they differ in several respects that seem to be extensions of
Freudian theory rather than from direct contradictions. As a group they concluded
that Freud neglected the direct study of normal or healthy behavior.
Heinz Hartmann was an early ego analyst who was profoundly versed in Freud’s
theoretical contributions (Loewenstein, 1966). He postulated that the psychoanalytic
theories of Freud could prove valid for normal and pathological behavior. Hartmann
began with the study of ego functions and distinguished between two groups: those
that develop from conflict and those that are “conflict free,” such as memory,
thinking, and language, which he labeled “‘primary autonomous functions of the
ego.” He considered these important in the adaptation of the individual to the
environment. Hartmann’s conception of the ego as an organ of adaptation required
further study of the concept of reality. Hartmann emphasized that a person’s
adaptation in early childhood and his ability to adapt to the environment in later life
had to be considered. He also described the search for an environment as another
form of adaptation—the fitting together of the individual and society. He believed
that, although the behavior of the individual is strongly influenced by culture, a part
of the personality remains relatively free of this influence.
Sandor Rado developed the concept of adaptational psychodynamics, providing
a new approach to the unconscious, as well as new goals and techniques of therapy
(Salzman, 1962). Rado saw human behavior as being based on the dynamic
principles of motivation and adaptation. An organism achieves adaptation through
interaction with culture. Behavior is viewed in terms of its effect on the welfare of the
Crisis Intervention: Theory and Methodology
individual, not just in terms of cause and effect. The organism’s patterns of
interaction improve through adaptation, with the goal being the increase of
possibilities for survival. Freud’s classical psychoanalytic technique emphasized the
developmental past and the uncovering of unconscious memories, yet he attached
little if any importance to the reality of the present. Rado’s adaptational
psychotherapy, however, emphasizes the immediate present without neglecting the
influence of the developmental past. Primary concern is with failures in adaptation
“today,’’ what caused them, and what the patient must do to learn to overcome them.
Interpretations always begin and end with the present; preoccupation with the past
is discouraged. As quickly as insight is achieved, it is used as a beginning to
encourage the patient to enter into the present real-life situation repeatedly. Through
practice, the patient automatizes new patterns of healthy behavior. According to
Rado, this automatization factor—not insight—is ultimately the curative process. He
believes that it takes place not passively, in the therapist’s office, but actively, in the
reality of daily living (Ovesy and Jameson, 1956).
Erik H. Erikson further developed the theories of ego psychology, which
complement those of Freud, Hartmann, and Rado, by focusing on the epigenesis of
the ego and on the theory of reality relationships (Rappaport, 1959). Epigenetic
development is characterized by an orderly sequence of development at particular
stages, each depending on the previous stage for successful completion. Erikson
perceived eight stages of psychosocial development spanning the entire life cycle of
the individual and involving specific developmental tasks that must be solved in each
phase. The solution achieved in each phase is applied in subsequent phases. Erikson’s
theory is important because it offers an explanation of the individual’s social
development as a result of encounters with the social environment. Another
significant feature is his elaboration on the normal rather than on the pathological
development of social interactions. He dealt in particular with the problems of
adolescence and saw this period in life as a “normative crisis,” that is, a normal
maturational phase of increased conflicts and one with apparent fluctuations in ego
strength (Pumpian-Mindlin, 1966). Erikson integrated the biological, cultural, and
self-deterministic points of view in his eight stages of human development and
broadened the scope of traditional psychotherapy with his theoretical formulations
concerning identity and identity crises. His theories have provided a basis for the
work of others who further developed the concept of maturational crises and began
serious consideration of situational crises and individual adaptation to the current
environmental dilemma.
Caplan believes that all of the elements that comprise the total emotional milieu
of the person must be assessed in an approach to preventive mental health. The
material, physical, and social demands of reality, as well as the needs,
instincts, and
impulses of the individual, must all be considered important behavioral
determinants.
As a result of his work in Israel (1948) and his later experiences in Massachus
etts
with Lindemann and with the Community Mental Health Program
at Harvard
University, he evolved the concept of the importance of crisis periods
in individual
and group development (Caplan, 1951).
Caplan defined crisis as occurring “when a person faces an obstacle
to important
life goals that is, for a time, insurmountable through the utilizati
on of customary
methods of problem solving. A period of disorganization ensues, a period of upset,

during which many abortive attempts at solution are made” (Caplan, 1961). In
essence the individual is viewed as living in a state of emotional equilibrium, with
the goal always to return to or to maintain that state. When customary
problem-solving techniques cannot be used to meet the daily problems of living, the
balance or equilibrium is upset. The individual must either solve the problem or adapt
to nonsolution. In either case a new state of equilibrium develops, sometimes better
and sometimes worse insofar as positive mental health is concerned. There is a rise
in inner tension, there are signs of anxiety, and there is disorganization of function
resulting in a protracted period of emotional upset. This he refers to as “‘crisis.”” The
outcome is governed by the kind of interaction that takes place during that period
between the individual and the key figures in his emotional milieu.
Evolution of Community Psychiatry

In today’s healthcare environment, community psychiatry has emerged and has
been changed due to economics, need, and demographics. More women, the tra-
ditional caretakers of the family, are employed outside the home. This is due in part
to the necessity of the family to have two incomes to survive. It is also due to the
reality that many spouses have lost their jobs. Because of economic conditions, many
plants and businesses have closed, putting many men out of work (Janoff, 1992). This
shift has significantly influenced the nature of the demands on the family and the
availability of internal resources to meet these demands.
The increasing number of the elderly in our society has created a generation gap
within families. Communities face the dilemma of how to cope with the tremendous
number of people over the age of 65. Families do not always have the resources
available and neither does the community. The burden thus becomes another problem
for community psychiatry (Ravenscroft, 1994).
According to Bellak (1964), community psychiatry evolved from multiple
disciplines and is intrinsically bound to the development of psychoanalytic theory.
The social and behavioral sciences that advanced during the first half of the century
were predicated on psychodynamic hypotheses. At the same time, concepts of public
health and epidemiology were advancing in community health programs.
After World War II the general public’s increasing awareness and acceptance of
the high incidence of psychiatric problems created changes in attitudes and demands
for community action. The discovery and use of psychotropic drugs were important
steps forward; they resulted in opportunities for open wards and rehabilitation of the
hospitalized patient in his home milieu.
It would be incorrect to assume that all of these factors merged spontaneously,
creating a successful, structured cure for mental illness. Rather, it was a slow process
of trial and error. Widely different programs—each striving to solve problems
involving different cultures, interests, knowledge, and skills—were developed and
related to other programs similarly initiated. Disciplines once separated in their goals
became aware of their interdependence in attaining mutually recognized goals. New
allied disciplines developed; roles changed and expanded. Tasks were diffused, and
lines between disciplines became more flexible.
Crisis Intervention: Theory and Methodology
The origin of day hospitals for the care of psychiatric patients grew out of a
shortage of hospital beds (Ross, 1964), which forced premature discharges of patients
to their homes, rather than treatment innovation. The first reported day hospital was
associated with the First Psychiatric Hospital in Moscow in 1933. As Dzhagarov
(1937) states: “‘The need to continue treatment and for special observation in a setting
similar to that of a hospital suggested a practical solution in the form of admission
to the preventive section of the hospital. In time a transformation took place; the day
hospital was created, proving to be adequately prepared to meet the new needs.” In
referring to this day hospital in Moscow, Kramer, as quoted by Ross (1964), says:
“While this day center is little known and probably had little effect on later
developments in the Western world, it is accurate to say that this was the first
organized Day Hospital for individuals with severe mental illness.”’
In the late 1930s Bierer (1964) began the Marlborough Experiment in England.
Patients, as members of a “therapeutic social club,” lived outside the hospital and
were treated at day hospitals or part-time facilities. According to Bierer, the primary
goal of the program was to change the patient’s role concept from that of a passive
object of treatment to one of an active participant-collaborator. At the same time, the
psychiatrist and staff had to reconceptualize the patient as a human being accessible
to reason and emphasize his assets rather than concentrating on his psychopathology
and conflicts. The reality of the ‘here and now” was the focus of attention.
These innovations in attitude gave rise to the concept of “therapeutic com-
munity.’’ The patient became a partner and collaborator with the staff and was granted
equal rights, opportunities, and facilities. The medical staff and their assistants
functioned as advisors. The patient group assumed responsibility for the behavior of
its members, as well as for planning activities, planning their futures, and offering
Support to each other. Group and social methods were used that encouraged the
constant interaction of the members. Other complementary projects developed in the
Marlborough Program were the Day Hospital, the Night Hospital, the Aftercare
Rehabilitation Center, the Self-Governed Community Hotel, Neurotics Nomine, and
the Weekend Hospital.
Linn (1964) describes Cameron’s first day hospital in Montreal, Canada, in 1946,
in which he and others were responsible for defining and giving formal structure to
the program as a treatment innovation.
With this frame of reference, it was only natural that the general hospital added
to the various roles in which it serves the community that of becoming a focal point
of preventive medicine and public health functions in psychiatry.
In 1958 a “Trouble-Shooting Clinic” was initiated by Bellak (1960) as part of
City
Hospital of Elmhurst, New York, a general hospital with 1000 beds. The clinic
was
designed to offer first aid for emotional problems and was not limited
to urgent crises.
It combined two aspects of service on a walk-in basis around
the clock: major
emergencies, as well as minor problems involving guidance, legal
problems, and
marital relations.
After the passage of the California Community Mental Health
Act in 1958, the
California Department of Mental Hygiene established the first
state agency in the
country (1961) to undertake the training of specialists in commun
ity psychiatry. It
was recognized that clinics were needed to accommodate those
individuals in the
community who were unfamiliar with established forms of psychiatric treatment.

The cause for these individuals’ exclusion from treatment conceivably could have
been divergence in social or cultural background, lack of communication, or lack
of recognition of the need for services by both the population and the existing
agencies.
In January 1962 the Benjamin Rush Center for Problems of Living, a division of
the Los Angeles Psychiatric Service, was opened as a no-wait, unrestricted intake,
walk-in crisis intervention center. The center is currently under the direction of the
Didi Hirsch Community Mental Health Center. After more than 30 years of operation,
the Benjamin Rush Center has accumulated considerable evidence that persons who
come to the center are often those who would not typically seek treatment in a
traditional clinic. The approach has been to attract persons who, although judged to
be genuinely in need of psychiatric treatment, would not have sought traditional
treatment because of reluctance to consider themselves “‘sick,”’ to assume the patient
role, or to accept the stigma of psychiatric treatment.
In 1967 crisis intervention replaced emergency detention at the San Francisco
General Hospital. On each of the psychiatric units, interdisciplinary teams were
established whose primary goal was to reestablish independent functioning of the
patients as soon as possible. In a follow-up study, Decker and Stubblebine (1972)
concluded that the crisis intervention program achieved the anticipated reduction in
psychiatric inpatient treatment.
In the early 1970s the Bronx Mental Health Center (Centro de Hygiene Mental
del Bronx) (Morales, 1971) was created for crisis intervention for Spanish-speaking
people of low socioeconomic status; it was staffed by Spanish-speaking psy-
chiatrists.
At about the same time, suburban churches in Montreal, Canada, offered brief
crisis intervention services on an experimental basis (Lecker and others, 1971). The
goal of the program was to reach families undergoing a variety of stresses through
a mobile walk-in clinic. The clinics served to facilitate delivery of these services to
a latent population at risk, not reached by other means, and at a point early in the
evolution of a life crisis.
The first hot line was started at Children’s Hospital in Los Angeles in 1968.
Hot lines and youth crisis centers have been created in recognition of the failure
of traditional approaches to make contacts among adolescents. Twenty-four-hour
crisis telephone services, free counseling with a minimum of red tape, walk-in
contacts, crash pads, and young people serving as volunteer staff in such services
continue to be increasingly attractive to youth who have emerged as the locus
of a counterculture.
Trends such as these are being repeated around the country as community mental
health programs recognize the value of providing primary and secondary prevention
services unique to the needs of their particular clients. Increasing recognition is also
being given to the need for more services for those clients who need continuing
support in rehabilitation after resolution of the immediate crisis. The major concern
of community mental health centers is no longer that of discerning just what services
are appropriate for the needs of potential clients. It is not even that of recruiting
clients for the services provided. The centers are faced with the problems of
maintaining an adequate staff to meet the demands for their services and obtaining
the finances to pay for these services. Professionals and nonprofessionals alike have
been recruited and trained to fill the gap between supply and demand for these
services. This has led to the deprofessionalization of many mental health functions
previously considered to be solely within the scope of the professional’s skills. Role
boundaries have undergone increasing diffusion as the needs of the individual client
and his community have become the determining factors in establishing appropriate
services.
In most cities hot lines have increased for those seeking anonymous help. The hot
lines are usually available 24 hours a day, 7 days a week. In most cities one seldom
has strong and constant family support. One works with virtual strangers, lives
among unknown neighbors, or shares an apartment with a “roommate,” again a
stranger. There is seldom anyone available to share their thoughts, concerns, and
fears.
Hot lines may be used to provide assistance to rape victims or to give information
about sexually transmitted diseases. There are hot lines established to provide
information about acquired immunodeficiency ‘syndrome (AIDS) and human
immunodeficiency virus (HIV). Most metropolitan cities have Psychiatric Emer-
gency Teams (PET) who respond to calls in the community when a visit to a home
is necessary. Suicide hot lines are available in most cities as a result of the high
incidence of suicide (Brent and others, 1993; Herman, 1992; Goh, 1993; Jones, 1990;
Shneidman, 1993; Foa, 1992; and Janoff, 1992).
Crises Related to Technological Advances

Rapid increases in the use of technology have contributed to new challenges that
could instigate the development of crises. Stress has increased in some families as
a result of the use of personal computers. In some cases the computer, with its Internet
and Cyberspace, has limited the communication between family members and
possibly created new and different crises within the family unit.
The first and only study, to this author’s knowledge, to examine the possible
pathological uses of the Internet was presented at the American Psychological
Association’s annual meeting in Toronto, Ontario, Canada, in August of 1996.
Kimberly S. Young, a clinical psychologist at the University of Pittsburgh at
Bradford, presented a study on the dependency of individuals on the Internet (Roan,
1996).
Dr. Young in her study suggests that there is accumulating psychological evidence
that people can become dependent on Internet use in ways very similar
to drug,
alcohol, and gambling addictions. This study is the first to propose pathologic
al uses
of Internet addiction as a legitimate clinical disorder that carries serious
conse-
quences.
These addicts “reported significant problems in their lives because
they had
simply lost control over their ability to limit the time they used the
Internet.” They
typically tried to reduce their Internet use but couldn’t, and when
they tried to stop
using the Internet, they showed signs of physical withdrawal,
such as anxiety and
shakiness.
Consequences of overuse ranged from not being able to pay their on-line service
provider (one monthly bill was $1400) to a formerly happily married mother who was
given an ultimatum by her husband—‘me or the computer” —and chose her
computer.
Dr. Young placed an advertisement on-line seeking ‘avid Internet users” and
placed flyers around local college campuses. The respondents completed surveys and
participated in telephone or personal interviews. She recruited 396 individuals whom
she later classified as 296 dependent users and 100 nondependent users.
Her findings suggested that Internet dependence can happen to both men and
women. The ages ranged from 14 to 71, but most were middle age. Many of the
dependent users did not match the stereotypical “computer nerd.” ‘Forty-two
percent said they were currently not employed because they were homemakers,
retired, or disabled.”
The people who became dependent seemed to have more time on their hands.
Many were new to the Internet—they had been accessing for an average of
8 months—and were discovering this new world, which then became enticing.
So enticing, in fact, that although nondependent users in the survey said they
spent 1 to 2 hours a day on-line, dependent users spent about eight times longer.
Young’s study pointed to another telltale characteristic of dependence. Users spent
most of their time in “chat rooms” or playing Multiuser Dungeons, which allows
users to take on a different persona. In contrast, the nondependent users logged
on mostly for e-mail or to access the World Wide Web to gather information.
For the people who are addicted, the Internet is not an information database. It
is an emotional attachment, a fantasy created on-line. Chat rooms can give people
a feeling of power or status or camaraderie. For the most part, dependent users did
not identify themselves as having current or past mental problems. A weakness of
the study is that “‘it relies on the respondents’ own reports, which may be biased.”
Dr. Young states that “Internet addiction could be a manifestation of some other
underlying clinical disorder.”
She also states that “‘... there were few warning signs that a dependence was
developing.” This, Young says, is another area in need of more research. The
respondents said it was very insidious; that the problem grew quickly over time. The
2 hours in which they intended to stay on turned into 6 or 7 hours. They were staying
up late, then they were getting up in the middle of the night. Most people who overuse
on-line services change their behavior after they receive their first shocking bill;
however, dependent users found that they could not cut back. Many dismantled their
computers but felt compelled to reassemble them.
SIGNS OF AN ON-LINE ADDICT

A “dependent” Internet user may meet as few as four of the following criteria
(similar to those used to identify alcohol and drug addiction) over a 1-year period
(Young, 1996):
¢ Thinks about the Internet while off-line
* Has an increasing need to use the Internet to achieve satisfaction
¢ Unable to control Internet use
° Feels restless or irritable when attempting to cut down or stop Internet use
Uses the Internet as a way of escaping from problems or relieving a poor

mood
¢ Lies to family members or friends to conceal the extent of Internet involve-
ment
¢ Jeopardizes or risks loss of a significant relationship, job, educational, or
career opportunity because of the Internet
¢ Keeps coming back for more, even after spending an excessive amount of
money for on-line fees
* Goes through withdrawal when off-line
¢ Stays on-line longer than intended
Although Young’s study suggests some interesting possibilities, the population of
her study (i.e., unemployed, homemakers, retired, or disabled) does not represent the
majority of those who currently use the Internet. Those who seek information on the
World Wide Web to communicate with others in their profession or field of interest
do so because of the instant access otherwise unavailable through conventional mail
delivery service. They can receive information from all over the world instanta-
neously. It may be a recent medical breakthrough, research in genetics, medications,
or theories or treatments being used in fields such as psychiatry, psychology, nursing,
social work, ophthalmology, and dentistry.
The Internet is the communication domain of the future. This writing is already
obsolete—passé. The Internet is mushrooming to the point that anything written
today is already “old.” As with anything new and novel, there will always be those
who cannot cope and will seek out methods by which to abuse this otherwise highly
productive mode of communication and learning. The Internet is here to stay, to bring
knowledge to mankind from all over the world.
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Young KS: Personal communication, 1996, University of Pittsburgh.
ADDITIONAL READING
American Journal of Nursing: Health care reform (video), 32nd Biennial Convention of Sigma
Theta Tau, 1993, Alan Trench/Helene Fuld Trust.
Bachrach LL: Community psychiatry’s changing role, Hosp Community Psychiatry 42:573,
1991.
Beeber LS: The one-to-one relationship in nursing practice: the next generation. In Anderson
CA, editor: Psychiatric nursing 1974 to 1994: a report on the state of the art, St. Louis,
1995, Mosby.
Betemps E, Ragiel C: Psychiatric epidemiology: facts and myths on mental health and illness,
J Nurs 32:23, 1994.
Bishop JB: The university counseling center: an agenda for the 1990s, J Counsel Dev 68:408,
1990.
Clark MJ: Nursing in the community, Norwalk, Conn, 1992, Appleton & Lange.
Dazord A and others: Pretreatment and process measures in crisis intervention as predictors
of outcome, Psychother Res 1(2):135, 1991.
Fontes LA: Constructing crises and crisis intervention theory, J Strat Syst Ther 10:59, 1991.
Grob GN: Mental health policy in America: Health Aff Fall, p 7, 1992.
Huffman K, Vernoy M, Williams B: Psychology in action, ed 2, New York, 1995, John Wiley
& Sons.
Kaplan H, Sadock B: Synopsis of psychiatry, ed 6, Baltimore, 1994, Williams & Wilkins.

Kocmur M, Zavasnik A: Patients’ experience of the therapeutic process in a crisis intervention
unit, Crisis 12(1):69, 1991.
Miller WR and others: The helpful responses questionnaire: a procedure for measuring
therapeutic empathy, J Clin Psychol 47:444, 1991.
Olsen DP, Rickles H, Travlik K: A treatment team model of managed mental health care,
Psychiatr Serv 46(3):252, 1995.
Pollin IS: Linda Pollin Foundation NIMH workshop attendees: model curriculum in medical
crises counseling super (SM). A model for counseling the medically ill: the Linda Pollin
Foundation approach, Chevy Chase, MD, Gen Hosp Psychiatry 14(suppl 6):11, 1992.
Redick R and others: Expansion and evolution of mental health care in the United States, Ctr
Ment Health Serv Publ No. #210, 1994. :
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P sychotherapy as a form of treatment has had many definitions, some conflicting

and others concurring. Areas of divergence are generally those of methodology,
therapeutic goals, length of therapy, and indications for treatment. There is general
agreement, however, that psychotherapy is a set of procedures for changing behaviors
based primarily on the establishment of a relationship between two (or more) people.
Psychoanalysis and Psychoanalytic Psychotherapy

The original theories of Sigmund Freud, the founder of psychoanalysis, passed
through several phases as he subjected changing hypotheses to the tests of experience
and observation, all directed toward the goal of making the unconscious available to
the conscious.
In collaboration with Breuer, Freud first developed the psychotherapeutic
technique of ‘cathartic hypnosis.” Recognizing that ego control of the unconscious
was released under the influence of hypnosis, Freud used hypnotism to induce the
patient to answer direct questions in an effort to uncover the unconscious causes of
the symptomatology and to allow free expression of pent-up feelings.
Freud observed, however, that to obtain therapeutic results, the procedure had to
be repeated. He recognized that material brought to consciousness during hypnosis
returned to the unconscious as the awakening patient regained control over his
emotions. The therapeutic task of making the conscious patient recall and face
repressed emotions to gain insight and increased ego strength was only transiently
achieved by this technique.
Freud then experimented with what he referred to as “waking suggestion.” Laying
his hand on the patient’s forehead, he would strongly suggest that the patient could
recall the past if he tried. Freud soon learned that a person could not be forced to recall
13
repressed, conflictual emotional events through this approach. He next devised an

indirect method of freeing unconsciously repressed material for confrontation by the
conscious. Using the process of “free association,” the patient was expected to
verbalize whatever thoughts came into his mind, freely associating events from his
whole life span of experiences, feelings, fantasies, and dreams without concern for
logic or continuity. Freud concentrated on gaining an intellectual understanding of
the patient’s psychogenic past. He insisted on the “‘basic rule” that the patient tell
the therapist everything that came into his mind during each interview. Nothing, no
matter how inconsequential the patient might think it was, could be withheld from
the analyst. In this search for repressed memories, Freud found that repressed
emotions were gradually discharged as they emerged, although not as dramatically
as in cathartic hypnosis.
“Transference phenomena” is considered to be one of the most important
discoveries by Freud. He deemed transference to be a valuable therapeutic tool in
overcoming the patient’s defenses in resisting the release of unconscious, repressed
emotional experiences. He thought of transference as an emotional reaction of the
patient to the therapist in which the patient would relive his conflicts and emotions
as they emerged from the past, from his unconscious. He would transfer to the
therapist emotions he had felt toward authority figures in his childhood.
Freud referred to this reliving of the neurotic past in a present relationship
with the therapist as transference neurosis. The principal factor in this process
was that the patient expressed his aggressions against the therapist without any
fears of the reprisal or censure that he may have been subjected to by the authority
figure in his childhood. Through the therapist’s nonjudgmental acceptance, the
patient was encouraged to face new material released from his own unconscious
with reduced fear and anxiety. As these new experiences were assimilated into
the conscious ego, coping skills increased, which in turn facilitated further release
of repressed material. Alexander (1956) refers to this process as a “corrective
emotional experience.”
Psychoanalysis is concerned with theory as well as techniques. Alexander and
French (1946) also state that the traditional approach in psychoanalytic therapy
has
been nondirective. The therapist is a passive observer who follows the lead of
the
patient’s verbal expressions as they unfold. Tarachow (1963) indicates that psycho-
analytic therapy is for those whose personalities and ego strengths are relatively
intact, despite neurotic symptoms or mild to moderately severe charactero
logical
disturbances due to unconscious conflicts.
Stone (1951) lists eight factors in the situation and technique of psychoan
alysis
from which technical variations have derived.
1. Practically exclusive reliance during the hour of the patient’s
free associa-
tions for communications
2. Regularity of the time, frequency, and duration of appointments
and clearly
defined financial agreement
3. Three to five appointments a week (originally six), with
daily appointments
the dominant tendency
4. Recumbent position of the patient, in most instances with
some impedi-
ment against seeing the analyst directly
Chapter 2: Differentiation Among Psychotherapeutic Techniques 15
5. Confinement of the analyst’s activity essentially to interpretation or other

purely informative interventions such as reality testing or an occasional
question
6. Emotional passivity and neutrality (benevolent objectivity) of the analyst,
specifically abstention from gratifying the patient’s transference wishes
7. Abstention by the analyst from advice or any other direct intervention or
participation in the patient’s daily life
8. No immediate emphasis by the analyst on curing symptoms, the procedure
being guided by the patient’s free associations from day to day; in a sense,
regarding the whole scope of the patient’s psychic life as the field of ob-
servation
In psychoanalytic psychotherapy the therapist is more active than in psycho-
analysis. The therapist interacts more with the patient and does not interpret the
transference attitudes as completely as in analysis. The most helpful attitude is one
of calmness, continued interest, and sympathetic, understanding helpfulness; this
differs from the neutral attitude of the analyst in psychoanalysis. The contention is
that this calm, helpful, interested attitude of the therapist in psychotherapy provides
support for the patient in dealing with tension, sustains contact with reality, and
provides gratifications and rewards in the therapeutic relationship that provide
incentives for thé patient to continue to deal with emerging unconscious material.
Alexander (1956) has noted that in procedures that deviate from the classical
psychoanalysis of Freud, one or another of the basic phenomena is emphasized from
the standpoint of therapeutic significance and is often being dealt with in isolation.
For example, Rank centered on the life situation, believing that insight into infantile
history had no therapeutic significance. Feranczi placed emphasis on the emotional
experience in transference (abreaction factor). Reich concentrated on the analysis of
the resistances to allow, by their removal, the discharge of highly charged emotional
experiences. He emphasized the importance of hidden forms of resistance and the
understanding of the patient’s behavior apart from his verbal communication.
Psychoanalytic psychotherapy procedures have customarily been divided into two
functional categories based on methodology; these are frequently referred to as
supportive and uncovering.
According to Alexander (1956), the aim of the uncovering method is to intensify
the ego’s ability to handle repressed emotional conflict situations that are uncon-
scious. Through the use of transference, the patient relives his early interpersonal
conflicts in relation to the therapist. Supportive and uncovering methods overlap, but
it is not difficult to differentiate between them. Primarily, supportive methods of
treatment are indicated when functional impairment of the ego is temporary in nature
and caused by acute emotional distress. Alexander designated therapeutic tasks in
supportive methodology as follows:
1. Gratifying dependency needs of the patient during stress situations, thereby
reducing anxiety
2. Reducing stress by giving the patient an opportunity for abreaction
3. Giving intellectual guidance by objectively reviewing with the patient his
acute stress situation and assisting the patient in making judgments, thereby
enabling him to gain proper perspective of the total situation
16 = Crisis Intervention: Theory and Methodology
4. Supporting the patient’s neurotic defenses until his ego can handle the
emotional discharges
5. Actively participating in manipulation of the life situation when this might
be the only hopeful approach in the given circumstances
Psychoanalysis and psychoanalytic psychotherapy require many years of inten-
sive training on the part of the therapist; this in itself has limited the number of
therapists available. Both methods may require that the individual remain in therapy
over an extended period, often for years. The obligations of time and expense for such
extensive treatment also limits its availability for many.
Brief Psychotherapy
Brief psychotherapy as a treatment form developed as the result of the increased
demand for mental health services and the lack of personnel trained to meet this
demand. Initially, much of it was conducted by psychiatric residents as part of their
training. Later, psychiatric social workers and psychologists became involved in this
form of treatment. ;
Brief psychotherapy has its roots in psychoanalytic theory but differs from
psychoanalysis in terms of goals and other factors. It is limited to removing or
alleviating specific symptoms when possible. Intervention may lead to some
reconstruction of personality, although it is not considered the primary goal. As in
more traditional forms of psychotherapy, the therapy must be guided by an orderly
series of concepts directed toward beneficial change in the patient. It is concerned
with the degree of abatement of the symptoms presented and the return to or
maintenance of the individual’s ability to function adequately. To attain this goal the
individual may choose to get involved in a longer form of therapy. Another goal is
assistance in preventing the development of deeper neurotic or psychotic symptoms
after catastrophes or emergencies in life situations.
Free association, interpretation, and the analysis of transference are
also used
successfully in a modified manner. According to Bellak and Small (1965), free
association is not a basic tool in short-term therapy. It may arise in response
to a
stimulus from the therapist. Interpretation is modified by the time limit and the
immediacy of the problem. Although it may occur in brief psychotherapy,
it is
commonly used with medical or environmental types of intervention.
Bellak and Small also believe that positive transference should be
encouraged. It
is crucial in brief therapy that the patient see the therapist as being
likeable, reliable,
and understanding. The patient must believe that the therapist
will be able to help.
This type of relationship is necessary if treatment goals are to
be accomplished in
a short time. This does not mean that negative transference feelings
are to be ignored;
it does mean that these feelings are not analyzed in terms
of defenses.
The therapist assumes a more active role than in the traditio
nal methods. Trends
not directly related to the presenting problem are
avoided. The positive is
accentuated, and the therapist acts as an interested, helpful
person. The difficulties
faced by the patient are circumscribed. The therapist uses
the patient’s environmental
position to help him evaluate the reality of his situation
in an attempt to modify and
change it. Productive behavior is encouraged.
Diagnostic evaluation is extremely important in short-term therapy. Its aim is to

understand the patient and his symptoms dynamically and to formulate hypotheses
that can be validated by historical data. The results of the diagnosis enable the
therapist to decide which factors are most susceptible to change and to select the
appropriate method of intervention. Part of the evaluation should be the degree of
discrepancy or accord between the patient’s fantasies and reality. The patient’s
probable ability to tolerate past and future frustrations should also be considered; the
adequacy of his past and present relationships is also pertinent. The question ‘““Why
do you come now?” must be asked and means not only ‘What is it that is going on
in your life that distresses you?’ but “What is it that you expect in the way of help?”
It is reasonable to assume that a request for help is motivated by emotional
necessities, both external and internal, that are meaningful to the patient. Short-term
goals can be beneficial for all patients.
After determining the causes of the symptoms, the therapist elects the appropriate
intervention. Interpretation to achieve insight is used with care. Direct confrontation
is used sparingly. An attempt is made to strengthen the ego by increasing the patient’s
self-esteem. One facet of this approach is to help the patient believe that he is on the
same level with the therapist and no less worthwhile. The patient’s problems should
not be seen as being more unusual than those of others. This technique not only
relieves the patient’s anxiety but also facilitates communication between the patient
and the therapist. Other basic procedures used include catharsis, drive repression and
restraint, reality testing, intellectualization, reassurance and support, counseling and
guidance to move the patient along a line of behavior, and conjoint counseling
(Bellak and Small, 1965).
The ending of treatment is an important phase in brief therapy. The patient must
be left with a positive transference and the feeling that he may return if the need
arises. The learning that has taken place during therapy must be reinforced to
encourage the patient to realize that he has begun to understand and solve his own
problems. This has a preventive effect that helps the patient recognize possiblé future
problems.
As an adjunct, drug therapy may be used in selected cases, in contrast to pure
psychoanalysis, where drugs are seldom used. Environmental manipulation is
considered when it is necessary to remove or modify an element causing disruption
in the patient’s life pattern. Included might be close scrutiny of family and friends,
job and job training, education, and plans for travel (Bellak and Small, 1965).
Brief psychotherapy is indicated in cases of acutely disruptive emotional pain, in
cases of severely destructive circumstances, and in situations endangering the life of
the patient or others. Another indication involves the life circumstances of the
individual. If the person cannot participate in the long-term therapeutic situation,
to
which implies a stable residence, job, and so forth, brief therapy is advocated
alleviate disruptive symptoms.
It is imperative that the patient feel relief as rapidly as possible, even during the
number
first therapeutic session. The span of treatment can be any reasonable, limited
clinics expect the number of visits to
of sessions but usually is more than six. Most
in this short time if the patient is
be under 20. Treatment goals can be attained
Circumst ances associate d with
seen quickly and intensively after requesting help.
disrupted functioning are more easily accessible if they are recent. Only active
conflicts are amenable to therapeutic intervention. Disequilibriated states are more
easily resolved before they have crystalized, acquired secondary gain features, or
developed into highly maladaptive behavior patterns.
Crisis Intervention
Crisis intervention extends logically from brief psychotherapy. The minimum

therapeutic goal of crisis intervention is psychological resolution of the individual’s
immediate crisis and restoration to at least the level of functioning that existed before
the crisis period. A maximum goal is improvement in functioning above the precrisis
level.
Caplan (1964) emphasizes that crisis is characteristically self-limiting and lasts
from 4 to 6 weeks. This time constitutes a transitional period, representing both the
danger of increased psychological vulnerability and an opportunity for personality
growth. In any particular situation the outcome may depend to a significant degree
on the availability of appropriate help. On this basis the length of time for
intervention is from 4 to 6 weeks, with the average being 4 weeks (Jacobson, 1965).
Because time is at a premium, a therapeutic climate is generated that commands the
concentrated attention of both therapist and patient. A goal-oriented sense of
commitment develops, in sharp contrast to the more modest pace of traditional
treatment modes.
METHODOLOGY
Jacobson and associates (1968, 1980) state that crisis intervention may be divided
into two major categories, which may be designated as generic and individual
. These
two approaches are complementary.
Generic approach. A leading proposition of the generic approach is that
there
are certain recognizable patterns of behavior in most crises. Many
studies have
substantiated this thesis. For example, Lindemann’s (1944) studies
of bereavement
found a well-defined process that a person goes through in adjusting
to the death of
a relative. He refers to these sequential phases as ‘“‘grief work” and
found that failure
to grieve appropriately or to complete the process of bereavement
could potentially
lead a person to future emotional illness.
Subsequent studies of generic patterns of response to stressfu
l situations have been
reported. Kaplan and Mason (1960)* and Caplan (1964)*
studied how the birth of
a premature baby affects the mother and identified four
phases or tasks that she must
work through to ensure healthy adaptation to the experie
nce. Janis (1958) suggests
several hypotheses concerning the psychological stress
of impending Surgery and the
patterns of emotional response that follow a diagnos
is of chronic illness. Rapoport
(1963)* defines three Subphases of marriage during
which unusual stress could
precipitate crises. These are only a few of the broad
research studies done in this field.
The generic approach focuses on the characterist
ic course of the particular kind
of crisis rather than on the psychodynamics of
each individual in crisis. A treatment
*These studies are also discussed in Chapters 8 and

9 of this text.
plan is directed toward an adaptive resolution of the crisis. Specific intervention

measures are designed to be effective for all members of a given group rather than
for the unique differences of one individual. Recognition of these behavioral patterns
is an important aspect of preventive mental health.
Tyhurst (1957) has suggested that knowledge of patterned behaviors in transi-
tional states occurring during intense or sudden change from one life situation to
another might provide an empirical basis for the management of these states and the
prevention of subsequent mental illness. He cites the studies of individual responses
to community disaster, migration, and retirement of pensioners as examples.
Jacobson and associates (1968) state that generic approaches to crisis intervention
include
... direct encouragement of adaptive behavior, general support, environmental manipula-

tion and anticipatory guidance. ... In brief, the generic approach emphasizes (1) specific
situational and maturational events occurring in significant population groups, (2) inter-
vention oriented to crisis related to these specific events, and (3) intervention carried out by
non-mental health professionals.
This approach has been found to be a feasible mode of intervention that can be
learned and implemented by nonpsychiatric physicians, nurses, social workers, and
others. It does. not require a mastery of knowledge of the intrapsychic and
interpersonal processes of an individual in crisis.
Individual approach. The individual approach differs from the generic in its
emphasis on assessment, by a professional, of the interpersonal and intrapsychic
processes of the person in crisis. It is used in selected cases, usually those not
responding to the generic approach. Intervention is planned to meet the unique needs
of the individual in crisis and to reach a solution for the particular situation and
circumstances that precipitated the crisis. It differs from the generic approach, which
focuses on the characteristic course of a particular kind of crisis.
Unlike extended psychotherapy, the individual approach deals relatively little with
the developmental past of the individual. Information from this source is seen as
relevant for the clues that may result in a better understanding of the present crisis
situation only. Emphasis is placed on the immediate causes for disturbed equilibrium
and on the processes necessary for regaining a precrisis or higher level of functioning.
Jacobson (1968, 1980) cites the inclusion of family members or other important
persons in the process of the individual’s crisis resolution as another area of
differentiation from most individual psychotherapy methods. In comparison with the
generic approach, the individual approach is viewed by Jacobson as emphasizing the
need for greater depth of understanding of the biopsychosocial process, intervention
oriented to the individual’s unique situation, and intervention carried out only by
mental health professionals.
Morley, Messick, and Aguilera (1967) recommend several attitudes that are
important adjuncts to the specific techniques. In essence, these attitudes comprise the
general philosophical orientation necessary for the full effectiveness of the therapist.
These attitudes are vital for the therapist to have ingrained and inherent in his basic
personality if they are to be effective in working with patients in crisis. If one cannot
make changes in the way in which one interprets this philosophical orientation, it may
¢+.

be necessary to accept the fact that working with crisis patients is not for him. The
recommended attitudes follow.
4 It is essential that the therapist view the work being done not as a “‘second-
best”’ approach but as the treatment of choice with persons in crisis.
2 Accurate assessment of the presenting problem, not a thorough diagnostic
evaluation, is essential to an effective intervention.
. Both the therapist and the individual should keep in mind that the treatment is
time limited and should persistently direct their energies toward resolution of
the presenting problem.
. Dealing with material that is not directly related to the crisis has no place as
an intervention of this kind.
. The therapist must be willing to take an active and sometimes directive role
in the intervention. The relatively slow-paced approach of more traditional
treatment is inappropriate in this type of therapy.
. Maximum flexibility of approach is encouraged. Such diverse techniques as
serving as a resource person or information giver and taking an active role
as an established liaison with other helping resources are often appropriate in
particular situations.
. The goal toward which the therapist is striving is explicit. Energy is directed
entirely toward returning the individual to at least his precrisis level of func-
tioning.
STEPS IN CRISIS INTERVENTION

There are certain specific steps involved in the technique of crisis intervention
(Morley, Messick, and Aguilera, 1967). Although each cannot be placed in a clearly
defined category, typical intervention would pass through the following sequence of
phases.
Assessment: Assessment of the individual and his problem is the first phase. It
requires the therapist to use active focusing techniques to obtain an accurate
assessment of the precipitating event and the resulting crisis that brought
the
individual to seek professional help. The therapist may have to judge
whether
the person seeking help presents a high suicidal or homicidal lethality.
If the
patient is thought to show a high level of danger to himself or to
others, refer-
ral is made to a psychiatrist for consideration of hospitalization.
If hospital-
ization is not considered necessary, intervention proceeds.
Planning therapeutic intervention: After accurate assessment
is made of the
precipitating event(s) and the crisis, intervention is planned. It
is not designed
to bring about major changes in the personality structure
but to restore the per-
son to at least the precrisis level of equilibrium. In this phase
determination
is made of the length of time since onset of the crisis.
The precipitating event
usually occurs from 1 to 2 weeks before the individ
ual seeks help. Frequently,
it may have occurred within the past 24 hours. It is
important to know how
much the crisis has disrupted the person’s life and
the effects of this disruption
on others in his environment. Information is also
sought to determine what
strengths he has, what coping skills he may have
used successfully in the past
and is not using currently, and what other people
he used as supports.
S 435407
* Intervention: The nature of intervention techniques is highly dependent on the

preexisting skills, creativity, and flexibility of the therapist. Morley, Messick,
and Aguilera (1967) suggest some of the following, which have been useful.
1. Helping the individual to gain an intellectual understanding of his crisis. Of-
ten the individual sees no relationship between a hazardous situation occurring
in life and the extreme discomfort of disequilibrium that he is experiencing.
The therapist should use a direct approach, describing to the patient the
relationship between crisis and the event in his life.
2. Helping the individual become aware of his present feelings. Frequently the
person may have suppressed some very real feelings, such as anger or other
inadmissible emotions toward someone he ‘“‘should love or honor.”’ It may
also be denial of grief, feelings of guilt, or failure to complete the mourning
process following bereavement. An immediate goal of intervention is the
reduction of tension by providing means for the individual to recognize these
feelings and bring them into the open. It is sometimes necessary to produce
emotional catharsis and reduce immobilizing tension.
3. Exploring coping mechanisms. This approach requires assisting the individual
to examine alternate ways of coping. If for some reason the behaviors used in
the past for successfully reducing anxiety have not been tried, the possibility
of their use in the present situation is explored. New coping methods are
sought, and frequently the individual devises some highly original methods
that he has never tried before.
4. Reopening the social world. If the crisis has been precipitated by the loss of
someone significant to the individual’s life, the possibility of introducing new
people to fill the void can be highly effective. It is particularly effective if
supports and gratifications provided in the past by the “lost” person can be
achieved to a similar degree from a new relationship.
¢ Resolution of the crisis and anticipatory planning: In this last phase the
therapist reinforces those adaptive coping mechanisms that the individual
has used successfully to reduce tension and anxiety. As coping abilities in-
crease and positive changes occur, they may be summarized to allow the per-
son to reexperience and reconfirm the progress made. Assistance is given as
needed in making realistic plans for the future, and there is discussion of ways
in which the present experience may help in future crises.
USE OF COGNITIVE THERAPY IN CRISIS INTERVENTION

When patients seek help in a crisis, the two cardinal symptoms that the therapist
ly
usually observes are anxiety and/or depression. Cognitive therapy can appropriate
crisis patients with some modificatio ns. The time line of
be used in working with
6 weeks must be given considerati on, as well as the methodolog y.
Beck recognized the contributions of the behavioral therapies in the development
on the
of cognitive therapy (Beck, 1979). Beck places much more importance
es of the patients than do behavioral therapists (Beck,
external, or mental, experienc
1979).
Beck believes, as do other theorists, that the way in which an individual structures
behavior and
the world through thoughts and evaluations largely influences both
CASTLEBAR CAMPUS
outcome. How one perceives a situation influences the emotions one has toward that
situation. It then follows that behaviors and actions will match the emotions. Beck
explored this concept and found a consistency in the way in which individuals who
experience depression structure their experiences. He organized this into a cognitive
model of depression with three components, which he named the “Cognitive Triad.”
The cognitive triad, the concept of schemas, and faulty patterns of processing
information, is the basis of Beck’s cognitive theory of depression.
Cognitive triad. The cognitive triad is Beck’s term to identify three common
characteristics in the thinking of people with depression. First, depressed people
hold a very negative view of themselves; they tend to see themselves as defective
in some way, either psychologically, morally, or physically. Because of these
presumed defects, they have a tendency to view themselves as worthless. Second,
people with depression tend to evaluate ongoing life events in a negative way. The
person with depression tends to misinterpret available data so as to always result in
a negative outcome, for example, defeat, humiliation, rejection, or inadequacy. Third,
the person with depression assumes that the future holds no promise and that the
current difficulties will continue. He expects despair, frustration, and failure to
persist.
The cognitive triad is basic to Beck’s understanding of depression. He views all
other symptoms of depression as connecting back to the cognitive patterns of
negative self-image, negative interpretation of ongoing experiences, and the negative
view of the future.
Schemas. Schema refers to an individual’s organization of incoming data into
meaningful patterns. Beck (1971) points out that, although people tend to
conceptualize situations in a variety of ways, an individual will be fairly consistent
in interpreting similar sets of data. These schemas have been learned over time
and
represent attitudes or assumptions that have been formed on the basis of one’s
experiences. Schemas affect how an individual will cognitively respond to them.
He
proposes that in a state of depression, dysfunctional schemas become prevalent
and
the data from a situation are distorted to fit the dysfunctional schema. The
individual
is no longer able to match an appropriate schema to a situation
because the
dysfunctional schema predominates over so much of the thinking.
In effect, any
stimulus will trigger the negative, dysfunctional schema. This would
then explain
why people with depression cannot “see” or respond to the many
positive aspects
of their lives.
Faulty patterns of processing information. This aspect of the cognitive theory
of depression refers to the characteristics of a depress
ed individual’s thinking.
Beck (1971) calls depressed thinking “primitive,” as
opposed to more mature
thinking.
Primitive thinking is more absolute than relative, more
judgmental than flexible,
and more invariable than variable. It is “black and white”
thinking, with the emphasis
on black. There are no shades of gray. Primitive
thinking misses the context and
variations of life and tends to be rigid and fixed.
It locks the person with depression
into a flat and unidimensional way of thinking—an
“‘all-or-none” mentality whereby
he views self and actions as “all-bad.” Faulty
patterns of processing information
follow.
Arbitrary inference: Drawing a conclusion when evidence does not support it

Selective abstraction: Paying attention to only one detail of a situation, tak-
ing that detail out of context, and ascribing the meaning to the situation
based on this single detail
Overgeneralization: The practice of drawing a conclusion based on one inci-
dent and then applying it in general
Magnification and minimization: The inability to evaluate the importance or
significance of an event to the point of creating a distortion
Personalization: The tendency to assume that external events are related to
one’s self, when there is no reason to make such a connection
Absolute thinking: The habit of defining experiences in one or two opposite
categories, for example, good or bad and perfect or imperfect
Summary
A differentiation among psychoanalysis, brief psychotherapy, and crisis intervention
methodology has been explored. No attempt has been made to state that one type of
therapy is superior to another. Table 2-1 shows some of the major differences.
In psychoanalysis the goal of therapy is restructuring the personality, and the focus
of treatment is the genetic past and the freeing of the unconscious. Psychoanalytic
psychotherapeutic procedures are usually divided into two functional categories:
Table 2-1 Major Differences Among Psychoanalysis, Brief Psychotherapy, and Crisis
Intervention Methodology
Psychoanalysis Brief psychotherapy Crisis intervention
Goals of therapy Restructuring the Removal of specific Resolution of im-

personality symptoms mediate crisis
Focus of treat- 1. Genetic past 1. Genetic past as it re- 1. Genetic present
ment 2. Freeing the lates to present situa- 2. Restoration to
unconscious tion level of func-
2. Repression of uncon- tioning before
scious and restraining crisis
of drives
Usual activity of 1. Exploratory 1. Supportive 1. Supportive
therapist 2. Passive ob- 2. Participant observer 2. Active partici-
server 3. Indirect pant
3. Nondirective 3. Direct
Indications Neurotic person- Acutely disruptive emo- Sudden loss of
ality patterns tional pain and severely ability to cope
disruptive circum- with a life situa-
stances tion
Indefinite 1-20 sessions 1-6 sessions
Average length
of treatment
Cost of treat- $100-200 $75-100 $0-75
ee ment ee ee ee ee
supportive and uncovering. The therapist’s role is nondirective, exploratory, and that
of a passive observer. This type of therapy is indicated for those individuals with
neurotic personality patterns. The length of therapy is indefinite and depends on the
individual and the therapist.
The goals in brief psychotherapy are to remove specific symptoms and aid in the
prevention of deeper neurotic or psychotic symptoms. Its focus is on the genetic past
as it relates to the present situation, repression of the unconscious, and restraining
of drives. The role of the therapist is indirect, supportive, and that of a participant
observer. Basic tools used are psychodynamic intervention coupled with medical or
environmental types of intervention. Indications for brief psychotherapy are acutely
disruptive emotional pain, severely disruptive circumstances, and _ situations
endangering the life of the individual or others. It is also indicated for those who have
problems that do not require psychoanalytic intervention. The average length of
treatment is from 1 to 20 sessions.
The goal of crisis intervention is the resolution of an immediate crisis. Its focus
is on the supportive, with the restoration of the individual to his precrisis level of
functioning or possibly to a higher level of functioning. The therapist’s role is direct,
supportive, and that of an active participant. Techniques are varied and limited only
by the flexibility and creativity of the therapist. Some of these techniques include
helping the individual gain an intellectual understanding of the crisis, assisting the
individual in bringing his feelings into the open, exploring past and present coping
mechanisms, finding and using situational supports, and anticipatory planning with
the individual to reduce the possibility of future crises. This type of therapy is
indicated when a person (or family) suddenly loses the ability to cope with a life
situation. The average length of treatment is from one to six sessions. The cost of
each therapy is dependent on the geographic region.
When patients are in a crisis, they are usually depressed and/or anxious. Beck’s
(1971, 1979) theory of cognitive therapy with depressed patients can be used with
these patients if certain guidelines are followed. His theory has been added to give
the therapists more flexibility in working with crisis patients.
These recommended guidelines are inherent in the philosophy of crisis theory.
* The crucial time line of six sessions
* Focus on the immediate problem
* Use of the direct approach by the therapist
* Maximum flexibility and creativity of the therapist
* The belief that crisis theory is their treatment of choice—not
a temporary
bandage
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Alexander F, French TM: Psychoanalytic therapy, New
York, 1946, Ronald Press.
Beck AT: Depression: causes and treatment, Philadelphia,
1971, University of Pennsylvania
Press.
Beck AT and others: Cognitive therapy of depression,
New York, 1979, Guilford Press.
Bellak L, Small L: Emergency psychotherapy and
brief psychotherapy, New York, 1965,
Grune & Stratton.
Caplan G: Principles of preventive psychiatry, New York, 1964, Basic Books. Strachey A, and
Strachey J).
Jacobson G: Crisis theory, New Dir Ment Health Serv 6:1, 1980.
Jacobson G: Crisis theory and treatment strategy: some sociocultural and psychodynamic
considerations, J Nerv Ment Djs 141:209, 1965.
Jacobson G, Strickler M, Morley WE: Generic and individual approaches to crisis intervention,
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Janis IL: Psychological stress, psychoanalytical and behavioral studies of surgical patients,
New York, 1958, John Wiley & Sons.
Kaplan DM, Mason EA: Maternal reactions to premature birth viewed as an acute emotional
disorder, Am J Orthopsychiatry 30:539, 1960.
Lindemann E: Symptomatology and management of acute grief, Am J Psychiatry 101:101,
1944.
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Rapoport R: Normal crises, family structure, and mental health, Fam Process 2:68, 1963.
Stone L: Psychoanalysis and brief psychotherapy, Psychoanal Q 20:217, 1951.
Tarachow S: An introduction to psychotherapy, New York, 1963, International Universities
Press.
Tyhurst JA: Role of transition states—including disasters—in mental illness. Paper presented
at Symposium on Preventive and Social Psychiatry, sponsored by Walter Reed Institute of
Research, Walter Reed Medical Center, and National Research Council, Washington, DC,
April 15-17, 1957, U.S. Government Printing Office.
ADDITIONAL READING
Corrigan PW, Holmes EP, Huchins D: Identifying staff advocates of behavioral treatment
innovations in state psychiatric hospitals, J Behav Ther Exp Psychiatry 24(3):219, 1993.
Ellis A: Reflections on rational-emotive therapy, J Consult Clin Psychol 61:199, 1993.
Mahoney JM: Introduction to special section: theoretical developments in the cognitive
psychotherapies, J Consult Clin Psychol 61(2):187, 1993.
Mason EA: Method of predicting crisis outcome for mothers of premature babies, Public
Health Rep 78:1031, 1963.
women,
Maynard CK: Comparison of effectiveness of group interventions for depression in
Arch Psychiatr Nurs 7(5):272, 1993.
for borderline
Miller CR, Eisner W, Allport C: Creative coping: a cognitive-behavioral group
personality disorder, Arch Psychiatr Nurs 8(4):280, 1994.
c disorder:
Newell R, Shrubb S: Attitude change and behaviour therapy in body dysmorphi
two case reports, Behav Cog Psychothe r 22(2):163, 1994.
pain: a validation
Nobily P, Herr KA, Kelley LS: Cognitive-behavioral techniques to reduce
study, Int J Nurs Stud 30(6):537, 1993.
the World Trade
Ofman PS, Mastria MA, Steinberg J: Mental health response to terrorism:
counseling perspective,
Center bombing. Special Issue: disasters and crises: a mental health
J Ment Health Counsel 17(3):312, 1995.
suicidal behaviors: cognitive
Rickelman BL, Houfek JF: Toward an interactional model of
hopeless ness, and depressio n, Arch Psychiatr Nurs
rigidity, attributional style, stress,
9(3):158, 1995.
ad
Ly
EH
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-
\
ccording to Caplan (1964), a person is constantly faced with a need to solve

ee to maintain equilibrium. When he is confronted with an imbalance
between the difficulty (as he perceives it) of a problem and his available repertoire
of coping skills, a crisis may be precipitated. If alternatives cannot be found or
if
solving the problem requires unusual amounts of time and energy, disequilib
rium
occurs. Tension rises and discomfort is felt, with associated feelings
of anxiety, fear,
guilt, shame, and helplessness.
One purpose of the crisis approach is to provide the consultation
services of a
therapist who is skilled in problem-solving techniques. The therapist
will not have
an answer to every problem; however, he will be expected to be compete
nt in problem
solving, guiding and supporting his client toward crisis resolutio
n. The therapeutic
goal for the individual seeking help is to establish a level of
emotional equilibrium
equal to or better than the precrisis level.
Problem solving requires that a logical sequence of reasoni
ng be applied to a
situation in which an answer is required for a question
and in which there is no
immediate source of reliable information (Black, 1946).
This process may take place
either consciously or unconsciously. Usually the need
to find an answer or solution
is felt more strongly when such a resolution is most
difficult.
The problem-solving process follows a structured,
logical order of steps, each
depending on the one preceding. In the routine
decision making required in daily
living, this process is rarely necessary. Most people
are unaware that they may follow
a defined, logical sequence of reasoning in making
decisions; often they remark that
only some solutions seem to have been reached
more easily than others. Finding out
the time or deciding which shoe to put on
first rarely calls for long, involved
reasoning, and more often than not the questi
on arises and the answer is found
without any conscious effort.
26
Chapter 3: Problem-Solving Approach to Crisis Intervention 27
Factors Affecting the Problem-Solving Process

Depending on past experience related to the immediate problem, some people are
more adept at finding solutions than others. Both internal and external factors affect
the process at any given time, although initially there may be a temporary lack of
concrete information. For example, when a driver finds himself lost because of a
missing road sign, how much finding the right directions means to him in terms
of his physical, psychological, and social well-being could affect the ease with
which he finds an answer to the problem. His anxiety will increase in proportion
to the value he places on finding a solution. If he is out driving for pleasure, for
example, he may feel casually concerned, but if he is under stress to be somewhere
on time, his anxiety may increase according to the importance of his arrival at his
immediate goals.
When anxiety is kept within tolerable limits, it can be an effective stimulant to
action. It is a normal response to an unknown danger, experienced as discomfort, and
helps the individual use his resources to solve the problem. As anxiety increases,
however, perceptual awareness narrows and all perceptions are focused on the
difficulty. When problem-solving skills are available, the individual is able to use this
narrowing of perceptions to concentrate on the problem at hand.
If a solution is not found, anxiety may become more severe. Feelings of discom-
fort intensify, and perceptions are narrowed to a crippling degree. The ability to
understand what is happening and to make use of past experiences gives way to
concentration on the discomfort itself. The individual becomes unable to recognize
his own feelings, the problem, the facts, the evidence, and the situation in which he
finds himself.
Although problem solving involves a logical sequence of reasoning, it is not
always a series of well-defined steps. It usually begins with a feeling that something
has to be done. The problem area is general rather than specific and well defined.
Next, the memory is searched in an attempt to come up with ideas or solutions from
similar problems in the past. March and Simon (1963) refer to this as “reproductive
problem solving,” and its value greatly depends on past successes in finding
solutions. When no similar past experiences are available, the individual may then
turn to “productive problem solving.” Here he is faced with the need to construct
new ideas from more or less raw data. He will have to go to sources other than himself
to get his facts. For example, the driver looking for the road sign may find someone
nearby who can give him the needed new data—directions to the right road. If no
one is nearby, he will have to find some other source of information. He may resort
to trial and error and with luck and patience find the way himself. Finding a solution
in this way may meet a present need, but the information gained may not always be
applicable to solving a similar problem in the future.
Anxiety is created by some type of stress. Robinson (1990) has divided stress into
three phases: immediate, intermediate, and long term. Since patients in crisis usually
experience anxiety or depression, it would be of value to look at the biophysiological
components.
¢ Immediate physiological processes: The autonomic nervous system is activated
when an individual perceives a threat or demand from the environment. In the
stress response the hypothalamus stimulates the sympathetic fibers. The

body prepares for “‘fight or flight,” increasing its likelihood of survival. The
effects of sympathetic stimulation occur within 2 to 3 seconds and last be-
tween 5 and 10 minutes. Sympathetic nerve fibers release the catecholamines
epinephrine and norepinephrine. Anxiety is experienced and can be ob-
served both through a person’s verbal report and through clinical signs, includ-
ing perspiration, tremulousness, and rapid pulse and breathing.
Intermediate response: Within 2 to 3 minutes after perception of the stressor,
epinephrine and norepinephrine are secreted; these neurotransmitters travel to
the end organs, where they maintain the processes already initiated. These
sympathetic effects are maintained for 1 to 2 hours. The adrenal medulla does
not continue its response but is reactive only after the central nervous sys-
tem triggers the sympathetic nervous system again. The catecholamines also
stimulate gluconeogenesis, which provides the body with additional energy.
* Long-term response: Three pathways of the endocrine system perpetuate the
long-term effects of stress: the adrenocorticotropic, the thyroxine, and the va-
sopressin pathways. The adrenal cortex secretes two types of corticoids: mineral-
ocorticoids and glucocorticoids. Aldosterone, a mineralocorticoid, raises the
systemic blood pressure. Cortisol, representative of the three glucocorticoids, is
pivotal to the breakdown of fats and proteins for energy. Their prolonged secre-
tion, however, has negative effects. The effects of thyroxine are not observed
until it peaks at about the tenth day after the stressful event, and the effect may
last 6 to 8 weeks. Thyroxine increases the body’s metabolism as much as
60% to 100%. Vasopressin is released from the posterior gland and elevates
blood pressure.
The therapist should assess the crisis patient for stress and anxiety not
only
psychologically but also physiologically. With a high level of stress the
patient will
be unable to understand everything that the therapist is trying to elicit from
him. This
is just one more reason for the therapist to have solid problem-solving
skills and use
them wisely.
To summarize, problem solving is a process for settling a
difficult situation
- or satisfying an unmet need, resolving the discrepancy between
what is and what
should be. Decision making is the process of arriving at a
judgment about a need
or problem, reaching a conclusion about what to do, and then
choosing the action
that should be taken. Both problem solving and decisio
n making involve the
following:
* Logical consideration of the relevant facts and feeling
s
* Reasoning characterized by analysis and evaluation
of available infor-
mation
* Use of memories
* Recognition of knowledge deficits
Effective decision making is the outcome of effecti
ve problem solving. Ineffective
decision making is arrived at impulsively, withou
t thoughtful consideration, or by
relying on inaccurate information. Effective proble
m solving and decision making
occur thoughtfully and involve acquisition,
analysis, and the use of accurate
information (Haber and others, 1992),
Problem Solving In Crisis Intervention

John Dewey (1910) proposed the classical steps or stages represented in different
episodes of problem solving: (1) a difficulty is felt; (2) the difficulty is located and
defined; (3) possible solutions are suggested; (4) consequences are considered; and
(5S) a solution is accepted. With minor modifications this approach to the steps in
problem solving has persisted over the years. Johnson (1955) simplified problem
solving by reducing the number of steps to three: preparation, production, and
judgment.
In 1962, Merrifield and associates extensively researched the role of intellectual
factors in problem solving. They advocated returning to a five-stage model: prepara-
tion, analysis, production, verification, and reapplication. The fifth stage was in-
cluded in recognition of the fact that the problem solver often returns to earlier stages
in a kind of revolving fashion.
According to Guilford (1967), the general problem-solving process involves the
following:
¢ Input: From environment and soma
¢ Filtering: Attention aroused and directed
¢ Cognition: Problem sensed and structured
¢ Production: Answers generated
¢ Cognition: New information obtained
¢ Production: New answers generated
¢ Evaluation: Input and cognition tested, answers tested; new tests of prob-
lem structure, new answers tested
Fortinash and Holoday-Worret (1996) believe that critical thinking is more
important in the therapeutic process and contains many of the components of keen
judgment, intuition, and expertise. Critical thinking skills enhance and become a part
of the therapist’ s continually expanding knowledge base and help the therapist decide
which data are meaningful and which take priority.
When using this process, the therapist incorporates experience and knowledge
from other fields to apply theories and principles in practice. Knowledge of basic
human needs; anatomy and physiology; disease processes; growth and development,
sociological patterns and trends; and various cultures, religions, and philosophies are
all crucial components of the critical thinking framework. The following critical
thinking skills are used in all phases of crisis intervention:
* Observing, which should be planned and continual versus casual and singular
* Distinguishing between relevant and irrelevant data
° Validating data through observations and communication
* Organizing data into meaningful parts
* Categorizing data for efficient retrieval and communication
ASSESSMENT OF THE INDIVIDUAL AND THE PROBLEM

When professional help is sought because a person is in crisis, the therapist must use
n.
logic and background knowledge to define the problem and plan the interventio
Mental health professionals should be familiar with the model for problem solving
in the crisis approach.
The crisis approach to problem solving involves assessing the individual and the
problem, planning of therapeutic intervention, intervention, and resolution of the
crisis and anticipatory planning (Morley, Messick, and Aguilera, 1967).
The first therapy session is directed toward finding out what the crisis-
precipitating event was and what factors are affecting the individual’s ability to solve
problems. It is important that both therapist and patient be able to define a situation
clearly before taking any action to change it. Questions such as ‘‘What do I need to
know?” and “What must be done?” are asked. The more specifically the problem
can be defined, the more likely it is that the “correct” answer will be sought.
Clues are investigated to point out and explore the problem or what is happening.
The therapist asks questions and uses observational skills to obtain factual knowledge
about the problem area. It is important to know what has happened within the
immediate situation. How the individual has coped in past situations may affect his
present behavior. Observations are made to determine his level of anxiety, expressive
movements, emotional tone, verbal responses, and attitudinal changes. It is important
to remember that the therapist’s task is to focus on the immediate problem. There
is not enough time and no need to go into the patient’s history in depth.
One of the therapist’s first questions usually is ““Why did you come for help
today?” The word today should be emphasized. Sometimes the individual will try
to avoid stating why he came by saying, “I’ve been planning to come for some time.”
The usual reply is ““Yes, but what happened that made you come in today?” Other
questions to ask are “What happened in your life that is different?” and “When did
it happen?”
In crisis the precipitating event usually occurs 10 to 14 days before the individual
seeks help. Frequently it is something that happened the day before or the night
before. It could be almost anything, for example, threat of divorce, discovery of
extramarital relations, finding out that a son or daughter is taking drugs, loss of
a
boyfriend or girlfriend, loss of job or status, or an unwanted pregnancy.
The next area on which to focus is the individual’s perception of the event:
What
does it mean to him? How does he see its effect on his future? Does he
see the event
realistically, or does he distort its meaning? The patient is then questione
d about
available situational supports: Who in the environment can the
therapist find to
support the person? With whom does he live? Who is his best friend?
Whom does
he trust? Is there a member of the family to whom he feels particular
ly close? Crisis
intervention is sharply time limited, and the more people involved
in helping the
person, the better. Also, if others are involved and familiar with
the problem, they
can continue to give support when therapy is terminated.
Next determined is what the person usually does when he
has a problem he cannot
solve: What are his coping skills? Has anything like
this ever happened to him
before? How does he usually reduce tension, anxiety, or
depression? Has he tried the
same method this time? If not, why not, if it usually
works for him? If his usual
method was tried and it did not work, why did it not work?
What does he feel would
reduce his symptoms of stress? The patient usually thinks
of something; coping skills
are individual. Methods of coping with anxiety that
have not been used in years may
be remembered. One patient recalled that he used
to “work off tensions” by playing
the piano for a few hours, and it was suggested that
he try this method again. Because
he did not have a piano, he rented one; by the next session his anxiety had reduced
enough to enable him to begin problem solving.
One of the most important parts of the assessment is to find out whether the person
is suicidal or homicidal. The questions must be very direct and specific: Is he
planning to kill himself or someone else? How? When? The therapist must find out
and assess the lethality of the threat. Is the person merely thinking about it or does
he have a method selected? Is it a lethal method, for example, a loaded gun? Has he
picked out a tall building or bridge? Can he tell the therapist when he plans to do
it, for example, after the children are asleep? If the threat does not seem too imminent,
the person is accepted for crisis therapy. If the intent is carefully planned and details
are specific, hospitalization and psychiatric evaluation are arranged to protect the
person or others.
PLANNING THERAPEUTIC INTERVENTION

After identifying the precipitating event and the factors that are influencing the
individual’s state of disequilibrium, the therapist plans the method of intervention.
Determination must be made as to how much the crisis has disrupted the individual’s
life. Is he able to work? Go to school? Keep house? Care for his family? Are these
activities being affected? This is the first area to examine for the degree of disruption.
How is his state of disequilibrium affecting others in his life? How does his wife (or
husband, boyfriend, girlfriend, roommate, or family) feel about this problem? What
do they think he should do? Are they upset?
This is basically a search process in which data are collected. It requires the use
of cognitive abilities and recollection of past events for information relative to the
present situation. The last phase of this step is essentially a thinking process in which
alternatives are considered and evaluated against past experience and knowledge, as
well as in the context of the present situation.
Tentative solutions are advanced about why the problem exists. This step requires
familiarity with theoretical knowledge and anticipation of more than one answer. In
the study of behavior it is important to seek causal relationships. Clues observed in
the environmental conditions are examined and related to theories of psychosocial
behavior to suggest reasons for the individual’s disturbed equilibrium.
INTERVENTION
In the third step, intervention is initiated. Action is taken with the expectation that,
if the planned action is taken, the expected result will occur.
After the necessary information is collected, the problem-solving process is
continued to initiate intervention. The therapist defines the problem from the
information that has been given and reflects it back to the individual. This process
clarifies the problem and encourages focusing on the immediate situation. The
therapist then explores possible alternative solutions to the problem to reduce the
symptoms produced by the crisis. At this time, specific directions may be given as
to what should be tried as tentative solutions. Then the individual can leave the first
session with some positive guidelines for going out and testing alternative solutions.
At the next session the individual and therapist evaluate the results. If none of these
solutions has been effective, they work toward finding others.
The therapist may validate observations and tentative conclusions by reviewing

the case with another therapist, when he thinks it may be helpful or necessary. Briefly,
the therapist identifies the crisis-precipitating event, symptoms that the crisis has
produced in the individual, degree of disruption evident in the individual’s life, and
plan for intervention. Planned intervention may include one technique or a
combination of several techniques. It may be helping the individual to gain an
intellectual understanding of the crisis or helping him to explore and ventilate his
feelings. Other techniques may be helping the individual to find new and more
effective coping mechanisms or utilizing other people as situational supports. Finally,
a plan is presented for helping the person establish realistic goals for the future.
ANTICIPATORY PLANNING
An evaluation determines whether the planned action has produced the expected
results. Appraisal must be objective and impartial to be valid. Has the individual
returned to his usual level or a higher level of equilibrium in his functioning? The
problem-solving process is continued as the therapist and the individual work toward
resolution of the crisis. :
Paradigm of Intervention
According to Caplan (1964), a crisis has four developmental phases.
1. There is an initial rise in tension as the stimulus continues and more discom-
fort is felt.
2. There is a lack of success in coping as the stimulus continues and more dis-
comfort is felt.
3. A further increase in tension acts as a powerful internal stimulus that mobi-
lizes internal and external resources. In this Stage, emergency problem-
solving mechanisms are tried. The problem may be redefined, or there may be
resignation, and certain unattainable aspects of the goal may be given up.
4. If the problem continues and can be neither solved nor avoided, tension in-
creases and a major disorganization occurs.
Whenever a stressful event occurs, certain recognized balancing factors
can effect
areturn to equilibrium; these factors are perception of the event, available
situational
supports, and coping mechanisms (Figure 3-1). The upper portion
of the paradigm
illustrates the “normal” initial reaction of an individual to a stressful
event.
A stressful event is seldom so clearly defined that its source can
be determined
immediately. Internalized changes occur at the same time as the
externally provoked
stress. As a result, some events may cause a strong emotional response
in one person,
yet leave another apparently unaffected. Much is determin
ed by the presence or
absence of factors that can effect a return to equilibrium.
In column A of Figure 3-1, the balancing factors are
operating and crisis is
avoided. However, in column B the absence of one or more
of these balancing factors
may block resolution of the problem and thus increase
disequilibrium and precipitate
crisis.
Figure 3-2 demonstrates the use of the paradigm for
presentation of subsequent
case studies. Its purpose is to serve as a guideline
to help the reader focus on the
Stressful event ———~— —+— Stressful event
Balancing factors present One or more balancing factors absent
PLUS , AND
PLUS AND
RESULT IN RESULTIN
Figure 3-1 Paradigm: the effect of balancing factors in a stressful event.

Possible symptoms ——> <— Told of need for
of cancer diagnostic tests
Mr. A : Mr. B
Figure 3-2 Paradigm applied to case study.

problem areas. An example of its applicability is presented in the cases of two people
affected by the same stressful event. One resolved the problem and avoided crisis;
the other did not.
Balancing Factors Affecting Equilibrium

Between the perceived effects of a stressful situation and the resolution of the
problem are three recognized balancing factors that may determine the state of
equilibrium. Strengths or weaknesses in any one of the factors can be directly related
to the onset of crisis or to its resolution. These factors are perception of the event,
available situational supports, and coping mechanisms.
Why do some people go into crisis when others do not? Figure 3-2 illustrates the
case of two men, Mr. A and Mr. B. Both men have possible symptoms of cancer and
are told of the need for diagnostic tests. Mr. A is upset but does not go into crisis,
whereas Mr. B does go into crisis. Why does Mr. A react one way and Mr. B another?
What “things” in their lives make the difference?
PERCEPTION OF THE EVENT

Cognition, or the subjective meaning, of a stressful event plays a major role in
determining both the nature and degree of coping behaviors. Differences in cognition,
in terms of the event’s threat to an important life goal or value, account for large
differences in coping behaviors. The concept of cognitive style (Cropley and Field,
1969) suggests uniqueness in the way people take in, process, and use information
from the environment.
Cognitive styles, or the characteristic modes for organizing perceptual and
intellectual activities, play an important role in determining an individual’s coping
responses to daily life stresses. According to Inkeles (1966), cognitive style helps to
set limits on information seeking in stress situations. It also strongly influences
perceptions of others, interpersonal relationships, and responses to various types of
psychiatric treatment.
For example, in stressful situations a person whose cognitive style is identified as
“field dependent’ is very dependent on external objects in the environment for
orientation to reality. This type of individual tends to use such coping mechanisms
as repression and denial. In contrast, the “‘field-independent” person tends to prefer
intellectualization as a defense mode.
If the event is perceived realistically, the relationship between the event and
feelings of stress is recognized. Problem solving can be appropriately oriented toward
reduction of tension, and successful resolution of the stressful situation is more
probable.
Lazarus (1966) and colleagues (1974) focused on the importance of the mediating
cognitive process, appraisal, to determine the various coping methods used by
individuals. This approach recognizes that coping behaviors always represent an
interaction between the individual and the environment and that environmental
demands of each unique situation initiate, form, and limit coping activities that may
be required in the interaction. As a result, people engage in widely diverse behavioral
and intrapsychic activities to meet actual or anticipated threats. Appraisal, in this
context, is an ongoing perceptual process by which a potentially harmful event is

distinguished from a potentially beneficial or irrelevant event in one’s life.
When a threatening situation exists, first a primary appraisal is made to judge the
perceived outcome of the event in relation to one’s future goals and values. This is
followed by a secondary appraisal, whereby one perceives the range of coping
alternatives available either to master the threat or to achieve a beneficial outcome.
As coping activities are selected and initiated, feedback cues from changing internal
and external environments lead to ongoing reappraisals or to changes in the original
perception.
As aresult of the appraisal process, coping behaviors are never static. They change
constantly in both quality and degree as new information and cues are received during
reappraisal activities. New coping responses may occur whenever new significance
is attached to a situation.
If, in the appraisal process, the outcome is judged to be too overwhelming or too
difficult to be dealt with by using available coping skills, an individual is more likely
to resort to use of intrapsychic defensive mechanisms to repress or distort the reality
of the situation. An appraisal of a potentially successful outcome, however, more
likely leads to the use of direct action modes of coping such as attack, flight, or
compromise.
If the perception of the event is distorted, a relationship between the event and
feelings of stress may not be recognized. Thus attempts to solve the problem are
ineffective, and tension is not reduced. In other words, what does the event mean to
the individual? How is it going to affect his future? Can he look at it realistically or
does he distort its meaning? In the example, Mr. A perceived the need for diagnostic
tests; his perception of the event was realistic. Mr. B was unable to accept the need
for tests to confirm or refute the possibility of having cancer; his perception was
distorted, and he used denial.
SITUATIONAL SUPPORTS
By nature, human beings are social and dependent on others in their environment to
supply them with reflected appraisals of their own intrinsic and extrinsic values. In
establishing life patterns, certain appraisals are more significant to the individual than
others because they tend to reinforce the perception the individual has of himself.
Dependency relationships may be more readily established with those whose
appraisals tend to support the individual against feelings of insecurity and with those
who reinforce feelings of ego integrity.
These meaningful relationships with others provide a person with nurturanc
e and
support, which are vital resources for coping with a wide variety of stressors.
Social
isolation, whatever the cause, denies a person the availability of social
interactions
and opportunities to develop meaningful relationships. Sudden or unexpect
ed social
isolation results in the loss of usual resource supports. With these
lacking, a person
is much more vulnerable to daily living stressors.
Loss, threatened loss, or feelings of inadequacy in a supportive relation
ship may
also leave a person in a vulnerable position. Confrontation
with a stressful situation,
combined with a lack of situational support, may lead to a state
of disequilibrium and
possible crisis.
Appraisal of self varies across ages, sexes, and roles. The belief system that forms
the basis of the self-concept and self-esteem develops out of experiences with
significant others in a person’s life. Although self-esteem is fairly static within a
certain range, it does fluctuate according to internal and external environmental
variables that impinge on it at a specific time and in a specific situation. To achieve
and maintain a sense of value and self-worth, a person must feel loved by others and
capable of achieving an ideal self, one that is strong, capable, good, and loving of
others.
When self-esteem is low or when a situation is perceived as particularly
threatening, the person is strongly in need of and seeks out others from whom positive
reflective appraisals of self-worth and ability to achieve can be obtained. The lower
the self-esteem or the greater the threat, the greater the need to seek situational
supports. Conversely, a person avoids or withdraws from contacts with those he
perceives as threatening to his self-esteem, whether the threat is real or imagined. Any
potentially stressful situation can set off questions of self-doubt about how one is
perceived by others, the kind of impression being made, and the real or imagined
inadequacies that might be disclosed (Mechanic, 1974).
Success or failure of a coping behavior is always strongly influenced by the social
context in which it occurs. The environmental variable most centrally identified is
the person’s significant others. From them, a person learns to seek responses such
as advice and support in solving daily problems in living. Confidence in being liked
and respected by these peers is based on past testing and reaffirmation of their
expected supportive responses. Any perceived failure to obtain adequate support to
meet psychosocial needs may provoke, or compound, a stressful situation. Negative
support could be equally detrimental to a person’s self-esteem.
Situational supports are those persons who are available in the environment and
who can be depended on to help solve the problem. In the example, Mr. A talked to
his physician and told him of his fear of having cancer. He asked about the tests that
would be conducted and what would be done if the tests did reveal that he had cancer.
He talked with his wife and children about the possibility of having cancer. He
received reassurance from his family and his physician. In effect, he had strong
support during this stressful event. Mr. B did not feel close enough to his physician
to discuss his fears about the possibility of having cancer, and he did not talk to his
family or friends about his symptoms. His denial made him isolate himself. He did
not have anyone to turn to for help; therefore he felt overwhelmed and alone.
COPING MECHANISMS
Through the process of daily living, people learn to use many methods to cope with
anxiety and reduce tension. Lifestyles are developed around patterns of response,
which in turn are established to cope with stressful situations. These lifestyles are
highly individual and quite necessary to protect and maintain equilibrium.
The early work of Cannon (1929, 1939) provided a basis for later systematic
research on the effects of stress on the human organism. According to Cannon’s
“fight or flight” theory, reactions of acute anxiety, similar to those of fear, are vital
to prepare the individual physiologically to meet any real or imagined threat to self.
From his studies of homeostasis, Cannon described the mechanisms whereby human
and other animal life systems maintain steady life states, with the goal always to
return to such states whenever conditions force a temporary departure.
Over the years it has been unusual to find the term coping used interchangeably
with such similar concepts as adaptation, defense, mastery, and adjustive reactions.
Coping activities take a wide variety of forms, including all the diverse behaviors that
people engage in to meet actual or anticipated challenges. In psychological stress
theory, coping emphasizes various sirategies used, consciously or unconsciously, to
deal with stress and tensions arising from perceived threats to psychological integrity.
It is not synonymous with mastery over problematical life situations; rather, it is the
process of attempting to solve them (Lazarus, 1966).
Coleman (1950) defined coping as an adjustive reaction made in response to actual
or imagined stress in order to maintain psychological integrity. Within this concept
human beings are perceived as responding to stress by either attack, flight, or
compromise reactions. These reactions become complicated by various ego-defense
mechanisms whenever the stress becomes ego involved.
Attack reactions usually attempt to remove or overcome the obstacles seen as
causing stress in life situations. They may be primarily constructive or destructive
in nature. Flight, withdrawal, or fear reactions may be as simple as physically
removing the threat from the environment (such as putting out a fire) or removing
oneself from the threatening situation (running away from the fire area). They might
also involve much more complex psychological maneuvering, depending on the
perceived extent of the threat and the possibilities for escape.
Compromise or substitution reactions occur when either attack or flight from the
threatening situation is thought to be impossible. This method is most commonly
used to deal with problem solving and includes accepting substitute goals or changing
internalized values and standards.
Masserman (1946) demonstrated that, in situations of extended frustration,
individuals find it increasingly possible to compromise for substitute goals. This
often involves use of rationalization, a defense mechanism whereby “half a loaf”
does indeed soon appear to be “‘better than none.”
Tension-reducing mechanisms can be overt or covert and can be consciously or
unconsciously activated. They have been generally classified into such behavioral
responses as aggression, regression, withdrawal, and repression. The selection of a
response is based on tension-reducing actions that successfully relieved anxiety
and
reduced tension in similar situations in the past. Through repetition the response may
pass from conscious awareness during its learning phase to a habitual
level of
reaction as a learned behavior. In many instances the individual may not
be aware
of how, let alone why, he reacts to stress in given situations. Except
for having vague
feelings of discomfort, the individual may not notice the rise and consequent
reduction in tension. When a novel stress-producing event arises and
learned coping
mechanisms are ineffectual, discomfort is felt on a conscious
level. The need to “‘do
something” becomes the focus of activity, narrowing perception
of all other life
activities.
Normally, defense mechanisms are used constructively in the
process of coping.
This is particularly evident whenever there is danger of becomi
ng psychologically
overwhelmed. Almost all defense mechanisms are seen as
important for survival.
None is equated with a pathological condition unless it interferes with the pro-
cess of coping, such as being used to deny, to falsify, or to distort perceptions
of reality.
According to Bandura and others (1977), the strength of the individual’s
conviction in his own effectiveness in overcoming or mastering a problematical
situation determines whether coping behavior is even attempted. People fear and
avoid stressful, threatening situations that they believe exceed their ability to cope.
They behave with assurance in those situations where they judge themselves able to
manage, and they expect eventual success. It is the perceived ability to master that
can influence the choice of coping behaviors, as well as the persistence used once
one is chosen.
Available coping mechanisms are what people usually use when they have a
problem. They may sit down and try to think it out or talk it out with a friend. Some
cry it out or try to get rid of their feelings of anger and hostility by swearing, kicking
a chair, or slamming doors. Others may get into verbal battles with friends. Some may
react by temporarily withdrawing from the situation to reassess the problem. These
are just a few of the many coping methods people use to relieve their tension and
anxiety when faced with a problem. Each has been used at some time in the
developmental past of the individual, has been found effective in maintaining
emotional stability, and has become part of his life style in meeting and dealing with
the stresses of daily living.
Continuing with the example, Mr. A made an appointment for the tests
recommended by his physician, The tests were conducted; the diagnosis was negative
for cancer. His tension and anxiety were reduced, equilibrium was restored, and he
did not have a crisis. Mr. B withdrew; he had no coping skills. He did not make an
appointment for the needed tests, no tests were made, and, as a result, he had no
definitive diagnosis, and his tension and anxiety increased. Unable to solve the
problem and to function, Mr. B went into crisis.
The balancing factors that affect equilibrium were demonstrated in Figure 3-2.
Mr. A had a realistic perception of the event and returned to his original state of
equilibrium. He did not have a crisis. Mr. B had a distorted perception of the event,
used denial, remained in a state of disequilibrium, and went into crisis.
What if Mr. A’s tests had been positive instead of negative? Figure 3-3 presents
a new paradigm of comparative cases and introduces Mr. C, whose balancing factors
are identical to Mr. A’s with one exception: Mr. C had the diagnostic tests for cancer
and his results were positive. His tension and anxiety increased, and he had surgery
that successfully removed the cancer. He did not have a crisis. The balancing factor
that made the difference was his realistic perception of the event. The relationship
between the event and his feelings of stress was recognized. His problem solving was
appropriately oriented toward reduced tension, and his stressful situation was
resolved successfully.
It can be seen how the paradigm helps the therapist focus on the essential areas
that have created the problem for Mr. B in Figure 3-2. The utilization of the paradigm
can also be seen in the comparative cases in Figure 3-3. In subsequent chapters there
will be actual case studies followed by a paradigm with a blank right column for the
reader to complete using the format of those in this chapter.
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The reader will be able to compare his paradigm with the completed one in
Appendix D. This chapter should be used as a resource when the reader completes
the blank paradigm. This exercise should enhance skills in resolving crises.
REFERENCES
Bandura A and others: Cognitive processes mediating behavioral change, J Pers Soc Psychol
spel, ISIE
Black M: Critical thinking: an introduction to logic and scientific method, Englewood Cliffs,
NJ, 1946, Prentice-Hall.
Cannon WB: Bodily changes in pain, hunger, fear, and rage, New York, 1929, D Appleton.
Cannon WB: The wisdom of the body, ed 2, New York, 1939, WW Norton.
Caplan G: Principles of preventive psychiatry, New York, 1964, Basic Books.
Coleman JC: Abnormal psychology and modern life, Chicago, 1950, Scott, Foresman.
Cropley A, Field T: Achievement in science and intellectual style, J App! Psychol 53:132,
1969.
Dewey J: How we think, Boston, 1910, DC Heath.
Fortinash KM, Holoday-Worret PA: Psychiatric-mental nursing, St. Louis, 1996, Mosby.
Guilford JP: The nature of human intelligence, New York, 1967, McGraw-Hill.
Haber J and others: Comprehensive psychiatric nursing, ed 4, St. Louis, 1992, Mosby.
Inkeles A: Social structure and the socialization of competence, Harv Ed Rev 36:265, 1966.
Johnson DM: The psychology of thought and judgment, New York, 1955, Harper & Row.
Lazarus RS: Psychological stress and the coping process, New York, 1966, McGraw-Hill.
Lazarus RS and others: The psychology of coping: issues in research and assessment. In
Coehlo GV and others, editors: Coping and adaptation, New York, 1974, Basic Books.
March JG, Simon HA: Organizations, New York, 1963, John Wiley & Sons.
Masserman JH: Principles of dynamic psychology, Philadelphia, 1946, WB Saunders.
Mechanic D: Social structure and personal adaptation: some neglected dimensions. In
Coehlo GV and others, editors: Coping and adaptation, New York, 1974, Basic Books.
Merrifield PR and others: The role of intellectual factors in problem-solving, Psychol Monogr
76:1, 1962.
Morley WE, Messick JM, Aguilera DC: Crisis: paradigms of intervention, J Psychiatr Nurs
3:5383, 1967.
Robinson L: Stress and anxiety, Nurs Clin North Am 25:(4)935, 1990.
ADDITIONAL READING
Altmaier EM: Linking stress experiences with coping resources and responses: comment on
Catanzaro, Horaney, and Creasey (1995), Long and Schutz (1995), Heppner and others
(1995), and Bowman and Stern (1995), J Counseling Psychol 42(3):304, 1995.
Antonietti A, Gioletta MA: Individual differences in analogical problem solving, Pers
Individual Differences 18(5):611, 1995.
Bergan JR: Evolution of a problem-solving model of consultation, J Educational Psychol
Consultation, 6(2):111, 1995.
D’Zurilla T, Chang EC: The relations between social problem solving and coping, Cognitive
Ther Res 19(5):547, 1995.
D’Zurilla TJ, Maydeu-Olivares A: Conceptual and methodological issues in social problem-
solving assessment, Behav Ther 26(3):409, 1995.
Davila J and others: Poor interpersonal problem-solving as a mechanism of stress generation
in depression among adolescent women, J Abnorm Psychol 104(4):592, 1995.
Diehl M, Willis SL, Schaie K Warner: Everyday problem-solving in older adults: observational
assessment and cognitive correlates, Psychol Aging 10(3):478, 1995.
Goodman SH, Gravitt GW, Kaslow NJ: Social problem solving: a moderator of the relation
between negative life stress and depression symptoms in children, J Abnorm Child Psychol
23(4):473, 1995.
Littlepage GE and others: An input-process-output analysis of influence and performance in
problem-solving groups, J Pers Soc Psychol 69(5):877, 1995.
Nickols FW: Reengineering the problemi-solving process (finding better solutions), Perfor-
mance Improvement Q 7(4):3, 1994.
Nystul MS: A problem-solving approach to counseling: integrating Adler’s and Glasser’s
theories, Elementary School Guidance Counseling 29(4):297, 1995.
Powell CA: Cognitive hurdles in the use of decision support systems to enhance problem
understanding. Special issue: decision making under conditions of conflict, Group Decision
Negotiation 3(4):413, 1994.
Rooney EF and others: I can problem solve: an interpersonal cognitive problem-solving
program, J Sch Psychol 31(2):335, 1993.
Sautter FJ, Heaney C, O’Neill P: A problem-solving approach to group psychotherapy in the
inpatient milieu, Hosp Community Psychiatry 42:814, 1991.
Sternberg JA, Bry BH: Solution generation and family conflict over time in problem-solving
therapy with families of adolescents: the impact of therapist behavior, Child Fam Behav
Ther 16(4):1, 1994.
Stewart SL, Rubin KH: The social problem-solving skills of anxious-withdrawn children, Dev
Psychopathol 7(2):323, 1995.
Tomic W: Training in inductive reasoning and problem solving, Contemporary Educational
Psychol 20(4):483, 1995.
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The lawis‘the witness and external depositof ouroral life
Its oF is the history of the moral| development of the race.
er Wendell Holmes, Jr
f mental health professionals are to be expected to know the relevant law, it is

important to provide a definition of mental health law that sets boundaries for the
field. Mental health law is defined as the field of inquiry that is concerned with the
intersection of the law with the mental health status of individuals: the operation of
the mental health system and of other public or private systems in their provision of
services to individuals with mental illness (e.g., education and child welfare systems
and private psychiatric hospitals) and the roles, functions, and responsibilities of
mental health professionals, who need to be familiar with the law as it operates in
each of these contexts (Sales and Shuman, 1994).
Law and mental health care are now so interconnected that it is difficult to
remember a time when they did not interact. For better or for worse, mental health
professionals are both directly and indirectly affected by the law. Their practice
is directly controlled by laws that regulate such matters as licensure and cer-
tification, third-party reimbursement, and professional incorporation. The quality
of their services is subject to review by courts in malpractice actions. Indirectly,
the law affects mental health professionals through the increasingly frequent
involvement of their patients in legal entanglements in which mental status issues
are pivotal (e.g., divorce proceedings, child custody disputes, litigation over
mental and emotional injury, and involuntary civil commitment) (Sales and
Shuman, 1994).
Laws relating to the competence of a patient to consent to mental health services
focus on the patient’s mental status, as well as on the patient’s legal right to
consent or refuse to consent to these services. Laws focusing on the authority
of the state to operate a public mental health system that includes both voluntary
and involuntary services are an important component of mental health law and
continue to raise significant legal controversy. Mental health professionals’ roles,
43
functions, and responsibilities are also an important component of mental health

law because patients’ rights (e.g., a right to confidentiality of information revealed
during therapy) concomitantly involve mental health professionals’ responsi-
bilities (e.g., to maintain confidences) and because laws specify the involve-
ment of mental health professionals in their administration (e.g., evaluating
defendants who claim that they were insane when they committed the crime) and
affect mental health professionals’ practices (e.g., malpractice law) (Sales and
Miller, 1993).
Therapeutic Jurisprudence
Although some of the key components of the stated definition of mental health law
have been exemplified, there is still a need to clarify the goals of that law. The
generation of mental health law scholarship and legal decision making that began in
the early 1960s and has recently ended was dominated by a moral perspective that
conceives of the law as advancing important values, often ensconced within
normative constitutional principles (e.g., the right to an attorney, right to a hearing,
and privilege against self-incrimination). The deontological (moral obligation)
perspective contrasts with the utilitarian, consequentialist perspective that espouses
legal rules as important to achieve some end. For example, from the moral
perspective, recognition of the patient’s right to a judicial hearing preceding
involuntary civil commitment should turn on whether commitment is a deprivation
of liberty under the Fourteenth Amendment to the U.S. Constitution; from the
utilitarian perspective, the right to a hearing should turn on its consequences, such
as the accuracy of the hearing’s results or patient compliance with the hearing’s
decision (Tyler, 1993).
Although much of the previous generation of mental health law scholarship and
decision making was deontologically oriented, there developed concurrently a
significant body of literature that arose from a utilitarian perspective, with roots in
the early twentieth-century Legal Realist movement (Monahan and Walker, 1990).
It was concerned with empirically testing whether laws were achieving their explicit
and implicit goals. This approach to law and behavioral and social science
interactions asserts that almost all laws are based on behavioral, social, and economic
assumptions, the validity of which can be empirically determined (Sales, 1993; Sales
and Hafemeister, 1985; Shuman, 1993). When a federal court ordered that mentally
ill persons who reside in state hospitals be accorded their right to privacy,
utilitarian-driven research was able to demonstrate that the institutional changes
aimed at fulfilling the court order did not achieve their goal (O’Reilly and Sales,
1986, 1987). The findings of this type of research can be used to argue for changes
in the law or in its implementation.
Building on this empirical heritage, a new school of thought in mental health law
has evolved called therapeutic jurisprudence (Wexler and McGrath, 1993).
Rather
than exclusively relying on moral-driven legal rules, this new movement
looks to
analyze the consequences of legal rules and incorporate this information
in legal
decision making. The overarching goal of therapeutic jurisprudence is that
mental
health law realize its potential to advance therapeutic outcomes,
at least when it is
Chapter 4: Legal and Ethical Issues in Psychotherapy 45
possible to do so without offending other important considerations (e.g., constitu-

tional principles). The notion is not that therapeutic considerations should trump
all others but rather that legal decisions involving both mentally ill and non-
mentally ill individuals take into account their therapeutic or antitherapeutic con-
sequences (Sales and Shuman, 1994).
LIMITS OF THERAPEUTIC JURISPRUDENCE

Therapeutic jurisprudence seeks to advance therapeutic outcomes by encouraging
legal decision makers to consider therapeutic consequences; it does not dictate the
selection of legal rules that advance a therapeutic outcome. Therapeutic jurispru-
dence clarifies the decisional stakes but does not purport to resolve them; balancing
of values is not given to a simplistic formulaic analysis. If empirical research reveals
that recognition of a right to refuse treatment is antitherapeutic, a court or legislature
may, because of this finding, refuse to recognize that right or, notwithstanding this
finding, recognize that right based on a moral valuation of the importance of
autonomy (Schopp, 1993).
When legal decision makers choose to recognize a rule that is therapeutic or
refuse to recognize a rule that is antitherapeutic, the judgments of the legal system
and the mental health system are congruent. The congruence in the judgments
of the two disciplines can occur either because legal decision makers use a
utilitarian approach that accepts the empirical outcomes as dispositive or because
legal decision makers use a deontological approach that coincidentally concurs
with the empirical research. The absence of congruence occurs when, for moral
reasons, legal decision makers choose laws that are antitherapeutic or reject laws
that are therapeutic. It is this absence of congruence that has understandably
troubled mental health professionals, whose language and professional values do
not share the legal system’s deontological concerns. Mental health professionals
should not expect from therapeutic jurisprudence a change in legal values or
orientation that subordinates normative constitutional values to therapeutic values
(Sales and Shuman, 1994).
Even when attempts are made to achieve appropriate communication, tensions can
result when, in an attempt to avoid addressing various normative and policy questions
head on, legal decision makers erroneously recast them as technical or scientific
issues to be answered by “experts.” Even when issues require scientific rather than
normative judgments, legal reliance on mental health expertise is problematic
because mental health professionals often lack available, relevant, empirically
grounded knowledge or are willing to render opinions beyond their areas of expertise
(Grisso, 1986).
There can be tensions and conflicts based on the different values, interests, and
needs among key participants in law and mental health interactions (e.g.,
policymakers, institutions and organizations providing services, program adminis-
trators and providers, patients, family members, and researchers). What if a state
institution wishes to deinstitutionalize a minor, but the parents do not wish to have
the minor returned to the home (Frohboese and Sales, 1980)? And what if the mental
health professional providing services objects to being used for social control
purposes by prison administrators, for example, when they ask the mental health
professional to conduct evaluations to determine for security purposes whether the

patient is dangerous.
ALLIANCE OF MENTAL HEALTH LAW AND CARE
In what ways can a therapeutic jurisprudence perspective serve to form a working

relationship between law and practice in mental health? Both mental health
professionals and lawyers may find some benefit in a therapeutic jurisprudence
perspective, since it explicates the tensions between law and mental health, even if
it does not always resolve them. Therapeutic jurisprudence serves to remind lawyers
and mental health professionals that therapeutic consequences of legal decision
making need examination and helps to make the rationale for these decisions more
explicit. As mental health professionals well know, talking openly about conflict has
therapeutic value.
In those areas of the law in which false conflicts now exist between the goals of
mental health law and mental health care, therapeutic jurisprudence may advance
shared therapeutic goals previously frustrated by ill-conceived legal rules (Wexler
and McGrath, 1993). Consider the matter of plea bargaining by sex offenders, in
which the defendant is often allowed to plead no contest without acknowledging the
specific acts of abuse, thereby avoiding the danger of losing at trial. If research
reveals that not acknowledging one’s guilt promotes the abuser’s cognitive
distortions and makes treatment less likely to succeed, changing the legal rule to
require acknowledgment of the abusive acts in the plea may advance the shared
therapeutic goal of reducing abuse.
Therapeutic jurisprudence reveals that legal rules often have explicit or implicit
therapeutic agendas that sometimes get lost in the tumult of day-to-day application.
By focusing its therapeutic lens, therapeutic jurisprudence assists the law to achieve
its own therapeutic agenda. Malpractice laws, though often caught up in a political
diatribe, are intended to improve the quality of care delivered by mental health
professionals and to aid in making whole those injured by substandard care. By
understanding the impact of these laws on providers and consumers of mental health
services, legal decision makers can better develop rules that accomplish these goals
(Shuman, 1993).
Perhaps most important, a therapeutic jurisprudence view of mental health law is
needed, since the traditionally deontologically driven mental health law perspectiv
e
has advanced about as far as it can go (Shuman, 1992). For example, the
deontological approach has substantially succeeded in establishing for mentally
ill
persons who face involuntary hospitalization many of the constitutional
rights
applicable to persons facing criminal prosecution; the recognition of more
rights is
unlikely at this time given our national temperament (Perlin,
1994). Now, the
accomplishments of this morally driven analysis need examination
to determine how
the imposition of the law affects the interests of its intended beneficiar
ies and whether
therapeutic outcomes have been advanced. Such work should (1)
use feedback from
mental health professionals and patients, mental health scholars,
and empirical
research and (2) focus on the availability and delivery of effectiv
e systems of mental
health services.
The next generation of mental health law and scholarship would ideally have the
law participate with mental health professionals in making their services available
to consumers who seek them. Without abandoning normative constitutional values,
such efforts should include a plan for mental health services that incorporates the
following*:
* Identification of those in need of services and those not being served and
the reasons for discrepancy
* Development of a comprehensive plan of integrated services
* Provision of services with clear outcome goals
* Systematic collection of accurate information on delivery of services and
operation of systems providing those services, and the reporting of those
data in a meaningful fashion
* Use of these data to aid in decision making on mental health care
* Provision of appropriate services to ethnic minorities
* Provision of sufficient funding to support legally mandated entitlements
This shift in focus should help to reorient mental health law to the core concerns of
those consumers who need and want mental health services and of mental health
professionals who are devoted to providing those services. The plan would support
a rational planning and implementation process by legal and public policymakers
and administrators who are responsible for interpreting and implementing legal
guidelines. In addition, it would facilitate effectiveness and efficiency in the delivery
of mental health services (Sales and Shuman, 1994).
Legal and Ethical Defined

According to Black’s (1990) Law Dictionary there are several definitions of the term
legal. The following are included.
1. Conforming to the law; according to law; required or permitted by law; not
forbidden or discountenanced by law; good and effectual in law; of or per-
taining to the law; lawful
2. Proper or sufficient to be recognized by the law; cognizable in courts;
competent or adequate to fulfill the requirements of the law
3. Cognizable in courts, as distinguished from courts of equity; construed or
governed by the rules and principles of law, in contradistinction to rules of
equity (with the merger in most states of law and equity courts, this dis-
tinction generally no longer exists)
4. Created by law
Now that /egal is more than sufficiently defined, it is only equitable to examine
the definition of ethics by Karasu (1984) as it pertains to psychotherapy. Karasu states
that ethics is a code of morality of a person or group of people, such as a professional
group. Morality is the distinction between right and wrong conduct. The mental
health sciences, on the other hand, are concerned with the establishment of facts and
knowledge. From one point of view, ethics and psychotherapy are two separate areas
ro
* National Institute of Mental Health, 1991.
of study and are almost opposite in focus. Psychotherapy is concerned with

describing human nature and validating its ideas about what “‘is true’”’ about human
nature. Ethics is concerned with prescribing actions, and forming judgments, based
on “what ought to be.”
Related to ethical concerns, Karasu states that society is now experiencing an
“Age of Ethical Crisis’ compared with our previous ‘“‘Age of Anxiety.” This age of
ethical crisis has many components, including the following:
* Progressive loss of faith in traditional institutions
¢ Mistrust of authority
¢ Renewed concern for human rights
* Disappointment with mental health care sciences and their inability to solve
the problems of society
* Anti-elitism, the professionals’ misuse of power to maintain the unequal dis-
tribution of resources in society
Questions related to psychotherapeutic intervention may include the following:
* Whether traditional mental health care institutions meet the needs of the
population ’
* Whether professionals, entrusted with responsibility for providing care, have
the interests of patients in mind
* Whether the rights of patients are protected in mental health care
These questions should be expected. Traditionally, the treatment of the mentally ill
has evoked an image of ‘‘controller” and ‘“‘vulnerable victim” who cannot provide
consent for treatment because of illness. Also, both psychiatry and philosophy, tra-
ditionally the fields in which ethical matters are extensively studied, have discussed
ethical concerns in their fields in highly abstract terms and principles. The pressing
everyday concerns of patients seem removed from these abstract discussions.
Therapists in psychotherapeutic practice were once removed and left undisturbed
in the confines of their offices. Now therapists are questioned by other therapists
about their methods, ideas of mental illness, and other topics. This is not surprising,
since there are more than 250 models of psychotherapeutic methods, with the
proponents of each claiming that theirs is the correct method of treatment. Therapists
are also questioned by patients themselves, who are confused about methods
of
therapy, as well as about the power of the therapist. Increasingly, patients expect,
and
have the right to, treatment that is understandable. They demand that therapists
be
held accountable. Patients expect to have a part in planning and evaluating
their
treatment with the therapist. Therapists can no longer expect blind reverence.
Professionals in mental health care cannot ignore ethical questions.
Historically,
professionals have been relatively blind to ethical concerns. Ethical
issues are often
overlooked because they are not apparent. Therapists may
ignore ethical topics
because they, like all human beings, have internal forces that motivat
e people toward
both right and wrong.
Legal Issues
else AER MSU Pt Lean. ei tn
The landmark case establishing that therapists have a legal
duty to warn potential
victims of their patient’s behavior is Tarasoff v. Regents
of University of the
California (1976). The details of the case are well known. In the course of therapy,
Prosenjit Poddar threatened to kill Tatiana Tarasoff, a fellow student in his square
dancing class. Poddar was held for observation and released. No one notified Tarasoff
of the threat Poddar had made against her. Two months later, Poddar murdered
Tarasoff, and the Tarasoff family filed suit. The court held that ‘‘when a therapist
determines, or pursuant to the standards of his profession should determine, that his
patient presents a serious danger of violence to another, he incurs an obligation to
use reasonable care to protect the intended victim against such danger” (Tarasoff v.
Regents of the University of California, 1976).
DUTY TO WARN
The Tarasoff case identifies three elements central to therapists’ legal duty to warn.
One element is the likelihood that patients will cause physical harm to themselves
or others. The second is the special relationship between the therapist and client
(patient) (Schopp and Quattrocchi, 1985); therapists have special duties to control the
actions of their patients and to protect patients from harm. The third element is the
existence of an identifiable victim (Lamb and others, 1989). That a special relation-
ship exists between patients and therapists is rarely disputed. This relationship is
referred to as fiduciary, that is, related to a confidence or trust. The other elements
may be less clear.
Privilege, confidentiality, and disclosure statements. To understand the impact
of the Tarasoff ruling, therapists must understand the relationships among privilege,
confidentiality, and disclosure statements.
Confidentiality is the therapist’s ethical obligation to safeguard patient commu-
nications (Ciccone, 1985; Stein, 1990). Confidentiality is a general ethical duty, a
feature of many professional organizations’ code of ethics, and a component of many
licensing and certifying agencies’ regulations.
Privilege constitutes the particular legal rights that state law gives to patients
(Kamenar, 1984). According to Black’s Law Dictionary (1990), privileged com-
munications are “those statements made... within a protected relationship...
which the law protects from forced disclosure.” Privilege, notes Ciccone (1985),
“is a legal right belonging to the patient” not the therapist. Gumper and Sprenkle
(1981) define privilege as ‘‘a limited, legal right, usually vested in the patient
rather than the professional, to refuse or prevent disclosure of therapy commu-
nications.” In most states the therapist’s general duty of confidentiality must give
way when disclosure is necessary to warn or prevent harm to an identifiable third
party.
A disclosure statement is a written document detailing the policy, negotiated
between the therapist and patient, concerning therapist disclosure of patient informa-
is
tion. Frequently, the document expresses the standard policy of the therapist and
of the therapist’s legal responsibil i-
signed by the patient. It should inform the patient
law.
ties and indicate how the therapist will use discretion within the limits of the
The relationships among confidentiality, privilege, and a therapist’s disclosure
policy may be summarized as follows:
1. The duty to safeguard confidential information is a general duty of the thera-
pist’s. As a general duty, it may give way to other duties or rights.
Box 4-1
EXAMPLE OF A DISCLOSURE STATEMENT
Although the information you give me is generally confidential, there are important
exceptions of which you should be aware.
1. If, in my opinion, therapy cannot profitably proceed unless something you tell me
is shared with other family members, [ may need to give you the choice of telling the
other family members yourself, having me tell them, or terminating therapy.
2. Ihave an ethical obligation to balance the interests of all family members. If you
inform me of a situation that, in my opinion, is blatantly harmful, unfair, or unethical,
I may, at my discretion, give you the choice of correcting the situation when that is
feasible, informing other family members of the situation, having me tell them, or
terminating therapy.
3. If, in my opinion, you pose a danger to yourself or others, I have a legal duty to
intervene. For example, if you threaten someone’s life, I am legally obligated to warn
that person, even if you terminate therapy. If you threaten to commit suicide, I may have
to notify members of your family and/or the police‘or other agencies.
4. In general, I will follow, to the best of my ability, all state laws and regulations,
as well as the policies and codes of ethics of (the relevant licensing agency and/or
professional society). (Here, set forth a clear summary of the relevant laws, codes of
ethics, and any other appropriate information.)
5. Please feel free to ask for clarification about any of these matters at any time,
either now, during therapy, or before you tell me something I might have to share
with others.
2. A privilege is a specific right owned by the patient; privilege exists when

the law protects the patient’s communication from disclosure.
3. A written disclosure statement indicates to the patient the policy the
therapist
will follow concerning disclosure of patient information and communic
ations.
An example of the relevant section of a disclosure statement is provided
in Box
4-1. Any sample statement, including this one, may be inconsistent
with state law or
licensing agency policy in some areas. Statement 3, in the example
, may be invalid
in Maryland. Therapists must review (or preferably, seek legal
advice in reviewing)
local requirements before adopting a disclosure statement.
In the oral discussion of the policy, the therapist should provide
several examples
of each sort of patient information that the therapist might
need to disclose.
Legal and Ethical Consequences of Therapist Malfeasance

C e
Therapist-patient sexual involvement is increasingly being
acknowledged as the most
common and prolific problem for all mental health profess
ions. More disciplinary
actions are taken for therapist-patient sexual involv
ement than for all other unethical
discrepancies combined (Pope and Vetter, 1991). It
should be noted here that the term
psychotherapist refers to any licensed therapist,
including psychologists; psychia-
trists; psychiatric social workers; psychiatric nurses;
and marriage, family, and child
counselors. The harm that may occur for a patient has become the focus for clinical
inquiry.
Psychotherapists can obtain information relevant to ethical practice and standards
from a large number of sources. These sources include the American Psychiatric
Association; the American Psychological Association; the Board of Behavioral
Science Examiners; the formal ethics committees of all major health disciplines; and
published research, clinical, and theoretical works (Conte and others, 1989). Most
people are usually unfamiliar with the terms used in disciplinary actions, unless it
is a highly publicized incident or involves high-profile and well-known or popular
individuals. Therefore the Disciplinary Key in Appendix A defines important legal
terms used in disciplinary actions.
Case law (Roy v. Hartogs, 1976; Kardener and others, 1976) has reflected
agreement with the ethical codes of all mental professional societies that sexual
relations between therapists and their patients are at least unethical and under rare
circumstances criminal. Such relations represent a deviation from the standard of care
and a basis for the finding of malpractice if the other requisite elements (e.g.,
damages) are present (Gutheil, 1982). Case law dramatically fails, however, to reflect
the actual scope of the problem (Gartrell and others, 1986) because of the large
number of episodes never reported at all and the substantial number of filed legal
cases—probably. the majority—that are settled out of court. False accusations
represent a small fraction of total allegations: accusations are usually true. Therapists
can benefit from being aware of certain repeating patterns of errors in therapy and
countertransference responses. With this awareness, they can avert the serious
outcomes that result from these errors, such as trauma to the patient and/or highly
destructive litigation (Aguilera, 1996).
One caveat is necessary to prevent misunderstanding. To study the patient-
therapist dyad in clinical terms is not the same as indicting the patient (blaming the
victim) for some depravity, nor is it the same as explaining away (exoneration) or
excusing the therapist’s behavior. Sex with a patient is never acceptable.
Codes of ethics covering the practice of professional psychotherapists have been
adopted by at least 18 of the 45 national members of the International Union of
Psychological Science and by all but | of the 16 members of the European Federation
of Professional Psychologists’ Associations. These codes cover basic values such as
the protection and promotion of human dignity and welfare, assumption of
responsibility for professional action, restriction of practice to areas of competence,
confidentiality, and honesty in all matters. In most countries the codes are
implemented by ethics committees and usually enforced by appropriate sanctions
(Pope and Vetter, 1991).
Differences among nations in the definition of those qualified to provide
psychological services make the estimation of human resources in psychotherapy a
very uncertain endeavor. However, certain broad differences in the employment
patterns of psychological health service providers can be noted among the
industrialized countries of the West, the socialist countries, the dynamically
developing countries, and the less developed countries.
In the United States, for which data are most readily available, 31% of
by
doctoral-level psychotherapists work full time in independent practice, followed
20% in hospitals, and 14% in clinics. Another 19% work in academic or educational
settings, with the remainder distributed among business, government, and other
human service settings (Stapp and Fulcher, 1983). Counseling therapists are found
in the same general fields but in greater concentration in academic settings (40%),
where they counsel students in addition to teaching and performing research.
Throughout Europe the great majority of professional psychotherapists are
salaried employees of public agencies. Private practice is practically nonexistent in
the socialist countries and fairly rare in many countries of the industrialized West
(e.g., the United Kingdom), where high-quality public health and welfare services
may be available. There are wide variations in the specialties in which psychothera-
pists may be employed.
When examining urban areas and rural towns throughout the world, it is important
to keep in mind the heterogeneity of communities. Many cities require people of
different backgrounds to live close together and independently. This heterogeneity
may involve language, race, religion, social class, nationality, or a preferred lifestyle.
Stress is sometimes associated with this diversity and with pressures and conflicts
that may accompany acculturation. Factors such as national policies that force
assimilation or historical and economic factors that generate intergroup conflict are
predictive of high stress, and their absence is predictive of low stress (Berry and
others, 1984). The weakening of traditional support systems makes such stress
especially difficult to handle.
Increases in the rates of divorce, child abuse, crime, and mental illness within
urban centers of the world are requiring more services from psychotherapists than
has been typical in the past. To be effective such services must take the cultural
background of the patient into account. Psychotherapists who are competent to deal
with cross-cultural issues in health and human development have developed
techniques for measuring and reducing personal alienation, for adapting psycho-
therapy to local conditions, and for improving the mental health of
diverse
populations (Triandis and Draguns, 1980).
Crisis interverition is a relatively recent “frontline” mental health specialty
with
obvious implications for physical health. Experience acquired
in providing
assistance to ordinary well-functioning individuals on occasions
of intense stress
(e.g., rape, assault, combat shock or panic, and transitory episodes
of depression
related to changes in personal relationships or circumstances
of employment) has
enabled psychotherapists to become involved in large-scale
efforts to lessen the
harmful effects of human-created and natural disasters.
Therapist-patient sexual involvement confronts us with
a pressing problem that
has far-reaching implications for the professions. It may
also involve increased
understanding of the sexualization of teaching relationships
and the ways in which
training programs provide education and modeling regardi
ng sexual issues (Pope and
Vetter, 1991).
SEXUAL HARASSMENT
The effect of role modeling on the development of
professional ethics and behavior
cannot be dismissed (Pope, Levenson, and Schover, 1980). According to Sandler
(1990),
One of the most striking aspects of sexual harassment is that the victim feels quite powerless
in the situation. Students rely on the professors not only for grades but for future
recommendations, as well as academic and career opportunities. In a very real sense, a
student’s life chances are at stake.
It is rare, then, that a victim exhibits the courage and willingness to take the risk
to confront the harasser and, once the complaint process is complete, to share the
experience with others.
The Thomas-Hill case (October 1991) attracted the attention not only of the nation
but also of the world. The media had a proverbial field day. The results are still being
debated today. In Las Vegas, September 1991, the ‘““Tailhook” reunion for Navy
pilots was another graphic example of blatant sexual harassment.
Institutional administrators, managers, and supervisors attempting to formulate
strategies for the prevention and remediation of sexual harassment may feel caught
in a similar muddle: How are we to prevent what we cannot clearly define? How can
we be responsible for that which we did not know was occurring? The confusion is
due to the range of possible behaviors and judicial findings of sexual harassment.
Determinations as to whether sexual harassment has taken place necessarily proceed
on a case-by-case basis as courts and enforcement agencies consider circumstances
ranging from the outright demand for sexual favors at one extreme to complaints
about sexual innuendos at the other. Interpretation of such behavior is closely related
to context (Padgitt and Padgitt, 1986); the finding in one case is unlikely to predict
the finding in another. In addition, the fact that institutions and supervisors can be
liable for sexual harassment that “they anticipated or reasonably should have
anticipated” (Wetherfield, 1990) is not reassuring.
Although an honest case can be made for the difficulty of developing an absolute
definition of sexual harassment (Walker and Woolsey, 1985), neglecting to formulate
institutional policy is hazardous, and disciplinary employment decisions made
without pertinent written policy may not be defensible. Apart from concern about
legal liability, schools and human service providers should be as eager as they are
obligated to provide working and learning environments that are not hostile to
students and employees. Resorting to definitional difficulties to explain the absence
of policies and procedures concerning sexual harassment neither protects nor
empowers its potential victims, and the institutional climate may be expected to
remain unchanged.
Blanshan (1982) defined sexual harassment as “the unwanted imposition of
sexual requirements in the context of a relationship of unequal power.” A wide
in-
range of behaviors constitutes sexual harassment, including verbal (jokes,
sexual
nuendos, and catcalls), nonverbal (winks, leers, and the presence of visual
materials), and physical (patting, stroking, and blocking one’s path). In Sexual
Harassment (1978), the Project on the Status and Education of Women described
of the
and elaborated on the varieties of such behavior, and the 1980 guidelines
n (EEOC) include representat ive
U.S. Equal Employment Opportunity Commissio
have in common is the emphasis in such
examples. What all working definitions
attention
behavior on the sex of the recipient and the unwelcomeness of the
(Cammaert, 1985).
Specifically, the guideline definition of the EEOC (1980) is as follows.

Unwelcome sexual advances, requests for sexual favors, and other verbal or
physical conduct of a sexual nature constitute sexual harassment when one or more
of the following occur.
1. Submission to such conduct is made either explicitly a term or condition of
employment.
2. Submission to or rejection of such conduct by an individual is used as a
basis for employment decisions affecting such individuals.
3. Such conduct has the purpose or effect of unreasonably interfering with an
individual’s work performance or of creating an intimidating, hostile, or of-
fensive working environment.
Definitions 1 and 2 are quid pro quo harassment; definition 3 is hostile environ-
ment harassment.
In 1986 the U.S. Supreme Court adopted the EEOC’s definition and found sexual
harassment to be a violation of the victim’s civil rights as protected by Title VII of
the 1964 Civil Rights Act (Meritor Savings Bank v. Vinson; Aguilera, 1996). The
Court also alerted employers (and, by extension, educational institutions) to their
potential liability not only for quid pro quo harassment in the workplace but also for
acts of hostile environment harassment under certain circumstances. This finding and
related decisions applying it in lower courts have stimulated growing numbers of
employers and educational institutions to formulate sexual harassment policies and
to establish pertinent grievance procedures.
Thoughtfully written sexual harassment policies and procedures, widely dissemi-
nated, arguably constitute the best legal protection that may be available and may
reasonably be expected to provide a preventive influence as well. Organizat
ions
lacking such policies should be guided by their affirmative action personnel
and legal
counsels in formulating appropriate statements.
An adequate sexual harassment policy includes all relevant conduct
of a sex-
ual or gender-based nature that may be visited on an unwillin
g person. The
examples that come most readily to mind, especially with
respect to quid pro
quo harassment, tend to involve persons of unequal status (e.g.,
the harassment
of students by faculty or workers by their supervisors).
It is also important,
however, to anticipate those relationships in which the
inequality of power is less
apparent. Although less obvious, the power of graduate
teaching assistants over
their students, for example, should be considered
in the formulation of an adequate
policy.
It is also important to be aware of the growing
attention being paid to peer
harassment. As with sexual harassment in general,
such conduct may range from
innuendo and jokes to sexual assault (Project on the
Status of Women, 1988). Peer
harassment appears to be widespread and can have
devastating effects. An adequate
policy statement identifies it as a form of prohib
ited activity along with those
previously cited (Aguilera, 1996).
Students or others wishing to file a complaint
of sexual harassment need easy
access to nonthreatening grievance procedures that
should be described as part of the
policy statement. The procedures may be model
ed on other grievance procedures
within the organization but should include
the proviso that grievants may avoid
presenting the complaint to their immediate supervisors, who may be the source of
the problem (Van Tol, 1986).
Wagner (1990) suggested that a comprehensive policy and effective procedures
feature “‘informal channels that include mediation, and formal avenues which are
impartial and confidential, and protect the complainant and witnesses against
retaliation.” Most organizations have a designated person (or persons), such as an
equal opportunity or affirmative action officer, who acts in an official capacity to
receive and investigate formal complaints. This individual (or individuals) should be
specified in the policy.
With respect to informal channels, victims may be encouraged to report the
incident to another appropriate individual, such as a personnel officer, division
supervisor, department chair or dean, faculty member, health service personnel, or
counselor. For such informal means of resolution to work, persons likely to receive
these complaints must be provided with guidelines for resolving them and with easy
access to consultation with the organization’s equal opportunity or affirmative action
officer.
Persons complaining of sexual harassment are entitled to a prompt and impartial
investigation, which should both protect the complainant from retaliation and
observe the due process rights of the alleged harasser.
Case Study Therapist-Patient Involvement

Jennine stated on her form at the Crisis Clinic that she would like to see a woman
therapist. One was available, so the therapist went out, met Jennine, and took her to
her office. Jennine stated that she was 32 years old, lived alone, was originally from
another state, and was considering getting engaged to Neil. She further stated that
she was a school teacher at a local middle school and that she truly enjoyed her work.
The therapist asked her why she had come to the clinic. Jennine hesitated briefly
and then explained why she needed help. She had been in psychotherapy for
18 months with a licensed social worker named Jim. Jim was in his early 40s,
married, with two children. Jennine said that she was very lonely at the time when
she entered therapy with Jim. She explained that she had been in the state
approximately 6 weeks and was having difficulty meeting and making new friends.
All of the other teachers knew each other well and most were considerably older than
she. She felt that something must be “wrong”’ with her, because she was encountering
so much trouble getting to know people—a problem, she said, that she never had
before.
One night, while looking through the telephone directory, she found herself
looking at the advertising section for psychotherapists. Jim’s ad caught her attention
that
because he not only had a large ad, but he also had his picture in it. Jennine said
he had a “kind face and was smiling slightly.”” On impulse she called his telephone
the
number, expecting to get a “machine” or even an exchange. Jim answered
telephone himself. Jennine said that he had a “nice, soothing voice.” She explained
that she had not expected to have him answer the telephone. He laughed and said,
“T always answer. If someone has a problem, they don’t want to talk to an anonymous
name?”
machine. Why did you call? You must have a problem. What is your first
Jennine said he sounded so nice that she began talking to him. She told Jim ‘‘my
entire life history. We must have talked for at least 20 minutes. He told me that it
was more difficult to meet new people in a large city and that it would take a little
while to adjust.” He asked her if she felt she needed psychotherapy and she had
answered, “‘I certainly don’t think it could hurt—and I would have someone to talk
to.” She asked if he could see her in therapy, and he said that he had an opening at
4:00 pm on Thursday (in 2 days). Jennine asked him to book her for the appointment
and said she would bring her insurance forms.
Jennine began seeing Jim in therapy every Thursday at 4:00 pm. She thought he
was a competent therapist because she always felt “so good’’ after she left their
sessions. After their first five sessions, Jim walked her to the door and handed her
a card for her next appointment. Jennine said she laughed and said that she really
didn’t need an appointment card because she always looked forward to seeing him
on Thursdays. Jim smiled, took her in his arms and kissed her lightly on the lips. She
felt herself responding to his kiss. He kissed her again and said that he, too, “looked
forward to seeing her.”
Jennine left his office in a daze. She couldn’t*believe that he had kissed her and
that she had responded so strongly. She said that’ she knew he was married and had
children—there was a picture of them on his desk. He told her that it was a picture
of his wife and children—he certainly did not try to hide them.
On her next appointment, the minute she walked into his office he took her in
his arms and kissed her. He told her that since the last time he had seen her
She was all he could think about. He said that he wanted to make love to
her
and began to unbutton her blouse. She admitted that she responded by taking
off his tie and unbuttoning his shirt. In a few minutes they were on his
couch
making love. It was “wonderful,” he was gentle, very considerate
of her needs,
and, in essence, a wonderful lover. They had remained lovers for approximat
ely
the entire time she was in therapy. She said, bitterly, “If you can
call what we
were doing therapy!”
Jennine went on to explain that 3 months ago he started
canceling their
appointments, saying, for example, that he had to attend a meeting
or a lecture. Then
she went to an appointment, and he told her that he wouldn’
t be able to make any
more appointments with her because his wife had just had a
baby, and he wanted to
spend as much time as possible with her and his new daughter
.
“T sat there and felt like a fool! I had some fantasy in my
mind that one day he
would divorce his wife, and we would get married!”’ She
said she stood up and told
him, “I guess I won’t be needing any more therapy,” and
walked out. Jim didn’t say
a word.
Jennine went to her apartment and cried for hours,
then began to get angry. She
wanted to hurt him, too, but she didn’t want to call his wife. “I am not that
vindictive,” she stated. “Besides, it was as much
my fault as his.”
Three weeks later one of the teachers at school introd
uced Jennine to her younger
brother, Neil, who was in the process of movin
g to their city. Neil had accepted a
great job as corporate attorney for a well-known
company—something that he had
wanted ever since he left law school. He asked
Jennine to have dinner with him to
help him celebrate. She declined, Saying that
she had already made plans for the
evening. She admitted that she thought Neil was very nice looking and seemed
friendly. She said she felt “‘something’’ about Neil she couldn’t describe, but if she
could, she would have to say that she felt that she had fallen in love “‘at first sight.”
Jennine told Neil to call her when he got settled and gave him her telephone number.
She said she did not want to get hurt again and was afraid that she was responding
“on the rebound” from Jim.
The therapist asked if Jennine felt that she had been in love with Jim. She was
quiet for a few moments and then answered, ““No, I think I was lonely and needed
someone, and he happened to be the one I met at that time.”
The therapist asked Jennine why she had come to the Crisis Clinic that day.
Jennine responded saying that Neil had called her once he was settled in his new job
and town house, and they had gone to dinner. She said they seemed to have much
in common. They were both from small Midwestern towns, both came from large
close-knit families. She related that after dinner they went back to her apartment and
sat up drinking coffee and talking until 4:00 am. She said that she felt as if she had
known him forever. He had a marvelous sense of humor, and he didn’t try to make
a “pass” at her. As Neil was leaving, he asked her out the next day to a picnic. She
agreed. ‘“Jennine, do you believe in love at first sight?”’ he asked. “Maybe, I don’t
know,” she responded. “‘I do. . . Iknew that I loved you the day we met,” confessed
Neil. “Don’t worry, I’ll give you all the time you need to get to know me... but I
think you feel the same.”
They continued seeing each other almost every day, at the very least talking to
_each other every evening. Jennine said she knew she had fallen in love with him, but
she felt she had to tell him about Jim, and she was very concerned about how he
would react. Finally, she got up her courage and told Neil about Jim. Neil was furious;
however, not at her, as she had expected. He was furious at Jim for having taken
advantage of her. Speaking as an attorney, he told Jennine that what Jim had done
was not only unethical but illegal. He took money from her insurance company under
false pretenses. Neil told Jennine that she must report him to his licensing board
and to the ethics committee. She said she wanted only to forget about Jim and
didn’t want to cause any trouble. Neil told her that she must think of others who
would be seeing Jim “in therapy”—that he should be disciplined for what had
occurred between them.
Her reason for coming to the Crisis Clinic was to verify that what Neil had told
her was the correct thing to do. She was reassured by the therapist that what Neil had
told her was indeed accurate and that Jim should be reported to the appropriate board
and ethics committee.
Jennine was apparently relieved to hear that Neil had been correct in his advice.
“Is
She told the therapist that she understood she could have six therapy sessions.
Do you want
that correct?” she asked. “Yes, Jennine, you have five more sessions.
helps to have
to keep them?” Jennine smiled and said very firmly, “Yes, very much. It
to . . . and I will need your support after Neil reports Jim! I will
another woman to talk
never go to a male therapist again.”
“And what else won’t you do?” asked the therapist.
their
“I won’t see any professionals without first checking them out with
professional boards!”’
CASE STUDY: JENNINE
PLUS AND
RESULT IN
Figure 4-1
Jennine was seen for the full five sessions. The ethics committee found that there
had been two prior complaints against Jim. Jim’s disposition was license revoked,
effective _________, and he was placed on probation for 2 years.
Jennine and Neil became engaged to be married. She brought Neil to meet the
therapist, and Neil expressed his gratitude for the help and support that the therapist
gave to Jennine through the hearing. The therapist wished them well and a long and
happy life together.
The conscience does make cowards of us all.

—William Shakespeare
Complete the paradigm in Figure 4-1 for this case study, then compare it with the
completed one in Appendix D. Refer to the paradigms in Chapter 3 as needed.
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he American Psychiatric Association criteria from the Diagnostic and Statistical

Manual of Mental Disorders (DSM—IV) (1994) has placed posttraumatic stress
disorder and acute stress disorder into two separate categories. Table 5-1 compares
these two disorders. A brief review of the major differences is presented in this
chapter. The terms applicable to the mental status examination are defined in
Appendix B.
Posttraumatic Stress Disorder

Posttraumatic stress disorder (309.81) (PTSD) has been called shell shock, battle
fatigue, accident neurosis, and post rape syndrome. It has often been misunderstood
or misdiagnosed, even though the disorder has very specific symptoms that form
a
definite psychological syndrome.
PTSD affects hundreds of thousands of people who have been exposed to violent
events such as rape, domestic violence, child abuse, war, accidents,
natural disasters,
and political torture. Psychiatrists estimate that from 1% to 3% of the populatio
n have
clinically diagnosable PTSD. More still show some symptoms of the disorder.
It was
once thought to be a disorder of war veterans who had been involved
in heavy
combat, although research shows that PTSD can result from many types
of trauma,
particularly those that include a threat to life. PTSD can affect both females
and males
(Bile, 1993; Symes, 1995).
Not all individuals who experience PTSD require treatment. Some
will recover
with the help of strong situational supports such as their family,
friends, or a pastor,
priest, or rabbi. Many do require professional help to successfully
recover from the
psychological damage that can result from experiencing, witnessi
ng, or participating
in an overwhelming traumatic event.
62
Chapter 5: Posttraumatic Stress Disorder and Acute Stress Disorder 63
Table 5-1 Comparison of Posttraumatic Stress Disorder and Acute Stress Disorder
PTSD ASD
NATURE OF THE TRAUMA

Individual experienced, witnessed, or was con- Yes Yes
fronted with an event that involved actual or
threatened death or serious injury or a threat
to the physical integrity of self or others
Individual’s response involved intense feelings Yes Yes
of fear, horror, or helplessness
SYMPTOM CRITERIA
Persistent reexperiencing of the trauma Yes Yes
Avoidance of reminders of the trauma Yes Yes
Physical symptoms of hyperarousal Yes Yes
Symptoms of dissociation during or immediately No Yes
after the trauma
Clinically significant distress Yes Yes
TIME REQUIREMENTS
Duration of symptoms 1 Month 2 Days to 4 weeks
Onset of symptoms in relation to trauma Any time Within 2 days to
after trauma 4 weeks
SYMPTOMS OF PTSD
The symptoms of PTSD may initially seem to be part of a normal response to an
overwhelming experience. Only if those symptoms persist beyond 3 months are they
considered part of the disorder. Sometimes the disorder surfaces months or even
years later.
Although PTSD is based primarily on studies of trauma in adults, it also occurs
in children. It is known that traumatic occurrences (e.g., sexual or physical abuse,
loss of parents, or the disaster of war) often have a profound effect on the lives of
children. In addition to PTSD symptoms, children may develop learning disabilities
and problems with attention and memory. They may become anxious or cling and
may also abuse themselves or others.
Individuals suffering from PTSD often have an episode when the traumatic
event “intrudes” into their current life. This can happen in sudden, vivid memories
that are accompanied by painful emotions. Sometimes the trauma is “reexpe-
the
rienced.” This is called a flashback, a recollection that is so strong that
individual thinks he is actually experiencing the trauma again or seeing it unfold
before his eyes. In traumatized children this reliving of the trauma often occurs
.
in the form of repetitive play. At times the reexperiencing occurs in nightmares
event may evolve into
In young children, distressing dreams of the traumatic
or
generalized nightmares of monsters, of rescuing others, or of threats to self
others.
of emotion,
The reexperiencing may come as a sudden, painful onslaught
grief that bring tears, fear, or
seemingly without cause. These emotions are often of
anger. Individuals say these emotional experiences occur repeatedly, much like
memories or dreams about the traumatic event.
Another set of symptoms involves what is called avoidance phenomena. This
affects the individual’s relationships with others because he often avoids close
emotional ties with family, colleagues, and friends. The person feels numb, has
diminished emotions, and can complete only routine, mechanical activities. When the
symptoms of “‘reexperiencing”’ occur, people seem to spend their energies on
suppressing that flood of emotion. Often, they are incapable of mustering the
necessary energy to respond appropriately to their environment; individuals who
suffer posttraumatic stress disorder say frequently that they can’t feel emotions,
especially toward those to whom they are the closest. As the avoidance continues,
the individual seems bored, cold, or preoccupied. Family members often feel
rebuffed by the person because he lacks affection and acts mechanically (Blake,
Cook, and Keane, 1992).
Emotional numbness and diminished interest in significant activities may be
difficult concepts to explain to a therapist. This is especially true for children. For
this reason the reports of family members, friends, parents, teachers, and other
observers are particularly important. The person with PTSD also avoids situations
that are reminders of the traumatic event because the symptoms may worsen when
a situation or activity occurs that reminds them of the original trauma. An individual
who survived a prisoner-of-war camp might overreact to seeing people wearing
uniforms. Over time, people can become so fearful of particular situations that their
daily lives are ruled by their attempts to avoid them.
Many war veterans, for example, avoid accepting responsibility for others because
they think they failed in ensuring the safety of people who did not survive the trauma.
Some people also feel guilty because they survived a disaster while others—
particularly friends or family—did not. In combat veterans or with survivors of
civilian disasters, this guilt may be manifested if they witnessed or participated in
behavior that was necessary to survival but unacceptable to society. Such guilt can
deepen depression as the person begins to look on himself as unworthy, a failure, a
person who violated his predisaster values. Children suffering from PTSD may show
a marked change in orientation toward the future. A child, for example, may not
expect to marry or to have a career. He may exhibit “omen formation,” the belief
in an ability to predict future untoward events.
The PTSD patient’s inability to work out grief and anger over injury or loss during
the traumatic event means the trauma will continue to control his behavior
without
his being aware of it. Depression is a common product of this inability to
resolve
painful feelings (Symes, 1995).
PTSD can cause those who suffer with it to act as if they are still threatene
d by
the trauma that caused their illness. Individuals with PTSD may become
irritable,
have trouble concentrating or remembering current information, and
may develop
insomnia. Because of their chronic hyperarousal, many people with
PTSD have poor
work records, trouble with their bosses, and poor relationships with
their family and
friends (Henry, 1993).
The persistence of a biological alarm reaction is expressed in startle
reactions. War
veterans may revert to their war behavior, such as diving for cover
when they hear
a car backfire or a string of firecrackers exploding. At times those with PTSD suffer
panic attacks, whose symptoms include extreme fear resembling that which they felt
during the trauma. Many traumatized children and adults may have physical
symptoms, such as stomachaches and headaches, in addition to symptoms of
increased arousal (Herman, 1992).
PTSD can be defined as acute if symptoms have occurred from between 1 and
3 months and chronic if the symptoms have persisted fot at least 3 months or more.
When the onset of symptoms is more than 6 months after the traumatic event, the
disorder can be further defined as delayed onset (APA, 1994).
SPECIAL NEEDS OF CHILDREN WITH PTSD

Children are less likely than adults to speak directly about their problems or even to
know they are having them. Their stress-related difficulties may instead emerge in
their schoolwork, their relations with peers, or in their interactions with family
members. Children who have PTSD are very vulnerable because they have less
experience in coping with stressful events. Lack of prior experience may lead them
to exaggerate their problems and prevent them from seeing light at the end of the
tunnel.
Specific coping patterns need to be adjusted for children at their age-appropriate
level. The following apply specifically to children.
* Parents and teachers should be encouraged to listen in a nonjudgmental fashion
to children’s thoughts, concerns, and ideas about the stressful event, for ex-
ample, the war and reunion of the family.
Adults should provide warmth and reassurance to children without minimizing
their concerns. Children need to feel that there is a safe haven provided by
strong adults.
Adults should not impose their fears or burdens on children. Children should
not be entirely sheltered from family difficulties, but they should not be made
to feel that it is up to them to shoulder responsibilities that are beyond their
developmental capability.
* Most adults cope effectively, even if there are rough roads to travel in the pro-
cess of adjustment. Children, too, need to be given this positive expectation.
Because of their limited experience and the length of stressors like separa-
tion from parents, it is vital that children gain this perspective.
* Children’s reactions often mirror the reactions of their parents. If their parents
are combating stressors effectively, the children gain a sense that they, too, can
overcome their difficulties. If, however, their parents are not adjusting suc-
they
cessfully, children develop a sense that problems are insurmountable, and
support link. It is critical that parents see that seeking help for
lose their key
themselves when it is needed is the best therapy for their troubled children.
why, but this
* Children need accurate information about what has happened and
be appropria te to their developm ental stage. This informa-
information should
also
tion should be provided before, during, and after stressful events. Children
usually need
need to know why certain behaviors are required of them and
in their
behavioral examples and sometimes rehearsal of behaviors that are not
be assumed that children do not know the “dark side”’
repertoire. It should not
of current events. Given that they have seen horrible events on television or
have overheard serious discussions, it is incumbent on adults to help them
work through the meaning and significance of these events through discussion,
support, and—in cases in which a child is traumatized—professional treatment.
As with adults, children should be involved in helpful behaviors. By being part
of the solution in their own classrooms, families, and communities, children
develop an enhanced sense of mastery and control over their lives and cope
more effectively with war and other severe stressful events.
The overall message must be that adjustment is not a short-term process and that
commitment to these individuals cannot be short term (Milgran, 1989).
Acute Stress Disorder

Acute stress disorder (308.3) (ASD) (APA, 1994) is differentiated from PTSD in
three ways: the individual experiences at least three of the symptoms indicating
dissociation; the development time frame and the duration of symptoms is shorter;
and the dissociative symptoms may prevent the individual from adaptively coping
with the trauma.
Dissociative symptoms
Subjective sense of numbing or detachment
Reduced awareness of surroundings (e.g., being in a daze)
Derealization
Depersonalization
Dissociative amnesia
In terms of time, the symptoms may last from 2 days to 1 month. The onset of
the dissociative experience may occur during the trauma experience or develop
immediately thereafter. The defining characteristic of significant distress causation
or social and occupational functioning impairment is that the individual is prevented
from pursuing some necessary task, such as obtaining needed medical or legal
assistance (Fortinash and Holoday-Worret, 1996). The clinical profile of symptoms
of both PTSD and ASD include varying degrees of symptoms in the cognitive,
affective, physiological, behavioral, and relationship categories (Haber, 1997).
Cognitive symptoms
Difficulty concentrating
Recurrent and intensive recollections of traumatic experiences
Sudden reliving of traumatic experiences (illusions, hallucinations)
Dissociative experiences; psychogenic amnesia; inability to recall important
aspects of trauma
Anniversary reaction associated with traumatic event
Avoidance of thoughts associated with the traumatic event
Impaired career-related future orientation, marriage, family
Recurring vivid dreams/nightmares
Unconventional and often distorted perception of reality
Self-blame
Lack of cognitive integration of traumatic event perceived vulnerab
ility:
perception of threat and danger in innocuous/neutral situatio
ns
Absolutist thinking
Problem solving overridden by anger and anxiety
Affective symptoms
Irritability, explosive angry outbursts
Intense distress when confronted with events symbolizing, or in some aspect
resembling, the traumatic experience
Avoidance of feelings associated with traumatic event
Restricted range of affect
Inability to experience loving feelings
Diminished or constricted responsiveness (emotional anesthesia or psychic
blunting)
Emotional lability
Feelings of guilt
Inability to enjoy activities
Feelings of depression
Symptoms of anxiety (nervousness, jumpiness, jitteriness, or panic attacks)
Feelings of alienation
Phobias
Physiological reactions
Difficulty falling or staying asleep
Exaggerated startle response
Physiological reactivity in the presence of stimuli that reactivate memories,
feelings, or sensations associated with the trauma
Hypervigilance/hyperalertness
High resting heart beat, blood pressure; increased urinary catecholamines
Behavioral symptoms
Phobic avoidance of situations that elicit recall of the traumatic event
Diminished interest and participation in significant activities
Psychogenic fugue (unexpected travel away from home; assumption of a new
identity)
Restlessness
Impulsiveness (sudden trips, unexplained absences, changes in lifestyle or
residence)
Difficulty completing tasks
Episodes of unpredictable aggressiveness
Substance abuse (alcohol, street drugs)
Chemical dependency on prescribed antianxiety or pain relief medications
used to treat emotional distress and/or physical pain after the traumatic
event
Self-mutilation (attempt to end feelings of depersonalization)
Sexual dysfunction
Relationship symptoms
Detachment, estrangement and isolation from others
Impaired ability to experience intimacy, tenderness, and sexuality
Impaired marital relationships
Impaired parent relationships
Excessive interpersonal distance from others related to fear of a past experi-

ence of betrayal (e.g., an officer who put a partner in unnecessary danger,
a physically or sexually abusive parent or husband, or a mugger or rapist)
Avoidance of personal disclosure related to mistrust of others and fear of
rejection
Treatment of Stress Disorders

At present, psychiatrists and other mental health professionals have effective
psychological and pharmacological treatments available for these two psychological
disorders. These treatments can restore a sense of control and diminish the power of
past events over current experiences. The sooner individuals are treated, the more
likely they are to recover from a traumatizing experience. Appropriate therapy can
help with other chronic trauma-related disorders, as well (Shelby and Tredinnick,
1995).
Psychotherapists help individuals with stress disorders to accept the traumatic
experience without being overwhelmed by memories of the trauma and without
arranging their lives to avoid being reminded of it. It is important to reestablish
a sense of safety and control in the individual’s life. This helps him to feel strong
and secure enough to confront the reality of what has happened. For individuals
who have been badly traumatized, the support and safety provided by loved ones
is critical. Friends and family should resist the urge to tell the traumatized person
to “snap out of it” and instead should allow the individual time and space for
intense grief and mourning. Being able to talk about what happened and to get
help with feelings of guilt, self-blame, and rage about the trauma usually is very
effective in helping individuals put the event behind them. Psychotherapists know
that loved ones can make a significant difference in the long-term outcome of
the traumatized individual by being active participants in creating a treatment
plan—helping him to communicate and anticipating what he needs to restore a sense
of equilibrium to his life. If treatment is to be effective, it is also important that the
traumatized individual feel that he is a part of the planning process (Glynn and others,
1995).
Sleeplessness and other symptoms of hyperarousal may interfere with recovery
and increase preoccupation with the traumatizing experience. Psychiatrists have
several medications, including benzodiazepines and the new class of serotonin
re-uptake blockers, that can help people sleep and to cope with their hyperarousal.
These medications, as part of an integrated treatment plan, can help prevent the
development of long-term psychological problems in a traumatized individual
(Herman, 1992).
With individuals whose trauma occurred years or even decades before, the
treating psychotherapist must pay close attention to the behaviors—often deeply
entrenched—that the individual has developed to cope with his symptoms. Many
people whose trauma happened long ago have suffered in silence with symptoms
without ever having been able to talk about their trauma, nightmares, numbing, or
irritability. During treatment, being able to talk about what has happened and making
the connection between past trauma and current symptoms provides these individuals
with the increased sense of control needed to manage their current lives and develop
meaningful relationships.
Relationships are often a trouble spot for individuals with stress disorders. They
often resolve conflicts by withdrawing emotionally or by becoming physically
violent. Therapy can help them to identify and avoid unhealthy relationships. This
is vital to the healing process; only after the feeling of stability and safety is
established can the process of uncovering the roots of the trauma begin.
To make progress in easing flashbacks and other painful thoughts and feelings,
most individuals with PTSD need to confront what has happened to them and, by
repeating this confrontation, learn to accept the trauma as part of their past.
Psychiatrists and other psychotherapists use several techniques to facilitate this
process.
One important form of therapy for those who struggle with a stress disorder is
cognitive/behavioral therapy, which is a form of treatment that focuses on correcting
painful and intrusive patterns and thoughts by teaching the individual relaxation
techniques and by examining—and challenging—his mental processes. A therapist
using behavioral therapy to treat an individual with PTSD might, for example, help
a patient who is provoked into panic attacks by loud street noises by setting a
schedule that gradually exposes the patient to such noises in a controlled setting until
he becomes “desensitized” and is no longer prone to terror. Using other techniques,
the patient and therapist explore the patient’s environment to determine what might
aggravate the PTSD symptoms, and they work to reduce sensitivity and learn new
coping skills.
Psychiatrists and other mental health professionals also treat cases of stress
disorder with psychodynamic psychotherapy. Stress disorders result, in part, from the
difference between the individual’s personal values or view of the world and the
reality experienced during the traumatic event. Psychodynamic psychotherapy, then,
focuses on helping the individual examine personal values and how behavior and
experience during the traumatic event violated those personal values. The goal is
resolution of the conscious and unconscious conflicts that were created. In addition,
the individual works to build self-esteem and self-control, develops a good and
reasonable sense of personal accountability, and renews a sense of integrity and
personal pride.
Whether patients with stress disorder receive cognitive/behavioral treatment,
psychodynamic treatment, or crisis intervention, they need to identify the trig-
gers for their memories of trauma, as well as to identify those situations in their
lives that promote feelings of being out of control and the conditions that need
to exist for them to feel safe. Therapists can help patients construct ways of
coping with the hyperarousal and painful flashbacks that come over them when
they are around reminders of the trauma. The trusting relationship between patient
and therapist is crucial in establishing this necessary feeling of safety (Davidson,
1992).
PTSD and ASD treatment is usually done on an outpatient basis. For some
individuals whose symptoms make it impossible for them to function, or for those
who have developed additional symptoms as a result of their stress disorder,

inpatient treatment is sometimes necessary to create the vital atmosphere of safety
in which they can examine their flashbacks, reenactments of the trauma, and
self-destructive behavior. Inpatient treatment is also important for patients with
PTSD or ASD who have developed alcohol or other drug problems as a result
of their attempts to “‘self-medicate.”” Occasionally, also, inpatient treatment is very
useful in helping a patient with stress disorder get past a particularly painful period
in his therapy.
The recognition of PTSD and ASD as major health problems in the United States
is fairly recent. Over the past 20 years, research has produced a major explosion of
knowledge about the ways people deal with trauma—what places them at risk for the
development of long-term problems, and what helps them to cope. Mental health
professionals are working hard to disseminate this understanding, and an increasing
number of mental health professionals are receiving specialized training to help them
reach out to persons in their communities with posttraumatic stress disorder.
Many entire communities have experienced traumatic situations in the past few
years. There have been massive floods, major earthquakes, and devastating
hurricanes and tornados. There have also been an unusual number of human-created
disasters, for example, the tragic bombing in Oklahoma City, the complete
destruction of Trans World Airlines flight 800, and the bombing at the 1996 Olympic
games in Atlanta—and these are just a few of the traumas that affected men, women,
and children who are all vulnerable to a stress disorder.
PHYSIOLOGICAL REACTIONS
A mental health professional, either in a community mental health crisis center or in
an emergency room trauma center, must become familiar with the physiological
symptoms of possible stress disorders. Some of the reactions, emotions, and
observations to be aware of are increased heart rate, raised blood pressure, rapid
breathing, a sluggish digestive process, inhibited salivation, tightened muscular tone,
dilated pupils, increased blood sugar, and cold skin and extremities.
Assessment data
OBSERVATIONS SUBJECTIVE REPORTS
Sweating Feeling of weakness
Increased pulse Desire to escape situation
Increased respiratory rate Feelings of generalized fatigue
Increased blood pressure Trembling or shaking
Overeating or anorexia Complaints of dry mouth or thirst
Difficulty sleeping Feelings of restlessness
Flushed face Feelings of unsteadiness
Cold hands and extremities Empty stomach
Dilated pupils Bad taste, dry mouth
Unsteady voice Clammy hands, feet
Urinary urgency
Tense or rigid muscles
Less pain perception
Relationship to other emotions

SOURCE MANIFESTATION RELATION TO PTSD/ASD
Guilt (violation of Feeling of self- Fear of punishment
conscience) unworthiness
Shame (disapproved Feeling of unworthi- Fear of being discovered
action or wish ex- ness to others and disapproved
posed to others)
Grief (loss of love Feelings of sadness or Fear of separation
object) aloneness
Anger (being hostile Feelings of frustration Fear of control by
and demanding) or resentment authority
From a clinically descriptive standpoint, PTSD and ASD may be seen as a multifac-
eted set of psychological and biological symptoms assumed to be associated with
extreme trauma and thought to be exacerbated by stress and experiences of various
kinds. Kolb (1987) urged the classification of these disorders into mild, moderate, and
severe forms, depending on the number of symptoms, their expression, and the
potential for intensification on reexposure to emotional stress.
There appears to be no overriding agreement regarding the most appropriate
theoretical framework for understanding these disorders, particularly in accounting
for causation, expression, and course. Stress disorders are the most likely of all
psychiatric disorders to be explained by psychological constructs, with specific
reference to learning and conditioning processes and changes in behavior as a result
of experience. Although there may be biological and perhaps dispositional
vulnerabilities and contributors to these disorders, highlighting the role of the trauma
in marking disorder onset necessitates exploring both the stimulus and response
aspects of the disorder, as well as the affected person.
The following brief case study is one that involves a natural disaster. The mother
and her 7-year-old daughter were seen at a local crisis center.
Case Study Posttraumatic Stress Disorder

Ann and her 7-year-old daughter, Tiffany, were asleep when the January 17, 1994
earthquake began. Her husband, Neal, was out of town. Neal was a native
Californian, but Ann had always lived in the Midwest. She moved to California
8 years before, when she and Neal married.
Although they did not live close to the epicenter, there was considerable
shaking. Ann woke abruptly, confused. She realized that it was probably an
earthquake and jumped out of bed, grabbed her robe, and ran out the front door. She
was terrified. Their alarm system was on, and she could hear water running down the
street.
Ann’s neighbors were milling around, talking about what to do since all the lights
gas
were out. Several of the men were going from house to house, shutting off the
lines. Suddenly, one of the women turned to Ann and said, ‘Where is Tiffany?” Ann
stared at her in horror and said, “Oh, my God. Ileft her in the house!” As Ann turned
her arm.
to run back to her home, a neighbor, Jim, seeing her confusion, took
“T have a flashlight, I’ll go with you,” offered Jim. Trying to calm her he added,
‘Your daughter probably slept right through it.”
When they got to the front door, which Ann had left open, they heard Tiffany
crying and screaming, “Mommy! Mommy!” Ann almost collapsed.
Jim asked where Tiffany’s room was. Ann pointed toward the left, down a hall.
Jim yelled, ‘‘Tiffany, Mommy is coming.” He practically had to hold Ann up, as he
pulled her down the hall to Tiffany’s room. Very firmly he said to Ann, “Straighten
up. You have to be calm for her sake. Tell her you are coming.”
Ann, still shaking said, “Tiffany, Mommy is coming.” Jim shined the light on
Tiffany, and they could see blood running down her face. Apparently a small picture
on the wall above her junior bed had fallen, and a corner of the frame had hit her
on the head. Jim picked her up and said, ‘‘You are fine. Mommy is right here. See!”
He shined the light on Ann and started to give her Tiffany, but Ann was so weak she
almost dropped her. Jim, with his arm around both of them, said, ““Let’s go outside
with everyone else.” Tiffany was still sobbing.
As they went outside, the street and other lights that had been on before the
earthquake once again illuminated the area, and everyone cheered—except Ann. She
still appeared to be in a state of shock. Everyone was looking at her rather strangely,
and Jim was still carrying Tiffany and holding Ann up.
Jim’s wife, Linda, said very soothingly, “Tiffany, you and your Mommy come to
my house. I baked cookies yesterday, and you can have some with milk while your
Mommy and I have some coffee.” She added very firmly, “You are alright! Everyone
is alright.” Tiffany stuck her thumb in her mouth and stopped crying. Ann followed
them into the house.
Linda got out cookies and milk for Tiffany and put on the coffee, keeping up a
cheery chatter to distract Tiffany. As Linda cleaned the blood off of Tiffany’s face,
she said to both of them, “It’s just a tiny cut. I’ll put on a cute bandage.”
Ann had asked Tiffany to come and sit on her lap while she ate her cookies. While
sitting on Ann’s lap, Tiffany looked up at her mother and said, ‘““Where did you go,
Mommy? It was dark and I couldn’t see.”
“I went outside. I thought you would be alright,” said Ann. Linda didn’t say
anything.
When Ann finished her coffee and Tiffany her cookies, they thanked Linda and
went home to find the telephone ringing as they walked in. Ann answered. It was
Neal, and he wanted to know if they had felt the earthquake. Ann said that they had
and asked when he would be home because she needed him. Neal said he would leave
immediately and should be home in a couple of hours.
When Neal arrived, he could see that neither Ann nor Tiffany were injured, except
for a small cut on Tiffany’s head. When Ann saw Neal, she started crying and said,
“I needed you . . . you are never here when I need you!”” She was pale, trembling,
and wringing her hands.
Neal tried to calm her down. He held her in his arms and told her that everything
was alright and that he would take care of everything. He asked Tiffany if
she had
felt the “ground shake.” She answered that she had felt it but didn’t get scared
until
she called her mother and she didn’t answer.
: Chapter 5: Posttraumatic Stress Disorder and Acute Stress Disorder 73
CASE STUDY: ANN
PLUS AND
PLUS AND
RESULT IN
Figure 5-1
Her answer only increased Ann’s guilt feelings. Neal felt that he should get her
some immediate help. He asked their neighbors, Jim and Linda, if Tiffany could stay
with them while he took Ann to the nearest crisis center. They said of course; Tiffany
could have breakfast with them, and then she could stay and play with their two
daughters.
Neal thanked them and asked Ann to get her coat. She just looked at him like she
was in a daze. He took her hand and said, ‘““Never mind, I’ll get your coat.” Neal
realized that Ann was in a state of shock. He put her coat on and led her to his car.
When they arrived at the crisis center, it was very busy. Neal asked one of the
volunteers if someone could see his wife because he was very concerned about her.
The volunteer took them to an office to wait. Ann had not said a word; she just acted
like she was numb.
A therapist came in and asked Neal what the problem was. He told her that Ann
left their daughter in the house during the earthquake and that she was probably
feeling very guilty. The therapist agreed and tried to talk to Ann. Ann sat and cried
and tried to tell the therapist how she felt. It was obvious that Ann felt under a great
deal of stress and terribly guilty about leaving Tiffany in the house alone. The
therapist told Neal that Ann was in all probability suffering from posttraumatic stress
disorder. The therapist said that she would get Ann some medication so she could
get some rest.
The therapist told Neal that Ann should be seen for crisis therapy and then
probably for longer term therapy. She also recommended that Tiffany be included in
a peer support group as soon as possible. She told Neal that the support groups would
be available at all of the schools.
The therapist asked Neal if he would be able to stay in town until Ann and Tiffany
were stabilized. He replied, “Wild horses couldn’t get me away.” He, too, felt guilty
because he had not been available for Ann and Tiffany during the earthquake.
Of all the passions, fear weakens judgement the most.
—Cardinal de Retz
a ee ee
REFERENCES
American Psychiatric Association: Diagnostic and statistical manual of
mental disorders,
ed 4, Washington, DC, 1994, The Association.
Bile DA: Road to recovery: post-traumatic stress disorder: the hidden victim,
J Psychosoc Nurs
Ment Health Serv 31(9):19, 1993.
Blake DD, Cook JD, Keane TM: Post-traumatic stress disorder and
coping in veterans who
are seeking medical treatment, J Clin Psychol 48:695, 1992.
Davidson J: Drug therapy in post-traumatic stress disorder, Br J
Fortinash KM, Holoday-Worret PA: Psychiatric-mental health
nursing, St. Louis, 1996,
Mosby.
Glynn SM and others: Behavioral family therapy for Vietnam
combat veterans with
posttraumatic stress disorder, J Psychother Pract Res 4(3):214,
1995.
Haber J and others: Comprehensive psychiatric nursing, ed 5, St. Louis, 1997, Mosby.
Henry JP: Psychological and physiological responses to stress: the right hemisphere and the
hypothalamopituitary-adrenal axis, an inquiry into problems of human bonding, Physiol
Behav Science 28:369, 1993.
Herman JL: Trauma and recovery, New York, 1992, Basic Books.
Kolb, LC: A neuropsychological hypothesis explaining post traumatic stress disorder, Am J
Milgram NA: Social support versus self-sufficiency in traumatic and posttraumatic stress
reactions. In Lerner B, Gershon S, editors: New directions in affective disorders, New York,
1989, Springer-Verlag.
Shelby JS, Tredinnick MC: Crisis intervention with survivors of natural disasters: lessons from
Hurricane Andrew, J Counsel Dev 73(5):491, 1995.
Symes L: Posttraumatic stress disorder: evolving concepts, Arch Psychiatr Nurs 69(4):195,
1995:
ADDITIONAL READING
Breslau N and others: Traumatic events and posttraumatic stress disorder in an urban
population of young adults, Arch Gen Psychiatry, 48:216, 1991.
Davidson J and others: A diagnostic and family study of posttraumatic stress disorders,
Am J Psychiatry 142:90, 1985.
Kleber RJ, Brom D, Defares PB: Coping with trauma: theory prevention and treatment,
Amsterdam/Berwyn, Penn, 1992, Swets & Zeitlinger.
van der Kolk BA: Group therapy with traumatic stress disorder. In Kaplan HI, Sadock BJ,
editors: Comprehensive textbook of group psychotherapy, New York, 1993, Williams
& Wilkins.
Kulka RA and others: Trauma and the Vietnam War generation, New York, 1990, Brunner
& Mazel.
Nader K and others: Children’s PTSD reactions one year after a sniper attack at their school,
Am J Psychiatry 147:1526, 1990.
Stewart AL and others: Psychological distress/well-being and cognitive functioning measures.
In Stewart AL, Ware JE, editors: Measuring functional status and well-being: the medical
outcomes study approach, Durham, NC, 1992, Duke University Press.
Terr LC: Childhood traumas: an outline and overview, Am J Psychiatry 147:1526, 1990.
Ursano RJ, McCaughey B, Fullerton CS: Individual and community responses to trauma and
disaster: the structure of human chaos, Cambridge, England, 1993, The Cambridge
University Press.
1 (aetwentieth century has not been very tranquil or serene. Seldom does a week
go by that we are not confronted by the news of violent acts of apparent random
killing, rape, kidnapping, spousal abuse, abuse of the elderly, child abuse and neglect,
or murder. There have been a multitude of traumatic events. It appears that violence
is escalating in our lives and in the lives of those we love. Perhaps the violence we
encounter in our lives does not always appear in banner headlines. Sometimes it does
appear as a headline for a brief period, but it neither affects as many people nor
receives the same notoriety over a lengthy period.
This chapter presents some of the events that occur daily, maybe not to us
personally, but they still affect us. How can we as individuals not care when we read
about children being neglected, sexually abused, or murdered by their family
members or caretakers. Do we not identify with the wife or husband when we read
that a husband has killed his wife and their three children because she has been unable
to contend with his verbal and physical abuse and leaves him, seeking a divorce?
Aren’t we concerned about our children’s exposure to drugs and violence in schools
and with their peers? We are, of course, very concerned when we read of “gangs”
who shoot and kill innocent young boys and girls because they were thought to be
members of a “rival” gang. The police in most metropolitan cities are understaffed,
overworked, and underpaid. They try to do the best they can, but they can only
do
so much.
In the November 6, 1996, Los Angeles Times, Boyer wrote, “A former city
electrician was found guilty of slaying four city workers. He faces the death
penalty
after being convicted of killing four of his supervisors at the city’s downtow
n
technical center. Police said that he went to the communications
area, where he
worked as a radio repairman. He had an angry discussion there with someone
about
his performance and left, returning shortly with a Glock semiautomatic
pistol. He
76
Chapter 6: Violence in Our Society 77
then methodically searched out his victims and shot them.” This is just one incident
on one day in one city. Multiply this incident by the hundreds—because it does
happen somewhere every day.
Child Abuse and Neglect

For decades Americans have been pelted with images of disadvantaged children.
Though these images come from many sources, they reflect common assumptions.
Disadvantaged children, stereotypically, come from poor and broken homes. They
are commonly neglected or abused, and they (or their parents) often abuse drugs.
Most are African-American and live in ghetto neighborhoods. The future for these
children is dark and virtually sealed: it is widely assumed that most disadvantaged
children are destined to fail in school, become parents too early, land in jail, neglect
or abuse their own children, and drift in and out of employment and never earn a
decent wage. Most will be poor their entire lives, and their children will be cemented
into poverty (Cowen, 1994).
Many of these stereotypes are rooted in certain truths. Growing up poor can make
childhood miserable, and the climb into adulthood is stressful and steep. To be
protected from destruction all children, minimally, should live in an environment that
provides some order and meets their basic physical and material needs. All children
should have a continuous relationship with a consistently attentive and caring adult
who treats them as special (not as just another inhabitant of this world), who is able
to stimulate and engage them, who provides appropriate responsibilities and
challenges, and who passes on important social and moral exceptions. Some strong
friends and the affirmation and affection of community adults are often critical to
children, especially those who are deprived of the consistent presence of a parent or
guardian. All children should have freedom from exploitation and discrimination in
their communities, some sense of the justice of their world, and opportunities in
school and in the communities for constructive achievement. Many children also
need special health, social, and educational services to deal with inherited and
acquired ailments and disabilities. When children have these ingredients, they are
likely to have trust in themselves and in the world, inner vitality and resourcefulness,
and the capacity in adulthood for zestful play and gratifying work and love, even if
they suffer hardships and abrasions.
in
Clearly not only African-American children, underclass children, or children
in
single-parent families grow up without these ingredients. Looking at children
terms of these ingredients forces policymakers and the public to widen their fields
of vision to encompass all poor children, including poor white children and children
rs and
from diverse ethnic groups. Looking at children in this way forces policymake
not poor.
the public to see the many vulnerable children in this country who are
the
Stresses on parents, limited opportunities for accomplishment, peer problems,
absence of adults in the community, and learning and other disabilities are among
the pervasive problems that hurt children in every race and class (Weissbourd, 1996).
or
When it comes to the deaths of infants and children at the hands of parents
y disinterested
caretakers, society has responded in a strangely muffled, seemingl
non. The true
way. Little money has been spent to comprehend this tragic phenome
numbers and exact nature of the problem remain unknown, and the troubling fact of
abuse or neglect often remains a terrible secret that is buried with the child.
INCIDENCE AND PREVALENCE OF CHILD ABUSE AND NEGLECT

In 1988 a 15-member panel was established by the U.S. Congress to evaluate the
scope of child abuse in the United States and recommend ways to improve the child
protective system. Their report, titled ‘““A Nation’s Shame: Fatal Child Abuse and
Neglect in the United States,” (1995) represents the most comprehensive study yet
of children’s deaths at the hands of parents or caretakers in America.
Although it emphasizes that no single profile fits every case, the report attempts,
for the first time, to fill in some of the who, how, and why of children’s deaths. It
found, for example, that most physical abuse fatalities are caused by angry, extremely
stressed-out fathers, stepfathers, or boyfriends who unleash a torrent of rage on
infants over such “triggers” as a baby’s crying, feeding difficulties, or failed toilet
training.
Likewise, studies suggest that mothers are most often held responsible for deaths
resulting from bathtub drowning, starvation, or other neglect. Other major findings
include the following:
* Head trauma is the leading cause of child abuse deaths. So-called shaken baby
syndrome is so lethal that up to 25% of its victims die, and most survivors suf-
fer brain damage.
* Domestic violence is strongly linked to child abuse deaths. An estimated 50%
of homes with adult violence also involve child abuse or neglect.
Many states lack adequate legal sanctions. Only 21 states have statutes that al-
low parents to be prosecuted for killing their children under “felony murder”
or “homicide by child abuse’ laws.
In describing the scope and patterns of the problem, the report details the particular
susceptibility of very young children to fatal abuse. These victims are deemed the
“invisible kids” because their youth leaves them largely out of sight of the commu-
nity at large and the welfare system, but their young bodies are most vulnerable to the
hitting, shaking, or other punishments that might not injure an older child as
seriously.
The path to adulthood is stressful and steep. Weissbourd (1996) states that
there
is a good deal of evidence that most vulnerable children are not poor. Although
the
national debate on improving children’s prospects is now focused on poverty
and
single-parent families, poverty and single parenthood are only two of many hardships
that undercut our children. Whether parents are chronically stressed
or depressed
often more powerfully influences a child’s fate than whether there
are two parents
in the home or whether the family is poor.
Perhaps the most serious misconception is the concept of the undercla
ss that
makes no allowance for variation in the nature of the poor
children and forces
attention away from problems that typically deprive poor children
of basic needs. The
underclass and similar concepts promote another dangerous
myth about poor
children—that they are doomed to a life of waste and failure,
largely because poor
parents are incapable of raising their children properly. Such
images of poor families
are not new. Although there has also always been a
tendency to romanticize
poverty—to find grace, purity, and innocence in the poor—these sentiments have
long been buried in an avalanche of images of uncared for, poor children. Child abuse
and neglect are neither the provinces of the poor nor the propensities of African-
American, disadvantaged, or single-parent homes. Child abuse and neglect are found
in every race, color and creed—they have no boundary or territory.
The level of violence aimed at young children in America has reached public
health crisis proportions, claiming the lives of at least 2000 children annually and
seriously injuring more than 140,000 others (Rivera, 1995). The U.S. Advisory Board
on Child Abuse and Neglect (1995), concluding a 22-year nationwide study, found
a level of fatal abuse and neglect that is far greater than even experts in the field had
realized. Abuse and neglect in the home is a leading cause of death for young
children, as the majority of abused and neglected children are under 4 years of age.
In fact, the homicide rate among children in this age group has hit a 40-year high,
a chilling trend similar in scope to the violence directed at teenagers from street
gunfire. Equally grim is the finding that the child protective system has largely failed
to shelter our nation’s children. The report describes an alarming national
environment of underreported child abuse fatalities; inadequately trained investiga-
tors, prosecutors, and medical professionals; inconsistent autopsy practices; and an
American public who continues to regard child deaths as “rare curiosities.”
The congressionally established panel refers to research that concludes that 85%
of child deaths from abuse or neglect are systematically misidentified as accidents
or are the result of natural causes because police, physicians, and coroners are largely
untrained in identifying evidence of intentional trauma and severe neglect in children.
In addition, 69% of professionals (doctors, teachers, and social workers) who suspect
child abuse do not report the incidents to the proper authorities. There are even cases
when professionals have sought to protect child abusers. Many prosecutors concede
that child homicides are reduced to lesser crimes because most prosecutors have little
or no experience with abuse and neglect cases.
Also documented in this report is the emergence and success of child death review
teams composed of members of local law enforcement and social welfare agencies
who review cases of child death and offer appropriate follow-up. The report’s other
recommendations include state legislation that establishes regulations for child
autopsies, a national effort to increase research on and reporting of child abuse
fatalities, multidisciplinary training on child deaths, ensuring that children’s safety
is a priority in all family and child service programs, and increased funding for family
support services (Rivera, 1995).
In her very widely read newspaper column, Abigail Van Buren, “Dear Abby,”
wrote recently, ““The National Committee to Prevent Child Abuse . . . encourages
everyone to become involved in preventing child abuse before it occurs. If every
adult did just a little, fewer children would suffer pain, injury or death due to abuse”’
(Box 6-1).
DYNAMICS OF CHILD ABUSE AND NEGLECT

Child abuse occurs in a wide variety of ways. Recent trends have moved toward
greatly expanding its definition from physical abuse alone to also include emotional
however,
and sexual abuse, as well as physical and emotional neglect. In general,
Box 6-1
SEVEN STEPS TO STAMP OUT CHILD ABUSE
. Report suspected abuse or neglect. Inform authorities if you suspect that children are
being harmed. Your concern may result in children being protected from an abusive
environment.
. Advocate services to help families. Communities need comprehensive services that
address issues affecting families. Parenting programs, healthcare, and housing needs
are vital to maintaining healthy children and families.
. Volunteer at a child abuse program. Parent support groups, crisis centers, and hot
lines are typical programs that often welcome volunteers. Check your telephone
directory for the names of agencies in your area.
. Help a friend, neighbor, or relative. Someone you know may be struggling with
parenting responsibilities. Offer a sympathetic ear or a helping hand. Assisting
occasionally with child care or offering to locate sources of community help can be
a tremendous boost to someone under stress.
. Help yourself. Recognize the signs that indicate outside help is needed. If you feel
overwhelmed, constantly sad, or angry and out of control, get help. Remember,
asking for help is a sign of strength not weakness.
. Support and suggest local programs on child abuse prevention for community
organizations. Kiwanis Clubs, Exchange Clubs, PTAs, church groups, and women’s
and men’s clubs all offer excellent opportunities for raising public awareness in the
community.
. Promote programs in schools. Teaching prevention strategies can help to keep
children safe from those who would abuse them. This is a national problem. It takes
individuals who care, as well as organizations.
consensus is lacking among professionals for any single definition of the terms child
abuse or child neglect. Definitions vary greatly because there is much diversity in
sociocultural values and practices associated with child rearing, some of which may
result in physical and psychological harm to the child.
People who abuse children are not limited to any one well-defined group.
They
can be found among widely differing socioeconomic, racial, cultural, age, and
other
socially defined groups. Specific differences, however, have been identified
among
factors related to specific forms of abuse. For example, the physical size,
strength,
and power of the abuser obviously do not play as great a role in child
abuse as in
the abuse of adults. Obviously, few are as physically powerless as the
infant or small
child.
The abuse and neglect of children have been recorded through
out the centuries.
It has been suggested that these are by no means new problems,
but rather ones that
only now are being socially recognized and legally addressed.
Not until 1871 was
the first child protective agency, The Society for the Prevent
ion of Cruelty to
Children, established in New York. Nearly a century passed before
all 50 states finally
enacted legal mandates to report child abuse in 1968.
In 1962 Kempe originated the phrase battered child syndrom
e, which dramatically
focused professional and public attention on the abusive
actions by parents and other
adults on select groups of children (Kempe, 1962). The phrase provided a base for
the specific labeling and identification of the severest forms of child abuse, for which
there is clinically verifiable evidence. Clinical signs include bruises, abrasions,
lacerations, broken bones, burns, abdominal and chest injuries, and eye damage.
Frequently, examination of new injuries yields clinical evidence of past injuries.
Some children experience a single violent abusive event, others experience a long
series of violent episodes. This label was later superseded by the more comprehensive
term child abuse and neglect (Helfer and Kempe, 1976).
The federal Child Abuse Prevention and Treatment Act was recently reauthorized
and otherwise amended by the Child Abuse, Domestic Violence, Adoption, and
Family Services Act of 1992. In it “‘the term child abuse and neglect means the
physical or mental injury, sexual abuse or exploitation, negligent treatment, or
maltreatment of a child by a person who is responsible for the child’s welfare, under
circumstances that indicate that the child’s health or welfare is harmed or threatened
thereby” (Public Law 102-255, June 18, 1992).
Although the battered child syndrome may be among the easiest forms of child
abuse to prove legally, it has been found to be only a part of the overall problem of
abuse of children. Incidence reports on incest and sexual exploitation of children are
admittedly incomplete and, at the most, educated estimates. Case finding is quite
difficult, most often coming to the attention of healthcare agencies when the child
is seen for other healthcare problems such as venereal disease or pregnancy.
According to Justice and Justice (1979), sexual abuse, like child abuse, most often
involves more than just the victim and the abuser. It also involves another family
member or responsible adult who allows the victimization to continue.
In general, incestuous offenders do not exhibit any overtly psychotic or deviant
behaviors (Giarretto, 1976). Generally, the perpetrator is between 30 and 50 years
old, male, and, more than 75% of the time, the victim’s father. Reported female
victims outnumber male victims by a wide margin. Investigations of adults who were
abused as children reveal that 20% of girls and 10% of boys had experienced some
type of sexual molestation, abuse, or exploitation (Rubinelli, 1980; Salholz and
others, 1982).
People who sexually exploit children are usually men who are emotionally
by a
dependent with feelings of inferiority and whose lives have been dominated
ly high correlatio n between sexual abusers and a
significant woman. A significant
history of parental abuse in childhood has also been found. The abused child
meet nonsexual
frequently knows the abuser and may become involved solely to
affection. Children are particularl y vulnerable because of
needs for attention and
ce, shame, guilt, and
ignorance; fear of losing the caring relationship; or ambivalen
contribute
the fear of not being believed as the “innocent” victim. All these factors
to an ongoing conspiracy of silence on the part of the child.
resulting from
Documentation of the psychological and sociological damage
damage, in turn, may lead
abusive child-rearing patterns has been increasing. This
ed numbers of violent
to intergenerational patterns of abnormal parenting and increas
e as the norm is an
crimes perpetrated by those with histories of child abuse. Violenc
1968; Gelles,
expectation passed on from victims to the next generation (Silver,
1972).
Three factors intrinsic to child abuse have been identified by the National Center
for Child Abuse and Neglect (U.S. Department of Health and Human Services, 1993).
1. A capacity for abuse exists within the parent.
2. One child is perceived as special in some manner by the parents.
3. One or more crisis events occur before the abusive act is committed.
It is of great importance to recognize that what may appear to an observer as
intentional abuse may be perceived by the victim merely as a normal way of life.
Perhaps the only attention that some children can obtain from a parent or other
significant person in their lives is abusive. To a child, love may be inextricably linked
with violence. Unfortunately, those with whom they are closest also hold the power
to punish, either physically or psychologically (Bandura, 1973). Indicators of a
child’s potential need for protection are defined in Box 6-2.
Several theories have attempted to explain why some parents abuse their children.
Individually, none provides a comprehensive explanation for child abuse, yet each
has contributed significantly to the overall base of information needed to explain this
multidimensional problem. A broad scope of causal factors, none of which operates
in isolation, is becoming increasingly evident. Each theoretical model proposes
causal relationships to common problem areas. Collectively, this rapidly expanding
base of knowledge supports the need for a holistic approach to intervention.
Several efforts have been made to categorize the personality traits and character-
istics of child abusers in an effort to help explain their behaviors.Amajor problem has
been that, for the most part, data for these studies have been empirical and drawn
from clinical practice with identified child abusers. As such, they fail to explain why
other persons with similar personality characteristics and traits and under similar
circumstances do not abuse their children.
Personality or character traits that have been suggested as likely to lead to abusive
behavior by parents include emotional immaturity, inability to cope with
stress,
chronic suspicion and hostility, and poor impulse control. Any of these
could
precipitate rage reactions in the parent who is confronted with frustratio
n or undue
stress. When parents with a requisite psychological profile come into
confrontation
with the demands of a child, an inner-directed rage reaction may be
precipitated. As
anger and frustration build, such parents suddenly erupt, striking
out physically or
psychologically at the most vulnerable person within their environme
nt, the child
(Halper, 1979; Walker-Hooper, 1981).
It is not uncommon to find the family scapegoat as the recipien
t of such parental
acting out behavior. Scapegoating is an excellent example
of psychological abuse.
To survive as a unit, some families allocate the role of scapego
at to one member. Most
frequently, the most vulnerable person is.a child because
a child is dependent and
unable to retaliate against the parent’s power (Vogel and
Bell, 1960).
Based on the mechanisms of projection and displacement
, Scapegoating is often
used to divert conflicts between parents. Undesirable
traits or feelings are displaced
or projected from the parent to the child when tension
s become unbearable and
parents lack the ability to discuss openly their reactio
ns to stressful situations.
The abusive-dynamic model constructed by Kempe
and Helfer (1972) is based on
the presence and interaction of multiple dynamics.
Kempe postulates that there are
seven dynamics that interact and affect the parent
’s perception of the child:
Box 6-2
INDICATORS OF A CHILD’S POTENTIAL NEED

FOR PROTECTION
Physical abuse
Physical indicators
Unexplained bruises (in various stages of healing); welts; human bite marks; bald spots;
unexplained burns, especially cigarette burns or immersion burns (glovelike);
unexplained fractures, lacerations, or abrasions
Behavioral indicators
Self-destructive, withdrawn, and aggressive; behavioral extremes; uncomfortable with
physical contact, arrives at school early or stays late, as if afraid to be at home; chronic
runaway (adolescents); complains of soreness or moves uncomfortably; wears clothing
inappropriate to weather to hide body
Physical neglect
Abandonment, unattended medical needs, consistent lack of supervision, consistent
hunger, inappropriate dress, poor hygiene, lice, distended stomach, emaciated, regularly
displays fatigue or listlessness, falls asleep in class, steals food, begs from classmates,
reports that no caretaker is at home, frequently absent or tardy, self-destructive or school
dropout (adolescents)
Sexual abuse
Torn, stained, or bloody underclothing; pain or itching in genital area; difficulty walking
or sitting; bruises or bleeding in external genitalia; venereal disease; frequent urinary
or yeast infections; withdrawal; chronic depression; excessive seductiveness; role
reversal; overly concerned for siblings; poor self-esteem, self-devaluation, and lack of
confidence; peer problems; lack of involvement; massive weight change; suicide
attempts (especially adolescents); hysteria; lack of emotional control; sudden school
difficulties; inappropriate sex play or premature understanding of sex; threatened by
physical contact or closeness; promiscuity
Emotional maltreatment
Speech disorders, delayed physical development, substance abuse, ulcers, asthma,
severe allergies, habit disorders (sucking, rocking), antisocial, desiructive, neurotic
traits (sleep disorders, inhibition of play), passive and aggressive behavioral extremes,
delinquent behavior (especially adolescents), or developmentally delayed
n
mothering imprint, isolation, self-esteem, role reversal, spouse support, perceptio
of the child, and crisis events.
one’s own
Mothering imprint is the capacity to nurture and is learned only through
nurturing
childhood experiences. Parents whose needs were not met in a loving,
e in the care
manner in their infancy tend to lack the capacity for providing nurturanc
dependen cy needs, they
of their children. Overwhelmed by their own unmet
childhoo d memories of
misperceive the dependency needs of their children. Lacking
to respond
dependency gratification, they are unable to sense their child’s needs or
a helpless infant or
empathetically. Rather than feeling sympathy and concern when
child continues to fuss and cry despite their caring efforts, the parents perceive the
behavior as criticism. Feelings of failure and powerlessness arise, leading to lowered
self-esteem and increased frustration and anger. Unable to redirect these feelings
constructively, the parents project blame for the feelings of discomfort toward the
cause—the “‘bad child.”
Sometimes an abused child may be seen as special or unique by a parent. This
uniqueness may be real, such as a physical or emotional problem. It may also be
imagined, or the child may be perceived as quite similar to someone disliked or feared
in the parent’s past memories. In either case, when such a child behaves undesirably
or does not live up to the parent’s needs and expectations, he creates a negative
reflection on parental abilities and causes the threat of loss of self-esteem or
self-control to the parent. This child becomes the ‘“‘bad child,” the one who needs
to be corrected, to be “‘straightened out’”’ (Broadhurst and others, 1992).
Disciplinary actions taken by the parents are perceived as positive and corrective
rather than abusive behavior. Parents who were raised by similarly abusing parents
may see nothing abnormal in their abusive behaviors.
A common victim response to such abuse is to feel at fault and to feel that trying
harder to be a “good child” in the future will stop further abusive episodes. This
illogical response is supported by the abuser, and further blame is projected onto the
victim. This vicious cycle continues until broken by circumstances that may be
drastic enough to require medical-legal intervention. Examples of such could be the
death of a child or injuries requiring professional care; sudden overt, socially deviant
behavior by the child; or a child runaway.
Role reversal is another dynamic. In this situation the parent attributes adult
powers to the child and comes to depend on the child for emotional sustenance and
gratification of the parent’s dependency needs. Such persons are seldom able to
engage in any meaningful adult relationships or to intuit the needs of others. When
this parent is confronted with the need to provide nurturance to another and is unable
to meet his own emotional needs, conflict arises.
Other studies have suggested that abuse may occur when a child is perceived by
one parent as winning in a competition for love and caring from the other parent.
In
this concept the parents are perceived as having developed a strong symbiotic
relationship based on caring and love, with the advent of a child being a threat
to the
continuation of that relationship. Abuse is for the primary purpose of
physically or
psychologically eliminating the competition (Justice and Justice, 1976).
Social isolation has been identified as a contributing factor in all
theoretical
models of child abuse. Persons with low self-esteem and mistrust
of others are
unable to develop positive interpersonal relationships or to request,
accept, or use
help from others. Isolation may also be a leatned behavior
that parents actively
teach their children by socializing them to distance themselves
from experiences
that might promote learning how to establish positive social
relationships. It may
also be due to environmental factors such as socioeconomic
deprivation, living
in an isolated area, moving into a new neighborhood, or
a combination of any
such related factors.
People who abuse have a strong tendency to be suspicious
of others, most likely
because of fear of exposure. Quite frequently, such persons
make a great effort to
isolate their families socially and to enforce maintenance of a minimum social

network. Their goal is to present the appearance of a “‘normally’’ functioning family
to their community, thereby reducing chances for disclosure and outside intervention
(Bohn, 1990). Whichever the cause, social isolation has been found to reduce a
person’s access to situational supports and tangible resources. Without these, parents
experience increased stress in child rearing and are unable to optimize their coping
abilities to deal with the resulting feelings of powerlessness, frustration, and anger
in their parental roles.
The following case study involves a young divorced woman who is socially
isolated from her family and friends. She is the mother of two children and has
physically abused her 6-year-old son. After she was seen in the emergency room with
her son and daughter, it was recommended that she meet with a therapist on the
hospital’s crisis team.
Case Study Child Abuse

Alice, a 24-year-old divorced mother of two small children, was referred to the
therapist by the hospital’s emergency room physician. Earlier that evening, she had
brought her 1-year-old daughter, Joan, to the emergency room. The little girl was
bleeding profusely from a deep laceration on her forehead. Alice explained that, less
than an hour before, Joan had climbed over the rails of her crib and fallen, striking
her head on the edge of the crib as she fell. Alice said that she hadn’t heard Joan fall
because she had fallen asleep on the living room couch. They had just moved into
the house 2 days ago, and she was exhausted from unpacking all day. Her 6-year-old
son, Mike, had awakened her by calling loudly for her to help his sister. She had
rushed to the bedroom and found Joan lying on the floor, crying loudly, and bleeding
heavily from the cut on her head. Mike was vainly trying to pick her up but had only
succeeded in dropping her back on the floor. When Alice arrived, he too began to cry
loudly and cling to her.
Alice said that suddenly all she wanted to do was sit down and cry, too. “T just
wanted this all to go away. I wanted all of these problems out of my life. Ihave never
felt so angry and helpless.”
to the
She tried to stop the bleeding. When she couldn’t, she decided to take Joan
to put on his bathrobe and get
nearby hospital. She said that she quickly told Mike
thing about getting dressed
out to the car, but “she began to argue with me—some
take! I blew
first—and then started to run out of the room. I suddenly had all I could
hallway and hit the wall. I was
up and slapped him so hard that he flew across the
and grabbed him by the arm and
still so angry with him that I just picked up Joan
got into the car, though, I began
dragged him along out to the car. As soon as we all
to Mike. Sure, I’ve spanked him
to shake all over. I was horrified at what I’d done
then. Right now I’m afraid to
before, but I was so frightened and felt so alone right
be alone with either of them again!”
on her head, he asked
After the doctor examined Joan and sutured the laceration
d evidence of new
to have Mike brought into the room. An examination reveale
responded quietly to the
abrasions on the right side of his face and shoulder. Mike
spanked me because I was
doctor’s questions about the injuries and said, “‘Mommy
a bad boy.” He was no longer crying and clung tightly to his mother’s hand as he
spoke. There was no recent evidence of any other injuries.
In view of Alice’s obvious emotional state, the doctor decided to admit the
children to the hospital for overnight observation and further examination for signs
of past physical injuries indicative of abuse. He strongly advised Alice to meet with
a therapist on the hospital’s crisis team before going home. She agreed, and a call
was placed for the therapist to meet her at the hospital within an hour.
When the therapist arrived, Alice was waiting, slumped down in a chair in his
office. She appeared disheveled, tearful, and physically exhausted. Her tone of voice
sounded very depressed, yet defensive, as she began to speak about the incident that
evening.
She said that she and the children had just moved to this city a few days ago from
a small town in the northern part of the state. She was to start her new job as a
receptionist in a large law firm the next week. Divorced for almost a year, she had
no family or friends nearby.
When asked about her former marriage, she said that she had married when she
was an 18-year-old college sophomore and that the marriage had lasted for 5 years.
She added that her son Mike had been born only 5 months after the marriage. ‘““That,”’
she said rather cynically, “‘was definitely a case of ‘marry in haste, repent at leisure.’
We had 5 long years of trying to make a go of it. Having Joan last year was probably
our last big mistake.” She said that she became pregnant with Joan soon after Bob,
her ex-husband, had finished his schooling and started his law practice. It was a
planned pregnancy because they both believed that things in their lives would take
a turn for the better as soon as Bob began to build a practice. As it turned out,
his
practice was slow in building, and it began to seem to her that the need for
her
additional income would never end. Arguments between them increased until,
she
said, “One day, heaven help me, I found myself agreeing with Bob when he
told me
that he wanted a divorce.” She added that she had been given full custody
of the
children.
Bob had remarried less than a year ago, the day after the divorce became
final,
and, just 2 days before moving to this city, Alice had learned that a son
had been born
to Bob’s new wife.
When asked about her childhood, she stated that she had been
an only child
and that her parents had divorced when she was 12 years of age.
She had remained
with her mother. Her father, an attorney, soon moved to a different state and
remarried about a year later. She never saw him again
but recalled him as a strict
disciplinarian, someone to avoid in stressful situations because
“‘he’d always blow
up at me if I were around.” He died in an auto accident
when she was 15 years
of age. She recalled that her life with her mother after the
divorce had been “‘rather
dull and uneventful.” Alice met Bob during her freshma
n year at college; they
soon became engaged and planned to be married
after Bob’s graduation from
law school in about 4 years. She had planned to obtain
a law degree, finishing
about a year after Bob.
Alice described Bob as being everything then that
she thought she would ever
want a man to be. She doubted that she could ever
love anyone else as much and
assumed that he had felt the same way about her.
After she returned to school in the fall of her second year, she discovered she was
more than 4 months pregnant, too late for her to consider an abortion. She recalled
that neither she nor Bob was “‘exactly thrilled by this news” because neither had
income to support a child. They were even more concerned about their parents’
reaction to the news. At the time, the only solution that seemed feasible to both of
them was to get married immediately and then tell their parents that they had been
secretly married the past spring.
As expected, neither family was pleased to hear about the “‘secret marriage’”’ and
the impending birth of a grandchild. Their general attitude was that Alice and Bob
were still too young and in no financial position to support a family and continue in
college. Neither set of parents was financially able to help them any more than they
were at present. After much discussion, Bob finally gave in to Alice’s decision that
she would drop out of school and find a job to help support them both until Bob
graduated. Then she would return to school and complete requirements for her
degree.
She quickly obtained a part-time job as a receptionist at a law firm and worked
for a few months before Mike was born. After his birth, she was asked to return
full time and had remained until just before her recent move to this city. Her
new job here was similar and had been obtained through contacts made by her
former employers.
As Alice described her relationships with her former husband and their children,
the therapist noted that a pattern of scapegoating behavior by the parents seemed to
evolve whenever she described Mike’s role in the family. She frequently described
Mike as a child who had “created problems for them from the day he was born.”
As she recalled, she and Bob began to have their first “real” arguments about the
need to place Mike in a day nursery when she returned to work. Whenever she
expressed concern about leaving Mike with “strangers,” Bob would get very
defensive and angry with her. She remembered him once saying, “It wasn’t my idea
alone to get married and start raising a family so soon. You’re the one who got
pregnant! If you’d been careful, you could have been going to school right now. That
baby’s causing problems, too, not just me!”’
She said that Mike never was a “cuddly” baby, often bullied the other children
at nursery school, and continued to create problems for her and Bob as he grew older.
Bob
Their arguments increasingly seemed to center on Mike as he grew older.
never offered any
constantly criticized Alice’s decisions about Mike’s care yet
suggestions of his own. When asked how she and Bob handled this, she responded
he always left
that Bob always refused to get involved in any disciplinary problems;
Mike or sending
that to her, She had never seen anything wrong with either spanking
her mother and father
him to his room for a while. She added that spankings from
deserved one, he got
had never hurt her when she was young So, ‘““whenever Mike
one, too.”
of Mike, a child
She described her daughter, Joan, as being just the opposite
laugh, she added,
who was warm, loving, and very cooperative. With a sharp
more like his father
“But Mike—heaven help me because he seems to be getting
have his way about
every day. He’s always demanding attention and wanting to
everything.”
The therapist then asked her why she had decided to leave her old job and move
away from her friends to this city. She responded that since the divorce, the town had
just seemed too small for her to avoid meetings with Bob and his new family.
After the divorce, she had encouraged Bob to keep in close contact with their
children and, through them, with her. This continued even after his remarriage. She
frequently found herself calling him for advice. In fact, she was surprised to find
herself depending on him for advice much more than before their divorce.
Earlier this year, she had heard that Bob’s new wife was pregnant. She said that
her immediate reaction was concern for the children, wondering if Bob would
continue to visit with them as much after his new child was born or if he would focus
all his attention on his new family and rarely visit them anymore. The more she
thought about this, the more she felt an urgent need to get away from the whole
situation before it even happened. As she recalled, “I suddenly felt that I couldn’t
stand even being in the same town with him when the new baby arrived.”
She showed signs of increasing tension and anxiety as she discussed this with the
therapist. Suddenly she began to pound her fists on the arms of the chair and sob
loudly. “That woman! She’ll get to live the sort of life with Bob that I’d always
dreamed of. But me, I’m going to have to work the rest of my life and send my
children off to strangers because of it. I’ll never be able to get back to college, and
it’s just not fair! I have no one anymore to help me. I’m all alone and it’s Bob’s fault.
I hate him! Why did he leave me to handle all these problems alone?”
The therapist felt that Alice had never fully accepted the divorce as final or dealt
with her unrecognized feelings toward Bob. This was evidenced by her continued
efforts to draw him back home through repeated requests for his advice in caring for
the children and by encouraging his frequent contacts with her through the children.
She was in crisis, precipitated by the news of the birth of Bob’s son and the failure
of her usual method of coping with her feelings toward Bob (flight from
the
situation). This was compounded by the stresses of moving to a new job in a new
city far from her usual situational supports. She felt isolated and trapped in a
situation
not entirely of her own making.
Joan’s sudden, unexpected injury was for Alice “the last straw.”
It served as a
catalyst for the eruption of a rage reaction to her overwhelming feelings
of frustration
and anger about her current life situation. Her comment to the therapist
that Mike
“was getting more like his father every day”’ strongly suggested
that her assault upon
Mike was, in fact, displacement of her feelings of rage toward
Bob.
The goals of intervention were to encourage Alice to explore
and ventilate her
unrecognized feelings about Bob and the divorce, to help
her perceive the birth of
Bob’s new son realistically in relation to her own and her
children’s future, to provide
her with an intellectual understanding of her psychological
abuse of Mike caused by
her displacement of her anger toward Bob on Mike, and to
provide situational support
as she learned new coping skills to deal with her new
roles and responsibilities as
a single parent.
Before the end of the first session, the therapist
was notified that a more
complete examination of Mike revealed two healed fractur
ed ribs and a healed
fracture, with no displacement, of his right shoulde
r. The X-ray technician told
the physician that the injuries apparently had occurr
ed at different times within
the past 3 years. Alice was informed that the children would have to stay at the
hospital for a few days.
Alice turned pale and began to cry. She asked the therapist, “Why? They are going
to be all right, aren’t they?” The therapist informed her of Mike’s old injuries and
asked if she knew how he had received them. She got up and began to pace the floor
saying, ““You don’t know how difficult it is to control Mike—and Bob was never
there!’’ The therapist asked Alice if she had beaten Mike. She looked up and replied
softly, “Yes, I didn’t mean to—honest—I just got so frustrated with him.” It was
decided that an immediate priority for her and for the children would be to provide
her with situational support in her home as soon as possible. The purpose was to
ensure protection of the children against any possible further physical abuse and to
provide Alice with emotional support until she was better able to cope with the
stresses of developing new social networks and adjusting to her new environment.
She was given the telephone number and name of a woman who held weekly
self-help support group meetings for parents who abuse their children. She was
strongly encouraged to call as soon as she returned home, and she stated that she
would.
The therapist explored with Alice the possibility of her having a friend or relative
visit for a few weeks. Alice strongly agreed with this idea, admitting that she was
fearful of being alone with the children because “I might blow up again if they make
me angry. I’m just not sure how much more I can handle right now.”
She decided to telephone her mother and added in a very depressed tone of voice:
“It’s for sure there is no point in calling Bob. He’ll be much too busy with his new
family to help me now.” She called her mother from the therapist’s office, briefly
explained her need for help, and asked her to come for a few weeks. Her mother
agreed immediately and promised to be there the next afternoon. Before leaving for
home, Alice commented, ‘You know, suddenly I don’t feel quite so alone. Maybe
after I call that lady when I get home, I can just fall into bed and get some sleep for
a change.”
When Alice returned for her second session a week later, she appeared much more
relaxed and less depressed. She said her mother had arrived just as the children came
home from the hospital. “(Never in my life have I been so glad to see my mother!
She
She has been very helpful, and I never expected her to be so understanding.”
had also attended one of the self-help group meetings.
discussed
Alice was particularly surprised by her mother’s empathy when they
then she hadn’t realized that her
Alice’s many problems since the divorce. Until
problems after she and Alice’s
mother, too, had had many of the same feelings and
really enjoyed having their
father had divorced. She added that the children
like angels—I can’t believe that
grandmother around and “have been behaving just
Mike has quit bugging me all of the time.”
ning and reflection,
During this session and the next two, through direct questio
past unrealistic
Alice began to recognize her present crisis as a reflection of her
Throughout her marriage,
perception of her divorce and Bob’s subsequent marriage.
the role of a strong,
she had always seen herself as being expected to assume
family problems to devote
independent decision maker so Bob could be free of
he had often commented
his full attention to his law studies. She recalled that
to her and to their friends that his law degree should really have both their names
on it.
When asked if she had ever discussed these feelings with Bob, she said that she
had tried to at first, but he would get so angry with her and “shout and storm out
of the house” that she soon learned that it was easier for her not to argue back. With
continued questioning and reflection, Alice gradually began to recognize how, unable
to confront Bob directly with her feelings of frustration and anger, she had made Mike
a scapegoat for her unhappiness. She had perceived Mike as the cause of arguments
with Bob, and therefore it was Mike who she felt deserved to be punished. She
seemed surprised with the realization that his behavior problems with other children
possibly were his reaction to being scapegoated and abused at home. On further
reflection, she expressed concern for its effect on his future relationships with her and
with others. At the therapist’s suggestion, she agreed to consider seeking a
psychological evaluation and, if necessary, counseling for Mike.
She recalled that the year after Bob’s graduation had been an unusually happy one
for them. They had felt so optimistic about their future that they decided it would
be a good time to have another child.
As things turned out, however, Bob’s practice didn’t do as well as anticipated, and
Alice had to continue to work throughout her pregnancy. By the time Joan was born,
their marriage had greatly deteriorated. They no longer seemed able to communicate
anything but their anger and frustration toward each other. Bob began to spend most
of his time away from home, and, when he finally suggested that they divorce, it
seemed the only solution left for their problems.
When questioned directly, Alice admitted to the therapist how much she now
regretted the divorce. She added that she always believed that Bob felt the same way,
too. It was apparent to the therapist that Alice had still held hopes that Bob
would
return to her some day, despite his remarriage. His frequent visits with the
children,
even after his remarriage, had served to reinforce this belief in her mind. It
was only
when she heard that his new wife was pregnant that she began to experience
some
doubts and anxiety.
During the third session, through direct confrontation and reflectio
n on her
feelings about this news, she suddenly exclaimed, “Betrayed! That’s
how I felt when
I heard the news. I felt like a betrayed wife, angry that he had
done such a thing to
me and our children. All of a sudden it came to me that, now,
he couldn’t just pack
up and come back to us, even if he wanted to. Some way, I felt,
I just had to get away.
I just didn’t want to be there to see him with a new family.
If I stayed, I was sure
that my life could never be peaceful again.” As soon as she
made that last comment,
she gave a surprised laugh and said, “Did you hear
what I just said? I was acting
just like I did during our marriage. I was trying to keep
peace by getting out of the
situation—by taking a walk, or something like that.
Well, I certainly took a walk,
didn’t I? All the way down to this city!”
She now realized that her choice of flight as a means
of coping had indeed proved
ineffective in that Bob’s new son was born
2 days before she moved. At that time,
she had regarded her overwhelming feelings of
tension and anxiety as normal for
anyone moving away from familiar friends and
places. She had avoided any
discussion of her feelings with anyone, afraid that
she might have to discuss how she
felt about Bob’s new baby. She behaved as though she was much too busy with
packing and moving arrangements to visit with friends.
After the move, she found herself isolated from any situational supports. She
avoided telephoning Bob or friends, again using the excuse that she was too busy.
As her tension and anxiety increased, she soon felt too physically and emotionally
exhausted to do more than feed the children their meals and try to keep them from
interfering with the unpacking. After a deep pause, she said, ““You know, when I look
back, I must have been like a time bomb waiting to explode. I realize now that this
wasn’t the first time I’d ever felt that way. Perhaps it was easier, then, to just take
a walk and get away for a while. That way it was easy to avoid dealing with the real
cause of my anger—Bob. It was always much easier to talk at Bob through Mike’s
problems than to Bob about our problems!”
Providing immediate situational support while encouraging Alice to identify and
ventilate her unrecognized feelings about Bob had assisted her in viewing the recent
events in her life more realistically.
By the fourth week, Alice had made a good adjustment to her new job and
was enjoying it very much. She had made several new friends and said that she
was really enjoying time spent with her children at home. She said that she had
even called Bob and congratulated him on the birth of his new son. An excellent
day nursery had been found for Joan, and she had also located an after-school
play group for Mike where he could be supervised until she got home from work
in the evening.
As suggested by the therapist, she and Mike had visited the guidance counselor
at Mike’s new school and planned to meet with him regularly until Mike adjusted
to the many new changes in his life. Even more important, and on her own, she had
decided to attend meetings for divorced single parents that were held regularly at a
nearby YMCA, as well as continuing with the self-help group.
Reflecting back on her marriage in the final session, Alice summed it up by
saying, “Maybe we’d have never married if I hadn’t become pregnant. But that
was never Mike’s fault, and I never should have blamed him when things went
wrong. It’s Bob and I who are to blame. I'll never know if things might have
believe
been different if we had been able to wait longer, but I guess I always will
keep it going as well as it did.
that I gave up much more of my life than Bob did to
now why I felt so angry
My anger is with Bob, though. It’s not with Mike. I realize
was Bob being completely free
and frustrated when we divorced. All that I could see
to show any regrets about leaving
to start a new life all over again. He never seemed
or something,
me and the kids behind. I guess I’d hoped that he would feel guilty,
and come back to us.”
Most important, Alice was able to obtain an intellectual understanding of the
rage reaction toward
relationship between her pent-up feelings and her displaced
r those
Mike. She told the therapist that, if nothing else, she would always remembe
‘“‘even if Ihave to stand
moments and was quite positive it would never happen again,
out in the street and scream until I feel better!”
assessed the adjustments
Before termination, Alice and the therapist reviewed and
into her behavior. Alice was
that she had made and the insights that she had gained
. She was assured
very optimistic about the future, both for herself and for the children
CASE STUDY: ALICE
PLUS AND
that she could always contact the therapist if she ever began to feel overwhelmed by
problems again.
A simple child,
That lightly draws its breath
And feels its life in every limb,
What should it know of death?
—William Wordsworth
Violence in the Home

This may seem to be a very broad term—‘‘violence in the home.” The word
home encompasses not only the nuclear family, but also those who live there.
What is the interaction and action that occurs between them, and what are their
responses?
Children may live in the home. The first part of this chapter was devoted to the
staggering facts and figures on child abuse and neglect. Parents live in the home. How
do they interact with each other and with their children?
Are there other members outside of the nuclear family living in the home, for
example, a relative, perhaps an aunt or uncle? How do they fit in the family
constellation? Are they members who give help and support to other family
members? Do they create stress in the basic family unit by intruding (unintentionally)
into the family’s private territorial “space”? Ag
Is there a grandmother and/or grandfather living with the family? Are they healthy,
supportive, and helpful? Do they have physical or psychological problems and create
more of a burden than a help?
Let’s consider just a nuclear family. Is it stable or are there problems that create
instability? Every family has occasional disagreements; no one is perfect. If commu-
is
nication is open and a husband and wife are able to sit down and discuss what
creating stress between them and if both are willing to listen and compromis e, then
ely
they should be able to reach an understanding and solve their problem. Unfortunat
this does not always happen.
Men
Until approximately 25 years ago there was no such term as battered women.
by whatever means necessary, and if it
were expected to keep women in their place
physical abuse has
took battering, she had better shape up. In recent years, however,
icized court
been dragged from the closet with books, television films, and well-publ
Joel Steinberg, an attorney, not only
cases like Hedda Nussbaum’s, whose spouse
findings have
brutally battered her but also killed their daughter in 1989. Research
to resist battering
also given women new awareness and, as a result, new strength
(Miller, 1995).
battering is the single
¢ According to former Surgeon General C. Everett Koop,
rape, and mug-
major cause of injury to women and is greater than accidents,
gings combined.
Box 6-3
DOES YOUR PARTNER...
Hit, punch, slap, shove, or bite you?

Threaten to hurt you or your children?
Threaten to hurt friends or family members?
Have sudden outbursts of anger or rage?
Behave in an overprotective manner?
Become jealous without reason?
Prevent you from seeing family or friends?
Prevent you from going where you want, when you want?
Prevent you from working or attending school?
Destroy personal property or sentimental items?
Deny you access to family assets such as bank accounts, credit cards, or the car?
Control all finances and force you to account for what you spend?
Force you to engage in sexual acts you do not enjoy?
Insult you or call you derogatory names?
Use intimidation or manipulation to control you or your children?
Humiliate you in front of your children?
Turn minor incidents into major arguments?
Abuse or threaten to abuse pets?
* FBI figures indicate that a woman is beaten every 15 seconds.

Twenty-one percent of the women who use hospital emergency surgical ser-
vices are battered.
As many as 4000 women are beaten to death annually by a family member
—
about one third of all female homicide victims.
Fifty-nine percent of the women who killed a so-called loved one
were abused
at the time.
* In one half of all marriages there is at least one violent incident
; in almost one
third the violence is severe (Dutton, 1995).
Physical battering in all its enormity and horror is
no longer a secret.
Nonphysical battering, however, remains in the dark closet
where few want to
look. The Battered Women’s Task Force of the New York
State Coalition Against
Domestic Violence, along with organizations in other States,
has made great strides
in helping women identify nonphysical abuse so as to offer
support and guidance.
The first step is to ask women to answer the questio
ns that identify abusive
behaviors (Box 6-3).
If they answered yes to one or more of these questions,
they might be abused. Note
that only one of the nineteen behaviors is physical.
The other eighteen identify four
different kinds of nonphysical battering (Miller, 1995),
Abuse seldom, if ever, goes away of its own accord
; it escalates. Name-calling
grows into public humiliation, isolation, and
eventually threats, at which level a
union may continue “until death do us part,” or
the threats may become the reality
of beatings and eventually murder.
VIOLENCE IN “NEW” FAMILIES

Until fairly recently, the term “‘battered wife’ has been the operative term. But life
is a continuous process of change. When gays and lesbians came out of the closet,
slowly, and then more rapidly (due to some degree to HIV and other sexually
transmitted diseases), the concept of “‘family’’ changed. Gays living together for
years were a family. Lesbians living together were a family. Their living together and
rearing children constituted a cohesive family unit. The children may be theirs from
a previous commitment, through adoption, or by artificial insemination.
Before continuing with the theoretical concepts of the current thinking of family
violence, these ‘“‘new”’ families should be considered. How are they functioning as
a family? If errors are made when using the term “battered wife,” patience and
understanding is requested. There is so little research literature available at this time.
It is certain that this field of research is fertile land for those who understand, accept,
and realize that gays and lesbians, and their families, are here to stay.
Unfortunately the traditional nuclear family has no monopoly on violence. In 1996
Hawaii became the first state to grant permission for gay and lesbian couples to
marry, legally. Although sexual orientation has little impact on the frequency of
domestic violence, it can strongly affect how and when society intervenes. The
Los Angeles Gay and Lesbian Center has embarked on an expanded program to
publicize and help prevent gay domestic violence (Hanania, 1996). New terminology
is now required. Instead of ‘battered wife,” the terms that are more accurate and
appropriate are spousal abuse, or domestic abuse, thus eliminating any gender bias.
A straight woman fleeing domestic violence may seek a women-only shelter that
bars her batterer. A lesbian fleeing domestic violence may seek the same shelter only
to find her batterer there, too. A straight man trying to escape his wife’s explosive
temper can usually walk away safely. A gay male trying to walk away from his partner
may find himself physically threatened. Should he manage to leave and ask to be
placed in a shelter, he might, instead, be referred to a mental hospital or to a homeless
shelter, where his lover could seek him out.
Although a straight woman fleeing her batterer can reasonably count on police
protection, a gay person often cannot. Rather, police often view same-sex domestic
and
violence as either a manifestation of “boys will be boys” or a “cat fight”
safety. Police protection for battered
sometimes do little to ensure the victim’s
victims remains separate and unequal, depending on sexual orientation.
dangerous
This is the hidden world of gay domestic violence, a world all the more
would rather ignore it. And yet among
because many people, both straight and gay,
may be marred by sometime s lethal
both groups, 25% to 33% of all relationships
or of the Los Angeles Gay and
physical violence. Susan Holt, program coordinat
1 million gay and lesbian battered
Lesbian Center, states that there are an estimated
victims nationwide.
, which counsels
To combat this violence, Holt has expanded the center’s program
offers a counsel ing program staffed
250 people a month. Most important, the center
how the dynamics of
by seventy-five volunteers, both men and women, trained in
domestic violence are intensified by homophobia.
preventing
Batterers may threaten to “out” their victims to family and friends,
to employers, jeopardizing
escape. They may threaten to reveal victims’ HIV status
their jobs, or they may threaten to cut their victims off financially, leaving them
penniless. Batterers also seek both to intimidate their partners and to undermine their
emotional and spiritual well-being. Their goal is control, virtually telling their
partners, “I can make you do anything I want.”
Because victims frequently fail in their attempts to escape, Holt frequently advises
victims that their safest short-term course may be to stay with the abuser, albeit with
protective measures. These measures include keeping an extra car key and spare
change in a jacket pocket by the door. They also include leaving a bag of emergency
supplies at a friend’s home, scouting out the closest pay phone or all-night
convenience store, and putting sharp objects in hard-to-reach places.
The center’s program also helps batterers—who are referred by the courts or join
on their own—to explore how their conduct pushes away their lovers, adding to
batterers’ isolation and self-hatred. Participating in therapy groups, abusers explore
the causes of their behavior and develop alternative ways of acting out their anger.
Finally, the center is reaching out to traditional anti-domestic violence programs,
with volunteers informing their mainstream counterparts of the often unique
circumstances faced by gay victims. :
DYNAMICS OF VIOLENCE IN THE HOME
(K Battering involves a pattern of escalating abuse in a situation from which the victim
believes he cannot escape. Because they are usually physically stronger than their
spouse, men are less likely to be battered. Often a battered spouse has grown up with
violence and accepts it as a pitiful form of caring or at least as something inevitable
in a relationship. She may believe that the world is a dangerous place and that
she
needs a protector, even a spouse who beats her. Ashamed, terrified that any resistance
will provoke greater violence, isolated from her family and friends, often without
any
means of support other than her spouse, many a battered spouse sinks into despairing
submission from which the only escape is eventual widowhood, her own
murder (or
her husband’s), or suicide.
Doctors, social workers, and psychiatrists have frequently been less
helpful than
the police. Straus (1980), in a study of family violence, concluded
that the medical
profession and social agencies are an essential part of the battered
syndrome. They
often treat the spouses like they are “crazy”; physicians fail to
note signs of abuse,
label battered spouses as psychotic or hypochondriacal, prescrib
e tranquilizers, and
tell them to go home. They make battered spouses doubt their
own sanity by sending
them to a family therapist for psychotherapy.
What kind of person would hit a spouse—not only hit
her but also blacken her
eyes, break the bones in her face, beat her breasts,
kick her abdomen, and menace
her with a gun? There is a very good chance that he was
beaten as a child. Perhaps
because of his early trauma, he is often emotionally stunted.
An interesting analogy
exists between a male batterer and a 2- or 3-year-
old child; their tantrums are very
similar. Like a narcissistic child, the batterer bites
when throwing a tantrum.
The spouse beater probably drinks, but he does
not beat because he drinks; rather,
he drinks to beat. Unemployment does not cause
battering, but hard times make it
worse. The typical spouse beater is unable to
cope with the traditional notion of
masculinity, or the male role, which requires men
to be stoic. It requires men not to
need intimacy, to be in control, to be the “‘big wheel,”’ and when there is a problem,
to “give ’em hell.” The difficulty is that nine of ten men fail at that list, at least in
their own judgment. The batterer is often afflicted with extreme insecurity. The man’s
spouse is the emotional glue that holds him together, and, as a consequence, he is
desperately afraid of losing her. The husband is trying to make her be closer to him
by controlling her physically, but he does not realize that he is driving her away
(O’Reilly, 1983).
Batterers can be very calculating in how they deal with their spouses and with the
authorities once they are caught. They are frequently charming to a fault. They can
play therapy off against the court system and not have to be responsible.
The first self-help group for abusive men was formed in Boston in 1977. There
are now about 85 such groups. Very few men go to such centers on their own. Either
their partner has left or is threatening to, or they are attending under court order. By
and large, they do not believe they have done anything wrong, sometimes insisting
they are not batterers at all. Those who own up to being violent frequently believe
their partners are at fault.
Historically, batterers have fallen between the cracks and were considered
neither crazy nor criminal, at least by the standards of the day. A man beats up
his spouse because he can. He usually does not beat up his boss or male ac-
quaintances; the consequences—loss of job, a charge of criminal assault, im-
mediate physical retaliation—are simply too great. Now, the consequences are
rising for violence against one’s spouse. Shelters for abused women have created
a safety net for spouses who previously would have been afraid to take their
husbands to court. Newspapers, judges, hospitals, neighbors, and even a growing
number of once exasperated police officers are beginning to understand the di-
mensions of the problem. More important, states and municipalities are enacting
laws that give women a realistic chance of getting protection and redress through
the courts.
The tightening of laws against spouse beating has resulted in higher conviction
rates. Still, only a fraction of abusive husbands are even reported to the authorities,
much less arrested and convicted. For the glib, angry men who pummel their spouses,
a brush with the law sometimes has a sobering effect. In general, arrests work because
spouse
they show the man that such behavior is inappropriate. They also show the
that somebody will help her.
who have
The following case study of a battered spouse illustrates how women
assume, although incorrectl y, that they
been repeatedly beaten by their husbands
below was precipita ted when a young woman
“deserve it.” The crisis represented
was hospitalized with serious injuries.
Case Study mere

red
BatteTC Spouse
TIL ST
aac tA Ea ea A
rs (Karen, age 15, and
Suzan, a 39-year-old housewife and mother of two daughte
metropo litan hospital . Her husband, Ron, age
Leslie, age 12), was admitted to a large
stated that she had ‘‘fallen down the stairs
43, drove her to the emergency room and
name of their family physicia n, Ron
at home.” When asked by the resident the
‘““We don’t have one.” The resident asked
casually shrugged his shoulders and said,
permission to call in an internist and an orthopedic specialist because he believed that

Suzan was badly injured.
The resident ordered x-rays for Suzan “from head to toe” and then contacted an
internist and orthopedist and told them he suspected a possible case of spouse
beating. Both physicians stated they would be at the hospital within 30 minutes to
see the x-rays and Suzan. Suzan went through the series of x-rays and was admitted
to the hospital.
The internist, Dr. W, and the orthopedist, Dr. V, looked at the X-rays with a sense
of shock and disbelief. Suzan’s current injuries included two black eyes, two
fractures in the pelvic girdle, and two fractured ribs. The x-rays also revealed past
injuries: four fractured ribs, fractures of the left wrist and left arm in two places, and
fractures of the right ankle.
The two physicians went to Suzan’s room, introduced themselves, and asked
Suzan if they could sit down. Suzan’s blackened eyes were almost swollen shut, but
both physicians could see the fear in her eyes as she looked past them to see if her
husband was with them. Dr. W ordered no visitors for Suzan, including family, unless
they had the permission of one of the doctors. Suzan appeared to relax slightly.
During the taking of her medical history, Suzan stated that she had no previous
injuries. Dr. W then casually asked Suzan how she had sustained her present injuries.
Suzan responded quickly, “I tripped and fell down the stairs at home.”
Dr. V told her about her current injuries, stating that they were quite extensive for
a fall down a flight of stairs. Dr. V then told Suzan that she would have to stay in
the hospital from 4 to 6 weeks for the fractures in her pelvic girdle to heal. Suzan
gasped and repeated, “‘Four to six weeks! What about my daughters? They need me!”’
Dr. V asked, “Don’t you have family that could stay with them?” Suzan replied,
“My mother would love to come out and take care of them, but Ron
doesn’t
get along with her.”
The doctors explained the extent of Suzan’s injuries to Ron, and then
Dr. W told
him that Suzan’s mother would be called to take care of their daughter
s. Dr. W called
Suzan’s mother, who, when told of her daughter’s injuries,
commented that Ron had
probably beaten her again. Her mother made arrangements to
be at the hospital the
next morning.
Dr. W then faced Suzan with her mother’s accusation that Ron
had beaten her in
the past; Suzan denied this. After discussing the case,
Dr. W and Dr. V decided to
call in a psychotherapist with experience in dealing with
battered wives.
The clinical psychologist called in to assist believed that
he would have to work
with Suzan’s mother and her two daughters to break through
Suzan’s denial. The first
step would be to confront Suzan with the x-rays that
clearly showed the previous
injuries and to demand an explanation. He would use Suzan’s
mother’s statement that
Ron had “beaten her many times before” as leverage
against Suzan’s denial. He
would plan to see the daughters alone to see if they
would admit that their father had
abused their mother in the past, as well as in
the most recent ‘‘accident.” The second
step would be to get Suzan to realize that other
women had been battered by their
spouses and that it was not her fault that she had
been beaten. She had to be made
to view the events in a realistic manner. The third
step was to get situational support
for Suzan and have her talk with other wives who
had been battered and hear how
they had coped with their situations. The fourth step would be to tell Suzan about
the facilities that were available for battered spouses and about the therapeutic groups
her husband could attend with other men who had battered their spouses.
The next morning Suzan was introduced to the psychotherapist and told that one
of his areas of expertise was working with battered spouses. The therapist showed
Suzan all her old fractures on the x-rays. He asked her when and how she had
received them and told Suzan that he would ask her mother and her daughters if she
did not answer. Then, the therapist sat back in his chair and waited in silence as Suzan
began to cry. As Suzan continued to cry, occasionally he handed her more tissues but
said nothing. Finally Suzan asked, ‘“‘Aren’t you going to say something?” The
therapist replied, “No. It’s time for you to answer my questions.” (Because most
individuals have difficulty coping with silence, it can be a very effective technique
in psychotherapy—if the therapist can handle it.)
Suzan finally commented that none of the other doctors had ever asked her any
questions, and the therapist asked her to start at the beginning. Suzan began by
saying, “I know Ron loves me and I love him. You’ll see, I’ll probably receive a
dozen yellow roses today with a card asking me to forgive him. And I will, I always
do. I probably deserve to be beaten. I am not a good wife or mother.”
Suzan continued, “‘It really is my fault. Ron didn’t want to get married, but I got
careless and ended up pregnant. Ron wanted me to have an abortion, but I refused.
I just couldn’t. I’m Catholic, but Ron isn’t, so we got married. Karen was born
7 months after we were married. I loved him so much, and I really believed that he
loved me.” She said he was a good husband and a very good father. “I had no
experience in taking care of a house, husband, or a baby. I didn’t even know how
to cook—thank heavens, someone gave me a good cookbook when we got married.
I still can’t iron his shirts to suit him. I have truly been a failure. You see, I was an
only child and my mother and father spoiled me rotten. I never had to do anything
around the house.”
The first time Ron had hit her was after they had been married about 2 years
because she had burned the dinner. She said she had been taking care of Karen, who
had a fever, and completely forgot the roast in the oven. When Ron came home, she
was rocking Karen trying to get her to sleep. He walked into Karen’s room and said
very coldly, “Put the baby in her crib and come with me.” Suzan put Karen down, and
Ron grabbed her by the arm and pulled her into the kitchen. He had taken the roast out
of the oven. It was burned to a crisp, and the kitchen was filled with smoke. Ron said,
“Do you think money grows on trees?” and he slapped her. Then he just kept hitting
her. She said, “I begged him not to, but he just kept punching me. Finally, he stopped,
probably because he was tired, but that is when I received my first black eye. So, you
see, I did deserve it. It was my fault.” The therapist told Suzan she did not deserve that
beating and asked if the beatings continued. Suzan said that she “just couldn’t seem
to please him. He didn’t like the way I ironed his shirts—that’s when he broke my
did
tibs. If I didn’t season the food to his liking, another beating. Almost anything I
wrong ended up with his beating me. That’s why we have never had just one doctor,
he would take me to a different one or to a different emergency room every time.”
The therapist asked Suzan if Ron drank much. She said that he usually had a
couple of beers, maybe more occasionally. The therapist asked her if she could
remember if he usually had been drinking when he beat her. She replied, “Yes, yes,
I remember; every time he beat me, he had been drinking. He wasn’t drunk, you
understand. Even last night he had been drinking!’’ She asked, “Do you think his
drinking makes him beat me?” The therapist answered, “‘Not really. Although he
drinks to beat you, he doesn’t beat you because he drinks.”
The therapist asked about Ron’s family. Suzan said that she really did not know
them, and Ron wasn’t very close to them. His father was apparently a violent man
who had beaten his three sons and his wife. She continued, saying that Ron’s father
was an alcoholic and that his mother had died 5 years ago. The therapist told Suzan
that because Ron’s father had beaten him and his mother, he considered this
acceptable behavior between a husband and wife.
The therapist explained to Suzan that shelters had been established for battered
women and their children and that therapy groups had been formed for men who
battered their spouses. The therapist then asked if he could have a woman who
lived in one of the facilities come and talk to her. Suzan said that she would
like very much to talk to someone who had been through what she had been
through. The therapist told Suzan he would arrange it as soon as possible. He
reminded her that she was safe in the hospital, but she must seriously think about
whether she wanted to return home to more beatings or go with her daughters to one
of the facilities.
As Suzan had predicted, Ron sent her roses and asked for her forgiveness. At the
same time the flowers came, Suzan’s mother arrived at the hospital, and the therapist
left so that Suzan and her mother could talk. When he returned, they had decided that
Suzan would divorce Ron and she and her daughters would move to Chicago and live
with Suzan’s parents. Suzan called Ron to come to the hospital so she could tell him
of her decisions.
When Ron arrived, Suzan very quickly told him that she wanted a divorce
and that she and the girls would be moving. At first, Ron was shocked and briefly
tried to change her mind. He became angry with Suzan’s mother, who he assumed
was responsible for Suzan’s unexpected actions. At this point, the therapist ushered
Ron from the room and offered to talk with him later about his problems con-
cerning his beating Suzan. Ron said he would call in a few days and then
left
the hospital.
Ron never called, but the therapist continued to see Suzan every few days until
she was discharged in the fifth week. She fairly blossomed under the loving
care of
her mother. She filed for divorce, with no protest from Ron. Her daughters
were
delighted at the thought of moving to Chicago to live with their grandparen
ts. They
admitted they were terrified of their father and had been afraid of saying
anything
to anyone. They said he had moved out of the house because he could
not stand being
around their grandmother.
Suzan had been made to feel totally inadequate as a wife and mother.
She had led
a very sheltered life until her marriage and had no experience
in keeping a home or
caring for children. She felt that she deserved the beatings by
her husband, and she
was too embarrassed and ashamed to let anyone know that she
was a battered spouse.
She had an unrealistic perception of the event. Her only situatio
nal supports were her
family, who lived in another state. She had no adequate
coping mechanisms. Her
CASE STUDY: SUZAN
|
: PLUS AND
:
;
PLUS AND
RESULT IN RESULT IN
Figure 6-2
injuries from the last beating were so extensive that she was unable to deny her fear
of her husband and thus entered a state of crisis.
Nothing vivifies,
and nothing kills
like emotions.
—Joseph Roux
Violence in the Schools

The problem of violence in schools, which is part of the overall problem of violence
in society, has become one of the most pressing issues in the United States. In
many school districts, concerns about violence have even surpassed academic
achievement—traditionally the most persistent theme on the nation’s educational
agenda—as the high-test priority for reform and intervention (Noguera, 1995).
Public clamorings over the need to do something about violence in schools has
brought the issue to a critical juncture; if schools fail to respond decisively to this
problem, popular support for public education may be endangered. The escalation of
violent incidents and the apparent inadequacy of traditional methods to curtail them
has led to a search for new strategies to ensure the safety and security of children
and teachers in schools (Toby, 1993/1994).
Accepting the fact that it may not be realistic to expect that schools can ever be
completely immune from the violence that plagues society, this section seeks to
understand why schools may be especially vulnerable to its occurrence. Current
efforts aimed at combating violence may, in fact, have the opposite effect,
particularly given the weakening of the moral authority schools once enjoyed.
The search for solutions to the problem of violence in schools has generated
measures that closely resemble those used to combat the threat of violence and
crime
in U.S. society (Currie, 1994). Some of the more popular measures include
the
following:
* The installation of metal detectors at school entrances to prevent students
from bringing weapons onto school grounds.
* The enactment of “‘zero tolerance’ policies that guarantee the
automatic re-
moval of students (through either suspension, expulsion,
or transfer) who
perpetrate acts of violence.
° The use of police officers and security guards to patrol
and monitor student
behavior while school is in session (Kemper, 1993),
Accompanying such measures has been an increased tendenc
y of school officials
to treat violent incidents (and sometimes nonviolent inciden
ts) involving students
as criminal offenses to be handled by law enforcement
officials and the courts,
rather than by school personnel. In their desire to demonst
rate toughness and re-
assure the public that they are in control, school official
s have become increasingly
rigid and inflexible when meting out punishment
on students who violate school
rules, even when the infractions are not of a violent nature (Davila, 1995; Freed,
1994).
Other less punitive approaches have been introduced to reduce the incidence of
violence in schools. Conflict resolution programs have been promoted as a way of
teaching children to settle disputes nonviolently. Mentoring programs that pair
students with adult role models have also become popular in school districts across
the country, serving to reduce violence by proving students perceived to be at risk
with the attention, support, and counseling of an adult (McPartland and Nettles,
1991). Teachers have been encouraged to design curricula that teach children how
to avoid violent situations and to explore in their classrooms the ethical and moral
issues related to violent behavior. Finally, a variety of counseling programs has been
implemented by establishing partnerships between schools and social service
agencies to provide direct services to students.
Though some of these less coercive strategies for reducing violence have proven
relatively successful in particular schools, the overall momentum of school policy has
been biased in favor of the “‘get-tough”’ approach.
The phrase “‘fighting violence”’ might seem to be an oxymoron. For those con-
cerned with finding ways to prevent or reduce the occurrence of violence, “fighting”
it might seem to be the wrong way to describe or to engage in the effort to address the
problem. The choice of terms, however, is not accidental. The prevailing wisdom
among policymakers and school officials is that violence must be countered with
force; that schools can be made safe by converting them into prisonlike facilities, and
that the best way to curtail violence is to identify, apprehend, and exclude students
who have the potential for committing acts of violence from the rest of the population
(Noguera, 1995).
Within the context of the fight against violence, symbols such as crime statistics
take on great significance, although they have little bearing on how people actually
feel about the occurrence of violence. Pressed to demonstrate to the public that the
efforts to reduce violence are effective, school districts often pursue one of two
strategies: either they present statistics quantifying the results of their efforts or they
go to great lengths to suppress information altogether, hoping that the community
will perceive no news is good news (Nemeth, 1993). Metal detectors, barbed wire
fences, armed guards and policemen, and principals wielding baseball bats as they
patrol the halls are all symbols of tough action. A student who wants to bring a
weapon to school can get it into a building without being discovered by a metal
detector, and it is highly unlikely that any principal will hit a student with a baseball
bat; the symbols persist, masking the truth that those responsible for school safety
really don’t have a clue about what to do to stem the tide of violence. Rather than
looking to solve this problem through increased security or improved technology,
school administrators must begin to ask more fundamental questions as to why these
institutions have become so vulnerable to violence.
DISCIPLINE AS AN EXERCISE OF POWER

With concerns about order, efficiency, and control dominating the thinking that
guided the early development of schools in the United States, we must ask ourselves
the
how this legacy has influenced the current character of public schools. As
demographics of cities began to change in the 1950s and 1960s with the arrival of
new immigrants (e.g., West Indians and Puerto Ricans), and the migration of
African-Americans from the South (Moynihan and Glaser, 1987) and as social and
economic conditions within urban areas began to deteriorate, the character and
conditions of schools also began to change. However, this shift did not produce
immediate changes, for although the student population changed, in many cases the
teachers remained the same, with most still relying on methods of control that had
proven successful in the past (Conant, 1961). Writing about the conditions of schools
in what he described as “‘slum areas,’’ James B. Conant (former President of Harvard
University) (1961) spoke of the need to impose a harsher standard of discipline to
ensure that discipline and order prevailed:
Many educators would doubtless be shocked by the practice of on-the-spot demotion of one
full academic year, with no questions asked, for all participants in fights. In one junior high
school I know of, a very able principal found so intolerable a situation that very rule. As
a consequence, there are fewer fights in his school among boys, many whom at one time
or another have been in trouble with the police. The school must attempt to bring some
kind of order to their chaotic lives... . This formal atmosphere appears to work. School
spirit has developed. ... Children must stay in school till they are sixteen or till graduation
to prevent unemployed, out-of-school youth from roaming the streets (Conant, 1961, p. 22).
By the mid 1960s, however, the situation had changed. Students’ insubordination
and aggression toward teachers were becoming increasingly common, and violence
within schools, especially among students, was widely seen as the norm (Metz,
1978). Some educators made the connection between the difficulty schools were
having in maintaining control over students and the political turmoil that accompa-
nied the civil rights movement and the riots that took place in many cities across the
country. Describing the political dimension of this problem and advising teachers
about how to respond to it, Allan Ornstein (1972) wrote:
Some Negro children have newly gained confidence, as expressed in the social revolution
sweeping across the country. Some see themselves as leaders, and not helpless,
inferior
youngsters. This new pride is evidenced by their tendency to challenge
authority. The
teacher should expect, encourage and channel this energy toward constructi
ve goals.
With control and compliance increasingly difficult to obtain, many
urban schools
lowered their expectations with respect to student behavior. The preoccup
ation with
enforcing rules was gradually replaced with a desire to maintain
average daily
attendance, since this was the key funding formula for schools.
As teachers have
come to realize that they cannot elicit obedience through the “terror
of degradation,”
concerns about safety have led more of them to think twice about
how to reprimand
a student, lest their attempt at chastisement be taken as
a challenge for a physical
confrontation, for which most are unprepared.
Still, schools have not given up entirely on the goal of
exercising control over
students; though the task may be far more difficult now than
it ever was, schools are
still expected to maintain some form of order. Beyond
being a threat to the personal
safety of students and teachers, violence in schools
challenges the authority and
power of school officials. In carrying out their duties as caretakers of youth, school
officials serve as both legal and symbolic representatives of state authority. With the
power vested in their position, they are expected to control the behavior of those in
their charge. When violence occurs with impunity, a loss of authority is exposed.
Therefore the issue of violence is seldom discussed in isolation from other control
issues. More often, violence is equated with insubordination, student misconduct, and
the general problem of maintaining order in school. The way the issues become
melded together is indicative of how schools perceive their role in relation to the
social control function that schools have historically performed in the United States.
ALTERNATIVE APPROACHES TO SCHOOL VIOLENCE PREVENTION

The approach to discipline that is most widely practiced in the United States today
is due to the fact that many teachers and students have been victims of violence and
deserve the right to work at and attend safe schools. In many schools, violence is real,
and the fear that it produces is understandable. In some classrooms teachers are
working effectively with their students, and fear is not an obstacle to dialogue or even
friendship; however, other teachers in the school may be preoccupied with managing
their students’ behavior, an endeavor at which they are seldom successful. The same
students may enter other classrooms willing to learn and comply with their teacher’s
instructions.
Many of these “exceptional” teachers have to ‘cross borders” and negotiate
differences of race, class, or experience to establish rapport with their students
(Giroux, 1992). “Border crossing” is a phrase coined by Henry Giroux to describe
the personal transformation experienced by teachers and students engaged in critical
discourse and pedagogy. He writes (Giroux, 1992, p. 169):
Critical educators take up culture as a vital source for developing a politics of identity,
community and pedagogy. Culture is not monolithic or unchanging, but is a site of multiple
and heterogeneous borders where different histories, languages, experiences, and voices
intermingle amidst diverse relations of power and privilege. Within this pedagogical
borderland known as school, subordinate cultures push against and permeate the alleged
nonproblematic and homogeneous borders of the dominant cultural forms and prac-
tices.... Radical educators must provide conditions for students to speak so that their
narratives can be affirmed.
When students are asked what makes a particular teacher “‘special” and worthy
n; and
of respect, students consistently cite three characteristics: firmness; compassio
g teaching style. Of course, even a teacher
an interesting, engaging, and challengin
students can be a victim of violence, particularl y
who is perceived as exceptional by
occurrence . Some teachers confront student
because of its increasingly random
up fights or dice
institutions that others would not dare to engage, boldly breaking
ful student, without showing the slightest
games, or confronting a rude and disrespect
bit of apprehension or fear (Noguera, 1995):
ents and
There are a variety of ways in which to humanize school environm
Improvi ng the aesthetic characte r of
thereby reduce the potential for violence.
or by making space available within
schools by including art in the design of schools
make schools more
schools for students to create gardens or greenhouses can
pleasant and attractive. Similarly, by overcoming the divide that separates urban
schools from the communities in which schools are located, the lack of adults who
have authority and respect in the eyes of children can be addressed. Adults who live
within the community can be encouraged to volunteer or, if possible, be paid to tutor,
teach, mentor, perform, or just plain help out with a variety of school activities. These
examples are meant to begin a discussion of alternative practices for building humane
school communities. There are undoubtedly a variety of ways this can be done, and
although such efforts may not eliminate the threat of random violence, they can help
to make schools safer, less impersonal, and better able to provide students with a
sense of stability in their lives.
The goal of maintaining social control through the use of force and discipline
has persisted for too long. Although past generations could be made to accept
the passivity and constraint such practices engender, present generations will not.
Most urban youth today are neither passive nor compliant. The rewards that are
dangled before them, such as a decent job and material wealth for those who
do well in school, are seen by too many as either undesirable or unattainable.
New strategies for proving an education that is perceived as meaningful, and
relevant, and that begins to tap into the intrinsic desire of all individuals to obtain
greater personal fulfillment must be devised and supported. Anything short of this
will leave us mired in a situation that grows increasingly depressing and dangerous
every day.
The urban schools that feel safe to those who spend their time there don’t have
metal detectors or armed security guards, and their principals don’t carry baseball
bats. What these schools do have is a strong sense of community and collective
responsibility. Such schools are seen by students as sacred territory, too special to
be
spoiled by crime and violence and too important to risk being excluded. Such
schools
are few, but their existence serves as tangible proof that there are
alternatives to
chaotic schools plagued by violence and controlled institutions that aim at producing
docile bodies (Noguera, 1995).
The following case study illustrates how a psychotherapist of one culture
can work
effectively with a patient of a different culture. Not only do they
have different
cultures, but they also have different backgrounds, values, and
ideals.
Case Study
—_—_—
I Violence at School
_ CE at DCO
Ricardo was assigned to a particular therapist at the
Crisis Center because the
volunteer assumed (incorrectly) that she was also Latino.
The therapist met Ricardo
and introduced herself and asked him to come to her
office. When they reached her
office, she asked him to have a seat while she looked
briefly at the chart that he had
completed. He had stated that his problems were “probl
ems at school.”
The therapist asked Ricardo what school he was attendi
ng. He answered with the
name of an intercity school that was notorious as being
the “‘hub” of two well-known
rival gangs. The therapist asked Ricardo if he was
an active member of one of the
gangs. He was quiet for a few minutes, and then
asked the therapist, ““You aren’t
Latino are you?” The therapist answered, “No,
but my husband is from Spain—that
is why everyone assumes that I am Latino. Why
do you ask Ricardo?” He answered,
“Maybe you won’t be able to understand my problem.” The therapist smiled, ““Well,
we won’t know until you tell me what the problem is, will we?”
Ricardo returned her smile, “‘I haven’t talked to anyone about this—I just don’t
know what to do.” She replied, “Ricardo please tell me what you are so concerned
about, maybe I can help and maybe I can’t.” He looked at the therapist intently and
said, “Okay, I’ve got to trust someone.”
Ricardo began by asking the therapist if she knew anything about the two rival
gangs at his school. The therapist told him that almost everyone had heard about
them. One gang was Latino, and the other was African-American. The rivalry
frequently erupted into violence with fights between the two with guns and knives.
Not only had some of the members been killed but also innocent bystanders. Some
had been shot and killed or severely injured from cars because one of the gangs
assumed, wrongly, that those in the car were members of the rival gang. She related
this to Ricardo.
The therapists asked Ricardo if he was a member of the Latino gang. He answered,
“No, and that is the problem!’ He continued, saying that he had a friend in the gang
and had overheard him talking about one of members of the other gang. He heard
him say that this member was on a “‘hit”’ list and that “‘it’” was planned for the next
evening, and even where they were planning to do the “hit.’”’ He said that he had
refused to become a member of the Latino gang because he did not believe that
violence achieved anything. He continued by saying that he didn’t want to get his
friend in trouble, so he couldn’t say anything to anyone at school. There were too
many “‘snitches,” so if he went to the police, someone would find out that he was
the one who leaked the information of the “hit.”
The therapist asked Ricardo if he had told anyone that he was coming to the Crisis
Center. He answered in the negative, saying, ““God no! No one must know that I’ve
been here.”
The therapist asked him if he wanted to let the police know about the “hit.”
He looked at the therapist and said, ‘“‘Yes, I just don’t know how I can without
someone finding out.” The therapist said, “Ricardo, what if I just accidently, of
course, left the telephone number of a ‘hot line’ on my desk that would not ask
you anything about yourself but that handles problems like the one you are faced
with? I, of course, will not be in my office with you.” She paused, “I am going
to get some coffee. Would you like me to bring you some, or perhaps a soft
drink?” In almost a whisper she added, “In case you want to make a telephone
call while I am gone, just dial ‘9’ for an outside line.” Ricardo hesitated, “Can
they trace this number?” “No, they never have in the past.” He looked at her
knowingly and said, “You have done this before, haven’t you?” “Done what?”
They exchanged glances. “Did you decide if you wanted coffee or a soft drink?”
Ricardo followed her lead, “I would like a coke, if you have one.” The therapist
put a card from her Rolodex in the center of her desk and placed the telephone
next to it. “I’ll be back with my coffee and your coke in about 10 minutes, okay?”
Ricardo smiled, ““Thanks.” She returned the smile, walked out her office, and closed
the door firmly behind her.
When the therapist returned, the card had been replaced in the Rolodex and
Ricardo had left her a note, “Thanks, friend. Your pal, R.” He had left “‘no clues.”
CASE STUDY: RICARDO
PLUS AND
AND
RESULT IN RESULT IN
Figure 6-3
Ricardo was not her first experience with gangs, and she doubted it would
be her last.
Violence is essentially wordless, and it can begin

only where thought and rational communication
have broken down.
—Mohandas K. Gandhi
Elder Abuse and Neglect

How many older people in the United States suffer in silence . . . abused, neglected,
exploited and isolated, or trapped in nonfunctional bodies or by poorly functioning
minds? Despite reports of “granny bashing”’ in the literature some 20 years ago and
the fact that abuse and neglect of older people will be an increasing problem in the
next century, we remain unsure of many aspects of this complex phenomenon,
including its true incidence. Although frightening evidence exists that older
individuals in institutions are more likely to be at risk than those living in the
community, data regarding institutional abuse and neglect are so scarce that it would
be impossible to make national estimates of the extent of the phenomenon. We do
know, based on reports of advocacy groups, media, and a few random studies, that
it exists and is not uncommon.
TYPES OF ELDER ABUSE AND NEGLECT

Abuse and neglect of older people are not uncommon. Problems of such abuse and
neglect are estimated to be as widespread as child abuse and affect about 2 million
older persons each year, many of whom suffer repeated episodes. Identification of
abuse and neglect requires an awareness of its existence and knowledge of risk
factors and signs.
Despite the fact that case reports of abused older adults appeared in the literature
20 years ago, there is still no clear and consistent definition of what constitutes abuse
and neglect of older adults in the literature or the law. The term elder mistreatment
is used by some to describe acts of commission or omission that result in harm or
threatened harm to the health and welfare of older adults and refers to the suffering
imposed as a result of abuse and neglect.
The manner in which mistreatment of older people is categorized varies in the
literature. Categories commonly include physical abuse, physical neglect, psycho-
and
logical abuse, psychological neglect, financial/material abuse or exploitation,
violation of personal rights.
Physical abuse. Physical abuse describes acts that include pushing, shaking,
slapping, punching, kicking, biting, choking, using physical or chemical restraints in
an inappropriate manner, force feeding, burning, or attacking with objects or
and
weapons. Sexual abuse/exploitation is sometimes included within this category
another
consists of any nonconsensual sexual activity, including situations in which
is physically forced, pressured, or manipulated into sexual contact or is unable to

grant informed consent. Forms of sexual abuse include verbal abuse (suggestive talk,
jokes, and labeling); unwanted touching; rape; fondling; inappropriate sexual
relations such as with a child or one’s professional caregiver; or any other sexual
activity with an older person when that person is unable to understand, unwilling to
consent, physically forced, or threatened.
Psychological abuse. Psychological abuse is an act that results in psychological
distress or emotional anguish. Examples include threats, intimidation, provocation,
harassment, ridicule, withholding security and affection, isolation from others,
infantalization, and violation of rights.
Physical neglect. Neglect can be defined as the failure or omission on the part
of a caregiver or of oneself to provide the care and services necessary to maintain
physical and mental health, including, but not limited to, food, clothing, medicine,
shelter, supervision, and medical services that a prudent person would deem essential
for the well-being of another. Neglect may represent repeated conduct or a single
incident of carelessness that produces or could reasonably be expected to result in
serious physical or mental harm or a substantial risk of death.
Neglect may be intentional or unintentional. Categories of neglect include
physical neglect in which the caregiver fails to provide services and goods necessary
for optimal functioning and avoidance of harm. Examples include the following:
* Failure to provide adequate nutrition and hydration
* Failure to provide physical assistance such as help with toileting or hygiene
* Withholding of medications or medical care
* Failure to provide for safety
Passive neglect is defined as the failure or refusal to fulfill a caretaker’s role,
excluding a conscious or intentional attempt to inflict physical or emotional distress
on the elder person. Self-neglect is a controversial category recognized by some state
laws and refers to the failure of an individual to provide oneself with the care and
services necessary to maintain physical and mental health.
Psychological neglect. Psychological neglect is often difficult to substantiate.
Psychological neglect is defined as the failure to provide a dependent older
person
with social stimulation and includes leaving the person alone for long periods,
failing
to provide socialization or companionship, restricting access to community
events,
and socially or physically isolating an individual.
Financial abuse or exploitation. Financial or material abuse, sometimes termed
exploitation, involves the unauthorized use of an older person’s money,
property, or
other resources for personal gain. Deceit, treachery, coercion, or intimidat
ion may be
knowingly used by a person in a position of trust and confiden
ce to gain access to
an older person’s funds, assets, or property. Examples include
stealing money or
goods, coercing another to obtain goods or property or to change
legal documents,
and using another’s guardianship or power of attorney for
one’s personal advantage.
Some indicators of exploitation follow.
Unusual activity in bank accounts, such as unexplained
withdrawals
Disparity between income and lifestyle
Excessive payments for services
Unusual interest by others in the older person’s assets
A power of attorney given when the person is unable to understand the finan-
cial situation and in reality is unable to give valid power of attorney
Numerous unpaid bills, especially overdue rent, when someone is supposed to
be paying the bills
Recent acquaintances expressing gushy, undying affection for a wealthy older
person
A friend or housekeeper trying to isolate the older adult from family or
friends
Violation of rights. Violation of rights of an otherwise able older person include
the following:
Failure to allow decision making
Deprivation of the right to privacy, self-determination, or to worship and vote
Verbal, sexual, physical, or mental abuse
Failure to allow participation in healthcare decisions, including refusal of
treatment
Involuntary seclusion
Failure to allow full access to advocates
Inappropriate physical or chemical restraints
Physical findings indicative of possible abuse and neglect include patterns of
bruising or of injuries that are morphologically similar to an object (e.g., belt marks,
hand marks, lesions at the corners of the mouth indicating use of a gag, and marks
left by restraints, ropes, or cords), burns, immersion injuries of extremities in a
stocking/glove distribution, and unexplained fractures and falls. Sexual abuse should
be suspected when findings include trauma or tenderness of genital, rectal, or mouth
areas; bruising in areas of thighs, buttocks, face, and chest; gait abnormalities related
to genital/anal trauma; the presence of sexually transmitted diseases in adults unable
to consent to sexual activity; or fear, shame, anxiety, or other nonverbal signs of
distress when receiving personal care. Other general indicators of abuse and neglect
are listed in Box 6-4.
DOCUMENTATION OF ELDER ABUSE AND NEGLECT

Accurate documentation in cases of suspected abuse and neglect is crucial.
Information obtained from interviews of the alleged victim, perpetrator, and
of the
witnesses should be recorded verbatim, if possible, and a detailed description
injuries, functional status, and cognitive status,
physical examination, including
size and
should be documented. Injuries must be described in detail, including
be
location and, if possible, photographs of the injuries obtained. These may
invaluable in proving cases of abuse or neglect.
CHARACTERISTICS OF ABUSIVE CAREGIVERS

situation than are
Characteristics of the caregiver are more predictive of an abusive
indicates that perpetra tors of abuse commonly
victim characteristics. Johnson (1986)
depende nt persons who often rely on the elderly
display psychopathology. They are
l support. Abusive caregive rs often have had
for housing and financial and emotiona
for psychiat ric illnesses , and problems with
difficulties with the law, hospitalizations
skills,
alcohol and other drugs. They tend to have poor social and communication
Box 6-4
GENERAL INDICATORS OF ELDER ABUSE AND NEGLECT
Delay in obtaining necessary treatment

Malnutrition, dehydration
Contractures
Pressure ulcers
Evidence of inappropriate medication use, oversedation, and lack of administration of
antihypertensives or insulin
Pattern of “doctor shopping” or physician hopping
Previous unexplained injuries/injuries inconsistent with medical findings
Lack of appropriate clothing or assistive devices, such as glasses, hearing aid, or
dentures
Certain nonverbal victim behaviors, such as apprehension, fear, withdrawal, or passivity
Reluctance to provide information
Depression or severe helplessness/hopelessness
Anorexia
Tearfulness
which are often reflected in their interpersonal relationships and: employment

histories, and may demonstrate poor emotional reserve and coping skills. Pillemer
and Finkelhor (1988) summarize the profile of the abusive caregiver when they
indicate that abusers do not tend to be well-meaning persons driven to abuse
by the
demands of another but are severely troubled individuals with histories of antisocial
behaviors or instability.
Assessment protocols have been developed that concentrate on
physical and
behavioral symptoms of elder abuse. These protocols are focused
on identifying
abuse but were developed with the assumption that problems can
be identified after
abuse has occurred. Protective services and mandatory reportin
g of elder abuse
resulted in the identification of potential problems (Faulkner, 1982; Salend and
others, 1984). Despite these measures, elder abuse is an invisible
problem. In Elder
Abuse: The Hidden Problem (U.S. Congress, House Select
Committee on Aging,
1980), it was estimated that one of every three cases of
child abuse is reported, but
only one of every six cases of elder abuse is reported.
Several explanations for the
invisibility of elder abuse reflect factors that affect both
research and applied efforts.
The family is sacred, and interference with family life
by outsiders is not tolerated,
even when professionals believe they are justified
in intervening when there are
family dysfunctions. Family members may engage
in a conspiracy of silence and
reject attempts by outsiders to explore or intervene
in their lives.
The American Medical Association (AMA) has issued
its first guidelines on elder
abuse, urging physicians and other healthcare profes
sionals to be more alert to signs
of mistreatment or neglect of older patients by their
families or caregivers (Formica,
1992). The 42-page guidelines, part of anew AMA
campaign against family violence,
come amid growing national concern about a
long-hidden problem in which as many
as 2 million elderly Americans are believed
to be victims of abuse or neglect
(Formica, 1992). Because abuse occurs within the confines of a private dwelling, it
is hidden from outside scrutiny. Unlike the circumstances of children, whose abuse
can be detected outside the home, there are no requirements such as school
attendance and health checkups for the elderly. They do not need to leave their homes
and risk being seen by non-family members.
The elderly are reluctant to report abuse by relatives. Lau and Kosberg (1979)
found that one third of the elderly who were judged to have been abused denied any
problem. It is not difficult to understand the reasons the elderly do not report abuse.
They may believe that the problem is a family affair. They may fear reprisals by the
abuser or may be embarrassed or ashamed of the behavior of the abuser. The elderly
may be reluctant to initiate legal or criminal action against a relative for fear that the
solution will be worse than the problem itself—institutionalization. They may
believe that they are being paid back for their earlier abusive behavior toward others,
such as a child or spouse.
The invisibility of elder abuse can result from the failure of professionals to detect
or report the problem, even in states having mandatory reporting legislation.
Although empirical verification is lacking, the reluctance on the part of professionals
to report child abuse may also be a characteristic of the professional responses to
mandatory reporting laws for elder abuse. It is suspected that not all professionals
in states with mandatory reporting legislation are aware of their responsibility
(O’Brien, 1986).
For these reasons, elder abuse often remains invisible. Community efforts,
protective services, and mandatory reporting legislation affect only a fraction of the
abused elderly and only after the abusive behavior has occurred. Accordingly, it is
important to place frail and vulnerable elderly persons in the care of appropriate
family members or other persons.
Family membership does not prevent people from engaging in abusive behavior;
in fact, family members have been found to be the major perpetrators of elder abuse.
The instinctive and uncritical use of family members as caregivers of vulnerable,
of
elderly persons should not continue. A systematic assessment of the capacity
potential or present family caregivers to provide nonabusive care is needed (Kosberg,
1988).
from earlier
The predominant image of elder abuse, which has been derived
media, is that abuse is primaril y committed
studies and reinforced by the popular
The stereoty pe is that of a mentally and
against the elderly by their children.
in with and becomes a difficult burden to a
physically dependent elder who moves
to frustration, lashes out
resentful daughter or son. The son or daughter, in response
(1988) found that 58%
or withholds certain necessities of life. Pillemer and Finkelhor
victim’s spouse; 24% of the abusers were the
of elder abuse was committed by the
lived with their spouses alone, the rate of abuse
victim’s children. Among elders who
alone, the rate was
was 41 per 1000. Among those who lived with their children
more elderly live with their
44 per 1000. The percentage difference is because many
seem inherently more
spouses than with their children. Actually, spouses do not
parents, but spouses are more
violent toward their partners than children toward their
their opportunities for
likely to be present in an elderly person’s household, and thus
abusive behavior are greater.
Elder abuse has been the most recent and most neglected form of family violence
to vie for public attention. Those who have sought to gain this attention have cast
the problem in its most compelling light. The image of one elderly person hitting or
neglecting another does not convey the same pathos as an elderly person being
abused by an adult child.
Although ample evidence of variables associated with elder abuse exists,
inappropriate placements continue to result in problems for vulnerable, ‘elderly
persons. Most community programs and state legislation focus on the problem of
elder abuse after it has occurred and necessitate the detection and reporting of abuse.
Yet the problem is essentially invisible, and greater attention should be given to
assessing the potential caregivers of impaired older persons. Assessment should
include attention to high-risk indicators for the aged person, caregiver, and family
system, along with the perceptions of family members. Such assessments will not
eliminate the problem, but public education, professional awareness, detection
protocols, alternatives for and support of family care, and social legislation may
contribute to a comprehensive effort in preventing this form of abuse (AMA, 1992).
Collaboration between researchers, legislators, practitioners, professionals, and
the general public needs to continue. Those working with the elderly should
remember that no group of elderly persons is immune to the possibility of abusive
behavior.
Elder abuse will continue as long as ageism and violence exist. The following
characteristics appear to make the elderly especially vulnerable to elder
abuse:
1. Female. Simply because there are more older women than there
are older
men, more of the abused elderly are women. Older women also
are less likely
to resist abusive behavior and are more vulnerable to sexual molestat
ion.
2. Advanced age. The older the person, the higher the risk of
abusive behavior.
Advanced age is also associated with physical and mental impairm
ents and an
inability to resist adversities.
3. Dependency. Older persons who depend on others for their
care are more vul-
nerable. Economic dependency can result in hostility by
a caregiver and lead
to abuse.
4. Internalizing blame. Older persons engaged in self-bl
ame may be especially
vulnerable to elder abuse through self-deprecating behavio
r. They may fail to
acknowledge the abuse as the fault of the abuser.
5. Excessive loyalty. An older person who has a strong
sense of loyalty to an
abusive caregiver will probably not seek to report
the problem.
6. Past abuse. Older persons who have been subjec
ted to abusive behavior by a
family member in the past are candidates for
similar treatment when they dis-
play increasing impairments and dependency.
7. Isolation. An older person isolated from others
may be especially vulnerable
to abusive behavior because of the lack of detect
ion and intervention by
neighbors, friends, other relatives, or servic
e providers.
People who provide services to the elderly need
to be educated about the problem
of spouse abuse. If their image of elder abuse
is limited to the current Stereotype of
elderly persons mistreated by their adult childr
en, they are not likely to properly
identify situations where the aged are being
abused by their spouses.
The elderly themselves need to be educated about spouse abuse. They grew up
in an era when spouse abuse was tolerated more and when information on the subject
was not available. Elderly victims may be vulnerable to spouse abuse because they
believe it to be acceptable. They need to be encouraged not to accept it and to see
it as a serious problem. Education can reduce the feelings of embarrassment and
shame at being a victim and make it easier to take actions to stop the abuse.
Services need to be provided that are tailored to the problem of spouse abuse
among the elderly. Nursing homes, which are used as a solution to elder abuse in a
substantial number of cases, are often inappropriate because they are designed for
persons much less capable of taking care of themselves. Shelters for battered women
may be better solutions, but many of these shelters are not suited to the needs of the
older woman. Furthermore, the presence of young women and children may
intimidate older women and prevent them from seeking assistance. It would be more
appropriate to establish safe apartments in congregate housing units where abused
elders can take refuge. The types of self-help groups that have been effective with
younger abused wives should be offered to groups of abused elderly women. Perhaps
they can help the elderly stop the abuse, escape from it, or get other kinds of
assistance (Pillemer and Finkelhor, 1988).
The following case study concerns the abuse of a 72-year-old woman by her
76-year-old husband.
Case Study Elder Abuse

A young boy visiting friendsin the neighborhood where Hattie and Max lived
accidentally threw his ball into their backyard. He climbed the fence to get his ball
and heard Hattie crying for help. The boy looked in the window and saw that Hattie
had bruises on her face, a black eye, and blood pouring from her nose. He ran to the
house he was visiting and reported what he had observed; the neighbors then called
the police and paramedics.
The paramedics took Hattie to a local hospital. She was seen in the emergency
a
room immediately. The physician discovered that she had a broken nose,
to multiple
concussion, and a compound fracture of the right forearm, in addition
facial bruises and a black eye. She was emaciated and confused, and when she was
she was
asked what had happened, she said, “I must have fallen.” When asked if
married, Hattie said, ‘““Yes. Max went to the market.”
to the local
The police had left a note on the door saying that Hattie had been taken
Max showed up at the hospital and was met by the
hospital. After about an hour,
wanted to know where his wife was and what she was
police. He was very angry and
apparent to the police that he had been drinking. They
doing at the hospital. It was
market; I was out of beer.”
asked him where he had been and he said, ‘‘I went to the
and asked if he had beaten her. He responded, ‘‘Hell,
He was told of Hattie’s injuries
on time—she never
no! All I did was give her a shove. She didn’t have dinner ready
would have to.be hospital ized and that they were
does!” They told him that his wife
wife could tell them how she had been injured.
taking him into custody until his
treated; her arm would
Hattie was hospitalized and most of her injuries were
members of the
require surgery. The physician requested a consultation with
hospital’s Elder Assessment Team (EAT). The team consists of nurses, social
workers, physicians, psychologists, and an ethics specialist. He met briefly with
representatives of the EAT and told them of Hattie’s injuries and his belief that her
husband, Max, had beaten her. Ellen, a nurse, and James, a psychologist, would
interview Hattie. Bill, a social worker, and Alan, the ethics specialist, agreed to
interview Max at the city jail the next day.
Ellen and James went to Hattie’s room. She was drowsy from the pain medication
but did not appear confused. They introduced themselves and explained that they
were members of the EAT. They asked Hattie if she felt like talking. She hesitated
with tears in her eyes and said, “Yes, I do. Max is a good man and he really doesn’t
mean to hurt me. I just can’t seem to please him. It really is my fault, Iknow he likes
his dinner at 6 pm every night—not 5 minutes earlier or 5 minutes later. It’s my fault,
it always is. Can we talk tomorrow? I’m getting sleepy. Can we call our daughter,
Angela, tomorrow?” Ellen and James agreed to meet with Hattie the following day
and to help her call her daughter.
The first priority was to get help for Hattie. The second priority was to find out
from Hattie and Max how long he had been abusing her. The third priority was to
talk with their daughter, Angela, to determine if she was aware of the abuse and
what
she could do to help her mother and father.
The morning following Hattie’s admission, the EAT members met to discuss
the information received from their interviews with Hattie and Max. Bill
and Alan,
who had visited Max at the jail, told the team what they had learned from
Max.
Max said that he had retired late (at age 70) and that he had been an engineer
—
‘a damn good one.” He and Hattie had been married for 52 years and
had one
daughter, Angela, age 49. Angela was divorced and lived in
another state
approximately 2500 miles away. Max said that they rarely saw her
because she was
a “big-shot career woman.” Hattie had worked as a “dumb cashier”
until they had
married. He had made her quit. “I made good money—no wife
of mine was going
to work.”” When asked what Hattie did all day when he was working,
he said, “What
a wife is supposed to do, take care of the house. You
know, clean, cook, wash and
iron clothes, and mow and water the lawn. She had enough
to keep her busy!” He
was then asked what Hattie and he did after he retired.
He looked confused and said,
“What do you mean? Nothing changed. She took care of
the house, and I watched
television.’’ When asked if they ever went out with friends
or traveled, he responded,
“What for? I don’t need to waste my money on things
like that, and believe me,
I have enough to take care of me for as long as I live.
I’ve never been sick a day in
my life.”
Bill and Alan admitted that they were very frustra
ted with Max. When Alan
asked Max, “Why did you hit Hattie?” Max answer
ed angrily, ‘She asked for
it! Always with her nose stuck in a book or
knitting. She knows I always want
my dinner on the table at 6:00 sharp! She
hadn’t even started dinner, and it
was 5:45!”
Alan asked, “Do you beat her often when
your dinner is late?”” Max replied,
“I don’t call it beating, I just knock her around
a bit.” Bill said, “We do call it beating.
Do you know the extent of her injuries?” Max
looked a little guilty and said, ‘“Well,
I probably had one or two beers too many.”
Bill replied, “How many beers do you
usually have during the day?” “Maybe a six-pack,” said Max, “sometimes more.”
“You always have at least six beers a day and sometimes more?” asked Alan.
“Yeah,” replied Max. “‘So what? I buy it!”
Bill and Alan told the EAT members that they strongly believed that Max was a
chronic abuser. They asked Ellen and James what they had learned about Hattie. Ellen
said that after talking with Hattie, they had met with the radiologist. He showed them
the x-rays he had taken. They disclosed previous multiple fractures of her ribs,
fingers, toes, and the bones in her face. They also agreed that Hattie had been abused
over many years by Max.
James had called Angela and told her of Hattie’s injuries. Her response was,
“I’m amazed he didn’t kill her. He has always slapped or knocked her around
for as long as I can remember. I left home as soon as I could. He hit me one time
when I was 13. I told him I would kill him if he ever touched me again. Mom just
never had the guts to stand up to him. I have begged her to leave him and move here,
but she wouldn’t leave him. I’ll fly out there this weekend and make her come back
with me.”
The team agreed that they would do everything they could to persuade Hattie to
leave Max and live with or near her daughter.
The orthopedic surgeon was asked to treat Hattie’s arm as soon as possible.
He agreed. Hattie came through the surgery quite well and was getting stronger
every day. She was eating and sleeping well. Angela arrived and talked with her
mother at length. Hattie agreed to return with her but stated she didn’t want to
live with her. Angela told her mother that there was an excellent retirement home
close to where she lived. Hattie agreed to try it but was worried that Max wouldn’t
agree to pay for her leaving him and moving away. Angela told her mother, ““He’ll
pay or I’ll see that he never gets out of jail. I’ve already talked with an attorney
“‘Well,
here, and you will get half of everything Dad has, and more!” Hattie said,
in that case, I won’t worry. I just didn’t want to be a burden to you. You work
and
so hard.” Hattie asked when they could leave. She was reassured by Angela
the EAT members that she could leave the next day. Hattie and Angela were both
very pleased.
the
Hattie has been abused repeatedly by her spouse, Max. She always believed
to have
beatings to be her fault. Max kept her isolated, and she was not permitted
daughter lived out of state. Hattie had never stood up to her
friends. Their only
and her husband
husband or defied him. After a severe beating, she was hospitalized
daughter came and took her back with her to live in a nearby
put in jail. Her
retirement home.
Last scene of all,

That ends this strange event in history,
Is second childness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.
then compare it with the

Complete the paradigm in Figure 6-4 for this case study,
3 as needed.
completed one in Appendix D. Refer to the paradigms in Chapter
CASE STUDY: HATTIE
PLUS AND
AND
RESULT IN RESULT IN
REFERENCES
American Medical Association: Panel to curb elderly abuse, New York, 1992, The
Association.
A nation’s shame: fatal child abuse and neglect in the United States, U.S. Bureau of Census,
Washington, DC, 1995.
Bandura A: Aggression: a social learning analysis, Englewood Cliffs, NJ, 1973, Prentice Hall.
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ad
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.
the bows Jrom which your children
___ as living arrows are sent forth
any couples now plan their families as meticulously as they plan their
TN oe choice of career, living situation, and other major financial
investments. They measure all factors and wait for the
opportune moment to start
their family.
For one of every six couples of childbearing age, fertilit
y is not a force that can
be turned on at will. Infertility, the inability to achieve
pregnancy after 1 year of
regular sexual relations or the inability to carry
pregnancy to a live birth, is
experienced by 15% of the population of childbearing
age. The U.S. Census Bureau
(1993) states that there are now over 300 million
Americans; of these, 66 million ,
or about 30%, are between the ages of 22 and
40 years. If the accepted rate of
infertility (15%) is applied to this number, it is
probable that there are more than 10
million who may, at some time, be unable to achieve
or Carry pregnancy. Of this
number, about 40% have an infertility problem
related solely to the female, another
40% have a problem related solely to the male,
and the remaining 20% have a
problem that either affects both members
of the couple or is of unknown origin
(Halpert, 1994).
Although the childless couple is more social
ly acceptable in modern society,
there is a distinct group of infertile coupl
es who feel what they consider to be
social pressures to become parents. As a
woman and her partner begin to realize
that she may never bear a child, an
emotional state develops that can be called the
crisis of infertility (Bresnick and Taymo
r, 1979), Approximately 30 years ago,
40% to 50% of infertility cases were thoug
ht to be the result of emotional factors.
Infertile couples were described as havin
g typical personality traits that resulted
their inability to conceive. More recently in
our increased understanding of neuroen-
docrinology, as well as other advances
in the field, has reduced emotional factor
a cause of infertility to less than 5%. s as
Infertility itself is frequently a source
of
122
Chapter 7: The Psychological Trauma of Infertility 123
emotional trauma for couples, placing considerable stress on their relationship

(Eisener, 1963).
Infertility as a Life Crisis

At some point during infertility investigation and attempted treatment, it is common
for an infertile person to experience a state of crisis. Crisis in this situation can be
succinctly defined as a disruption in the steady state, or a period of disequilibrium.
Since there may be repeated crisis states during infertility investigation and
treatment, there is a very real risk of maladaptive behavioral changes, just as there
is the real chance for positive growth and increased insight. Crisis intervention by
an understanding, knowledgeable, and caring professional may make all the
difference (Menning, 1980).
It is naive for the physician who treats infertility to say that feelings are not within
his province. Whether by acts of omission or commission, the physician very much
affects the outcomes of the crisis state. The person in crisis is extremely vulnerable
and can be gravely hurt by indifference, lay psychiatric advice, or comparisons with
those who have suffered more. Members of a couple, as if by tacit agreement, do not
usually get into crisis at the same time. This may lead the one who is dysfunctional
to believe that the other cannot understand. The man and woman may have little to
give each other, forcing the person in crisis to depend on outside help. The physician
is immensely important at such a time, and if he does not possess the necessary
counseling skills, at least he may, be an important bridge to therapeutic intervention
(Winkleman, 1995).
There is a very positive side to the disequilibrium and vulnerability of the crisis
state. Since existing coping mechanisms have failed, the person is very open to
change and growth. Old, defeated coping patterns are often discarded at times of
crisis, and new and more appropriate methods may be learned. The anxiety that most
people in crisis experience is actually a high-energy state. If this energy can be
focused on a tangible problem by a skilled therapist, it can be useful in resolving the
situation. The fundamental goal of crisis intervention should be “primum noli
the
nocere”—above all do not harm. The therapeutic goal in crisis intervention is for
than the
individual to achieve a level of equilibrium equal to or, preferably, better
precrisis level.
The Emotional State of the Infertile Couple

feelings are
The crisis of infertility evokes many feelings in the couple. Some
real and correctly perceive d insults that society or
rational and based on very
and treatmen t have thrust on them. Other feelings
the infertility investigation
in part on myths and superstit ions or on magical
may be more irrational and based
in order and intensity , but most individua ls face
childlike thinking. Feelings vary
as they attempt to work through the infertilit y
a similar syndrome of feelings
feel ““damaged”’
crisis. Regardless of the cause of infertility, both men and women
have described themselves as feeling “hollow” or
and “defective.” Women
In addition,
“empty,” and men have spoken of intercourse as “‘shooting blanks.”
some couples begin to feel that they are “doing it wrong” or that there is something
about sex that they do not know.
THE AFFECTIVE STAGES OF INFERTILITY

Rosenfeld and Mitchell (1979) emphasize that the infertile couple in a crisis situation
experience tremendous stress as a couple, as well as individually. They view the
stages of emotional response to infertility as surprise, grief, anger, isolation, denial,
and acceptance. They feel that therapy can be very helpful in each of these areas and
extremely helpful in the area of acceptance. According to Menning (1982), the
following seven affective stages occur in a logical order:
Surprise. The first reaction most people have to the news of infertility is one
of total shock and surprise. Most couples in their childbearing years are
usually thinking in terms of preventing pregnancy. They naturally assume
that they can have children if and when they desire them. It is ironic that
most couples discover their infertility after having used some form of birth
control, sometimes for many years. The discovery of an infertility prob-
lem is felt most keenly by those who are highly achievement oriented and
who believe themselves capable of surmounting any obstacle if only
enough effort and will are exerted.
Denial. “This can’t happen to me” is often the reaction to infertility, espe-
cially if the initial tests reveal an absolute and untreatable problem in ei-
ther partner. Denial serves a purpose. It allows the mind and body to adjust
at their own rate to an overwhelming situation. Denial is dangerous only
when it becomes a long-term or permanent coping mechanism, for ex-
ample, when chronically depressed women staunchly maintain that they
never really wanted a family and when both men and women
refuse to ap-
ply the label ‘‘infertile” to themselves in spite of 5 to 10 years of
invol-
untary childlessness. Psychotherapy of some duration is usually
indicated for individuals who need this level of defense.
Anger. When a couple enter into an infertility investigation
and attempt treat-
ment, they surrender much of their control over their bodies.
Even in the
best physician-patient relationship, frustration, helplessness,
and embarrass-
ment may be present. Anger is a predictable response
to loss of control.
The anger may be quite rational and focused on real
and correctly per-
ceived insults, such as social pressuring from family
and friends to “pro-
duce,” and the pain and inconvenience of the tests
and treatments
themselves. Sometimes the anger is more irrational
and is projected on tar-
gets, such as the physician or marriage partner,
or even social issues, such
as pro-choice abortion advocates or people who
“‘breed like rabbits.” This
irrational anger is usually a front for more primary
feelings, such as intense
loss or grief that has not yet been acknowledged.
Whatever the source or
type of anger, it is necessary that the person be
able to ventilate it. An-
ger tends to dissipate in the telling and retellin
g of the indignities that pro-
duce it. This can be done without detriment
to the angry person or others
in the milieu, such as a peer support group.
Isolation. It is common for infertile couples to state that they are the only
people they know who cannot achieve a pregnancy. Infertility is a diffi-
cult subject for most people to discuss. It is very personal and inherently
sexual.
Couples may keep their infertility a secret because they do not wish to
be the objects of pity or because they fear unsolicited advice, such as
“relax” or “why don’t you take a second honeymoon.” However, secrecy
may have several negative effects. It usually increases the pressuring and
needling from family and friends about the plans of the couple to start a
family. More important, it cuts the couple off from potential sources of
comfort and support in a time of great stress. In extreme cases infertile
couples may be so sensitized to the sight of children or pregnant women
that they withdraw from any social situations that might produce such con-
tact. This may even involve a change of work or living situation.
Isolation may occur between the members of a couple as well. The
woman may despair over her husband’s inability to empathize with her
feelings about menstruation, her fixation on her basal temperature chart
around ovulation, or her nervous hopes if menstruation is overdue. The
man may find it impossible to share his anxiety over being “counted and
scored” in semen analysis or over having to perform sex on demand,
whether he feels like it or not. The result may be a breakdown in commu-
nication and a loss of pleasure in the sexual relationship. Marital stress
and tension over sex are commonly present in certain phases of infertility.
Since the couple often have no others to validate their feelings, they may
presume that not only are they infertile, but also their marriage and sex life
are in jeopardy. It is always a relief when infertile couples find each other
because they share the same frustrations and concerns. One of the most
helpful ways to ease the isolation of infertility is to help couples find each
other and join a support group.
Guilt. Another reason for the secrecy that so often surrounds infertility is the
presence of guilt. People seem to need to construct a cause and effect rela-
tionship for events that happen to them. The infertile couple review their
they
mutual and individual histories and search for a guilty deed for which
Some common guilt producers are premarital sex, use
are being punished.
al sex or
of birth control, a previous abortion, venereal disease, extramarit
on, homosexua l thoughts or acts, and even sexual
interest, masturbati
may go to
pleasure. Once the guilty deed is discovered, the infertile person
take any form,
great lengths to atone and achieve forgiveness. Atoning may
areas such as
from religious acts to personal denial or working in painful
Guilt and
counseling unwed mothers or teaching other people’s children.
l level. Some
atonement appear to have no relationship to one’s educationa
belief in “God’s
of the most sophisticated people have applied a mystical
be-
punishment” to their own infertility, even in the absence of religious
of the Old Testament and folklore from early
liefs. Certainly the teachings
person (particu-
civilization can contribute to the view that the infertile
larly the woman) has fallen from grace and is being punished by higher
powers. People who have poor self-esteem tend to be particularly vulner-
able to guilty thoughts about infertility. Believing in their hearts that
they really do not deserve a pregnancy and child, they may keep their
infertility secret for fear how bad they really are might be discovered.
Grief. Without question the most compelling feeling of conclusive infertility
is grief. This state may be preceded by a period of depression, as the final
testing or treatments are pursued to no avail. Once all hope for preg-
nancy and live birth is abandoned, the appropriate and necessary response
should be grieving. It is a strange and puzzling kind of grief, involving
the loss of a potential, not actual, life. Society has elaborate rituals to com-
fort the bereavement in death. Infertility is different. There is no funeral,
no wake, and no grave. Family and friends may never even know. The in-
fertile couple often reach the point of grief alone. Stillbirth or miscarriage,
although tragic, is more often perceived as an actual death. Family and
friends are more often aware of the loss and offer solace and support.
Infertility that is conclusive represents‘ many losses: the loss of children,
the loss of genetic continuity, and the loss of fertility and all of its means
to sexuality, including the loss of the pregnancy experience itself. For each
individual, some aspects of loss are keener than others. When grieving
over infertility does take place, it is quite focused. As painful as the initial
grief work may be—accompanied by weeping; sobbing; and its physical
symptoms; such as loss of appetite, exhaustion, and choking or tightness
in the throat—it does run a predictable course and it does end. This is im-
portant to point out to the person who is afraid to express these feelings.
Resolution. The desired goal of any crisis, including infertility, is its
success-
ful resolution. The process of resolution requires that each of the
difficult
feelings detailed above be discovered, worked through, and
overcome.
Feelings are never laid away forever. They may be reactivated
by special
reminders, such as the anniversary of a loss, or by new
and different crises.
However, the feelings are never as difficult or as overwhelming
as they
initially were. Reactivation is usually brief and to be expected.
The state of resolution may be described as a return of
energy, perhaps
even a surge of zest and well-being; a sense of optimi
sm and faith re-
turns, a sense of humor returns, and some past absurdi
ties may even be-
come grist for storytelling. The concepts of sexuality,
self-image, and self-
esteem are reworked to become disconnected from
childbearing but are
nevertheless wholesome and complete. The couple
plan for the future
again, building a way around the obstacle of infertili
ty. They are ready to
act with confidence in selecting an alternative
life plan. Once resolution
is achieved, the couple are ready to proceed with
their lives.
Miscarriage and Stillbirth

Infertility is a complex life crisis. It rarely proce
eds as ideally as Suggested in the
preceding discussion, for example, from discov
ery of a problem to working through
feelings to resolution and development of an alternative plan for building a family.

One of the more complex issues involved in infertility is a couple’s experience with
miscarriage or stillbirth.
One aspect of infertility concerns itself not with the inability of a couple to achieve
a pregnancy but with problems resulting from termination of a pregnancy before a
live birth. Miscarriage is a more common occurrence than many people realize. It is
estimated that one in six pregnancies ends in miscarriage. Seventy-five percent of all
miscarriages occur in the first trimester and are the result of unavailable care and
medically untreatable problems (e.g., lack of prenatal care, appropriate vitamins, and
adequate diet). These random mistakes of nature rarely repeat themselves in the
childbearing years of norma! couples. Infertile couples may be defined as those who
have repeated miscarriages possibly caused by structural, hormonal, or genetic
problems. It also appears that couples who have had great difficulty in conceiving
are at greater risk. It is thought that they run a 40% risk of miscarriage, often resulting
from the very problem that made it difficult for them to conceive.
Medically, miscarriage is a potentially dangerous, even life-threatening, situation.
When emotional aspects are added to the physical trauma, this may seem like a life
event of critical importance. Miscarriage is almost always totally unexpected. It may
be over within a matter of minutes, in early pregnancy, or it may drag on for days
and even weeks. Occasionally, medical intervention is successful in preventing loss
of pregnancy, and the couple may experience alternate states of hope and despair as
they await the final outcome. Most often the onset of bleeding and cramping
continues until the fetus is expulsed.
There are a number of issues that are unique to the experience of miscarriage. One
that is most troublesome is the practice in many hospitals of admitting a person who
threatens miscarriage into the obstetrical unit. There she may be in close proximity
with laboring and newly delivered patients and also with the newborn nursery.
Hospitals justify this policy by explaining that miscarriage is not a routine
gynecological event and must be managed in the obstetrical area where the delivery
room is available for surgical intervention. The emotional impact on the couple,
however, may be profound. The couple who have experienced a miscarriage should,
at the very least, be screened from laboring and newly delivered patients. A special
indicator should be posted on the door so that hospital staff are aware of the situation.
to his
The husband should not be treated as a visitor but allowed unlimited access
wife. Privacy from all but a few caretakers will facilitate the couple in experiencing
their grief.
who had
The need for grieving after a miscarriage—especially for the couple
personnel are
longed for a child—is obvious. Unfortunately, many hospital
grieving as
uncomfortable with this basic human emotion. They may interpret
common for
“suffering” or disturbing to the welfare of other patients. It is all too
vating drugs.
physicians to prescribe sedation, tranquilizers, or even mood-ele
the earliest possible
Probably the best management for the grieving couple is
take place unimpeded in
discharge home, where both grief work and recovery can
familiar surroundings.
is usually one of
The reaction of family and friends to news of a miscarriage
the near future.
abbreviated support and assurances of successful pregnancy in
Platitudes and assurances are not only medically unsound, but they also invalidate
the couple’s right to grieve their particular loss.
In some cases couples have endured five, six, or more miscarriages before giving
up hope. They received news of each subsequent pregnancy with dread and
foreboding instead of with joy. They kept their pregnancy secret for fear of raising
the hopes of family and friends, and they heavily practiced denial to prevent their
own nervous hopes from mounting with each passing week. The emotional toll in
such cases is exhausting. Some couples finally choose sterilization in preference to
more attempts at pregnancy.
Stillbirth is technically the loss of a body that has reached sufficient gestation to
be viable outside the womb (usually after 28 weeks). It is a much less common
occurrence than miscarriage and usually is not a recurring event. There are several.
possible situations, each fraught with its own pain and turmoil. There may be
cessation of fetal life, whereby the couple are admitted to the hospital and know
before delivery that their baby is dead. There may be a viable baby who expires in
the labor or delivery process or as a result of congenital abnormalities at birth when
it is separated from its placental blood supply. In these cases the death is not
anticipated. Finally, there may be a crisis for both'mother and child such as premature
separation of the placenta, in which bleeding may be profuse and oxygenation of the
baby is interrupted. This latter example is a life-threatening situation, and
the
emotional issues become secondary.
Whatever the circumstance, several common issues arise. The couple
are
inevitably admitted to the labor and delivery area and afterward to the postpart
um
unit. Screening and privacy from normally laboring and delivering patients and
those
in the recovery phase is paramount. If the baby is known to be dead, delivery
by the
least hazardous means to the woman and attendance of the husband
or another person
to comfort her are recommended. It appears to be important to the
grieving process
for the couple to be able to view and handle the body of the baby.
This option should
be sensitively suggested and available on request. Since an autopsy
is often done in
these circumstances, it is best for the couple to view the body before
it is sent to the
pathology laboratory. The woman who has had a stillbirth
is in a postpartum state
of recovery, as well as in a state of grieving. She has
all the needs of the usual
postpartum patient in addition to her emotional needs.
Sensitive caretaking and
nurturing from hospital staff plus unlimited access to
her husband will facilitate
recovery. The couple who have been through a miscarriage
or stillbirth need to know
why. They may fantasize that they did something wrong,
which resulted in this event.
Any information of medical value that can be discovere
d by autopsy, especially if
it has bearing on future pregnancies, should by all
means be researched and shared
(Menning, 1982).
Psychotherapy and Infertility

Frustration and anxiety over failure to achieve
pregnancy must inevitably underlie
the decision of all infertile couples to seek medica
l help. Sturgis and others (1957)
suggest that it would be reasonable to include
a screening psychiatric interview as
part of the initial evaluation of all infertile
couples. A psychotherapist is also
suggested as an integral part of the routine evaluation of infertile couples. In a

report by Karahasanglu and others (1972), the therapist functions in four major
areas:
1. Screening and evaluating
2. Relationship improvement
3. Sexual compatibility guidance
4. Supportive counseling
Realizing that most infertile couples thought that children should inevitably result
from marriage and that many infertile couples thought that failure to reproduce
was synonymous with failure to fulfill one’s biological role led others to use group
therapy as a supportive adjunct in the treatment of the infertile couple. In this
experience, marked improvement in the spontaneity and frequency of sexual
intercourse occurred as the couples achieved deeper mutual understanding.
Patients’ attitudes became more positive, and tension diminished. In addition, the
husband became more actively interested, and both partners decreased their sense
of isolation.
Group sessions have also been used with the result that much of the pressure and
marked sense of personal failure diminished when patients were able to share their
feelings and anxieties with others who were experiencing infertility. The psycho-
therapist’s role in infertility should include therapeutic techniques combined with
education, encouragement, behavioral techniques, and situational support. Other
areas where a therapist may be of assistance to a couple include helping them to
mourn the fact that they have been unable to have children; helping in decisions
involving artificial insemination and adoption; and helping couples deal with the
uncertainty when no definite cause for the infertility is found.
Although it may be clear to the physician and therapist that for certain patients
little hope exists, as long as a patient is receiving medication or undergoing
laboratory tests, she is usually putting aside resolution of her infertility crisis by
postponing decisions about career, life plans, and adoption and personal confron-
tation with her childlessness. At this crucial time the therapist may be of great
assistance in helping patients recognize, work through, and overcome this situation.
caution
In particular, in cases of unexplained infertility it is imperative to exercise
in inadvertently suggesting that the patient is “causing her own infertility”
to the
psychogenically unless the physician is absolutely certain of this fact. Quite
infertility that
contrary, Taymor and Bresnick (1978) state that in most cases it is the
charged “‘crisis
results in emotional tension. They describe the intense, emotionally
and their
of infertility” that affects every area of the couple’s relationship
to diminish
employment. They suggest more widespread use of infertility counseling
and obsession
the various forms of anxiety, depression, frustration, guilt, isolation,
that infertility
that crisis exacts. In a subsequent study (1979) they demonstrate
become victims of their
counseling enhances the quality of life in many patients who
“infertility crisis.”
PSYCHOSOCIAL THERAPY
trauma of suffering one or
Many couples will need therapy during the psychological
a tremendous loss to
more spontaneous abortions or having a stillborn child. This is
them. They will need to go through the stages of grief and mourning, and they will
need emotional support and a therapist who can listen to them, with an impartial,
unbiased, and empathic approach. Menning (1980) suggests the following:
Treat infertility as a problem of the couple. No matter whose body ulti-
mately has the problem, the other partner has a very strong interest in investi-
gation and treatment. Involving the partner in discussions and planning from
the beginning is optimal. From the patient’s perspective, to be seen as a couple
allows several distinct advantages. When two people visit a physician, the
power tends to be equalized. They gain courage and assertiveness from each
other’s presence and will often negotiate their needs more honestly right away.
“Blame” seems to be dispelled; not just one person is involved. Each mem-
ber of the couple will have twice the opportunity for hearing information at a
time when they are anxious and twice the opportunity to ask questions and
seek clarification.
Plan the investigation and treatment with the couple. The physician is the
only one who will know what tests or treatments are indicated for a given
couple. These can be offered as recommendations not as mandates. There is
room for negotiation in a number of areas: the sequence of tests or treat-
ments can often be flexible if there is no detrimental effect; the pace of testing
and treatment can always be slowed for those who are cautious or acceler-
ated for those who are pushing an age deadline or are highly motivated;
and
the cost of tests and treatment and the patient’s ability to pay or the insurance
situation needs to be made clear at the onset.
Provide emotional support and education. Emotional Support and
education
should be the responsibility of the physician and his staff. A number
of physi-
cians now employ nurses or therapists to educate, for example, in
charting
basal body temperature and in fertility awareness, and to assist
in offering
emotional support and in screening couples for important decisions
, such as
donor insemination. A well-informed patient is much easier to
deal with than a
partially educated one. Literature by some respected infertilit
y specialists
should be provided at the very beginning. Recognizing
that the physician has
limited time for providing emotional support, the therapist
’s role should be
a very important adjunct. There is not a complete dichot
omy of the physical
and emotional aspects of infertility; they are interwoven.
The physician
becomes an important and powerful figure to the infertil
e couple. It is very dif-
ficult for the couple with absolute infertility or with
“normal infertility”’ to be
sent away at the end of the period of contact becaus
e “there is no need to
return.” Offering such couples a chance to return
for several therapy sessions
to discuss their feelings can be very productive
and can offer them a life-
line until they find new resources for emotional
support.
Refer the couple to a qualified infertility specia
list. Physicians seldom agree
among themselves about who is qualified to
conduct the complete infertility
investigation and treatment. It should come
as no surprise that the infertile
couple are often confused. Fortunately, physic
ians with specialized and addi-
tional training in reproductive endocrinolog
y, obstetrics and gynecology, and
urology are now available as qualified infertility specialists. Most university

medical centers have a list of these specialists.
Determining the Cause of Infertility

The first step in infertility treatment is a diagnostic workup that is usually performed
by a physician who specializes in infertility, such as a reproductive endocrinologist.
The workup may include an internal pelvic examination; a postcoital test, in which
cervical mucus is examined microscopically shortly after unprotected intercourse to
determine the consistency of mucus and whether the sperm are swimming properly;
and a hysterosalpingogram (HSG), in which radiopaque dye is injected into the
uterus and viewed on x-ray films to see if the uterus and the fallopian tubes are
clear. Blood and hormone tests, laparoscopy, and genetic counseling might also be
recommended.
The male partner should have a semen analysis and a complete physical
examination. According to estimates, 30% of infertility cases are due to male
reproductive problems, 30% are the result of female reproductive problems, 20% are
due to a combination of factors in both sexes, and 20% are unexplained.
Age can be a factor. A woman’s fertility declines gradually every year past the
age of 30 but especially after 40. The older the woman gets, the more likely she is
to develop a purely mechanical cause of infertility. Endometriosis, for example, is
a disorder in which fragments of the uterine lining migrate to other parts of the pelvic
cavity and can cause obstructions in the fallopian tubes and other problems.
After a complete workup, the next step is treatment: This is true whether the cause
of infertility is found. A physician will try to correct any obvious physical maladies,
such as blocked fallopian tubes. Beyond that, treatment options range from low to
high. Most physicians begin by trying the least invasive methods of aiding
conception (Winkleman, 1995).
When Someone You Know Miscarries

Friends and family often try to reassure a woman who has had a miscarriage by
offering well-intentioned platitudes, but often these only end up making her feel
worse. To help someone through this difficult time, some things to say and not to say
follow (Bennetts, 1994).
Don’t tell her that the miscarriage was “‘nature’s way” of getting rid of a de-
fective fetus. Not only is this very insensitive but also may not be true.
Don’t say, “It wasn’t really a baby.” To the woman who was busy knitting
little booties, it was a baby, and denying her emotional reality will only
make her feel desolate.
Don’t say, ‘“You’ll get pregnant again soon.” This is unknown, and although
it might be true, right now the woman is afraid that she will never have a
baby. False assurances are infuriating.
Don’t say, “It won’t happen again,” because it might. This is grossly pre-
sumptuous.
Do remember that mourning is a process, and it takes time. Telling a woman

to put the experience behind her can make her feel angry that you do not
understand what she is going through. Emotions do not run on a set sched-
ule. She will get there when she gets there.
Do say, “How do you feel? Do you want to talk about it?” Then just listen.
Don’t try to talk her out of her feelings or minimize them. Be sympa-
thetic, but don’t tell her you know how she feels unless you have experi-
enced a similar trauma.
Do include the would-be-father. He is dealing with the same loss, and men’s
grief is often overlooked.
Do offer to help by getting the names of books or local support groups on
pregnancy loss.
There are many organizations available as support groups for individuals and
couples faced with a diagnosis of infertility. A list of some of these groups is found
in Appendix C.
The following case involves a young woman and her husband. They were referred
to the Crisis Clinic by the woman’s obstetrician after she had experienced a second
miscarriage.
Case Study Infertility

Angela and Barry were assigned to a therapist who was experienced in working
with patients who had suffered a recent loss, especially a child or someone who
had suffered a miscarriage. She met them, introduced herself, and asked them
to come to her office. She remarked that she had read what they had written
on their chart. She expressed her deepest sympathy. She asked Angela if she would
like to tell her what had happened or if she preferred Barry to tell her about
the crisis. Angela looked at Barry, he took her hand and said, “Angela, let me
tell her about us, not only about our crisis but also about us, you and I—everything.
I think she can help us more if she knows all about us as individuals, as well
as a married couple.”’ Angela, with tears in her eyes, agreed. Barry held her hand
tightly and began to tell the therapist “all.”
Angela had a second spontaneous abortion (miscarriage) 6 days ago. She still
was
in a state of disbelief. She is 35 years of age and Barry is 39. They have been
married
for 5 years. Originally from the East Coast, they had moved to the West
Coast 18
months ago. Barry’s company had recommended him for a promotion
in their
corporate law firm on the West Coast. Angela and Barry were
thrilled; they had
always wanted to live “‘without all the humidity.” Barry said that Angela’s
company
had a branch on the West Coast and that she had no trouble transferring
to that branch.
He continued, saying that she would also be receiving a promotio
n because Angela
was their top programmer.
Barry and Angela had bought a house that they both “loved”
and spent their free
time on weekends furnishing it, “Just the way they had
always talked about.” They
had discussed having children before they were married.
Angela was the oldest from
a family with four children, three girls and one boy. She had
told Barry that she would
be happy with two children, but no more.
Barry was an only child and agreed with Angela that two would be ideal. “I didn’t
enjoy being an only child.”’ They enjoyed traveling and skiing, both water and snow.
They always planned their vacations together and had decided that they wanted time
“just” for themselves before they started a family.
After they had moved to the West Coast, bought their home, and kept busy
getting it furnished, they discussed having children. They had agreed 9 months
ago that “now” was the time to start a family. With both of them getting
promotions, they felt financially secure. They had planned on getting a housekeeper
when their children came so Angela could return to her job, which she loved.
Angela went off the ‘pill’? and became pregnant 8 months ago. They were both
excited and thrilled.
Since they didn’t know any physicians in the area, they asked a fellow employee
who had a 2-year-old daughter for a recommendation. She recommended her own
obstetrician and said that he was “great.” Angela made an appointment to see him.
She told Barry that he was older than she had expected (he reminded her of her father)
but was very nice. He confirmed that she was pregnant, prescribed vitamins, and told
Angela that she was “very healthy’? and would probably have a healthy baby.
Other than about 3 weeks of morning nausea, Angela said that she felt fine. She
admitted that she would become tired in the afternoon, but since she was working,
she just ignored it.
When she was 32 months pregnant, one evening after dinner she asked Barry if
he would rub her lower back because she was very uncomfortable. Barry gave her
a nice long back rub. Angela said that the back rub felt good but that it really didn’t
help. She got up and went to the bathroom and discovered that she was spotting
blood. She called Barry, and when he came, she told him. He suggested that she go
upstairs, undress, and get in bed while he called the doctor. Barry called the doctor
and told him that Angela was spotting. The doctor said that it was “very common,”
that Angela should just stay in bed, and that the spotting would probably stop.
The bleeding became heavier, and Angela began to have cramps. Barry called the
doctor again and told him what was happening. He told Barry to take her to the
hospital and that he would meet them there. By the time they reached the hospital,
Angela was having severe cramps and the bleeding was getting heavier by the
minute. Both Barry and Angela were very frightened. When they got to the hospital,
the doctor was waiting for them. He gave Angela a pelvic examination and said that
she had probably already “‘lost the baby” and that he would have to do a D&C
(dilatation and curettage) to stop the bleeding.
Angela was given a general anesthesia. When she woke up, she said that other than
for
a few mild cramps, she felt fine. She stayed at the hospital with Barry at her side
had no more bleeding, just some spotting, and the doctor said that she
3 hours. She
her to
could go home but should stay home tomorrow and not go to work. He told
she was
make an appointment to see him in a week. If she had anymore bleeding,
to call him.
baby.
The therapist asked Angela how she and Barry had felt about losing the
were upset, but I was more concerned about Angela. I wanted
Barry answered, “We
could always
to be certain that she was alright physically and mentally. I figured we
have other children, but I could only have one Angela.”
Angela smiled at him and held his hand tighter. The therapist turned toward
Angela and said, ‘““How did you feel about losing the baby, Angela?’’ Angela looked
at the therapist with tears in her eyes and answered, “‘Terrible. I didn’t know how
it happened . . . I don’t really know why I lost this one 6 days ago . . . there must be
something wrong with me.” The therapist asked, “What did your doctor tell you?
You have lost two babies now.” Barry spoke up and said, ““That is the problem. . . he
hasn’t told us anything . .. we don’t know why. He just says stupid things like ‘these
things happen’ and sometimes it just isn’t meant to be!”
The therapist asked, “Has he recommended an infertility specialist to you?”
Angela and Barry looked at each other and both said, “NO!” Barry said, “I didn’t
know there was such a specialty.” The therapist told them that there were definitely
infertility specialists and that she felt they should see one. She told Barry to contact
the University Medical Center and get the names of the three top infertility
specialists. She emphasized that they both should be seeing an infertility specialist.
“Tt may not be anything wrong with you,” she said to Angela. “It could be something
wrong with Barry.”
Barry turned pale. “ME?! What could be wrong with me?” The therapist smiled
and replied, “There may not be anything wrong with you, Barry, but you should have
tests conducted too. Any number of things could contribute to a miscarriage ... it
isn’t always something wrong with the wife. That is what an infertility specialist
could find out... that is his specialty.”
“What do we tell the doctor Angela has been seeing?” Barry asked the therapist.
“The truth,” she replied. ““You want to find out why Angela is having miscarriages
and you are going to consult an infertility specialist.”
The therapist took a list of support groups out of her desk and handed it to Angela.
“In the meantime I think it would be to your advantage to contact one of these support
groups. They have all been through the same thing you are going through—repeated
miscarriages. They not only could be a valuable source of information, but
they also
could help you and Barry ventilate your feelings. They could help you get rid
of some
of the misconceptions, fears, and anxieties that you both are experienc
ing.”
Both Angela and Barry looked more relaxed. The therapist asked
if they would
like to continue in crisis therapy for approximately 5 weeks. By that
time they should
have selected and seen a specialist in infertility and gone through
some of the tests.
They should also be attending one of the support groups.
Angela said, ‘We want to continue to see you, but why just 5
more times?” The
therapist smiled and replied, “You should be over your crisis
by that time, and you
should have some answers from your infertility specialist.
I want to know what he
discovers. Shall we make an appointment for next week?”
Barry answered firmly,
“We will be here. For the first time I feel we are finally getting
somewhere.” Angela
answered with a smile, ““Me too!”
Angela and Barry kept all of their appointments. They
were always eager to relate
everything that was happening in their lives. Both said
that the support group was
incredible. They not only enjoyed meeting couples
in their circumstances, but they
also were learning so much from them. They said that
they really liked their infertility
specialist . . . that he was young and always explai
ned every procedure and told them
what to expect. Angela said that she and Barry
respected him tremendously. She
CASE STUDY: ANGELA
PLUS AND
PLUS AND
RESULT IN RESULT IN
Figure 7-1
added that nothing had been found yet, but that they were just beginning all of the
tests. They were terminated at the end of 6 weeks, and they promised to let the
therapist know what they discovered. Both expressed their gratitude for her help in
getting them “‘on the right track.”
From fairest creatures we desire increase.
REFERENCES
Bennetts L: Preventing miscarriages, Parents p. 64, February 1994.
Bresnick E, Taymor ML: The role of counseling in infertility, Fertil Steril 32:154, 1979.
Eisner BG: Some psychological differences between fertile and infertile women, J Clin
Psychol 19:391, 1963.
Halpert FE: When you can’t conceive again, Parents p. 29, September 1994.
Karahasanglu A, Barglow P, Growe G: Psychological aspects of infertility, J Reprod Med
9:241, 1972.
Menning BE: The emotional needs of infertile couples, Fertil Steril 34:313, 1980.
Menning BE: The psychosocial impact of infertility, Nurs Clin North Am 17(1):155, 1982.
Rosenfeld DL, Mitchell E: Treating the emotional aspects of infertility: counseling services
in an infertility clinic, Am J Obstet Gynecol 135:177, 1979.
Sturgis SH, Taymor M, Morris T: Routing psychiatric interviews in a sterility investigatio
n,
Fertil Steril 8:521, 1957.
Taymor M, Bresnick E: Infertility counseling in infertility, 1978, Grune & Stratton.
U.S. Census Bureau: Estimates and projections, October 1993.
Winkleman M: The struggle for a second child, Parenting p. 64, June/July
1995.
ADDITIONAL READING
Allen M, Marks S: Miscarriage: women sharing from the heart,
1993, John Wiley & Sons.
Berg BJ, Wilson JF: Psychological functioning across stages
of treatment for infertility,
J Behav Med 14(9):11, 1991.
Borg S, Lasker J: When pregnancy fails, 1992, Bantam Press.
De Cherney AH: Male infertility. In Kase NG, Weingold AB, Gerson
DM, editors: Principles
and practice of clinical gynecology, New York, 1990, Churchill
Livingstone.
Isle S: Empty arms: coping with miscarriage, stillbirth
& infant death, 1982/ 1990,
Wintergreen Press.
Isle S, Hammer Burns L: Miscarriage: a shattered dream,
1985, Wintergreen Press.
Keaggy B, Keaggy J: A deeper shade of grace, 1993,
Sparrow Press.
Kedem P and others: Psychological aspects of male
infertility, Br J Med Psychol 63(1):73,
1990.
Kohn I, Moffitt PL, Wilkins MD: Silent sorrow:
pregnancy loss, 1992, Dell.
Meerabeau L: Husband’s participation in fertilit
y treatment: they also serve who only stand
and wait, Sociol Health Ill 13(3):369, 1991.
Menning BE: Counseling infertile couples, Contem
p Obstet Gynecol 13:101, 1979.
Menning BE: The emotional needs of infertile
couples, Fertil Steril 34(4):313, 1980.
Menning BE: The infertile couple: a plea for advocacy, Child Welfare 54:454, 1975.
Oldereid NB, Rui H, Purvis K: Male partners in infertile couples, personal attitudes and contact
with the Norwegian health service, Scand J Soc Med 18(3), 207, 1990.
Pines D: Emotional aspects of infertility and its remedies, Intl J Psychoanal 71:561, 1990.
Schiff HS: The bereaved parent, 1978, Penguin Books.
Seibel MM, Taymor ML: Emotional aspects of infertility, Fertil Steril 37(2):137, 1982.
Shapiro CH: The impact of infertility on the marital relationship, Soc Casework 67:387, 1982.
Taylor PJ: When is enough enough, Fertil Steril 54(5):772, 1990.
Williamson W: Miscarriage: sharing the grief... facing the pain... healing the wounds,
1987, Walker.
Wright J and others: Psychological distress and infertility: men and women respond differently,
Fertil Steril 55(1):100, 1991.
Defining Situational Crises
Any situation that occurs in our milieu has an impact on us. It may be something
that
happens physiologically, psychologically, or sociologically. It may be something
that
is extremely pleasant or extremely unpleasant, depending on our individual
mental
attitude and our point of view. We will respond as individuals. What is stressful
and
traumatic to one person may be something another person has
been eagerly
anticipating. This is why crisis intervention techniques always ask
the individual the
vital question, ‘““What does this mean to you; how is it going to affect
your life?” It
matters not that the therapist working with the client sees the precipitat
ing event as
“unimportant” or not, particularly pleasant or particularly stressful.
The frame of
reference is always from the patient’s point of view.
It is vital that the therapist accepts the situation as a proble
m for the patient.
Circumstances that may create only a feeling of mild concern
in one individual may
create a high level of anxiety, depression, or stress in another.
The therapist must
recognize the factors influencing a return to a balance of
equilibrium or homeostasis.
These factors are the perception of the event, availab
le situational supports, and
available coping mechanisms.
The perception of the event for each individual
is a product of all his past
experiences, his present expectations, and his future
anticipations. There are two
major ways in which the definition of life events
can lead to confusion. The first is
the distinction between subjective events and objecti
ve events.
Subjective events (e.g., sexual difficulty, a major
change in the number of
arguments with his spouse, and a major change
in sleeping habits) are more likely
to be manifestations of or responses to underlying
pathology. The problem is also not
138
Chapter 8: Situational Crises 139
limited to subjective events because many objective events, such as divorce or being
fired from work, are as likely to be consequences as causes of pathology. The
limitation on causal inference is especially severe in investigations of psychiatric
disorders that are often of insidious onset and of long duration.
Most samples of events also include major physical illness or injury, which seems
appropriate, since these are negative events that often entail serious disruption of
usual activities. It is a basic proposition of psychosomatic medicine that physical
disorders are accompanied by some degree of emotional disorder and that emotional
disorders are accompanied by some degree of somatic disturbance.
There is clearly a close relationship between crisis theory and intervention and
stressful life events. Both areas are concerned with the changes that occur within an
individual’s life and the impact of these changes on physical and mental health. Crisis
theory is closely linked to practice, and its emphasis is on understanding what is
likely to lead immediately to therapeutic intervention. Crisis theory investigates
whether and to what extent significant associations between life events and illness
exist. Those who work in crisis intervention begin, for the most part, with the
assumptions that there is something about life events that makes a difference to
well-being, whether these events be bereavement, premature births, or others.
It is important to recognize that the theoretical material preceding each case study
in this chapter is presented as an overview that is relevant to the crisis situation.
Therapists already trained in crisis intervention will recognize the need for much
greater depth of theoretical knowledge than is presented in this and the following
chapters. The intent is to provide only guidelines; further study of problem areas is
suggested for more comprehensive knowledge.
To clarify the steps in crisis intervention, extraneous case study material has been
eliminated. In crisis a person may be confronted with many stressful events occurring
almost simultaneously. He may have no conscious awareness of what occurred, let
alone which event requires priority in problem solving. These studies may seem
oversimplified to anyone who has struggled through the phases of defining the
problem and planning appropriate intervention.
The paradigm is a means devised to keep the reader focused on the problem area
and on the balancing factors that influence the presence or absence of crisis. It is
doubtful that it could be successfully used as a form that could be quickly completed
after an initial interview; rarely are stressful events so easily defined. It is the very
nature of a crisis that interrelated internal and external stresses compound the
problem area and distort the causes of objective and subjective symptoms.
One responsibility essential in assuming the role of a therapist in this method of
intervention is recognition of the need for knowledge of the generic development of
crisis.
Status and Role Changes

From the time our life begins until it ends, we “play” many roles and change our
status frequently, depending on our age and a multitude of circumstances. According
an
to Chaplin (1985) role is defined as “the function or behavior expected of
“‘the position of
individual or characteristic of him.” Chaplin also defines status as
an individual in a social group in terms of his relative standing in the class structure,
the honors or awards accorded to him, and the formal or informal power accorded
to his position.”” When we change our role and our status voluntarily and willingly,
we are not in conflict. But if our role or status is changed by other forces, either
internal or external, then we experience stress, low self-esteem, anger, depression,
and in some individuals a state of grief and mourning.
New words and terminology appear with each new generation. The present
generation’s new word is ““down-sizing.”’ The prior generation would have stated that
they had “‘lost their jobs” or had been “laid-off.” Our work or profession is part of
our identity. It lets others know what group we belong to; it becomes very important
to us. If for some reason we lose our position, we lose more than just a job; we lose
so much more.
Patterns of careers and job transitions are constantly changing as organizations
attempt to respond to both short-term fluctuations and longer term cyclical
developments in economic systems. The consequences for the lives of individuals at
work can often be quite radical, demanding changes in job skills, self-concept, work
hours, and even location of home. Relocation, or job transfer, in particular can have
profound effects on the lives of individuals and families. It can require changes in
children’s school, partner’s job, and also provoke difficulties associated with selling
and buying property in changing markets (Munton and others, 1993).
A study conducted by Munton and West (1995) found that people are more likely
to innovate in their new jobs if they perceive that they have the freedom to innovate.
The association between job discretion and role innovation may simply be a result
of an underlying operationalization of the two concepts. People may only discover
the extent to which they can innovate by pushing at the limits of discretion.
What are clear, at least within the context of job relocation, relatively stable
individual differences in symptom reporting, as monitored by self-esteem, are more
likely role requirements, such as job novelty, to determine personal change and role
innovation. This suggests a need to further develop the theory of work-role
transitions, since relationships between role factors and adjustment strategies have
been shown to be mediated by individual differences in effect.
If individual difference factors influence role adjustment, then one might expect
that role innovation as an adjustment outcome could be facilitated by specifical
ly
Supporting people’s confidence in the new role. This could be achieved
through
training, coaching, and similar strategies. Also, this suggests that since
esteem is an
important variable in predicting the likelihood of personal adjustmen
t orientation,
social support and supportive supervision strategies might decrease
the likelihood
that individuals will attempt to adjust by using the elements
of personal change
Strategies that have a negative impact on subjective well-being.
The relationship between role innovation and self-esteem could
be a reflection of
the impact that self-evaluation can have on choice of adjustm
ent strategy. People
whose self-esteem is low may believe that they lack the
ability or confidence to
innovate after a job change.
Understanding patterns of adjustment to job change and relocat
ion is of enormous
practical and theoretical importance, both because
of the ubiquity of change in
people’s lives and because of the increasing requirement
for employees to relocate
both nationally and internationally. This suggests the need for practitioners to be
aware of the dual dimensions of adjustment—personal change and role change—and
the very different factors within individuals and their environments that may
influence adjustment (Munton and West, 1995).
Case Study Status and Role Changes

Mr. E requested help at the Crisis Center on the advice of his attorney. He was in
a state of severe depression and anxiety. He described his symptoms as insomnia,
inability to concentrate, and feelings of hopelessness and failure. He is a well-dressed
47-year-old man who looks older than his age because of his tense posture; dull,
depressed facial expression; and rather flat, low tone of voice. He has been married
for 22 years and has three children, a daughter 13 years of age and two sons whose
ages are 8 and 10.
His symptoms began about 3 weeks previously when his company closed its West
Coast branch and he lost his job. During the past 2 days, his symptoms increased in
intensity to the point where he remained in his room, lay in bed, and did not eat. He
became frightened of his depressed thoughts and feared losing complete control of
his actions.
During the initial session, he stated to the therapist that he had never been without
a job before. Immediately after graduation from college 22 years ago, he started his
own advertising agency in New York City. It expanded over the years, and he
incorporated, retaining controlling interest and the position of company president. On
several occasions he was approached by larger companies with merger proposals.
About a year ago, one of the “top three’ advertising companies offered him the
presidency of a new West Coast branch, which he could run with full autonomy,
gaining a great increase in prestige and income. All expenses were to be paid for his
family’s move to the West Coast.
Mr. E saw this as a chance to ‘“‘make it big’’—an opportunity that might never
come his way again. His wife and children, however, did not share his enthusiasm.
Mrs. E had always lived in New York City and objected to his giving up his business,
where he was “really the boss.” She liked the structured security of their life and did
not want to leave it for one that she thought would be alien to her. The children sided
with her, adding personal objections of their own. They had known only city life, had
always gone to the same schools, and did not want to move ‘“‘way out West.” Despite
business
resistance from his family, he made the decision to accept the job offer. His
expressed full confidence in his
friends admired his decision to take the chance and
to his partner, he moved
ability to succeed. Selling out his shares in his own company
west with his family within a month.
leased a
In keeping with his new economic status and the prestige of his job, he
most of the responsib ility for
large home in an exclusive residential area. He left
involved in the organizat ion
settling his family to his wife and became immediately
‘“‘everything
of his new business. He described her reaction to the change as being
made few
negative that she told me it would be.” The children disliked their schools,
. His wife
friends, and did not seem to adjust to the pace of their peer group activities
could not find housekeeping help to her liking and consequently felt tied down with
work in the home. She missed her friends and clubs, was unable to find shops to
satisfy her, and was constantly making negative comparisons between their present
lifestyle and their previous one. He felt that there had been a loss of communication
between them. His present work was foreign to her, and he could not understand why
she was having so many problems just because they had moved to a new location.
Her attitude was one of constantly blaming everything that went wrong on his
decision to move west and into a new job.
About a month ago, the company suddenly lost four big accounts. Although none
of these losses had been a result of his management, immediate retrenchment in
nationwide operations was necessary to save the company as a whole. The decision
was made to close the newest branch—his branch. There was no similar position
available in the remaining offices, and he was offered a lesser position and salary in
the Midwest. He was given 2 months in which to close out his office and to make
a decision.
Mrs. E’s attitude toward these sudden events was a quick “‘I told you so.” She
blamed him for their being “stranded out heré without friends and a job.” He said
that he was not a bit surprised by her reaction and had expected it. He had been able
to tune out her constant complaints in the past months because he had been so
occupied by his job, but now he was forced to join her in making plans for his
family’s future and in considering their tenuous economic status. He felt that he had
been able to hold up pretty well under the dual pressures of closing out the business
and planning for his family’s future security. A week ago his wife had found a smaller
home that would easily fit into their projected budget during the interim until
he
decided on a new job. He had felt a sense of relief that she had calmed down
and
was “working with me for a change.”
However, 2 days ago their present landlord sent an attorney, threatening a lawsuit
if Mr. E broke the lease on their present home. His wife became hysterical
, blaming
him for signing such a lease and calling him a self-centered failure
who had ruined
his family’s lives. “‘Suddenly I felt as though the bottom had fallen
out of my world.
I felt frozen and couldn’t think what to do next, where to go,
and who to ask for help.
My family, my employees, everyone was blaming me for this
mess. Maybe it was
all my fault.”
Until now Mr. E had always experienced a series of successes
in his business and
home life. Minor setbacks were usually anticipated and overco
me with little need for
him to seek outside guidance from others. Now, for
the first time, he felt helpless to
cope with a stressful situation alone. The threat of having to
fulfill the lease on a house
he could no longer afford not only destroyed his plans for
his family but also broke
off what little support he had been receiving from his
wife. His feelings of guilt and
hopelessness were reinforced by the reality of the threate
ned lawsuit and the loss of
situational supports.
Because of his total involvement in his new work,
Mr. E had withdrawn from his
previous business and family supports. The sudden
loss of his job threatened him
with role change and loss of status, for which he had
no previous coping experiences.
Perceiving himself as a self-made success in the
past, he now perceived himself as
a self-made failure, both in business and
in his parent and husband roles.
When asked by the therapist about his successful coping methods in the past, he
said that he had always had recourse to discussions with his business friends. He now
felt ashamed to contact them ‘“‘to let them know he failed.” He had always felt free
to discuss home problems with his wife, and they usually had resolved them together.
Now he seemed no longer able to communicate at home with his wife. When
questioned if he was planning to kill himself, he said, ““No, I could never take that
way out. That never entered my mind.” After determining that there was no
immediate threat of suicide, the therapist initiated intervention.
One goal of intervention was to assist Mr. E in exploring unrecognized feelings
about his change in role and status. His loss of situational supports and lack of
available coping mechanisms for dealing with the present stressful situation were
recognized as areas in need of attention.
In the next 4 weeks, through direct questioning, he began to see the present crisis
as a reflection of his past business and family roles. Mr. E had perceived himself as
being a strong, independent, self-made man in the past, feeling secure in his roles
as boss, husband, and father. He now felt shame at having to depend on others for
help in these roles. Coping experiences and skills learned in the past were proving
to be inadequate in dealing with the sudden, unexpected, novel changes in his social
orbit. The loss of situational support from his wife had added to his already high level
of tension and anxiety, which resulted in the failure of what coping skills he had been
using with marginal success and in precipitation of the crisis.
After the fourth session Mr. E’s depression and feelings of hopelessness had
diminished. His perception of the total situation had become more realistic, and he
realized that the closing of the branch office was not the result of any failure on his
part. It was, in fact, the same decision that he thought he would have made, had he
been in charge of the overall operation. He further recognized what great importance
he had placed on the possibility that this job would have been his “last chance to
make it big.” His available coping skills had not lessened in value but had, in fact,
been increased by the experience of the situation.
By the fifth week, Mr. E had made significant changes in his situation, both in
business and in his family life. He had been able to explore his attitudes about always
feeling the need to be the boss and a sense of shame in being dependent on others
for support in decision making. He was now able to perceive the stressful events
realistically and to cope with his anxieties.
He met with his former landlord and resolved the impending lawsuit, breaking the
lease with amicable agreement on both sides. His family had already decided to move
into a smaller home, and his wife and children were actively involved with the
planning. He had contacted business friends in the East and accepted one of several
offers for a lesser position. He would return East alone, his family choosing to follow
later when he had reestablished himself. His wife and children made this choice
rather than repeat the sudden move into an unsettled situation as they had a year ago.
him
He felt pride that his friends had competed for his services rather than giving
the “I told you so” that he had been dreading.
Before termination, Mr. E and the therapist reviewed the adjustments and the
d that
tremendous progress Mr. E had made in such a short period. It was emphasize
such an ego-shatte ring
it had taken a great deal of strength for him to resolve
experience. He was also complimented on his ability to recognize the factors he could
change, those he would be unable to change, and his new status in life.
He viewed the experience as having been very disturbing at the time but believed
he had gained a great deal of insight from it. He thought that he would be able to
cope more realistically if a similar situation occurred in the future. He was quite
pleased with his ability to extricate himself from a seemingly impossible situation.
In discussing his plans for the future, he stated that he no longer believed he had lost
his chance for future advancement. He was realistic about past happenings and the
possibility that such a crisis could occur again. He was relieved about his family’s
rapid adjustment to the lesser status of his new position. They were happy to be
returning to family and friends on the East Coast. He expressed optimism about again
rising to a high position in business and concluded, “I wonder if I could ever really
settle for less.”
Mr. E’s crisis was precipitated by a sudden change in role status (loss of his job)
and threatened economic, social, and personal losses. Assessment of the crisis
situation determined that he was depressed but not suicidal. Because he was
overwhelmed by a sense of failure in both businéss and family roles, his perceptions
of the events were distorted. Having no previous experience with personal failure of
this scope, he was unable to cope with his feelings of guilt and depression. His wife’s
actions reinforced his low self-esteem, and she withdrew as a situational support.
Realistic perception of the event developed as the therapist assisted him in
exploring and ventilating unrecognized feelings: he was able to gain insight into
relationships between his symptoms of depression and the stressful events.
Mrs. E
resumed her role of situational support as his new coping skills were successful
ly
implemented in resolving the crisis.
Work and acquire, and thou has chained the wheel of Chance.
—Ralph Waldo Emerson
ee EE ee ee
Complete the paradigm in Figure 8-1 for this case study, then
compare it with the
completed one in Appendix D. Refer to the paradigms in
Chapter 3 as needed.
Rape
aer ee
The word rape arouses almost as much fear as the word
murder. In a sense it kills
both the rapist and his victim. The rapist dies emotionally
because he can no longer
express or feel tenderness or love, and his victim
suffers severe emotional trauma.
Women have nightmares about being sexually assaulted;
they anguish over what
to do. Either they can resist, hoping to fend off
the rapist, or they can obey his
commands, hoping he will leave without seriously
injuring or killing them.
Unfortunately, in 1997 the multitude of sexually
transmitted diseases (STDs) only
compounds their fears; the reality of being
raped is exacerbated knowing that
they may have contracted human immunodeficiency
virus, acquired immunode-
ficiency syndrome, herpes, venereal warts,
chlamydia, or other sexually transmitted
diseases.
CASE STUDY: MR. E
PLUS AND
PLUS AND
RESULT IN RESULT IN
Figure 8-1
The 1990s are also characterized by a phenomenon that has occurred for a long
time but is now receiving a great deal of attention—date rape. In all probability, the
increased recognition and publicity are due to the feminist movement. Women are
more aware of their rights and are acting on them. They have been the silent majority
for too long.
Over the past 20 years, there has been a significant increase in the publicity and
media focus on rape. The feminist movement took the lead in calling society’s
attention to the problem of sexual violence directed against women and was
instrumental in bringing about legal reform and the establishment of rape crisis
centers throughout the country. Rape laws have been reformed, many police
departments have instituted specially trained sex crime squads, and many hospitals
have created special programs for the medical and psychological treatment of rape
victims. Clinical research has been ongoing in developing and evaluating assessment
and treatment strategies for both rape victims and sexual aggressors. However, the
fear of rape remains a major issue for women in our society, and, in spite of all the
attention and special programs, it does not appear that rape rates have declined
significantly (Becker and Kaplan, 1991).
Stermac and others (1990) note that we must consider the context of sexual
violence as a socially constructed and socially legitimized phenomenon. They also
note the prevalence of sexual harassment, acquaintance rape, and abuse within
families, and state that contributing factors include negative social attitudes toward
women, sex role ideology restricting roles for women, and beliefs in rape myths.
RAPE DEFINED
Traditionally, the common law definition of rape is “carnal knowledge of a female
forcibly and against her will” (Koss and Harvey, 1991). Carnal knowledge refers
to
penile-vaginal penetration only.
Over the past several years, rape statutes have been reformed in numerous
states.
These reforms have focused on substituting other terms for rapes, including
sexual
battery, sexual assault, and criminal sexual penetration; placing the emphases
on the
perpetrator’s acts; and acknowledging the violent aspects of rape. In
general, reform
statutes define rape as nonconsenting penetration obtained by
verbal threat or
physical force. Individuals who are developmentally disabled, mentally
ill, or under
the influence of alcohol or drugs are considered incapable
of giving informed
consent. Reform statutes are not gender specific; both males and females
can be
victims or perpetrators.
Studies of rape should identify the various forms and types
of rape. A rape may
be perpetrated by one person, two persons, or more than
two as in gang rape. An
individual may be raped by a stranger, an acquaintance,
a date, or by a spouse. The
Tape may involve oral, vaginal, or anal penetration.
Rape may be planned or
spontaneous. The victim may report the rape to the police,
may tell family or friends,
or may not inform anyone. Researchers need to be precise
in defining rape, as well
as assessing the various forms of sexual aggression.
Although there is considerable individual variabi
lity in response to a sexual
assault, a number of commonalities of respon
se have been observed. Koss and others
(1991) described the three sequential phases
that represent a victim’s emotional
response to rape as shock, outward adjustment, and integration. They described a

cluster of symptoms consistently described by most rape victims. They defined these
as rape trauma syndrome. The syndrome has two stages: the acute stage, during
which the victim’s life is completely disrupted by the rape, and the long-term process
of recovery, during which the victim attempts to reorganize her life.
During the acute phase (disorganization phase), the victim may experience
physical reactions including sleep disturbances; eating pattern disturbances; and
physical symptoms, including mouth or throat irritation (if she was forced to perform
oral sex), vaginal discharge or itching, urogenital problems, and rectal pain and
bleeding or generalized pain.
Emotional reactions include fear (of death or physical injury), humiliation,
degradation, guilt, shame, anger, self-blame, and embarrassment. Victims may be
prone to mood swings during this period. Cognitively, victims may attempt to block
thoughts of the rape or to ruminate on how they might have escaped or handled the
situation differently.
The long-term process of recovery (reorganization phase) can last weeks, months,
or years. Various factors can influence the long-term recovery factors. Women may
experience changes in lifestyle, they may relocate, and they may terminate
relationships or have relationships terminated. They may have difficulty functioning
at work or school; they may curtail activities. Sleep disturbances and nightmares
about the assault may continue. Victims may develop phobias or other forms of
anxiety disorders.
FEAR AND ANXIETY

Perhaps one of the most frequent sequelae of a sexual assault is fear. During the
assault, victims often fear for their lives. After the assault, victims have fears for their
personal safety and of the assailant returning and attacking them again. Recently fear
of HIV infection has become a major concern of those victims by perpetrators
unknown to them. Some victims may become phobic as a result of the rape.
DEPRESSION
Depression is frequently noted in victims immediately after the rape. Rape victims
describe mild to severe levels of depressive symptoms during the first month
post-assault in 75% of the reported cases. By 4 months these levels decreased for
most symptoms to within the normal range. Attempted suicide is also a sequela to
rape.
Calhoun and Atkeson (1991) state that despite almost 3 decades of clinical
observation and empirical research, we are only now beginning to understand the
serious consequences that sexual assault can have for a woman and those close to
her. Data indicate that a significant number of women are victims of rape. The impact
of victimization can be both short term and long term. Rape can have an impact on
also
the emotional, cognitive, social, and physical functioning of victims. Rape can
have an emotional impact on the victim’s family and significant others.
Therapy outcome studies for rape victims should control time since the rape, and
as
victims should be in active interventions within a support group. Factors such
social supports and ways of coping must also be included.
Unfortunately, most rapists can neither admit nor express the fact that they are a
menace to society. Even convicted rapists who are serving long prison terms deny
their culpability; they tenaciously insist that women encourage and enjoy sexual
assault. These men tell others that they are the greatest lovers in the world.
The case study that follows concerns a legal secretary who was raped. After the
rape, she went home to shower and change her clothes, and then she went to work.
She was obviously in a state of shock and disbelief.
Case Study Rape

Ann, an attractive 26-year-old legal secretary, was brought to the Crisis Center by
her employer. That morning on her way to work, she had been raped. After being
raped, she returned to her apartment, showered, changed her clothes, and calmly went
to work.
At approximately 11:30 am she matter-of-factly announced to her employer that
she had been raped and told him the details. He was shocked and horrified. He asked
her to go to the hospital for treatment and to notify the police. She stated very
unemotionally that she was “‘fine’’-and had only numerous superficial cuts on her
breasts and abdomen and would continue working. By midafternoon she appeared
to her employer to be in a state of shock and was acting disoriented and confused.
He drove her to the Crisis Center where she was seen immediately in the emergency
room by a female therapist who had expertise in working with rape victims.
The therapist offered Ann a cup of coffee, and she accepted. While they were
drinking their coffee, the therapist quietly asked Ann to tell her what had happened.
Ann began to sob. The therapist handed her some tissues, put her arms around her
shoulders, held her close, and told her that she understood how she was feeling.
Gradually Ann calmed down and stopped crying. She then said, “‘I feel so filthy; I
feel I should have resisted more; I am so confused.” She was reassured that
these
feelings were normal and was asked to tell what happened.
Ann stated that she always got up early and took the bus to work because it was
very convenient, and she arrived before anyone else was in the office. She liked
to
get her desk in order for the day and make the coffee so that she could serve
coffee
to the attorney she worked for when he arrived. She smiled slightly and said,
“‘He
isn’t fit to talk to until he has finished his second cup of coffee in the
morning. He
commutes in from a suburb, and he has to battle the traffic for at least
an hour or an
hour and a half.”” The therapist smiled and asked her to continue.
She took a deep
breath and stated that this morning she had gotten up as usual and
ridden the bus to
work. As she was walking from the bus stop to her office building,
approximately
three blocks, a man walked toward her. He was tall, attractive, and
well dressed.
When he approached her, he smiled and said, “Can you tell
me where Fifth Street
is?” She returned his smile and said, “You are going the
wrong way. It’s the next
street up” (pointing in the direction she was walking). He
said, “Thank you” and,
turning around, fell into step with her and started talking
about the weather—‘“‘what
a beautiful morning’”’—and other small talk. They had
walked approximately 100
yards when he suddenly pulled out a knife, shoved her
against a car, put the knife
to her throat, and said, ‘““Don’t scream or I’ll kill
you, Get in the car.” Ann began to
tremble and tears rolled down her cheeks. The therapist said, “How frightening!
What did you do?” Ann said, “I was so shocked and terrified; I thought he would
kill me. So when he opened the car door, I got in.”
Ann continued to tell what had happened. He made her slide over to the driver’s
seat, keeping the knife firmly at her waist, ordered her to start the car, and told her
where to drive (an isolated area near the river). He then made her get in the back seat
and undress. He started caressing her and talking obscenities to her, telling her how
he was going to make love to her “‘like no other man could.”’ Ann said that she began
to cry and plead with him, but it only seemed to make him angry. He began making
small cuts on her breasts and abdomen and kept saying he would kill her if she did
not “‘cooperate.”’ Ann said that he acted “‘spaced out’ and had a glazed look in his
eyes, as if he were not really raping her personally—just somebody.
Ann stated that after he raped her, he seemed to “‘come to” and started to cry,
saying, “I’m so sorry. I didn’t mean to hurt you. Please forgive me; I just can’t help
it. Please don’t tell anyone.”’ Ann got dressed, and he helped her into the front seat
and kept asking her if she was alright and generally expressing concern for her
well-being. He asked if he could drive her someplace, and Ann asked him to drop
her off approximately four blocks from her apartment, telling him she was going to
a girlfriend’s to “clean up.” He dropped her off and again begged her not to tell
anyone and to please forgive him. Ann said that when she was certain he had driven
away, she walked to her apartment in a daze. All she could think about was taking
a shower to “‘get clean again’”’ and to change her clothes completely to try to erase
her feelings of degradation. She stated that she thought she should go to work “to
keep her mind off it.”” Only later in the afternoon as she “relived” the events in her
mind did she begin to feel terribly guilty over not “resisting” or “fighting back”
when he first pulled the knife. She said (with a tone of great remorse), “I didn’t even
scream!”’
The therapist felt that Ann should go to the hospital immediately for treatment of
her numerous cuts and determination of the presence of spermatozoa in the vagina,
and then she should report the incident to the police. After this was done, she should
return to the center to meet with the therapist and continue her mental catharsis. The
therapist explained to Ann that someone from the rape hot line would go with her
to the hospital and remain with her there and while she gave her report to the police.
She was assured that the therapist would contact the hospital to arrange that Ann be
examined by a female physician and that she would be interrogated by a female
police officer. Ann agreed to go, and a member of the rape team was called to be with
her and then to return her to the center.
When Ann returned, she was pale and trembling but apparently in control of her
emotions. Again she was offered coffee, which she accepted, and she and the therapist
discussed how things had gone at the hospital and with the police interrogation. Ann
it
stated it was definitely not pleasant, but that it was not as bad as she had thought
would be. She added, “‘Thank God I didn’t take a douche!”’
The therapist asked Ann if she had a friend or family member whom she would
still very
like to contact and possibly have spend the night with her because she was
frightened by her experience. Ann turned even paler and explained, “Oh, my
, ““My
God—Charles!”” She was asked, ‘“‘Who is Charles?” She replied, hesitantly
fiancé.” The therapist asked Ann if she could call Charles and tell him what
happened. Ann began to cry and said, ‘“‘I am so ashamed. He will probably hate me.
He probably will never want to touch me again. What have I done?” She was
comforted by the therapist and told that she had done nothing wrong. She continued
to cry and berate herself. The therapist gave her a mild sedative and asked her to lie
down and rest. Twenty minutes later, Ann asked the therapist if she would call Charles
and tell him what had happened, but she said that she did not want to see him until
she knew how he felt about her being raped. The therapist agreed and asked for
Charles’s telephone number.
The call was placed to Charles, and the therapist briefly explained that Ann was
raped and that she was not severely injured but psychologically very traumatized.
Charles responded with concern and anger and asked if he could see Ann. He was
told to come to the center and to ask for the therapist.
Charles arrived and was extremely upset and angry. The therapist took him to her
office and explained fully what had happened to Ann and what had been done for
her. He started to cry and to curse, stating, “My God, poor Ann” and “I’ll find that
dirty bastard and kill him!” The therapist allowed him to ventilate his feelings of pity
and anger, and he began to calm down. When he seemed calmer, he was asked, ‘“‘Does
this change your feelings for Ann?” He appeared startled and said, “No, I love her.
We are getting married!” The therapist told him that Ann was afraid he would not
love her anymore. He replied, “It wasn’t her fault; of course I still love
her!”
The therapist explained that after being raped, a woman usually feels “guilty,”
“unclean,” and very fearful of intimacy with another man, even if she loves him very
much. She added that Ann needed his strength, love, and constant reassuranc
e that
nothing has changed between them. He listened and said, “I'll do anything
I can to
help her forget this.”
The therapist asked if he sometimes stayed Overnight at Ann’s apartmen
t, and he
answered, “Yes, often.” He was asked if he would spend the night
with her (if she
agreed) and hold her (if she would let him), touch her, reaffirm his
love for her, and
speak about their coming marriage but not attempt sexual intercou
rse unless she
asked him; he agreed and asked to see Ann. The therapist
asked for a few minutes
alone with Ann first.
When the therapist entered, Ann was lying on the couch staring
at the ceiling. She
turned her head and looked fearfully at the door. The therapis
t smiled, sat down by
Ann, held her hand, and said, “I like your Charles.
He is a fine young man. He will
probably break down that door if I don’t let him in to
see you!” Ann asked, “What
did he say?” The therapist told her that he had stated
he loved her very much and
that he would do anything to help her forget the rape,
that it was not her fault, and
that he would like to “kill the bastard who hurt her.”
Amn said hesitantly, “Are you sure?” The therapist
replied firmly, ‘Positive! Now
comb your hair and put some makeup on, so I can
let him in!” Ann smiled weakly
and complied.
Charles entered the office, took Ann in his arms,
and held her gently, stroking her
hair and face, saying, “I’m so sorry, my love.
Let me take care of you. Everything
is going to be alright. I love you. You are the most
precious thing in my life.” Ann
cried softly on his shoulder.
The therapist said, ‘““Why don’t you two go home and get some rest, and I’ll see
you both next week.” Ann and Charles agreed and left with their arms around each
other and Ann’s head on his shoulder.
(Note: The therapist had listened to Ann’s account of the rape and modus operandi
with increasing feelings of helplessness and anger because in the past 3 months she
had worked with two other rape victims who had described the same details but with
one major difference: the first victim had only one minute cut on her throat, which
she received when he pushed her against the car; the second had several small
superficial cuts on her breasts; and now the third victim, Ann, had numerous cuts on
her breasts and abdomen. The rapist was obviously becoming increasingly violent
with each rape.)
The next sessions were spent in collateral therapy with Ann and Charles. The focus
was on ventilation of their feelings and helping Ann begin to express anger toward
her rapist. By the end of six sessions, they had resumed their normal sexual activities
and had advanced their wedding date 3 months. Charles felt he was really living at
Ann’s apartment because he wanted to be with her as much as possible; therefore they
agreed to get married sooner than they had planned.
Because rape is so emotionally traumatic, Ann was treated as an emergency
patient by the therapist. The sooner intervention begins with a rape victim, the less
psychological damage occurs.
Most women are totally unprepared for rape; therefore it is a new traumatic
experience to cope with, and previous defense mechanisms are usually ineffective
to resolve the crisis.
Ann greatly feared total rejection by her fiancé (a very real and common
occurrence). This is why the therapist saw both Ann and Charles in collateral
sessions; thus both would have a chance to explore and ventilate their feelings
together.
Ann perceived that the rape was her fault because she did not resist immediately
and did not scream. These feelings are common in women who have been raped.
Usually everything occurs rapidly, and the ever-present fear of being killed or
seriously injured tends to immobilize the victim.
ADDENDUM
Four months later a patient was referred to the center because he was on probation
for rape, and he became the same therapist’s patient. When he was questioned about
how and why, as he described his modus operandi, the therapist knew that he was
his
the one who had raped Ann and the two other victims. After the rapist discussed
feelings—guilt, shame, and helplessnes s in controlling his actions—th e therapist
his
asked about his background and family. This new patient, Phillip, described
of affection. His mother had left his father, and Phillip had
childhood as one deprived
ing
been reared by an aunt who was very cold, undemonstrative, and—to him—uncar
and rigid.
that he was
When questioned about his present living circumstances, he stated
small children. When asked why he felt the need to
married (happily) and had three
He began to cry and said, ‘‘Please help me. I can’t
rape, he stated, “I don’t know.”
help myself.”
When the therapist asked if his wife knew that he was on probation for rape, he
said, very hesitantly, ‘“‘No, but I know she thinks something is wrong with me.” The
therapist told Phillip that she had worked with three of his victims, and she felt that
he was becoming increasingly more violent, as evidenced by the increasing use of
the knife and the sight of blood to stimulate him.
Phillip stared intently at the therapist and said with amazement in his voice, ‘““My
God, don’t you hate me? I hate myself.” The therapist was able to admit that her bias
was toward his victims but that she felt he needed help because she was afraid he
might kill his next victim. He admitted that he did not know whether he would or
would not kill someone.
The therapist then asked him how his wife and children would feel if they found
out that he was a potential murderer. He shuddered and said, ‘Help me! I don’t know
what to do!” The therapist stated that he should tell his wife about being on probation
and about the rapes, and then the therapist would do all she could to get him help.
He agreed and called his wife and asked her to come to the center.
His wife arrived, and Phillip, with the therapist present, told her what he had done
and the possibility of what he could do in the future. She began to cry and said, “I’ve
known something was wrong, but I didn’t know what.” She turned to the therapist
and asked, ““What can we do?” The therapist was very candid and stated that Phillip
should be at a well-known maximum security prison where he could receive
consistent, intensive psychiatric therapy in order to protect the reputation of their
family and to protect the community.
They agreed with this decision. The therapist then called the judge and told him
the facts. He agreed that maximum security was needed and said that he would send
a car to transport Phillip to the facility.
It must be noted that rarely does a therapist work with rape victims and then with
their offender. It was extremely difficult to remain “cool, calm, and collected” while
Phillip related his modus operandi; however, he too was a “‘victim’’
who needed help,
and he did receive it.
Vicious actions are not hurtful because they are forbidden, but forbidden
because they
are hurtful.
—Benjamin Franklin
a eh ie ed ee
Complete the paradigm in Figure 8-2 for this case study, then
compare it with the
completed one in Appendix D. Refer to the paradigms in
Physical Illness
BS
a CORRES RCL ercomer s
garcra rr ate gl
Diseases are known to have their places and their times
(see Chapter 11). Primitive
societies have been characterized by health problems
related to recurrent famines,
and urban societies have been characterized by epidemi
cs of infectious disease.
Modern industrial societies are characterized by a
new set of diseases: obesity,
arteriosclerosis, hypertension, diabetes, and widesp
read symptoms of anxiety.
Arising from these are two of the three greatest disable
rs of our own place and time:
coronary heart disease and stroke.
CASE STUDY: ANN
PLUS '
PLUS AND
RESULT IN RESULT IN
Figure 8-2
In recent years increasing concern has focused not only on the etiology and
epidemiology of cardiac disease but also on factors affecting the process of recovery.
Statistics indicate that approximately 35% of deaths among adults between 25 and
44 years of age result from chronic medical conditions such as heart disease, cancer,
cerebrovascular, and pulmonary diseases (National Center for Health Statistics,
1994),
It is clear that chronic illness can be identified as a major stressor for all family
members. Illness demands have been found to be related to higher levels of
psychological distress in chronically ill adults (Kotchick and others, 1996). If one
family member has an illness, its effects can create repercussions in all other family
members. The family member who is ill does not live in isolation from the rest of
the family. This creates stress and in many cases role changes, which creates more
family stress.
A variable assumed to mediate between the impact of illness and psychological
distress among family members is the use of effective coping strategies. Coping has
been broadly defined as a constellation of responses that serve to control or reduce
emotional stress in the face of some externally imposed life strain, such as chronic
illness. Active coping consists of those strategies intended to directly affect
the
stressor, either behaviorally (such as doing something to eliminate the source of
the
problem) or cognitively (such as thinking about the stressor in a more positive light).
Avoidant coping strategies are behaviors and cognitions intended to draw attention
away from the stressful event; such avoidant strategies include doing something
to
keep from thinking about the problem or denying the presence or impact
of the
stressor.
Although the relationship between the use of certain coping
strategies and
individual outcome has been established, little is known about
the effects of the
maladaptive coping of one family member on significant others.
Maladaptive coping
by one family member may have adverse effects on the psycholo
gical functioning
of other family members by increasing the level of distress
experienced by the
individual using such coping Strategies, which, in turn,
has negative effects on the
functioning of other family members. A person’s use of
avoidant coping strategies
has been associated with elevated levels of depression
and anxiety.
The conceptualization of the recovery process in heart
disease as a response to
crisis provides strategic advantages in approaching the
problem. It leads to focusing
on the kinds of adaptive and maladaptive mechanisms
that patients employ in coping
with this illness, on the stages of recovery, and on the
resources that patients use and
require at each stage. Viewing response to coronary
heart disease as a problem that
can be approached through crisis intervention
permits the use of concepts and
formulations inherent in crisis theory.
In a discussion of the rehabilitation of patients
with cardiac disease, a report by
the World Health Organization in 1996 distinguishe
d between phases of the recovery
process in terms of time and coping tasks. The
first phase is categorized as one in
which the patient spends approximately 2 weeks
in bed, with minimal physical
activity. In the next phase the patient spends
approximately 6 weeks at home, with
a variety of sedentary activities. In the third
phase, which lasts from 2 to 3 months,
the patient makes a gradual reentry into the
occupational world.
Lee and Bryner (1961) conceptualize phases according to the kinds of care the
physician must provide for the patient at each point of the process. They specify (1)
evaluation of the patient and his environment, (2) management of the patient, and (3)
reestablishment of the patient in his community.
In other formulations of recovery phases, emphasis is on the kinds of therapeutic
or rehabilitative relationships that predominate at each point. Hellerstein and
Goldstone (1954) describe the first, or acute, phase as one in which the relationship
between the physician and patient is of primary importance. The convalescent
phase follows, and the relationship between the patient and family and friends
becomes primary. During the recovery, or third, phase the employer or vocational
counselor becomes the vital participant in the rehabilitation of the patient with
cardiac disease.
Phases have also been viewed in terms of the emotional adaptation of the patient.
Kubie (1955) suggests that the first phase is marked by initial shock, and the second
phase is marked by appreciation of the full extent of the disability. In the third phase
there is ‘recovery from the lure of hospital care’’; in the fourth and final phase there
is ‘‘a facing of independent, unsupported, and competitive life.”
Among the most obvious and critical determinants of the outcome of the recovery
process are the severity of heart damage, the degree of impairment, and the
physiological resources of the patient. Although cardiac damage has much to do with
setting limits on performance and affecting levels of adjustment, studies of
physiological factors alone contribute only partially to understanding the recovery
process. Research on the importance of the premorbid personality of the patient as
a determinant of adjustment to illness suggests that it is a second important factor
in the recovery process.
Other important factors bearing on the recovery process include the various
psychological mechanisms that the patient uses in handling illness. If the recovery
process is viewed as a response to a crisis situation, then the individual mechanisms
used by patients appear particularly important in the resolution of the crisis. The
significance of emotional response to disease has often been underlined in discussing
the elements that determine recovery. McIver (1960) states, ““The way in which a
crisis is handled emotionally may significantly influence the eventual outcome of a
case in terms of the extent of recovery and the degree of rehabilitation achieved.”
Reiser (1951) emphasizes that it is essential to deal with the anxieties associated with
to
the diagnosis and symptoms of heart disease if the therapy of cardiac disease is
attain its optimal effect. Acommon view is that during the acute phase of any serious
illness
illness the patient’s emotional state is characterized by fear because the
integrity, as well as his sense of personal adequacy and worth to
threatens his total
others.
Compared with other serious illnesses, heart disease has several unique features.
and family as an
Associated as it is with sudden death, it is viewed by the patient
that even in the most
immediate and severe threat to life. Hollender (1958) has written
t of anxiety.
stable patients the onset of heart disease is associated with an onslaugh
a passive
During the first days of illness, the patient with heart disease must assume
Physical restriction
role, and some believe that this role tends to compound anxiety.
n. The patient
usually increases feelings of helplessness, vulnerability, and depressio
is then handicapped in utilizing defense mechanisms that should ultimately help him
to adjust to an altered status.
Although coping responses vary widely, there appears to be a core of relatively
uniform responses of adjustment. For example, depression and regression have often
been reported as the initial reaction to the illness. Some patients display aggression
and hostility, placing the blame for the illness on external factors. Some deal with
the threat to life by denial of the illness.
It has been suggested that certain coping responses are appropriate at one stage
of recovery but are inappropriate at another. When patients at the same stage of
recovery are compared, similar responses may function in different ways:
constructively for some patients but hindering recovery for others. There is
disagreement at present about the role denial plays in recovery. Some regard denial,
which may lead to noncooperation with the physician, as a response of
self-destruction. Others consider that denial arises from a belief in the integrity of
the self and the invulnerability of the body and regard it as constructive and
associated with the maintenance of health.
Because each patient reacts as an individual*in this life-threatening situation, the
therapist, in all probability, sees a variety of coping responses being utilized. It is not
the therapist’s role to change the patient’s pattern of coping but to understand that
his reaction to illness is part of the patient’s defense.
King (1962) states: ““Man’s basis for action in health and disease is a composite
of many things. One crucial variable is the way that he sees or perceives
the
situation . . . and all of the social ramifications that accompany it.”’ These perception
s
are conditioned by socialization in a sociocultural context. How the patient
responds
to the disease is influenced by what he has learned. The content of the
learning is
in turn determined by the norms and values of the society in which
he lives. The
meaning of the disease, attitude toward medical practitioners, willingnes
s to comply
with medical advice, and the patient’s management of his life after
a heart attack are
all influenced by the attitudes and beliefs that he has learned.
Pertinent to the recovery process is the conceptualization of the
“‘sick role,”’ which
Parson (1951) describes as a social role, with its own cultural
ly defined rights and
obligations. Although a person may be physiologically
ill, he is not recognized as
legitimately ill unless his illness fulfills the criteria or standard
s set by the society.
Once defined as legitimately able to be in the “sick role,”
he is expected to meet
certain expectations of others. The person is expected, for
example, to make an effort
toward becoming well and to seek help. In turn, he has
the right to expect certain
kinds of behavior from others toward him, including
a willingness to permit him to
relinquish his normal social role responsibilities.
Willingness to accept the sick role may mean that
a patient with heart disease is
likely to follow the regimen of his physician and
to care for himself in ways that
maximize his recovery. At the same time, reluctance
to accept the sick role may also
influence the recovery process favorably. Such a
patient may be anxious to avoid
being defined as sick. Like the willing patient,
he too may follow the therapeutic
regimen to shorten the period of incapacity. Howeve
r, reluctance to view himself as
sick may lead a patient to comply minimally with
medical advice and to attempt full
activity before he is physically able to do so.
The following case study illustrates how a businessman responded to a sudden

heart attack with inappropriate and excessive denial.
Case Study Physical Illness

Mr. Z, age 43, was chairing a board meeting of his large, successful manufacturing
corporation when he developed shortness of breath; dizziness; and a crushing,
viselike pain in his chest. The paramedics were called, and he was taken to the
medical center. Subsequently, he was admitted to the coronary care unit with a
diagnosis of impending myocardial infarction.
Mr. Z is married, with three children. He is president and the majority
stockholder of a large manufacturing corporation. He has no previous history of
cardiovascular problems, although his father died at age 38 of a massive coronary
occlusion. His oldest brother died at the age of 42 from the same condition, and
his other brother, still living, is a semi-invalid after suffering two heart attacks
at the ages of 44 and 47.
Mr. Z was tall, slim, suntanned, and very athletic. He swam daily, jogged every
morning for 30 minutes, played golf regularly, and was an avid sailor who
participated in every yacht regatta, usually winning. He was very health conscious,
had annual physical checkups, watched his diet, and quit smoking to avoid possible
damage to his heart, determined to avoid dying young or becoming an invalid like
his brothers.
When he was admitted to the coronary care unit, Mr. Z was conscious. Although
in a great deal of pain, he seemed determined to control his own fate. While in the
coronary care unit, he was an exceedingly difficult patient, a trial to the nursing staff
and his physician. He constantly watched and listened to everything going on around
or
him and demanded complete explanations about any procedure, equipment,
medication he received. He would sleep in brief naps and only when he was totally
The
exhausted. Despite his obvious tension and anxiety, his condition stabilized.
minimal, and his prognosis was good. As the pain
damage to his heart was considered
back to
diminished, he began asking when he could go home and when he could go
moved to a private room so that he could conduct some
work. He was impatient to be
of his business by telephone.
although his
Mr. Z denied having any anxiety or concerns about his condition,
cted his denial. Recogni zing that Mr. Z was coping
behavior in the unit contradi
of illness, his physicia n requeste d as consulta nt a
inappropriately with the stress
with Mr. Z to help him
therapist whose expertise was crisis intervention to work
through the crisis period.
for 6 weeks. Their first
The therapist agreed to work with Mr. Z for 1 hour a week
day of his stay in the coronar y care unit. The
session was scheduled the second
talked with his physici an before the first session
therapist reviewed Mr. Z’s chart and
of Mr. Z’s physica l conditi on and to gain some
to gain an accurate assessment
conomi c status, marital status, family history) to
knowledge of factors (e.g., socioe
assist in assessing his biopsychosocial needs.
and covert signs of anxiety
In the first session the therapist observed Mr. Z’s overt
him, his perception of what
and depression and determined, through discussion with
hospitalization meant to him, his usual patterns of coping with stress, and available
situational supports. Through direct questions and reflective verbal feedback, she was
able to elicit the reasons for his behavior and reactions to his illness and to his
confinement in the coronary care unit.
Observing his suntanned, youthful appearance and the general physical condition
of a very active and persistent athlete, the therapist questioned him about his lifestyle
before his hospitalization. Mr. Z was quite adamant about his “minor” condition and
the possibility of curtailed activity. He stated that he was very aware of his family’s
tendency toward cardiac conditions but added, “I have always taken excellent care
of myself to avoid the possibility of becoming a cardiac cripple like my brother.”
Apparently he was not too concerned about the prospect of dying; in fact, he might
prefer it to the overwhelming prospect of being a useless, dependent invalid.
He expressed concern about the length of time he might have to spend in the
hospital. When questioned about his concern, he stated: “I have to be in good shape
by the second of December (in approximately 3! months). I’ve entered the big yacht
race, and I plan to win again!”
When he was asked how his wife and children were reacting to his illness and
hospitalization, Mr. Z’s facial expression and general body tension relaxed
noticeably. He smiled and said, ““My wife, Sue, is simply unbelievable; she takes
everything in stride. She is always cool, calm, and collected. She even met with
the
board of directors and told them to delay any major decisions until I return . . .
but
that she could handle any minor decisions!” The therapist asked if she could
meet
his wife. Mr. Z replied that his wife would be in to see him soon and suggested
she
stay and meet her.
After meeting with them briefly, the therapist asked Mrs. Z to stop
by her office
before leaving. Mrs. Z arrived at the office and sank gratefully into
a chair, losing
the bright, cheerful, and optimistic manner she had maintain
ed while with her
husband. Observing her concerned expression and slumped
posture, the therapist
inquired, “You are very concerned about your husband,
aren’t you?” Mrs. Z readily
admitted that she was concerned but did not want her husband
to know. When asked
what specifically concerned her, she replied: “‘Jim’s inability
to accept any type of
forced inactivity and his refusal to accept the possibility that
he might have to change
his hectic lifestyle. He can’t bear the thought of being
ill or being dependent on
anyone or anything!”
The therapist explained that it is difficult for many
patients to accept a passive,
dependent role while ill and that it takes time for them
to adjust to a changed lifestyle.
She then explained to Mrs. Z that the physician
had arranged for Mr. Z to have
therapy sessions for the next 6 weeks to help him
through his crisis. Mrs. Z seemed
relieved that someone else recognized the proble
ms confronting her husband and
would help him as he worked through his feeling
s about his illness and unwanted but
inevitable changes in lifestyle. The therapist
suggested that Mrs. Z might also need
some support, as she too had to adjust to Mr.
Z’s illness. They agreed to meet for
an hour each week so they could work togethe
r toward a resolution of the crisis. A
convenient time was arranged each week when
Mrs. Z came to visit her husband.
Mr. Z’s denial of the possibility that he might
die like his father and oldest brother
or that he might become an invalid, “useless and depen
dent,” like his other brother
was considered of prime importance. It was felt that the first goal of intervention was
to assist Mr. Z to ventilate his feelings about his illness and hospitalization. A second
goal was to assist him to perceive the event realistically. A third goal was to give
support to Mrs. Z and assist her in coping with the stress induced by her husband’s
hospitalization.
It was believed that Mr. Z’s high anxiety level would interfere with his ability to
express his feelings about his illness and his hospitalization. In an attempt to reduce
his anxiety, the therapist made two recommendations to his physician, which were
accepted. The first recommendation was that Mr. Z be moved out of the coronary care
unit to a private room as soon as possible. The environmental surroundings in the
coronary care unit, with its overwhelming and complex equipment, strange sounds,
and constant activities of the staff, apparently increased Mr. Z’s anxiety. Because of
the stressful situation, he was not getting sufficient rest. After his move to a private
room later that afternoon, he began to relax noticeably, became much less demanding
of the staff, and began sleeping and eating better.
The second recommendation was that he be permitted to use the telephone for 30
minutes three times a day. Thus he was able to conduct some of his business from
his bed. This apparently made him feel less dependent, and the increased mental
activity relieved some of his anxiety about becoming a “helpless” invalid.
In the next sessions Mr. Z began to discuss—hesitantly at first and then more
freely—his feelings about his illness and his reaction to hospitalization. He discussed
his father’s sudden death when he was in his teens and how lost he would have felt
if his older brother had not stepped in and taken over. All three brothers were very
close, and the death of the oldest one, while Mr. Z was in college, reactivated the grief
he felt for his father. He was just beginning to accept his oldest brother’s death when,
a year later, his other brother had a severe heart attack and was unable to continue
in the family business. As Mr. Z saw it, his brother was a “helpless” invalid. Mr. Z,
the youngest son, then became president of the corporation and controlled the
majority of the stocks. He stated that although he certainly didn’t want to die, he was
less afraid of dying than he was of becoming useless, helpless, and a burden to his
family.
Through discussion and verbal feedback, Mr. Z was able to view realistically his
Yes, he
illness and the changes it would make in his life. No, he was not an invalid.
and to live a normal life. No, he would not have to give up
would be able to work
have to have someone else do most of the crewing. Yes, he
sailing; he would just
a more leisurely
would be able to resume his activities but would continue them at
of scheduling fifteen things to do in a day, schedule seven.
pace. For example, instead
accepting as he began to realize that the mild myocardial
Gradually he became more
he should heed and that with proper care and some
infarction was a warning
pace, he could continue to live a productive and useful
diminishing of his usual hectic
life.
support and began
The therapist continued to meet with Mrs. Z to give her
husband ’s convale scence at home. They discussed Mr.
anticipatory planning for her
and the therapist
Z’s strong need to feel independent and in control of all situations,
for the family. She
encouraged her to continue to let her husband make decisions
ly normal life and that she
assured Mrs. Z that he would be able to continue a relative
did not need to protect and “‘coddle” him, something he would greatly resent. When
asked how their children were reacting to their father’s hospitalization, Mrs. Z
replied, “At first they were terribly concerned and silent; now they are beginning to
ask, ““When is he coming home, and what can we do?” It was obvious that Mr. Z
had strong situational support in his family.
Mr. Z’s recovery progressed fairly smoothly, and he began to ambulate and take
care of his basic needs. Although more accepting of his need for some assistance, he
still became upset and impatient if the staff attempted to assist him in routine care.
Mr. Z was discharged after his second week, with instructions for his
convalescence at home. The therapist continued to meet with Mr. and Mrs. Z at their
home during the rest of the sessions to assist the family toward stabilization as Mr.
Z adjusted to his new regimen of reduced activity and to provide anticipatory
planning for their future.
By the end of the fifth week, with the strong support of his family and the therapist,
Mr. Z was able to view his illness and his feelings about curtailing some of his hectic
activities in a more accepting and realistic manner. His family still consulted him for
advice and opinions about family decisions. This made him feel that he was still an
active, participating member of the family.
He was able to conduct a large part of his business from his home by having board
meetings there and by having periodic telephone conversations with his office staff.
His secretary came to his home 3 days a week to take dictation and to secure
his
signature when it was needed on documents. He also telefaxed materials and
orders
to his office employees. Thus he still remained in control of his business
life, which
contributed greatly to his self-esteem.
The children and Mrs. Z were encouraged to continue in their usual
daily activities
so that Mr. Z would not feel that his being at home was disrupti
ng to their lives. It
also helped Mrs. Z to cope with her feelings and her desire to
protect her husband
from stress. Gradually, she was able to realize that he was
capable of coping with
some stress and that he was not as fragile as she had believed
him to be.
Before termination, the therapist and Mr. Z reviewed the adjustm
ents he had made
and the insights he had gained into his own behavior. He
was intellectually able to
understand the reasons for his denial and dependence-indepen
dence conflicts. He was
very optimistic about his future and believed that he could
adjust to a reduced-activity
schedule. He still, rather wistfully, was hoping his
physician would approve his
entering the yacht race. He was realistic about
his physical condition and the
possibility that a coronary attack could occur again,
stating, ‘‘At least now I’ve
learned to relax and roll with the punches.”
Mrs. Z and the children felt they would be able to
cope with the occasional bouts
of frustration and temper flare-ups of Mr. Z. They
were now aware of how difficult
it was for him to make the many adjustments
necessary to his new way of life.
Mr. Z’s fear of becoming a “cardiac crippl
e” like his brother distorted his
perception of the event. He was unable to relax
and be dependent in the coronary care
unit; his anxiety and tension made him unable
to accept the fact that he had a
myocardial infarction. His family and _
his colleagues—his usual situational
supports—were unable to be with him becau
se of hospital rules and his restricted
activity. He used denial excessively because
he was unable to accept the fact that he
might have to change his lifestyle. Because this was his first hospitalization and the
first time he had to be in a dependent role, his anxiety increased considerably.
That dire disease, whose ruthless power

Withers the beauty’s transient flower.
—Oliver Goldsmith
Alzheimer’s Disease
Alzheimer’s disease is a progressive, degenerative disease that attacks the brain and
impairs judgment with mental functioning. Its victims generally experience
confusion and personality and behavioral changes. They ultimately require full-time
supervision or custodial care. The cause is still unknown. Although researchers have
linked two different susceptibility genes to the disease, it is clear that unknown
environmental factors also play a major role. Based on researchers’ studies of brain
cells grown in the laboratory, electromagnetic fields (EMFs) can disturb the normal
concentrations of calcium ions within cells. The increased concentration of calcium
within the cells produced by EMFs, researchers speculate, triggers a well-known
cascade of reactions that ultimately leads to the accumulation of damaging plaques
and tangles (Maugh, 1996).
Alzheimer’s disease afflicts as many as 4 million Americans; most are over the
age of 65. It is characterized by memory loss, disorientation, depression, and
deterioration of bodily functions. It is ultimately fatal, causing approximately
100,000 deaths each year (Maugh, 1996).
Unless a cure or means of prevention are found for Alzheimer’s disease, 12
10%
to 14 million Americans will be affected by the year 2000. Approximately
’s disease.
of the population over 65 years of age are afflicted with Alzheimer
is the
The percentage rises to 47.2% in those over the age of 85, which
significant because the
fastest-growing segment of the U.S. population. This is
and it is estimated that
nation’s entire elderly population is increasing rapidly,
people over the age
by the year 2050, the United States will have 67.5 million
‘‘graying of America!”
65, compared with 25.5 million at present. It is truly the
of Alzheimer ’s disease
More than 50% of all nursing home patients are victims
ranges between $24,000
or a related disorder. The annual cost of nursing home care
and $36,000.
ng costs of diagnosis,
Financing for care for Alzheimer’s disease, includi
is estimated to be more
treatment, nursing home care, informal care, and lost wages,
$4.4 billion and the states
than $580 billion each year. The federal government covers
borne by patients and their
another $54.1 billion. Much of the remaining costs are
families.
us and often imperceptible
The initial symptoms of Alzheimer’s disease are insidio
in many areas of
as organic changes start to occur in the brain and a decline
abilities begins. Initially, no objective or subjective
intellectual and physical
CASE STUDY: MR. Z
»
PLUS _ AND
PLUS
AND
RESULT IN _ RESULT IN
Figure 8-3
symptoms are reported. As the disease progresses, the earliest noticeable symptoms
are generally related to memory impairment. Although motor activities are not
affected at this time, subjective awareness of memory loss begins to interfere more
and more with the person’s daily living activities. It is a rare person among us who
has not occasionally misplaced needed items, forgotten familiar addresses and
telephone numbers, and even forgotten the names of close friends. If these lapses do
not happen too often, the usual response can be momentary embarrassment or
irritation. We blame it on being tired or under stress or on just having too much on
our minds to remember, but there is always a sense of self-confidence that the
memory will return.
For the Alzheimer’s disease patient, however, such forgetfulness begins to become
chronic, something that cannot be shrugged off so easily as only temporary. As
subjective awareness and concerns over memory loss increase, self-confidence in an
ability to recall lost memories diminishes. For many, written checklists and notes of
things to do become a way of life. Eventually, however, these no longer suffice as
memory supports as they, too, become lost and forgotten.
As memory loss increases, signs of early confusional behavior begin. A person
easily becomes lost in unfamiliar places and needs to depend increasingly on others
for help in finding his way when away from home or other familiar locations.
Changes to new environments create much anxiety, particularly when combined with
stressful events such as an illness requiring hospitalization. The person’s forgetful-
ness begins to be noticed by others and can no longer be seen simply as temporary
or “normal” behavior. At the same time, recent memory loss becomes much more
subjectively noted. Ability to concentrate decreases, and the use of denial as a defense
mechanism increases.
From this stage in intellectual decline, identifiable overt symptoms of Alzheimer’s
disease begin, and regression progresses into a late confusional stage. The person can
still handle his own immediate physical needs, yet motor skills gradually decrease.
Language becomes affected, and it becomes increasingly difficult for the person to
find the right words. The ability to concentrate diminishes greatly, and the ability to
handle finances, cooking, and other daily decision-making activities suffers
and
accordingly. The individual becomes more withdrawn and anxious. Frustration
anger increase as the use of denial becomes less effective. No longer can he deny
to himself or to others that something is wrong with him.
early
Inevitably, whether slowly or rapidly, regression progresses into a period of
this stage such persons can survive no longer without assistance from
dementia. At
is time disorienta tion and frequentl y forgetful ness of familiar
others. Now there
functions of
family names. Although the person is still capable of handling the basic
and bathing),
daily living (such as feeding himself, bowel and bladder control,
greatly as intellectu al and motor skills continue to decline.
caretaking needs increase
period of rapid decline as the disease progresse s toward the stage
For many this is a
of middle dementia.
ons, which are
By this time there are symptoms of hallucinatory types of percepti
may be
responded to with fear, agitation, and even violence. Familiar faces
is nearly nil. Variable awarenes s of recent events and past
recognized, but name recall
memories may be sketchy and incomplete.
As motor skills ‘decrease, bowel and bladder incontinence begins. Constant

attendance becomes necessary for all activities of daily living. Caretaking activities
may exceed the abilities of family and friends; institutionalization may be the only
family recourse. In the final, late dementia stage of Alzheimer’s disease, the person
becomes increasingly vegetative and requires total care. Speech decreases to one or
two words, all intellectual skills disappear, and motor skills decline until full
assistance is needed to eat, drink, and even turn in bed. Eventually, there is coma and
finally death.
A diagnosis of Alzheimer’s disease for a family member means that the whole
family, as well as the patient, must learn to live with the condition. Alzheimer’s is
insidious in its onset; a misdiagnosis of early symptoms can create added stress for
everyone concerned. Too often the early symptoms of memory loss, depression,
passive dependency, and emotional lability are misunderstood or passed off as
transient reactions to situational stress.
As the disease progresses, a person with Alzheimer’s becomes impaired in his
ability to control the appropriate expression of his own emotions and to comprehen
d
the effect of his behavior on others. He is emotionally labile, overreacts, and often
appears insensitive to others’ feelings. Emotional changes often appear
as
exaggerations of previously established behavioral characteristics. For example,
the
passive and withdrawn person may become even more dependent, suspicious,
and
depressed; the characteristically independent, aggressive person
may appear
demanding, hysterical, and even manic in behavior.
As organic changes in the brain occur, dependency on others increases
. This
may not be too disturbing for one whose past personality
characteristics were
those of passive dependency. However, for one whose personal
ity characteristics
emphasized independent, aggressive behaviors, feelings of
frustration and anger
increase as dependency needs increase. This can lead to
what has been termed
catastrophic reaction, which is best described as
an emotional overreaction, one
that is obviously out of proportion to an anxiety-provokin
g situation. It occurs
as intellectual impairment increases and emotional
control decreases. This is a
fairly common response as the affected individual is
increasingly confronted with
failure in achieving what formerly were, to that
person, simple tasks. Often
believing that the individuals concerned have
full control over their behavioral
changes, family and friends may, in turn, respond
inappropriately. Such a reaction
may only serve to increase stress and, consequently,
the severity of the symptoms
exhibited. Family members almost invariably
need to cope at some time with
feelings of fear, anger, guilt, shame, and isolation
, as well as persistent feelings
of grief and mourning. These feelings may
arise intermittently and in varying
degrees, dependent on each member’s past experien
ces, values, personal resources,
and current life situation.
Any unusual problems arising with the patien
t may, in fact, be a symptom of
family dysfunction. It would not be unusual
for family members, no longer able to
relate to each other openly and directly, to
relate through problems as they arise in
the patient. It is as though there is a need
for the patient to have problems in order
for family members to continue to relate.
This only serves to reinforce the patient’s
problematic behaviors.
Once the diagnosis of Alzheimer’s disease has been confirmed and denial of the
illness diminishes, each family member begins to face the reality of its consequences
for himself, as well as for the patient. Each member strongly feels a need to find a
satisfactory reason or meaning for the occurrence of the illness. Until one is
found—treal or imagined—feelings of helplessness, powerlessness, and insecurity
exist. It is realistic for family members to be anxious, confused, and fearful and to
feel alone with the situation. It is not at all unusual for them to be completely
uninformed when a diagnostic label like this is attached to one of their members.
Their only source of knowledge could be one of hearsay misinformation. There may
also be misperception of correct information provided them at the time of the
diagnosis.
Natural outcomes are feelings of anger and aggression, which can mobilize
members toward constructive actions, thereby reducing feelings of helplessness and
powerlessness. Another outcome may be outwardly destructive behavior, which leads
to increased feelings of helplessness and anger that are compounded by feelings of
guilt. Depression and discouragement are the most common feelings for close
relatives or friends of those with chronic, irreversible diseases. Anger and frustration
leading to rage reactions or internalized toward feelings of suicide are not uncommon
during the progressive course of the illness.
Family members are faced with the need to identify the meaning of the functional
loss of one of their members and what it will mean to each member as family roles
are redefined and functions are redistributed. Until these are dealt with, conflict and
chaos are inevitable. The family system becomes less cohesive and could eventually
break up or disintegrate. Any one role change, subtle or otherwise, almost invariably
leads to change in those of other members. Welcome or unwelcome, planned or
unplanned, a role change can affect each member’s usual ways of thinking, feeling,
and behaving. Feelings in particular strongly affect perceptions and the thinking
processes.
If a parent is affected and children are involved in the caretaking process, role
as
reversal becomes an inevitable problem with which they must deal. This occurs
making
responsibilities and control—from the more abstract, intellectual, decision-
be taken
responsibilities to, eventually, basic physical functions—gradually must
accept because of
from the affected person. This is particularly difficult for many to
nature of its
the relatively early age at which Alzheimer’s occurs and the insidious
of ambivalence,
onset and progress. It would not be unusual to find strong feelings
and the reversal of
anger, and reluctance to accept the loss of the child role
by the fact that
dependency roles with the parent. These feelings are compounded
self-care until the later
the parent may physically appear quite well and capable of
is also to acknowledge
stages of the illness. To accept the reversal in roles
anticipation of an ultimate desertion by death.
feelings as the disease
Family members experience many conflicting and unique
optimism to hopeless despair.
progresses. Emotions may run the gamut from hopeful
variable as is each member’s
All of these emotions are as highly complex and
may be feelings of
perception of the situation and its effect on his own life. There
the caregiving chores
frustration and anger as the caregiver’s patience wears thin and
continue to increase.
Denial is not an uncommon initial response when a person is overwhelmed with

a stressful situation. However, for those who do not cope through the use of denial,
the grief process may begin in anticipation of the loss. The more a person is
emotionally invested in the loved one, the more threatened that person may feel in
anticipation of the loss.
The extraordinary demands of caregiving to a family member with Alzheimer’s
or a related disorder are known to be a source of strain to caregivers. Caregivers are
resentful of behavioral symptoms that they often perceive as demanding or
manipulative, and they often respond with anger or avoidance. Examples of these
patient behaviors include intermittent incontinence, the exaggeration of physical
illness to gain sympathy or to stop the caregiver’s activities, or “putting on a sweet
image in front of other people” while being unpleasant to the caregiver. These
behavioral symptoms were perceived as related to the poor quality of the previous
relationship or the manifestation of the caregiver’s unpleasant temperament
(Jivanjee, 1994).
Caregivers’ perceptions strongly influence their responses to patient behavioral
symptoms, indicating the importance of looking at the meaning of behaviors
for
individual caregivers. Education about the behavior causes and consequen
ces of
dementia may help caregivers to modify their negative responses. Mintzer and
others
(1993) suggest that the agitated behaviors of dementia patients may be triggered,
sustained, or extinguished by elements in the environment. Attitude
change may be
difficult for those who have been in long unhappy relationships,
but with training
these caregivers may increase their understanding of the effects
of environmental
stimuli on patient behavioral symptoms. They may also be able
to modify the home
environment and their own reactions. Caregivers may also increase
their assertive-
ness in dealing with demanding behaviors and benefit from
increased support from
family members.
Social work intervention needs to be available at the
beginning of the caring
Process to support, educate, reduce abrasive situations,
and enhance well-being.
Extensive community education about Alzheimer’s
and related disorders and the
effects of caregiving will help to create awareness and
a higher level of community
support. At the policy level, caregivers’ varied needs
and preferences can be met by
a coordinated array of supportive services includi
ng individual, family, and group
support and low-cost home care, respite, and institut
ional care. Caregivers need
financial support to minimize their overall stress
level and to permit them to obtain
the services they need.
The four phases of grief and mourning are respon
ses to any situation involving
loss, not just the death of a loved one. Families
of patients with Alzheimer’s disease
are faced with prolonged periods of grief and
mourning. This greatly differs from an
overwhelming feeling of grief that gradually
lessens as time passes after a loved one’s
death. Grief and mourning for death is sancti
oned by our society, but overt, prolonged
grief and mourning for a chronically ill person
, particularly one who looks physically
well, are rarely accepted as connected with
death. More often, such mourning may
be perceived as self-pity or weakness.
When the stresses of caring for the affected
person become so great that a family
or personal crisis is precipitated, profession
al counseling may be required to avert
maladaptive problem-solving behavior. The case study that follows depicts a crisis
that was precipitated by a daughter who could not cope with caring for her mother,
who had Alzheimer’s disease.
Case Study Alzheimer’s Disease

Frank was referred to a community crisis clinic by his family physician because of
his increasing symptoms of tension, anxiety, and depression. When he arrived, he
appeared quite tense, with visible hand tremors. The receptionist contacted a
therapist, and Frank was directed to the therapist’s office.
When the therapist asked why he had come to the clinic that day, Frank replied
in a very depressed tone of voice, “My whole world is collapsing around me. My
wife, Molly, is sick, but I’ve been able to handle it—until now. My daughter has
always been such a help, but now she is walking out on us. I just can’t handle much
more; I can’t do it alone.” He became increasingly agitated as he spoke, his voice
rising in anger. After a long pause, he seemed to regain his composure. In response
to direct questioning by the therapist, he slowly described the problem that led up
to this visit to the clinic for help.
Frank said that he and Molly, who were both 56 years of age, had been married
for 20 years. They had one daughter, Kim, who was 17 years old and had just
graduated from high school. He described his family life as “good, no more problems
than most people,” until about a year ago when Molly had to quit her job. She had
worked for the same person all of their married life. When that person retired a year
ago, Molly was reassigned to a new office in the same company. Within a few days,
she began to complain that her new boss was very disorganized and seemed to go
out of his way to find fault with her work. She said that she was even accused of such
ridiculous things as misplacing records and forgetting to tell him of his appointments.
She started going to work earlier and staying later in an effort to “get the boss
organized,” but he continued to criticize and complain about her work. Frank said
that Molly became increasingly irritable, preoccupied, and forgetful at home during
that time. It seemed as though she were scapegoating him and Kim for all of her
problems at work.
Finally, she came home one day and told him that she was given the op-
tion of resigning or being demoted. With Frank’s encouragement, she decided
to resign and take a few weeks’ vacation before looking for another job. Frank
and
hoped that, with time and some rest, she would ‘‘pull herself together
become her cheerful, organized self again.” This, however, was not
eventually
to be the case.
and
As the weeks passed, Molly seemed to become even more disorganized
spoke of looking for a new job. She argued increasing ly,
forgetful. She never again
g her personal items, losing telephone messages,
accusing him and Kim of misplacin
learned to
and so on. Bills were left forgotten and unpaid in her desk until Frank
watch for them in the mail.
these
Neither he nor Kim seemed able to reason with her any longer about
and angry
incidents. Any references to her forgetfulness were met with denial
to cope as best they could with her erratic,
responses. Finally, they learned
irresponsible behaviors. Over time, they gradually took over many of her household
responsibilities.
Molly first displayed overt signs of confusion, disorientation, and memory loss
when she was hospitalized for elective surgery, about 6 months before Frank came
to the clinic. Nurses had found her late at night wandering down the halls in
her bare feet, “looking for her bedroom.” When the nurses suggested that she
had lost her way, she became verbally abusive to them for saying that to her.
Before dawn, she was found fully dressed and sitting on a chair in the hallway.
When questioned, she replied that she was “waiting for Frank to drive her to
work.” Further questioning revealed that she was disoriented as to place, could
not recall the day of the week or her physician’s name, and had forgotten why
she had come to the hospital.
Following this episode, further tests and examinations were completed, and a
diagnosis of Alzheimer’s disease was made. Findings suggested that Molly had
progressed into the early confusional stage.
When asked how he and Kim responded to this news, Frank said that their initial
feelings were quite mixed. “We were glad to finally find a physical reason for her
behavior changes but were shocked and really couldn’t believe that there was no
known cure for it. It made me really angry that this could happen to any of us.”
When it was strongly suggested that Frank contact a local Alzheimer’s support
group for ongoing support and information about Molly’s care at home, Frank saw
no immediate need to do so. To him, Molly appeared quite healthy. As he perceived
it, all that he and Kim would need was “<a little more patience with Molly when she
forgot things or lost her temper.’’ Over time, they had learned to help her avoid
stressful situations, even though it sometimes made life more stressful for them.
Gradually, however, the relationship between him and Kim became distant as he
spent increasing amounts of time away from home at his job.
At first, Kim never complained about having to spend more time at home with
her mother. Neighbors and friends visited often, and she could still leave Molly alone
for brief periods. As Molly’s memory loss increased, however, Molly’s frustration
tolerance decreased. Her unprovoked irritability became much more frequent; soon,
visitors rarely came to see them. At the same time, Kim found herself having to
assume an increasing number of the household roles and responsibilities formerly
held by her mother. Any attempts to bring in a housekeeper or a companion for her
mother were met with overt antagonism from Molly.
Two evenings ago, Frank came home late and was confronted by a tearful, angry
Kim. She told him that she “couldn’t take it anymore” and was going to move out
if he didn’t find someone else to take care of her mother. He said that her outburst
really took him by surprise. When he asked her the cause of this sudden change in
attitude, she angrily responded, “Sudden? There is nothing sudden about this! For
weeks I’ve been telling you how I feel, but you never listen to me anymore. You’re
always too busy at work, and when you come home, you seem to ignore just how
much mother has changed. She’s become like a spoiled, demanding little child. I feel
more like a live-in babysitter than like her daughter. I have no life of my own
anymore—and you don’t seem to care what happens to me!” The conversation was
abruptly ended by Kim leaving the house and slamming the door behind her. She
called her father about an hour later to say that she was going to spend the night at
a friend’s house. She added that she still had a lot to think over but would
be home
the next morning.
Frank said that he never slept that night and that his mind was in a turmoil,
thinking about what Kim had said. He felt shocked and overwhelmed with strongly
ambivalent feelings toward Molly, who slept quietly upstairs in their bedroom. He
said that he “suddenly faced reality—and hated it.” He felt completely alone and
trapped, with no way out of the whole situation. As he described it, “By morning
I had the shakes, couldn’t concentrate on anything, and felt like hell.”
When Kim came back the next morning, neither mentioned what had been said
the night before. He left for his office as quickly as he could. For the next several
hours, he drove his car randomly about the city, thinking about what had been
happening to his life for the past year. It was only then, he said, that he finally faced
the reality that he had lost forever the Molly whom he had loved and married. Now
he was in danger of losing Kim, too. He suddenly felt so overwhelmed with grief that
he pulled the car to the side of the street and parked. He felt so sick and trembled
so severely that he was afraid to drive. As soon as he felt able, he drove directly to
his physician’s office, where he was seen immediately. It was from there that he had
been referred to the clinic.
The therapist’s assessment was that, until his confrontation with Kim, Frank had
successfully used denial to cope with Molly’s illness. This evaluation was supported
by his avoidance of opportunities to obtain more information about Alzheimer’s
disease from one of the local support groups.
As Molly’s symptoms became more overt, he avoided having to ‘“‘do something
about it’”’ by extending his time at work. When Kim tried to communicate her need
for help and understanding, he effectively managed to tune her out. As a result, he
was not consciously lying when he said that he was shocked at the ‘‘sudden change
in Kim’s attitude.”
Frank’s crisis was precipitated by the threatened loss of his daughter and
compounded by unresolved feelings of grief and mourning for the anticipated loss
of his wife. The goals of intervention were to assist Frank to identify and ventilate
his unrecognized feelings about his wife, to help him obtain appropriate situational
supports for himself and Kim as he dealt with plans for Molly’s future care, and to
help him obtain an intellectual understanding of role reversal because it was affecting
Kim’s relationship with her mother.
During the first session, the therapist determined that Frank was not suicidal.
When asked to describe himself as he ‘‘usually was,” he said that he was a person
who prided himself on being able to maintain control over his life. He believed that,
to be successful, a person should be able to set goals and, with good planning, achieve
them. Reflecting further on his feelings about Molly, he admitted to the therapist that,
deep down, he had always believed that Molly could have controlled her behavior
if she had really wanted to do so. He felt that her failure to do so was, in some way,
a personal rejection of him. No longer able to communicate with her about his
feelings, he had used denial and avoidance to cope. As Molly’s condition
deteriorated, he felt more angry and frustrated with her and used his work to justify
the increasing amount of time spent away from home.
With further discussion and reflection about Molly’s behavioral changes, it

became very apparent that Frank had little factual information about Alzheimer’s
disease. When he was first informed by the doctors, his anxiety was so high that he
remembered hearing little other than that her memory loss would continue to get
worse and that there was no cure.
As Molly’s increasing episodes of unprovoked anger increased, their few
remaining friends gradually began to avoid contact with her. Recalling this now with
the therapist, he acknowledged that, in fact, this had been a relief for him. He no
longer had to worry about what she might do or say to their friends if she became
upset.
What he had failed to realize, though, was the added stress that this had placed
on Kim. After further questioning and reflection, he said, “Could it be that I didn’t
listen to Kim because I didn’t want to know? I didn’t want to hear how bad things
had really become?” He paused, and then said softly, ““The Molly that I loved so
much left me long ago. I miss her so much and wish that she could come back, even
for a little while. There’s so much I want to say to her. While I stay away from home,
I can make believe that she’s still there waiting for me. Going home hurts so very
much.”
It was suggested that he contact the local Alzheimer’s support group to learn about
alternative ways available to him for Molly’s care at home. He was made to realize
that, unless he began to face the reality of Molly’s illness and the situation at his
home, he might well lose Kim, too.
When questioned further about his confrontation with Kim the evening before, he
seemed unable to understand why Kim felt so angry about her mother. Further
discussion focused on the way Kim’s roles and responsibilities in the family had
changed during the past few months. As he slowly identified these changes for the
therapist, he began to obtain an intellectual understanding of parent-child role
reversal and its effect on the child, particularly on one as young as Kim.
Gradually he began to recognize Kim’s confrontation for what it was: a cry for
his understanding of what was happening to her. She was overwhelmed by her
inability to meet the ever-increasing dependency needs of her mother without some
help from him. Unable to communicate her own dependency needs to either him or
her mother, she saw escape from the entire situation as her only solution.
It was suggested to Frank that one of his first priorities was to find someone else
to assume major responsibility for Molly’s care and supervision. Until this happened,
he could expect further confrontations with Kim and should not be surprised if Kim
carried out her threat to leave home.
As an interim measure, Frank decided to take a few weeks of long overdue
vacation time and stay home to help out until he could find someone to provide
full-time help with Molly’s care.
During the second session, Frank appeared much more optimistic as he described
his past week at home. He said that he and Kim had talked together “for hours” the
evening after his first session at the clinic. He reflected that it had been difficult at
first for both of them to face the other with their feelings. ‘“But,” he added, “‘it was
such a relief when we did. Until then, neither of us had realized just how far apart
we had become and how much we needed to stick together to work things out.”
During the past week, Frank also contacted the local Alzheim
er’s support group.
By prearrangement, two members visited his home to
meet with him, Kim, and
Molly. He recalled his surprise at how easily Molly appeare
d to accept the “‘strang-
er’s”’ visit and the apparent ease with which they included her
in the conversation. As
a result of the visit, appropriate resources were identified for
assistance in Molly’s
care. After several interviews with applicants for a housekeeper’s
position and with
Molly’s agreement, they finally hired a woman who seemed best
able to cope with
Molly’s needs. The woman moved in 2 days before this session
and, he reported,
“Molly hasn’t scared her off yet.” However, he would continue to remain
at home for
another week to help Molly adjust to any new changes in her daily activiti
es.
Frank and Kim also attended a meeting of the local Alzheimer’s group. It surprised
them both to find several other young people of Kim’s age present. When
asked to
describe his feelings about the meeting, he said that both he and Kim went to
the
meeting “not expecting much, maybe coffee, cake, and sympathy, but that’s all.”
Instead, they found a group of people who, he said, seemed to know exactly what
his family had been going through. He learned that many of his experiences were not
unique but common to all of them. “For the first time,” he said, ‘“‘I was able to get
some answers that were useful to us. Maybe no one could tell us why she got this
disease, but this group of people could give me some good suggestions on how to
help all of us deal with it.” Most important for both him and Kim, as they left the
meeting, was their feeling that they were no longer alone with their problems and
that now a support group was available to them as problems arose.
Before the end of the session the therapist and Frank reviewed and assessed the
adjustment that he had made and his insights into his own feelings about Molly and
the effects of her illness on his future. They also discussed his understanding of the
effect that the process of role reversal with her mother was having on Kim. It was
strongly suggested that he encourage Kim’s continued attendance at the Alzheimer’s
group meetings. The purpose was to provide her with ongoing peer support as she
dealt with her changing relationship with her mother.
He was commended for taking direct action during the past week and for obtaining
appropriate resources to help him with his ongoing situation at home. Such action
strongly suggested that he no longer was coping solely through denial and avoidance
but was making a conscious effort to perceive the situation realistically. Frank was
encouraged to continue to be more direct in his communications with Kim and to let
her know that he was recognizing that she had needs, too. Before termination he was
reassured that he could return for help with any future crises should the need arise.
Frank had used denial and avoidance as methods for coping with his feelings about
Molly’s illness and eventual death. Kim saw his behavior as a rejection of her efforts
to communicate to him the realities of her mother’s deteriorating condition and its
effect on her own unmet dependency needs. Failing to recognize the extent to which
the process of role reversal with her mother had affected Kim’s life, Frank perceived
her threat to leave home as yet another rejection and threatened loss of someone close
to him. Lacking any previous coping experience with his new role demands, his
anxiety and depression increased to an intolerable level; Frank was in a state of crisis.
Intervention focused on helping him to identify and understand his unrecognized
feelings toward Molly, to obtain an intellectual understanding of the effects of role
because
reversal on Kim, and to obtain appropriate situational supports for the family
and as a unit, would undoubtedly be confronted with more
they, individually
stress-provoking situations as Molly’s illness progressed.
Old age and the wear of time teach many things.
—Sophocles Se ee
ECR ON EE
Complete the paradigm in Figure 8-4 based on this case study, then compare it with
the completed one in Appendix D. Refer to the paradigms in Chapter 3 as needed.
Suicide
SUICIDE IN ADOLESCENCE
Suicide is the eighth leading cause of death in the United States; it is the third leading
cause of death for young indiyiduals 20 to 24 years of age and the third leading cause
for adolescents 15 to 19 years of age (National Institute of Mental Health, 1996).
Youth suicide is clearly a significant public health problem in the United States
worthy of the concern and attention of parents, educators, and mental health
professionals. The suicide rate for people 15 to 24 years of age has more than tripled
over the last 30 years. Suicide rates for individuals 15 to 19 years of age increased
from 8.7:100,000 to 14.96: 100,000 in 1994. It is suspected that the actual suicide
rate among young people is even higher than reported. In a review of coroners’
reports for all suicides, undetermined cause of death, and questionable accidents over
a period of 24 years, it was concluded that suicides were underreported by
approximately 24% (Ladely and Puskar, 1994). The Statistical Abstract of the United
States (1995) lists suicide as 33.6:100,000 deaths in the population.
Now approaching epidemic proportions, suicide is currently the third leading
cause of death among teenagers in the United States. It is estimated that 300 to 400
teen suicides occur per year in Los Angeles County; this is equivalent to one teenager
lost every day. Evidence indicates that for every suicide, there are 50 to 100 attempts
at suicide (Student Health and Human Services Divisions, 1996). Due to the stigma
associated with suicide, these statistics may well be understating the problem.
Nevertheless, these figures do underscore the urgent need to seek a solution to the
suicide epidemic among our young people.
The majority of adolescent suicide completers exhibit symptoms of some
psychiatric disorder before their deaths, although only a small percentage ever
received mental health treatment. The focus for suicide prevention programs clearly
must be on the ability of parents and teachers to recognize symptoms that indicate
that the adolescent may be at risk for suicidal behaviors. Adults should look for
sudden changes in the adolescent’s behavior that are significant, last for a long time,
and are apparent in all or most areas of his life (pervasive). Parents, teachers, and
mental health professionals should be alert to the danger signs of suicide listed as
follows:
¢ Previous suicide attempts
¢ The verbalization of suicide threats
CASE STUDY: FRANK
PLUS AND
PLUS AND
; RESULT IN
The giving away of prized personal possessions

* The collection and discussion of information on suicide methods
* The expression of hopelessness, helplessness, and anger at oneself or the
world :
Themes of death or depression evident in conversation, written expressions,
reading selections, or artwork
Statements or suggestions that the speaker would not be missed if he were
gone
The scratching or marking of the body or other self-destructive acts
* Recent loss of a friend or a family member (or even a pet) through death
or suicide; other losses, for example, the loss of a parent resulting from
divorce
* Acute personality changes, unusual withdrawal, aggressiveness, or moodi-
ness; new involvement in high-risk activities
* Sudden dramatic decline or improvement in academic performance, chronic
truancy or tardiness, or running away
Physical symptoms such as eating disturbances, sleeplessness or excessive
sleeping, chronic headaches or stomach aches, or apathetic appearance
* Use or increased use of substances
When a child or adolescent talks of suicide you should:
* Listen. Encourage the child to talk to you or some other trusted person. Listen
to the child’s feelings. Don’t give advice or feel obligated to find simple solu-
tions. Try to imagine how you would feel in the child’s place.
Be honest. If the child’s words or actions scare you, tell him. If you’re worried
or don’t know what to do, say so. Don’t be a cheerful phony.
Share feelings. At times everyone feels sad, hurt, or hopeless. You know what
that is like; share your feelings. Let the child know he is not alone.
Get help. Professional help is crucial when something as serious as suicide is
considered. Help may be found at a suicide prevention or crisis center, local
mental health association, or through clergy. Become familiar with the suicide
prevention program at the child’s school. Contact the appropriate person or
persons at the school. Knowledge that help is available to him means that he is
unlikely ever to reach a time in life during which he perceives suicide to be
the only option. Remind him that suicide is a permanent solution to a tempo-
rary problem.
SUICIDE IN MIDLIFE
Midlife is usually a time when power peaks. By age 40 most of us are pretty much
what we are ever going to be, with a few notable exceptions. Most developmental
social psychologists have focused on early childhood not on midlife development.
At roughly ages 40 to 45 we need to make changes in our life dreams that will modify
existing early adult life structure, to appraise the past and rid ourselves of our
illusions, accommodate other given life changes (such as divorce, job plateauing,
children leaving home, diminished life energies, and job shifts), turn more inward
and be less concerned with mastery of the external environment, and resolve four
basic polarities (ice., young-old, creation-destruction, masculi

ne-feminine, and
attachment-separation). At midlife we need to modify our
dream and realize that
success does not necessarily entail happiness.
Middle age people are not as observable as the dependent young
or the elderly
nor are they usually in schools or institutions. Those of us in midlife
tend to be
society’s guardians and accordingly are routinely not ourselves
guarded. When
middle age people get into trouble, often no one is even watching or
expecting it.
Some subtypes of midlifers that require special assessment for their suicidal
potential follow (Maris, 1995).
* Executive suicides, especially males who tend to be “control freaks,” au-
thoritarian, and rigid thinkers, including police officers
Menopausal females, who may perceive themselves as having outlived
or grown weary of their reproductive and nurturing usefulness or
responsibilities
Younger midlife urban inner city African-Americans, who are often angry
(rageful), drug and alcohol abusers, are estranged from their families, and
are inclined to violence
AIDS patients (and others with physical impasses and little future or hope,
€.g., cancer and heart disease patients) (Note that most of the physically ill
do not resolve their life problems by suiciding.) ;
The pseudodeveloped, who tend to be stagnated and have accumulated ex-
cessive developmental debits, are chronically depressed, and are chrono-
logically older than their achievements or emotional maturity
Midlife males in crisis or burnout, who have estranged adult children and
spouses, are often substance abusers, and have work and economic prob-
lems concomitant with interpersonal and sexual problems
Of course, some of these midlife suicidal types overlap, and one has to consider
the 15 or so generic predictors of suicide, as well as the more ad hoc characteristics
of a particular midlife suicidal type. Many of these types of midlife suicide are poorly
understood and are underresearched. One consequence is that some important types
of midlife suicide may have been overlooked. Shneidman (1992) likes to say that the
“four letter word”’ in suicidology is “‘only,”’ as in, “It was the only thing I could do.”
RELATED FACTORS
Age and gender. Statistics indicate that women attempt suicide more often than
men but that men commit suicide more often than women. Currently, this trend is
changing because women are beginning to feel the same stresses in their changing
social roles that men feel. They are also beginning to use more lethal methods in their
suicide attempts. It is also known that the rate for completed suicide rises with
increasing age. Consequently, an older man presents the greatest threat of actual
suicide and a young woman the least. Within this framework, age and sex offer a
general, although by no means clear-cut, basis for evaluating suicidal potential. One
must remember that young women and young men do kill themselves, even when
their original aim is to manipulate other people. Each case requires individual
appraisal.
most
Suicidal plan. How an individual plans to take his life is one of the
the
significant criteria in assessing suicidal potential. The therapist must consider
following three elements.
1. Is it a relatively lethal method? An individual who intends to commit suicide
with a gun, by jumping from a tall building or bridge, or by hanging is a far
greater risk than someone who plans to take pills or cut his wrists. Be-
cause the person who plans either of the latter two methods is amenable to
treatment or resuscitation, these methods are less lethal than the irrevocable
consequences of putting a gun to one’s head.
2. Does the individual have the means available? It must be determined if the
method of suicide the individual has considered is in fact available to him.
A threat to use a gun, if the person has one, is obviously more serious than
the same threat without a gun.
3. Is the suicide plan specific? Can the individual say exactly when he plans to
do it (e.g., after the children are asleep)? If he has spent time thinking out de-
tails and specific preparations for his death, his suicidal risk is greatly in-
creased. Changing a will, writing notes, collecting pills, buying a gun, and
setting a time and place for suicide suggest a high risk. When a patient’s plan
is obviously confused or unrealistic, the therapist should consider the possi-
bility of an underlying psychiatric problem. A psychotic person with the idea
of suicide is a particularly high risk because he may make a bizarre attempt
based on his distorted thoughts. The therapist should always find out if the
patient has a history of any emotional disorder and whether he has ever been
hospitalized or received other mental health care.
Stress. The therapist needs to find out about any stressful event that may have
precipitated the suicidal behavior. The most common precipitating stresses are losses:
the death of a loved one; divorce or separation; loss of a job, money, prestige, or
status; loss of health through illness, surgery, or accident; and loss of esteem or
prestige because of possible prosecution or criminal involvement. Not all stresses are
the result of bereavement. Sometimes increased anxiety and tension are a result of
success, such as a promotion with increased responsibilities. Always investigate any
sudden change in the individual’s life situation. Learning to evaluate stress from the
individual’s point of view rather than from society’s point of view is necessary. What
may be minimal stress for the therapist could be perceived by the patient as severe
stress. The relationship between stress and symptoms is useful in evaluating
prognosis.
Symptoms. The most common and most important suicidal symptoms relate to
depression. Typical symptoms of severe depression include loss of appetite, weight
loss, inability to sleep, loss of interest, social withdrawal, apathy and despondency,
severe feelings of hopelessness and helplessness, and a general attitude of physical
and emotional exhaustion. Other persons may exhibit agitation through such
symptoms as tension; anxiety; guilt; shame; poor impulse control; or feelings of rage,
anger, hostility, or revenge. Alcoholics and all other substance abusers tend to be high
suicidal risks. The patient who is both agitated and depressed is particularly at high
risk. Unable to tolerate the pressure of his feelings, the individual in a state of agitated
depression shows marked tension, fearfulness, restlessness, and pressure of speech.
He eventually reaches a point where he must act in some direction

to relieve his
feelings. Often he chooses suicide.
Suicidal symptoms may also occur with psychotic states. The patient
may have
delusions, hallucinations, distorted sensory impressions, loss of contact
with reality,
disorientation, or highly unusual ideas and experiences. As a baseline for assessing
psychotic behavior, the therapist should use his own sense of what is real
and
appropriate.
Resources. The patient’s environmental resources are often crucial in helping
the therapist decide how to manage the immediate problem. Who are his situational
supports? The therapist must find out who can be used to support him through this
traumatic time: family, relatives, close friends, employers, physicians, or clergy. To
whom does he feel close? If the patient is already under the care of a therapist, the
new therapist should try to contact him.
The choice of various resources is sometimes affected by the fact that the patient
and the family may try to keep the suicidal situation a secret, even to the point of
denying its existence. As a general rule, this attempt at secrecy and denial must be
counteracted by dealing with the suicidal situation openly and frankly. It is usually
better, for both the therapist and the patient, if the responsibility for a suicidal patient
is shared by as many people as possible. This combined effort provides the patient
with a feeling that he lacks: that others are interested in him, care for him, and are
ready to help him.
When there are no apparent sources of help or support, the therapist may be the
person’s only situational support, his one link to survival. This is also true if available
resources have been exhausted or family and friends have turned away from the
individual. In most cases, however, people will respond to the situation and provide
help and support if given the opportunity.
Lifestyle. How has the person functioned in the past under stress? First, has
his style of life been stable or unstable? Second, is the suicidal behavior acute
or chronic? The stable individual describes a consistent work record, sound marital
and family relationship, and no history of previous suicidal behavior. The unstable
individual may have had severe character disorders, borderline psychotic behavior,
and repeated difficulties with major situations, such as interpersonal relationships
or employment.
A suicidal person responding to acute stress, such as the death or loss of
someone he loves, bad news, or loss of a job, presents a special concern. The
risk of early suicide among this group is high; however, the opportunity for
successful therapeutic intervention is greater. If the suicidal danger can be averted
for a relatively short period, individuals tend to emerge without great danger of
recurrence.
By contrast, individuals with a history of repeated attempts at self-destruction
may be helped through one emergency, but the suicidal danger can be expected
to return at a later date. In general, if an individual has made serious attempts
in the past, his current suicidal situation should be considered more dangerous.
Although individuals with chronic suicidal behavior benefit temporarily from
intervention, the emphasis should fall more on continuity of care and the
maintenance of relationships.
Acute suicidal behavior may be found in either a stable or an unstable personality;

however, chronic suicidal behavior occurs only in an unstable person. In dealing with
a stable person in a suicidal situation, the therapist should be highly responsive and
active. With an unstable person, the therapist needs to be slower and more thoughtful,
reminding the patient that he has withstood similar stresses in the past. The main
goals are to help him through this period and assist him in reconstituting an
interpersonal relationship with a stable person or resource.
Communication. The communication aspects of suicidal behavior have great
importance in the evaluation and assessment process. The most important question
is whether communication still exists between the suicidal individual and his
significant others. When communication with the suicidal patient is completely
severed, it indicates that he has lost hope of any possibility of rescue.
The form of communication may be either verbal or nonverbal, and its content
may be direct or indirect. The suicidal person who communicates nonverbally and
indirectly makes it difficult for the recipient of the communication to recognize or
understand the suicidal intent of these communications. Also, this type of
communication in itself implies a lack of clarity in the interchange between the
suicidal person and others. At the same time, it raises a danger that the individual may
act out suicidal impulses. The primary goal is to open up and clarify communication
among everyone involved in the situation.
The patient’s communications may be directed toward one or more significant
persons within his environment. He may express hostility, accuse or blame others,
or demand openly or subtly that others change their behavior and feelings. His
communication may express feelings of guilt, inadequacy, and worthlessness or
indicate strong anxiety and tension.
Significant other. When the communication is directed to a specific person,
the reaction of the recipient becomes an important factor in evaluating suicidal
danger. One must decide if the significant other can be an important resource
for rescue, if he is best regarded as unhelpful, or if he might even be injurious
to the patient.
The unhelpful significant other either rejects the patient or denies the suicidal
behavior itself by withdrawing, both psychologically and physically, from continued
communication. Sometimes this other person resents the patient’s increased
demands, insistence on gratification of dependency needs, or the demands to change
his own behavior. In other situations the significant other may act helpless,
indecisive, or ambivalent, indicating that he does not know what the next step is and
has given up. A reaction of hopelessness gives the suicidal individual a feeling that
aid is not available from a previously dependable source. This can increase the
patient’s own hopelessness.
By contrast, a helpful reaction from the significant other is one in which the other
person recognizes the communication, is aware of the problem, and seeks help for
the individual. This indicates to the patient that his communications are being heard
and that someone is doing something to provide help (Yu-Chin and Arcuni, 1990).
In the following case study, Carol attempted suicide because of lack of
communication with a significant other. She anticipated a rejection because of a
similar past experience.
Case Study
cee Suicide
ee eecie.
Carol was referred to a crisis center for help by a physician in the emergency
room
of a nearby small suburban hospital. The night before, she had attempted
suicide by
severely slashing her left wrist repeatedly with a large kitchen knife, and
she had
severed a tendon as a result.
When she was first seen by the therapist at the center, her left wrist and arm
were
heavily bandaged. She appeared tense, disheveled, very pale, and tremulous
. She
described her symptoms as insomnia, poor appetite, recent inability to concentrat
e,
and overwhelming feelings of hopelessness and helplessness. Carol, a 30-year-o
ld
single woman, lived alone. She had come to a large midwestern city about 4 years
ago, immediately after graduating from an eastern university with a master’s degree
in business administration. Within a few weeks she had obtained a management
trainee position with a large manufacturing distribution company. During the next 3
years, she advanced rapidly to her current position as manager of the main branch
office. She stated that her co-workers considered her highly qualified for the position.
She denied any on-the-job problems other than “the usual things that anyone in my
position has to expect to deal with on a day-to-day basis.” As a result of her rapid
rise in the company, however, she had not allowed herself much leisure time to
develop any close. social relationships with either sex.
About a year ago, Carol met John, a 40-year-old widower who had a position
similar to hers with another company. His office was on the same floor as hers. Within
a few weeks, they were spending almost all of their leisure time together, although
still maintaining separate apartments.
Carol’s symptoms began about 2 weeks ago, when John was offered a promotion
to a new job in his company, which he accepted before mentioning it to her. It meant
that he would be transferred to another office about 30 miles away in the suburbs.
She stated that she did feel upset “‘for just a few minutes” after he told her of his
decision; “‘I guess that was just because he hadn’t even mentioned anything about
it to me first.”
They went out that evening for dinner and dancing to celebrate the occasion.
Before dinner was over, John had to bring her home because she “suddenly became
dizzy, nauseated, and chilled” with what she described as “all of the worst symptoms
of stomach flu.”
Carol remained at home in bed for the next 3 days, not allowing John to visit her
because she felt she was contagious. After she returned to work, she continued to feel
very lethargic, had difficulty concentrating, could not regain her appetite, ‘‘and felt
quite depressed and tearful for no reason at all.’’ Convincing herself that she had not
yet fully recovered from the “‘flu,” she canceled several dates with John so that she
could get more rest. She described him as being very understanding about this, even
encouraging her to try to get some time off from work to take a short trip by herself
and really rest and relax.
During this same time, John had begun to spend increasing amounts of time at
his new office. Their coffee break meetings at work became very infrequent. Within
the next week, he expected to be moved completely. The night before Carol came
to the Crisis Center, she had come home from work expecting to meet John for
that
dinner; instead, she found a note under her door written by her neighbor. It said
John had telephoned him earlier and left word for her that he had “‘suddenly been
called out of town—wasn’t sure when he would be back but would get in touch with
her later.”
She told the therapist, “Suddenly I felt empty . . . that everything was over
between us. It was just too much for me to handle. He was never going to see me
again and was too damned chicken to tell me to my face! I went numb all over—I
just wanted to die.” She paused a few minutes, head down and sobbing, then took
a deep breath and went on, “I really don’t remember doing it, but the next thing I
was aware of was the telephone ringing. When I reached out to answer it, I realized
[had a butcher knife in my right hand and my left wrist was cut and bleeding terribly!
I dropped the knife on the floor and grabbed the phone. It was John calling me from
the airport to tell me why he had to go out of town so suddenly—his father was
critically ill.”
Through the sobs she told him what she had done to herself. He told her to take
a kitchen towel and wrap it tightly around her wrist. After she had done that, he told
her to unlock the front door and wait there, that he would get help to her.
He immediately called the neighbors, who went to her apartment and found her
with blood soaked towels around her wrist and sitting on the floor beside the door.
They took her to the hospital, and John continued on his trip. After being treated in
the emergency room, Carol went home to spend the night with her neighbors. They
drove her to the Crisis Center the next morning.
During her initial session, Carol told the therapist that she had no close relatives.
Her father and mother had died within a few months of each other during her last
year in college. Soon after, she had fallen in love with another graduate student, and
at his suggestion they had moved into an apartment together. She had believed that
they would marry as soon as they had both graduated and had jobs.
Just before graduation, however, her boyfriend had come home and informed her
that he had accepted a postdoctoral fellowship in France and would be leaving within
the month. They went out for dinner “‘to celebrate’’ that night because, she said, “I
couldn’t help but be happy for him—it was quite an honor—I just couldn’t tell him
how hurt I felt.”
The next morning after he had left for classes, she stated that she ‘“‘suddenly
realized I would never see him again after graduation—that he had never intended
to marry me—and I was helpless to do anything about it.”” She took some masking
tape and sealed the kitchen window shut, closed the door and put towels along the
bottom, and turned on all of the stove gas jets.
About an hour later, a neighbor smelled the gas fumes and called the fire
department. The firemen broke into the apartment, found her lying unconscious on
the floor, and rushed her to the hospital. She was in a coma for 2 days and remained
in the hospital for a week. Her boyfriend came only once to see her. When she
returned to the apartment, she found that he had moved out, leaving her a note saying
that he had gone home to see his family before leaving for France. He never contacted
her again. A month later Carol moved to the Midwest.
For the first few months after meeting John, Carol was very ambivalent about her
feelings toward him. She frequently felt very anxious and fearful that she was
“setting myself up for another rejection.” Even when John proposed marriage,
she found herself unable to consider it seriously and told him that they
should
wait a while longer “to be sure that they both wanted it.” Continuing, she
stated,
“Until about 2 days ago I had never felt so secure in my life. I’d begun to seriously
consider proposing to him! Then, suddenly, the bottom began to fall out
of
everything.”
When John accepted the new job without telling her first, Carol saw this as the
beginning of another rejection by someone highly significant in her life. As her
anxiety increased, she withdrew from communication with John “because of her
flu.” John’s well-intentioned agreement to cancel several dates so that she could get
more rest further cut off her opportunities to communicate her feelings to him. His
suggestion that she take a trip alone compounded her already strong fear of imminent
rejection by him.
Finding the neighbor’s note under the door was, for her, “the last straw,” final
proof that he was leaving her, “just like her boyfriend did in college.” Unable to cope
with overwhelming feelings of loss and anger toward herself for “letting it happen
to her again,” she impulsively attempted suicide.
Carol’s two suicide attempts, except for the method used, were quite similar. Both
were precipitated by the threat of the loss of someone highly significant in her life;
both were impulsive, maladaptive attempts to cope with intense feelings of
depression, hopelessness, and helplessness; and both demonstrated an inability to
communicate her feelings in stressful situations. When asked by the therapist how
she coped with anxiety in the past, Carol said that she would keep herself so busy
at work that she did not have much time to worry about personal problems. This had
been her method of coping with anxiety at school, too, until her first suicide attempt.
Because she had been too ill to work full time the past 2 weeks, her previous
successful coping mechanisms could not be effectively used.
The goal of intervention was to help Carol gain an intellectual understanding of
the relationship between her crisis and her inability to communicate her intense
feelings of depression and anxiety caused by the threat of losing John.
Before the end of the first session, the therapist’s assessment was that Carol was
no longer acutely suicidal. However, because of her continuing feelings of
depression, a medical consultation was arranged and an antidepressant prescribed. A
verbal contract was agreed on; Carol was to call the therapist if she felt suicidal again.
Carol agreed to the suggestion that she have a friend move into her apartment to help
her out until her arm was less painful. Before leaving, she assured the therapist that
she would call him immediately if she again began to feel overwhelmed by anxiety
before her next appointment.
When Carol returned for her next session, she was markedly less depressed. She
told the therapist that John had called her soon after she came home from the center
the week before. Although he had expressed great concern for her, she had been
unable to tell him exactly why she had attempted suicide. “I just couldn’t tell him
that I thought he had left me for good. He’d think that I was trying to blame him.
After all, I’ve been telling him for months that we both should keep our
independence!”’ However, she said she felt much more reassured of his love for her.
John expected to be back in about 2 more weeks.
During this and the next few sessions, the therapist explored with Carol why she
found it difficult to communicate her feelings to someone so significant in her life.
Carol was reluctant ‘at first to admit that this was a problem that could have
contributed to her recent crisis. She saw herself as someone who was completely
self-sufficient and denied any dependency needs on John. As a child, she had been
expected to control her emotions, to appear “‘ladylike” and composed at all times.
Efforts on her part to communicate her feelings as she passed through the normal
maturational crises of childhood and adolescence were met with rejecting behavior
from those most significant in her life—her parents. Slowly, she began to gain insight
into the ways in which she had learned maladaptive methods to cope with stress, such
as withdrawing from contact with others whenever she felt threatened by a stressful
situation, by somatizing her anxiety rather than admitting it was more than she could
handle. By the end of the third session, she reported that she had been able to
communicate her feelings to John more openly and honestly than she had ever done
in the past. She appeared to be surprised and pleased that John had responded so
positively to her. When asked what she would have done if he had not responded this
way, she paused thoughtfully, then answered, “‘It was a risk I had to take. I just had
to find out for sure if I could handle it this time.’’ She added that, although she had
been very anxious while talking to him, she at no time felt as though she could not
go on living if things had turned out differently.
By the end of the fourth session, John had returned to the city, and Carol had
returned to her job full time. She no longer felt depressed, and her wrist was slowly
regaining its functioning. They were seeing each other frequently despite the distance
between their offices, and Carol now said that she felt much more comfortable talking
things out with him.
Because Carol had attempted suicide once before under much the same crisis-
precipitating stressful situation, she continued in therapy for the full 6 weeks. The
purpose was to ensure that she could depend on situational support from the therapist
while adjusting to the fact that she would no longer be seeing John every day. She was
encouraged to telephone the therapist at any time she began to feel a recurrence of her
earlier symptoms and felt unable to communicate these feelings to John.
Because she now seemed to have a better understanding of the relationship
between her suicide attempts and the precipitating events, she said that she felt more
secure in being able to cope with stressful situations in a more positive manner.
Carol’s distorted perception of rejection by John was compounded by her previous
experience in losing someone highly significant in her life. Unable to directly
communicate her feelings to John, her anxiety and depression increased. Lacking
adequate coping mechanisms and situational supports, she became overwhelmed
with feelings of hopelessness and helplessness. Anticipating another rejection, Carol,
entering a state of crisis, impulsively attempted suicide. Intervention was focused on
getting her to understand why she was unable to communicate and cope with her
intense feelings of inadequacy in interpersonal relations.
O death, where is thy sting?
O death, where is thy victory?
—Holy Bible
Se
CASE STUDY: CAROL
ee
a
=.
—_—
PLUS AND
PLUS AND
RESULT IN RESULT IN
Figure 8-5
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ad ife Cycle
bo
iow Stressors
a2
2
U
n overview of the literature relating to life-cycle stressors and coping requires

TaN brief restatement of some definitions of the more pertinent concepts. Life
cycles refer to the various phases of human life from the perinatal period through
approaching death. Stress stimuli (stressors) are threat or loss conditions—
circumstances or situations that produce various degrees of bodily reactions that
indicate that an individual is experiencing stress or a state of stress. Stress, then, is
a set of nonspecific physiological and psychological responses of the body to any
demands made on it, whether these responses are pleasant or unpleasant experiences.
As people proceed through Selye’s general adaptation syndrome, they experience
(1) an alarm reaction that involves marshaling the body resources, (2) a stage of
resistance during which the bodily resistance to the stress response rises above
normal, and (3) a stage of exhaustion during which the adaptation response energy
is used up or dissipated. Persons have adapted positively to the stressor situation
when their bodily alterations have ensured their safety or survival and have increased
their functioning and enjoyment within their environment. They have maladapted
when the bodily responses or alterations have resulted in internal disharmony
(illness) or disharmony between them and their environment.
All people are exposed to a variety of stressors virtually all the time throughout
the course of their life spans. Both pleasant and unpleasant stimuli may produce stress
responses, and individual perceptions of and psychophysiological reactions to these
stimuli may vary quite widely. The problem seems to lie not so much in the fact that
people are exposed continually to life stressors; more accurately, the problem is in
the degree and duration of these stressor situations and in the variable range of
personal responses and capacities to withstand and cope with such stimuli. Although
most people have the capacity to sustain relatively high degrees of stress for short
periods of time, a prolonged stress response or an overly strong stimulus can
be
186
Chapter 9: Life Cycle Stressors 187
maladaptive or destructive. The literature cited in the following sections focuses on

the adaptive capacities of people in several phases of the life cycle beginning with
prepuberty.
Prepuberty
eM
tS SL ea aa
Prepuberty years are characterized as the learning stage; that is, “I am what I
learn” (Erikson, 1959, 1992). The child wants to be shown how to do things
both alone and with others; he develops a sense of industry in which he becomes
dissatisfied if he does not have a feeling of being useful or a sense of his ability
to make things and make them well, even perfectly. He now learns to win
recognition by producing things. He feels pleasure when his attention and diligence
produce a completed work.
Slow but steady growth occurs as maturation of the central nervous system
continues. In terms of psychosexual development, pressure is reduced in the
exploration of sensuality and the gender role while other skills are developed and
exploited.
The cognitive phase of development includes the mastery of skills in manipulating
objects and the concepts of his culture. Thinking enters the period of concrete
operations (Piaget, 1963, 1989), and the ability to solve concrete problems with this
ability increases, so that toward the end of this period the child is able to solve
abstract problems. The solution of real problems is accomplished with mental
operations that the child was previously unable to perform. By puberty, the child
exhibits simple deductive reasoning ability and has learned the rules and basic
technology of his culture, thus reinforcing his sense of belonging in his environment.
Self-esteem is derived from the sense of adequacy and the beginning of ‘‘best”’
friendships and sharing with peers. This also marks the beginning of friendships and
loves outside the family, as he begins to learn the complexities, pleasures, and
difficulties of adjusting himself and his drives, aggressive and erotic, to those of his
peers. By learning and adjusting, he begins to take his place as a member of their
group and social life. In making this adjustment, he seeks the company of his own
sex and forms groups and secret societies. The gangs and groups, especially with
boys, fight each other in games, baseball, and cops and robbers, working off much
hostility and aggression in a socially approved manner (Homonoff, 1991).
Feelings of inadequacy and inferiority may begin if the child does not develop a
sense of adequacy. Family life may not have prepared him for school, or the school
itself may fail to help him develop the necessary skills for competency. As a result,
he may feel that he will never be good at anything he attempts.
In general, children are better able to cope with stress when normal familial
supports are available. Any real or imagined threat of separation from a nuclear
family member could drastically reduce a child’s abilities to cope with new or
changing psychosocial demands. Children are particularly vulnerable to crisis-
precipitating situations such as the loss of a parent through death. Equally as stressful
are recurring partial losses of a parent from the child’s usual environment. Examples
of the latter are repeated episodes of parental hospitalization or frequent, extended
absences from home by one or both parents (Cassell, 1991).
An increasingly common source of emotional distress for children of this age

group is the entry or reentry of the “homemaker” parent into the work field. This
major change in the parenting role demands reciprocal changes in the child’s role.
For some children, externally imposed demands to assume increased independence
and responsibility for self may be more than the child is maturationally able to cope
with. Not yet able to assume the level of expected independence, the child may
actually perceive this action as a form of rejection by the parent.
A common symbol of this role change is the home “latchkey”’ that is bestowed
upon the child, much like a rite of passage and with the accompaniment of new social
rules and regulations. In general, such rules and regulations focus on protection of
the child and the home, with the child given implicit or explicit responsibility for
ensuring that neither is violated in the parent’s absence.
The following case study is about an 8-year-old boy for whom the latchkey
symbolizes only rejection.
Case Study Prepuberty

Billy B, 8 years old, was referred with his mother to the school counseling
psychologist by his homeroom teacher. For the past few weeks, she reported, Billy
had changed from his usual cheerful, outgoing, alert behavior to moodiness and
apparent preoccupation. He was falling behind in his schoolwork, and twice during
the past week he had failed to return to his classes after the lunch hour. The first time
that he had done this, the school had contacted his mother at her place of work. She
told them that Billy had already telephoned her from home. He told her that his
stomach was upset, so he had decided to go home and call her from there. She was
planning to go directly home when the call came from the school.
Yesterday, the counselor was told, Billy again failed to return to his classes
after the lunch hour. This time he did not call his mother, and he did not go
home. After being notified by the school, his mother had telephoned home. She
thought that Billy would be there, as before. Failing to get any answer, she went
directly home from work to begin looking for him around the neighborhood. About
an hour later, while making his routine security rounds, the apartment house
custodian heard muffled sounds coming from a basement stairway and went to
investigate. He found Billy crouched on the top steps, his head on his knees and
sobbing. He was taken immediately to his mother. When questioned, he denied
having been threatened by anyone or being injured, and he showed no signs of
physical abuse. He refused to say why he had left school early again, or why
he had not gone directly home.
Mrs. B immediately called the school and told them that Billy had been located
and was safe. She was asked, and agreed, to come to school the next day with Billy
to meet with his homeroom teacher. At the teacher’s request, during the meeting the
following day a referral was made for Billy and his mother to meet with a counseling
psychologist.
Billy was seen initially without his mother present. He was average in height and
weight, appeared physically healthy, although pale, and spoke hesitantly. He
sat
slouched in his chair, his eyes downcast, and appeared rather depressed. When asked
why he had left school without permission twice that week, he muttered,
“I don’t
know what everyone is so excited about. I can take care of myself—ask my

mother—I can go home alone because I have the house key and can get in when my
mother isn’t home.”
He stated that he had always liked school, got A’s and B’s, particularly enjoyed
gym and outdoor sports, such as soccer and football. Until a week ago, he had
attended an afterschool boys’ sport group with many of his friends. This, however,
had been suddenly canceled when the group director had resigned and moved to
another city. He also said that his parents had been divorced when he was “a little
kid” (4 years old) and that he now lived with his mother. He had frequently visited
with his father, who lived nearby, until about 4 months ago. At that time his father
had remarried and, a month later, his father’s company had transferred him out of
state.
After seeing Billy alone, the counselor talked to Mrs. B to verify and clarify this
information and to assess her feelings about his problems and her ability to cope with
them. Mrs. B was a tall, attractive, well-dressed woman who gave the impression that
she was deeply concerned about the recent changes in Billy’s behavior. She stated
that Billy, an only child, had always been considered “‘well-adjusted,”’ got along well
with his friends, and, until recently, could always be depended on to keep up with
his schoolwork. She went on to say that she and the boy’s father had been particularly
concerned about what effect their divorce might have on him. They had met regularly
with a family therapist during that period to help Billy through their separation and
eventual divorce.
Mrs. B had met her husband in college, and they had married right after
graduation. He was an electronics engineer and. she had majored in business
administration. During the 3 years before Billy was born, she had advanced to
a well-paying position as administrative assistant to the director of a large
advertising company. When she learned that she was pregnant, she arranged to
take a 6-month leave of absence after his birth. However, as she described it
to the counselor, Billy was not a healthy baby and seemed to have one medical
problem after another for more than 2 years. She described Billy’s father as very
possessive and domineering whenever they had decisions to make about Billy’s
care. “In fact,’ she said, “‘when the time came that I felt that I could safely
leave Billy with a sitter and go back to work, it became clear to me that our
marriage was in for a lot of rocky days.”
After many days of arguing and eventual compromise, they agreed that she would
return to work on a part-time basis and only if they were both satisfied that the
babysitter was giving Billy the best of care.
Furthermore, the father completely refused the idea of a day nursery, insisting that
they get a sitter to come to their home, stating, “It’s his home as much as it is ours,
and he is entitled to be here—not in some stranger’s house where I can’t check up
on things whenever I want.”
By the time Billy was 3 years old, his mother reported, both parents realized that
he was being emotionally “Ping-Ponged” between them and that her returning to
work, even for a day, would always be a point of conflict. Her husband had grown
up in a very patriarchal family, with his mother never daring even to dream of any
other role than that of ‘Kinder, Kirche, und Kuche.” Considering any other role for
his wife, now that they had a family, was difficult for him.
By contrast, Billy’s mother had grown up in a family that encouraged equal rights
for women. Her mother was a practicing attorney while rearing four children, and
her father had managed a produce company. She just could not understand why she
and her husband were having so many conflicts with only one child. By the time Billy
was 4 years old, they had separated, and they were eventually divorced when he was
5. The final decree provided Mr. B with ample visitation rights, and they shared
equally the responsibility for child support funds.
Until 4 months ago, Billy’s mother had been able to manage on part-time work
and was able to be home each day when he returned from school. However, earlier
this year Mr. B had remarried and, when he transferred out of the state 4 months
ago, he was more than 6 months delinquent in payments for his share of child
support. Being, as she put it, ‘‘a very realistic person,” Mrs. B decided that she
could no longer depend on Billy’s father for regular payments in the future. Three
months ago she went to her boss and asked if she could be reassigned to full-time
work on an ongoing basis as soon as possible. She stated that Billy had never
expressed any particularly negative feelings about his father remarrying and
moving away, only that he would miss seeing him as often as he had in the
past. She had taken particular care in planning with Billy for her return to full-time
work. She knew, for example, that she would not be able to be home before
he got back from school at the end of the day, so they planned for him to join
an afterschool supervised sport group. This was one that would pick him up at
the school and return him to his home by suppertime each day. ‘‘By that time,”
she said, “I would be home and he wouldn’t come home to an empty apartment.”
This, she felt, also took care of her worry about his playing unsupervised in the
neighborhood without her there to “keep an eye on things.”
Three weeks ago Mrs. B had started her full-time work. She had always managed
to get home before Billy returned from the sports group. She thought that they would
have no major changes for either of them to adjust to. One week ago, however, the
director of the sports group suddenly resigned without notice. A replacement had not
yet been found, and the group had been temporarily canceled. As the only interim
choice that she could think of, Mrs. B decided to give Billy his own key to the
apartment.
Worried about all of the real and imagined things that might happen to him before
she got home, she accompanied the key with many admonishments about coming
directly home from school, checking in with the apartment manager, and being sure
to keep the door locked until she got home. She said that Billy did not seem to object
to this at all. In fact, he had purchased a key chain to hook on his belt just like the
one the building manager wore.
When the school called her the first time Billy cut classes and went home,
she had counseled him to remain at school the next time he felt ill, and she would
pick him up there. She had told him that he must “never go home alone again
without first telling her or someone at the school. I don’t like the idea of your
being alone and sick. You know I would worry about you.” She had also reminded
him that they had planned this together and that they both had certain respon-
sibilities to each other in working out this new living schedule. “Neither of
us
had much choice in this, you know,” she told the counselor. “I’m making the
best of things that I know how, and Billy is just going to have to cooperate.
I just don’t know why he is acting this way now.”
The sudden, rapid changes in Billy’s life during the past few months had forced
him into assuming a degree of independence and self-responsibility beyond his
maturational level of skills. Not yet accepting the loss of his father and perceiving
it as a rejection of himself, he was forced into full dependence on his mother
for any sense of security and all decision making. The timely entrance into the
after-school sports group had provided him with opportunities to express his
feelings of anger and hostility about the situation through the competitive,
aggressive sports activities with his peers. Unfortunately, the group was canceled
about the same time his mother started her new job, and he lost his normal outlet
for expressing such feelings. Not only did he lose the situational support of his
peers when he most needed it, but also he had the further situational loss of his
mother from her familiar roles. He could no longer depend on her being at home
when he might need her during the day. His anxiety increased, as he perceived
this to be another sign of rejection from a parent figure. Billy had no coping
mechanisms in his repertoire with which to handle these feelings of added anxiety
and depression. At the particular time when he needed to use his usually successful
coping behaviors, the opportunity was not available because of the demand by
his mother that he “come home directly after school. You can’t play in the
neighborhood after school with your friends.”
The therapist thought that Mrs. B needed assistance in gaining a realistic,
intellectual understanding of the situation as it related to Billy’s current behaviors.
Increasingly anxious about the added responsibility that had been placed on her
during the past few months, she was possibly projecting her own feelings of
insecurity into overprotective behaviors toward Billy; that is, “It is Billy, not I, who
should not be out alone and unprotected. Something terrible might happen to him
when there is no longer a strong, dependable person nearby to help keep an eye on
things.”
Billy would need to explore his perceptions and feelings about the psychosocial
losses of both parents from the usual family roles that they had occupied in his
life. He needed to be helped to express his feelings constructively and to make
a positive adaptation to the new role demands made of him. During the first session,
the counselor focused on identifying with Mrs. B the many critical changes that
had occurred in Billy’s life during the past few months and their impact on his
level of maturational skill development. The goal was to provide her with insight
into how Billy might be perceiving such events at his level of comprehension
and concrete thinking. Although he was old enough to be fully aware of the events
happening, he was still too young to deal with them abstractly. For example, when
his father had remarried and then moved away soon after, Billy most likely had
perceived these actions as signs of complete rejection by his father and blamed
himself in some way. In his mind, he may have wondered, “Why else would
my father marry someone else and then move away, abandoning both me and
my mother?”
It was also suggested to Mrs. B that her comments at the time (e.g., “If I don’t
go back to full-time work, we won’t have a roof over our heads or food to eat’’) were
probably taken quite literally by Billy. So, also, was her later admonishment to him
always to come straight home from school, implying that he was one more source
of problems for her.
In the next two sessions, through the use of direct questioning and reflection of
verbal and nonverbal clues with Mrs. B, she became able to express her own feelings
about the recent chain of events in her life and to begin to relate them to Billy’s
behavioral changes. Her counselor suggested that she try to find some alternative
supervised peer group activities for Billy after school. The purpose was to reinstate,
for him, the opportunity for some normal, acceptable outlets for the angry, hostile
feelings that he must still be having from the recent losses in his life.
The counselor met with Billy at the beginning of each session to discuss with him
how he was doing in school classes and what things he was doing to occupy his time
after school before his mother got home from work. Billy’s feelings of rejection and
insecurity were dealt with during this time.
The remaining time was spent with Mrs. B. She was encouraged to continue to
provide Billy with as much independence as feasible, yet not expect him to assume
any more than he could comfortably cope with at this time. The importance of
providing Billy with every opportunity to learn new social skills and to develop
strong feelings of competency and self-adequacy was emphasized. The fact that
closing off his access to usual afterschool activities with his peers would greatly limit
his chances for new learning experiences was discussed. It might also precipitate his
return to the same maladaptive coping behaviors that he had been demonstrating
during the past few weeks.
Mrs. B was not able to locate another supervised activity group for her son to
attend after school. However, she did make arrangements with a retired gentleman
who lived in the same apartment house to keep an eye on Billy and to be a contact
for him when he came home and played in the neighborhood with his friends after
school.
An important focus of anticipatory planning was to review with Mrs. B the
maturational changes that she could expect to see developing in Billy over the next
few years. The need for her to continue to allow him normal opportunities for growth
and development was stressed. The fact that Billy was now a member of a
single-parent family should not create any particular peer-group problems, because
this situation was increasingly common among children his age. However, potential
stressful situations were identified and discussed in terms of how she might approach
coping with them as they arose, both for herself and in her dealings with Billy.
Billy was encouraged to be more direct in questions to his mother and in letting
her know when he felt confused or angry about things that were happening to him.
He understood that he could stop in and talk to the counselor whenever the need
arose, but that he should also be expected to keep in close touch with his mother about
his feelings in the future.
Billy had perceived his father’s remarriage and move out of state as a rejection
of himself. Unable to express his feelings to his mother, he coped by acting out
his
anger and hostility in competitive, aggressive sports activities with his peers. Despite
Mrs. B’s assumptions to the contrary, planning with Billy for her return to
full-time
work had served to reactivate his fears of another rejection. No longer having
his
sports activities available to him as before, his anxiety increased. Lacking any other
available coping skills, he became overwhelmed.
Boys are nature’s rare material.

—Saki
Adolescence
The individual is probably more aware of change during adolescence than during any
other period in life. Adolescence is a period that confronts both the individual and
the family with numerous problems and challenges. Erikson (1963, 1992) describes
the main task of adolescence as that of identity formation, and identifies four primary
components:
1. The physical and emotional separation from parents

2. The acquisition of socially oriented attitudes and opinions
3. The preparation for a working role
4. The definition of the sexual role
Unfortunately, these major psychological adjustments are expected to take place
during a time when everything else is changing—when a person is no longer a child
but not yet an adult. Adolescents are confronted almost simultaneously with rapid
physiological changes, increased cognitive development, increased peer group
pressures and activities, and changes in family and societal attitudes and
expectations, all of which serve as stressors during this phase of their development
and may interfere severely with the task of identity formation.
Emancipation from the family tends to be desired and feared by both the
adolescents and their parents. Adolescents frequently find themselves expected to
continue in the child role or to assume both the adult and child roles simultaneously.
This mixed role expectation often leads to aggressive behaviors and to conflicts
within the family structure because the adolescent is constantly pulled between the
need for adult support and the desire for independence (Peterson, 1972). Actual as
well as feigned illness tends to increase parental controls and promote more positive
relationships with siblings, even though the adolescents themselves continue to be
socially active.
In the search for identity, adolescents frequently attempt to submerge themselves
in a peer group identity, which provides them with a temporary feeling of
importance and belonging. The peer group serves a dual purpose: both insulating
the adolescent from the adult world and building its own norms for its members.
Although the group standards, values, and opinions can provide a positive
background for testing out adolescent roles and styles for future adult life, the
group pressures for untoward experiences (€.g., use of drugs and sex) may also
have the negative effect of promoting a sense of alienation from the rest of society
(Starr and Goldstein, 1975).
CASE STUDY: BILLY
PLUS AND
PLUS AND
RESULT IN RESULT IN
Figure 9-1
Tests of mental ability show that adolescence is also the period of greatest ability
to acquire and make use of knowledge. The adolescent is capable of a high degree
of imaginative thinking, which, although somewhat oversimplified and unoriginal,
sets up the structure for adult thinking patterns and the work role (Piaget, 1963).
Differences in cognitive skills development among male and female adolescents
(e.g., verbal skills among females, quantitative and spatial skills in males) are seen
as the result of interest, social expectations, and earlier training, rather than as
variations in the innate mental abilities.
The adolescent has a strong need to find and confirm his identity. Rapid body
growth equals that of early childhood, but it is compounded by the addition of
physical-genital maturity. Faced with the physiological revolution within himself,
the adolescent is also concerned with consolidating his social roles. He is
preoccupied with the difference between what he appears to be in the eyes of
others and what he believes himself to be. In searching for a new sense of
continuity, some adolescents must refight crises left unresolved in previous years
(Adler and Clark, 1991).
Changes that occur while secondary sex characteristics emerge make the
adolescent self-conscious and uncomfortable with himself and with his friends. Body
image changes, and the adolescent constantly seeks validation that these physiologi-
cal changes are “‘normal’’ because he feels different and is dissatisfied with how he
thinks he looks. If sudden spurts of growth occur, he concludes he will be too tall;
conversely, if growth does not occur as expected, he thinks he will be too short, or
too thin, or too fat. In this period of fluctuation, half-child and half-adult, the
adolescent reacts with childish rebellion one day and with adult maturity the next
(Lau, 1991).
The adolescent is as unpredictable to himself as he is to parents and other adults.
On the one hand, he seeks freedom and rebels against authority; on the other, he does
not trust his own sense of emerging maturity and covertly seeks guidelines from
adults. In his struggle for an identity, he turns to his peers and adopts their mode of
dress, mannerisms, vocabulary, and code of behavior, often to the distress of adult
society. The adolescent desperately needs to belong, to feel accepted, loved, and
wanted.
This is the age for cliques and gangs. The in-group can be extremely clan-
nish and intolerant of those who do not belong. Banding together against the
adult world, its members seek to internalize their identity, but because of dif-
ferent and often rebellious behavior they are frequently labeled incorrectly as
delinquent.
Having achieved a sense of security and acceptance from peers, the adolescent
begins to seek heterosexual involvement. This occurs first at group-oriented social
events, such as dances, parties, and football games. As comfort and confidence
increase, the adolescent progresses to more meaningful and deeper emotional
involvements in one-to-one heterosexual relationships. Because of conflict between
sexual drives, desires, and the establishment norms of society, this stage cat be
extremely stressful, and again the adolescent is faced with indecision and confusion
(Rose-Gold, 1991).
Occupational identity also becomes a concern at this time. Continual queries

by parents and school authorities arise about career plans for the future. Un-
certainties are compounded when a definite choice cannot be made because of
an inability to identify fully with the adult world of work. Having only observed
or participated in fragments of work situations, the adolescent finds it difficult
to commit himself to the reality of full-time employment and its inherent
responsibilities. To state what is not wanted rather than what is wanted as a career
is easier and more realistic (Baack, 1991).
Piaget (1963, 1989) refers to the cognitive development at this stage as formal
operations, the period in which the capacity for abstract thinking and com-
plex deductive reasoning becomes possible. At this time, the goal is “‘inde-
pendence,” and in midadolescence acceptance of the idea that to love someone
and at the same time be angry with that person is possible. If this stage is
successfully negotiated, the individual develops a capacity for self-responsi-
bility; failure at this stage may lead to a sense of inadequacy in controlling and
competing.
Because of the number and wide variety of stimuli and rapid changes to which
he is exposed, the adolescent is in a hazardous situation. A crisis situation may be
compounded by the normal amount of flux characteristic of adolescent development
(Cameron, 1963; Erikson, 1950, 1959, 1963, 1989; Piaget, 1963, 1989; Zachry,
1940).
The following case study illustrates some of the conflicts that adolescents face
while trying to find their identity, strive for independence, and win acceptance from
their peer group. It also points out the need for understanding and patience on the
part of parents as their adolescents grow up.
Case Study Adolescence

Mary V, a 14-year-old high school sophomore, was referred to a crisis center with
her parents by a school nurse. During the past few weeks, she had shown signs of
increased anxiety, cried easily, and had lost interest in school activities. That morning,
for no apparent reason, she had suddenly left the classroom in tears. The teacher
followed and found her crouched in a nearby utility closet, crying uncontrollably.
Mary seemed unable to give a reason for her loss of control and was very anxious.
When her mother came in response to a call from the school nurse, they agreed to
follow her advice and seek family therapy.
During the first session, the therapist saw Mary and her parents together to
assess their interaction and communication patterns and to determine Mary’s
problems.
Mrs. V was quiet and left most of the conversation up to her husband and Mary.
When she attempted to add anything to what was being said, she was quickly silenced
by Mr. V’s hard, cold stare or by Mary exclaiming in an exasperated tone, “Oh,
Mother!” Mr. V spoke in a controlled, stilted manner, saying that he had no idea
what
was wrong with Mary, and Mrs. V responded hesitantly that it must be somethin
g
at school.
Mary was particularly well developed for her age, a fact that was apparent despite
the rather shapeless dress she was wearing. She might have been very attractive if
she had paid more attention to her posture and general appearance.
When questioned, Mary said that she had not been sleeping well for weeks, had
no appetite, and could not concentrate on her schoolwork. She did not know why she
felt this way, and her uncontrolled outburst of tears frightened and embarrassed her.
She was also afraid of what she might do next, adding that her crying that morning
was probably because she had not slept well for the past two nights. At first, she tried
to brush this off as final exam jitters.
She evaded answering repeated questions about sudden changes in her life in the
past few days. When the therapist asked if she would be comfortable talking alone,
without her parents, she gave her father a quick glance and replied that she would.
Mr. and Mrs. V were asked if they objected to Mary talking to the therapist alone.
Both agreed that it might be a good idea and went to the waiting room.
For a time, Mary continued to respond evasively. It was obvious that she had
strongly mixed feelings about how to relate to the male therapist. Should it be
“woman to man” or “‘child to adult”? Throughout this and the following sessions,
she alternated between her child and adult roles. The therapist recognized the
role ambivalence of adolescence and adjusted his role relationship, using whichever
was most effective in focusing on the problem areas and making Mary more
comfortable.
Mary eventually relaxed and began to talk freely about her relationship with her
family, her activities at school, and some of the feelings that were troubling her. She
said that she had two older brothers. The younger of the two, Kirk, was 16 years old
and a senior in high school. She felt closer to him because “‘he understands and I can
talk to him.” Mary said that she had had “‘as good a childhood” as the rest of her
friends. However, she did think that her father kept a closer eye on her activities than
did the parents of most of her friends. He still called her his “baby” and “my little
girl” and lately had begun to place more restrictions than usual on her friendships
and activities.
She admitted that during the past year she had gone through a sudden spurt of body
growth and development. She was keenly aware of these differences in her appear-
ance and sensed the changing attitudes of her father and her friends. She felt her father
was worried about her growing “‘up and out so fast.”” He was the one who insisted that
she wear the almost shapeless dresses. She said she knew “it wasn’t really because I
outgrow things so fast right now—he thinks I look too sexy for my age!”
About 3 weeks ago, she had been invited to the junior-senior prom by a friend of
her brother Kirk. She liked the boy and wanted to go but was not sure Kirk would
approve because he would be at the prom too. Another problem was getting her
parents’ permission to buy the necessary formal. She had looked at dresses and knew
exactly the one she wanted but knew her father would not let her have it.
Mary was asked if she felt able to tell her parents these things that were bothering
her if the therapist were present to give her support. She thought that she could if
he would “sort of prepare them first” and explain how important it was for her to
go dressed like the rest of her girlfriends. He suggested that Mary discuss the situation
with Kirk to see how he felt about her going to the prom with his friend, and she
agreed to do this before the next session. The therapist assured her that he would
spend the first part of the next session with her parents to discuss and explore their
feelings about the prom.
It was thought that Mary needed support to assist her in convincing her parents
that she be allowed to grow up. Mr. and Mrs. V needed to gain an intellectual
understanding of some of the problems that adolescent girls face as they search for
an identity, seek independence, and feel the need to be like their peers. Mrs. V would
have to be encouraged to give support and guidance to Mary and help to resist Mr.
V’s attempts to keep Mary as the baby of the family.
At the next session the therapist went to the waiting room to get Mr. and Mrs. V
and saw that Mary had brought her brother Kirk with her. She asked if he could come
in with them at the last half of the session when the family would be together. The
therapist agreed, realizing that Mary had brought additional support and that
apparently Kirk had approved of her going to the prom.
The first part of the session was spent discussing with the parents the general
problems of most adolescents, as well as the reasons behind their often erratic
and unusual behavior. Both parents seemed willing to accept this new knowledge,
although Mr. V said that he had not noticed any of this with the boys. Mrs. V
said, “No, but you treated them differently. You were glad they were becoming
men.” The therapist supported Mrs. V and said that this was one of Mary’s specific
problems. He then repeated to the parents what Mary had said about the things
that were bothering her. Both parents seemed slightly embarrassed, and Mr. V’s
voice and manner became quite angry as he tried to explain why he wanted to
“protect”? Mary. ““She’s so young, so innocent—someone may take advantage of
her,” and so on.
Discussion then focused on Mary’s anxiety and the tension she was feeling
because her father had made her feel different from her friends. Compromise
between Mr. and Mrs. V and Mary was explored when Mary and Kirk joined
their parents in the last half of the session. Mary was more verbal with Kirk
present to support her, and Kirk told his father, “You are too old-fashioned. Mary’s
a good kid, you don’t have to worry about her. You make her dress like a
10-year-old,” and so on. Mr. V was silent for a while and then said, “You may
be right, Kirk. I don’t know.” He then asked him, “Do you think I should let
her go to the prom?” Kirk answered, “Yes, Dad. I’ll be there. She can even
double with me and my date.” Her father agreed, adding that Mrs. V should go
with her to pick out a “fairly decent dress.” Mary began to cry, and Mr. V in
great consternation asked, “What’s wrong now?” She replied, “Daddy, I’m so
happy. Don’t you know women cry when they are happy too?”
The next few sessions were spent in supporting the family members in their
changing attitudes toward each other. Anticipatory planning was directed toward
establishing open communication between the parents and Mary to avoid another
buildup of tensions and misunderstandings. Mary was encouraged to use Kirk
as a
situational support in the future, because he and his father were not in conflict.
The
family was told they could return for help with future crises if necessary
and were
assured that they had accomplished a great deal toward mutual understanding.
Mary suffered acute symptoms of anxiety because she had to ask her father for
permission to go to a dance. She wanted to be a member of her peer group but felt
uncomfortable because she was not allowed to dress as they did. She wanted
independence but was inexperienced and afraid to make a decision that would oppose
her father. Because the situation involved possible conflict with her brother, she did
not feel comfortable talking with him about her problem.
Intervention was based on exploring areas of difficulty with the family and
assisting them to recognize, understand, and support Mary’s adolescent behavior, her
bid for independence, and her need to become a member of her peer group.
Youth is wholly experimental.

—Robert Louis Stevenson
Adulthood
Because adulthood begins in the late teens and continues to the end of the life cycle,
talking about stressors in relation to the usual age-group phases—early, middle, and
late adulthood—may be considered more practical. What cannot be denied, however,
is that major changes or shifts in life circumstances very often occur at different
periods for different individuals. Moreover, a particular experience that is highly
threatening for one person may just as often be relatively innocuous for another,
depending on how each perceives and appraises the personal effect of the experience.
A life change need not be particularly undesirable to induce stress (Dohrenwend and
Dohrenwend, 1974). In addition, certain types of stressors or life strains can occur
repeatedly throughout a person’s total life period.
A number of investigators have focused on identifying which types of life
situations seem to present the greatest threats to human psychophysiological stability
and have developed lists of life events weighted according to the degree of
experienced stress among their study populations. Perhaps the most widely known
of these lists is the forty-third-item Social Readjustment Rating Scale (SRRS)
developed by Holmes and Rahe (1967). The scale consists of a mix of pleasurable
and undesirable life events identified by people as productive of bodily stress
responses (e.g., marriage, new job, job loss, death of a loved one, etc.). Since its
publication in 1967 the SRRS has generated considerable public and professional
interest and criticism as well as an extensive body of research. For example,
Dohrenwend and Dohrenwend (1974) found that both ethnicity and the degree of life
experience affected the rating of life events as stressors. In analyzing a number of
studies that focus on social class and ethnic group membership and their judgments
of the magnitude of stressful life events, Anderson and others (1977) found that
cultural judgments about this magnitude are even greater than the various reports
have suggested. In pretests of a more extensive list of 102 life events actually
experienced in a number of populations, group differences were found to vary more
by ethnicity than by sex or social class.
CASE STUDY: MARY
PLUS — AND
PLUS AND
Figure 9-2
An important resource for preventing or moderating responses to stressful life

events is that of social support. Cobb (1976) defines social support as “information
leading the subject to believe that he is cared for and loved, esteemed, and a member
of a network of mutual obligations.” In his review of over 50 studies, Cobb cites
findings identifying the mechanism of social Support as a moderator of acute stress
situations throughout the life cycle. The variable of social support too often has been
neglected as a mitigating or even preventive factor in the relationships between
stressful life events and illness, which suggests that considerable empirical research
needs to be done in this area. In this context, two of the many possible hypotheses
that could be tested concerning the reasons that social support may play a positive
role in the prevention of illness are that (1) social norms may affect group member
health behaviors and that (2) social interaction may provide preventive healthcare
information.
Many problem situations such as nutritional deficits, rest and sleep problems,
sexual difficulties, moral-religious conflicts, self-image problems, divorce, and
bereavement can be experienced at any time during the life cycle, since these stressor
events are neither predictable nor universally experienced. Moreover, other types of
life circumstances including environmental settings, educational preparation, and
economic resources can mitigate, submerge, or exacerbate life crises.
Discussions about the stages and stressors of life development are always
somewhat arbitrary at best, but are even more so when discussing the age 30-to-65
phase, or middle adulthood. In general, it can be said that the decisions made in young
adulthood tend to give shape and direction to life during the 30s. Certain expectations
have been fulfilled, certain skills have been learned, and a number of achievements
have been accomplished. Gratifications during the 30s and early 40s include success
in a job, a marriage, a family, which constitute fulfillment of earlier hopes and
expectations. Nevertheless, new decisions and lifestyle adjustments have to be made,
disappointments and discontentments occur more frequently, and ambition for
success may turn into desperation. The concomitant incidence of anxiety, depression,
and other symptomatology (e.g., psychosomatic complaints, fear reactions, and other
emotional reactions), which seemed high in the 30s, may reach maximum heights
during the 40s when a person begins to sense that life is finite and that health and
even interpersonal decrements are more permanent than temporary. However, certain
types of stressors including career and work-related stressors, changes in the family
unit structure (through death, divorce, departure of the last child, etc.), physical
aging, and the like, do tend to occur more frequently in this period of middle
adulthood.
Although a number of studies report that good work relationships can buffer
some occupational stresses and their related psychological strains, research into
specific occupations suggests that other factors such as personality and prior
experience may be more important in the development of effective coping
mechanisms.
Adulthood is the usual period in life when the responsibilities of life and/or of
parenthood are assumed, involving the abilities of a manor woman to accept the
strengths and weaknesses of one another and to combine their energies toward mutual
goals. It is a crucial time for reconciliation with practical reality.
Maturity is always relative and is usually considered to develop in adulthood.

Many adults who marry and have children never do achieve psychological maturity,
whereas others who choose not to marry may show a greater degree of mature
responsibility than many of their married peers.
Adult normality, like maturity, is also relative. Normality requires that a person
achieve and maintain a reasonably effective balance, both psychodynamically and
interpersonally. The normal adult must be able to control and channel his emotional
drives without losing his initiative and vigor. He should be able to cope with ordinary
personal upheavals and the frustrations and disappointments in life with only
temporary disequilibrium. He should be able to participate enthusiastically in adult
work and adult play, as well as have the capacity to give and to experience adequate
sexual gratification in a stable relationship. He should be able to express a reasonable
amount of aggression, anger, joy, and affection without undue effort or unnecessary
guilt.
In actuality, expecting to find perfect normalcy in any adult is unreasonable.
Absolute perfection of physique and physiology are rare rather than normal, and an
adult with a perfect emotional equilibrium is equally as exceptional.
This case study concerns a young woman whose lack of psychosocial maturity
created problems when she was faced with the responsibility of motherhood. Her
husband’s competence and pleasure in caring for their baby increased her feelings
of inadequacy and rejection.
Case Study Adulthood (Motherhood)

Myra and John, a young married couple, were referred by Myra’s obstetrician to a
crisis center because of her symptoms of depression. Myra said she was experiencing
difficulty in sleeping, was constantly tired, and would begin to cry for no apparent
reason.
Myra was an attractive but fragile blonde of 22 years whose looks and manners
gave her the appearance of a 16 year old. John, 28 years old, had a calm and mature
demeanor. They had been married 1! years and were the parents of a 3-month-old
son, John, Jr. John was an engineer with a large corporation. Myra had been a liberal
arts major when they met and married. John was the oldest of four children and was
from a stable family of modest circumstances; Myra was an only child who had been
indulged by wealthy parents.
When questioned by the therapist specifically about the onset of her symptoms,
Myra stated that they had really begun after their baby was born, with crying spells
and repeated assertions that she “wasn’t a good mother” and that taking care of the
baby made her nervous. She said she felt inadequate and that even John was better
with the baby than she. John attempted to reassure her by telling her she was an
excellent mother and that he realized she was nervous about caring for the baby.
He
suggested that he get someone to help her. Myra said she did not want anyone because
it was her baby, and she could not understand why she felt as she did. When
questioned about her pregnancy and the birth of the child, she said there
had been
no complications and had added hesitantly that it had not been a planned pregnancy.
When asked to explain further, she replied that she and John had decided
to wait until
they had been married about 3 years before starting a family. She
went on to explain
that she did not think she and John had had enough time to enjoy
their life together
before the baby was born.
After she recovered from the shock of knowing she was pregnant, she
became
thrilled at the thought of having a baby and enjoyed her pregnancy and shopping
for
the nursery. Toward the end of her pregnancy, she had difficulty sleeping
and was
troubled by nightmares. She began to feel uncertain of her ability to be a good mother
and was frightened because she had not been around babies before.
When she and John brought the baby home, they engaged a nurse for 2 weeks
to take care of the child and to teach Myra baby care. She thought that basically
she knew how, but it upset her if the baby did not stop crying when she picked
him up. When he was at home, John usually took care of the baby, and his
competency made her feel more inadequate. The precipitating event was thought
to have occurred the week before, when John had arrived home from work to
find Myra walking the floor with the baby, who was crying loudly. Myra told
him she had taken the baby to the pediatrician for an immunization shot that
morning. After they returned home, he had become irritable, crying continuously
and repeatedly refusing his bottle. When Myra said she did not know what to
do, John told her the baby felt feverish. After they took the baby’s temperature
and discovered that it was 102° F, John called the pediatrician, who recommended
a medication to reduce the temperature and discomfort. John got the medication
and gave it to the baby; he also gave the baby his bottle. The baby went to
sleep, but Myra went crying and upset to their bedroom.
Myra’s mixed feelings toward the baby would be explored in addition to her
feelings of inadequacy in caring for him. She apparently resented the responsibility
of the parental role, which she was not ready to assume. Unable to express her
hostility and feelings of rejection toward the baby, she turned them inward on herself,
with the resulting overt symptoms of depression. Bringing these feelings into the
open would be a necessary goal. Myra also needed reassurance that her feelings of
inadequacy were normal because of her lack of contact and experience with infants
and also because most new parents felt this same inadequacy in varying degrees. John
obviously was comfortable and knowledgeable in the situation as a result of his
experience with a younger brother and sisters; he would be used as a strong
situational support.
The therapist, believing that a mild antidepressant should help to relieve Myra’s
symptoms, arranged a medical consultation. It was not thought that she was a threat
to herself or to others, and intervention was instituted.
Myra’s mention in the initial session that she and John had not had enough
time to enjoy each other before the baby was born was considered to be an initial
reference to Myra’s negative feelings regarding her pregnancy and the baby. In
subsequent sessions, through the therapist’s use of direct questioning and the
reflection of verbal and nonverbal clues, Myra was able to express some of her
feelings about their life as a family with a baby in contrast to her feelings when
she and John were alone.
Their previous life pattern revealed much social activity before the birth of the
baby and almost none afterward. Myra said that although this had not really bothered
her too much at first, recently she had felt as if the walls were closing in on her. John
appeared surprised to hear this and asked why she had not mentioned it to him. Myra
replied with some anger that it apparently did not seem to bother him because he
obviously enjoyed playing with the baby after he came home from work. The
possibility of reinstating some manner of social life for Myra and John was
considered essential at this point. John told her that his mother would enjoy the
chance to babysit with her new grandson and that he and Myra should plan some
evenings out alone or with friends. Myra brightened considerably at this and seemed
pleased at John’s concern.
The therapist also explored their feelings about the responsibilities of parenthood
and Myra’s feelings of inadequacy in caring for the baby. Myra could communicate
to John and the therapist her feelings that the baby received more of John’s attention
than she and that she resented “‘playing second fiddle.” John explained that he had
originally assumed care of the baby so that she could get some rest and that he
enjoyed being with her more than with the baby. He told her that he loved her and
that she would always come first with him.
Myra was eventually able to see that she was being childish in resenting the baby
and that she was competing for John’s attention; as her social life expanded, her
negative feelings toward the baby lessened, and she said she was feeling more
comfortable in caring for him. After the fourth session, the medication was
discontinued, and Myra’s symptoms continued to decrease.
Because of John’s maturity, it was thought important that he should be aware of
the possibility that Myra could occasionally have a recurrence of feelings of
rejection. If the original symptoms returned, he would recognize them by the pattern
they would take and would be able to intercede by exploring what was happening,
discussing this openly with Myra. When the progress and adjustments they had made
in learning to cope with the situation were reviewed with them, both expressed
satisfaction with the changes that had occurred. They were told that they could return
for further help if another crisis situation developed.
Myra was an only child who had rarely had to accept responsibility for others
before her marriage. Because she had planned to wait 3 years before having a child,
she had strong, mixed feelings about the responsibilities of motherhood before that
time and felt unprepared. Her husband’s adequacy in caring for the baby when she
failed reinforced her mixed feelings. Loss of the social life shared with her husband,
combined with the diversion of his attention from her to the baby, reinforced her
strong feelings of rejection. Because she was unable to recognize and accept her
feelings of ambivalence and was also unable to tell her husband of her anger and
frustration, she turned them inward. Lack of previous experience in caring for infants
made her unable to cope with the situation, increased her frustration and anger, and
resulted in overt symptoms of depression and anxiety.
But I was one and twenty, No use to talk to me.
—Alfred Edward Housman
i A a a a ete te LS
CASE STUDY: MYRA
PLUS AND
PLUS AND
RESULT IN
Figure 9-3
To the average person, reaching late adulthood implies that life patterns have been
fairly well set and are no longer open to choices for change. Anxiety results if a man
or woman has not demonstrated some capacity for success in either family or career
roles. Symptoms of this are frequently noted in such forms as excessive use of
alcohol, psychosomatic symptoms, feelings of persecution, and depression (English
and Pearson, 1955).
Our culture seems unable to place any firm boundary lines on phases of the aging
process. The general tendency is to view a life as uphill from infancy and over the
hill and declining after reaching the peak of the middle years. With our cultural
emphasis on youthfulness, it is not unusual for a person of 50 years to view his future
with regret for things left unaccomplished. Hahn (1963) refers to this state as “heads
against the ceiling,”’ a time when “‘the realization strikes home that the probability
for appreciable advancement is remote. ...The ceiling is encountered relatively
early by some and at an amazing late time by others, but for all of us the ladder
eventually ends at a ceiling.” He further describes this as a period when “younger
men and women are beginning to crowd into the competitive economic, political and
social arenas.” With the rapid technological’ changes affecting business and
professions, younger persons are often better prepared to supply the necessary
knowledge and skills.
Family life changes as children grow up and become involved with school,
careers, and marriage. For parents, it is a time when specific tasks of parenthood are
over, and they must return to the family unit of two, making reciprocal changes in
role status in relation to their children and to the community. New values and goals
must be developed in the marriage to replace those values no longer realistic in the
present; failure to recognize this need can open the way to frustration and despair.
The wife and mother now has freedom from parental responsibility, but, if her entire
lifestyle was centered around the parental role, she may lack interests, skills, and
abilities with which to make the role change.
Menopause, or the cessation of the menstrual cycle, is often thought of as a
dividing point between young adulthood and middle age. The actual termination of
menstruation, however, occurs over a wide age range, usually between 45 and 55.
Menopause marks the abrupt loss of fertility in women, while in men the climacteric
occurs gradually and at a later age.
Menopause can represent a hazard for women because of its psychological
repercussions. For some, the end of fertility may represent the end of sexuality and
the loss of role identity. For women who have chosen not to have children the loss
of fertility may represent the closing of the door to bearing children, perhaps giving
rise to doubts about their choice. Women who have been raised to view menopause
as the beginning of middle age and the end of youth may well experience it as a
negative event and be thrown into a crisis (Pruett, 1980).
No definite evidence exists that sexual gland activity in the male undergoes similar
rapid decline and cessation; however, men can experience symptoms similar to those
of women at the same age period. Pruett (1980) considers these syndromes to be
neuroses rather than a result of any changes in the sexual gland activity.
The unmarried person who has had thoughts of eventual marriage and family is
now faced with the reality of advancing years. This is a particularly critical time for
anyone who has relied strongly on physical attractiveness. He or she now faces the
inevitability of physical decline. A person in this stage of life can continue to pursue
career interests but may face limitations to further career advancements.
The following case study concerns a 40-year-old wife and mother whose planned
changes in her family role after the marriage of her daughter seem to be threatened
by the onset of early menopause.
Case Study Adulthood (Menopause)

Mrs. C, a 40-year-old, youthful-appearing mother of three daughters (ages 17, 20,
and 22 years) was referred to a crisis center by her physician because of severe
anxiety and depression, as evidenced by recent anorexia, weight loss, insomnia,
crying spells, and preoccupation, which had begun after a visit to her physician 3
weeks earlier. At that time, she had been told that she was entering early menopause.
Her youngest daughter was to be married in a month; the two older ones were already
married and living out of state.
She described herself to the therapist as having always been socially active
both in community affairs and in her husband’s business and social life. Mr. C
was employed as a senior salesman for a nationwide firm selling women’s clothing.
His work required, frequent trips out of town and much business entertaining while
at home. She seldom traveled with him (because of the children) but was deeply
involved with planning and hostessing his in-town social engagements. She said
that she enjoyed this and had always been confident of her ability to do it well.
Part of her wife role was to wear the clothes of her husband’s company as an
unofficial model, and her husband had always expressed his pride in her
attractiveness.
In recent weeks, she had begun to feel inadequate in this role, and strong feelings
of doubt regarding her ability had begun to plague her. At the same time, she sensed
that her husband was becoming indifferent to her efforts to keep herself and their
home attractive to him. Her symptoms had overtly increased in the 2 days just past,
until now she feared a complete loss of emotional control.
Mr. C was 2 years older than Mrs. C. He was socially adept, and her women
friends frequently told her they thought he was “such a youthful, good-looking, and
considerate person.’’ She herself felt fortunate to have him for a husband. He was
aggressive in business and could be sure of advancement. She said they had always
been sexually compatible and shared interests and mutual esteem.
When asked about what had occurred in the past 2 days to increase her symptoms,
she said that her husband had come home 2 nights ago and found her disheveled and
crying and not ready to go to a scheduled business dinner for the second time in a
week. He angrily told her that he did not know what to do and to “‘pull yourself
together and find someone to help you because I’ve tried and I can’t!” Then he left
for the dinner alone. The next day he left town on a business trip after securing her
promise to see a physician.
Mrs. C said that she had seen several physicians during the past few months
because of various physical complaints. None had found any organic cause, but
all had advised her to get more rest, and one even told her to find a hobby. The
last physician, whom she saw 3 weeks ago, told her she was entering early
menopause.
Mrs. C had not told her husband of this because she feared his reaction in
view of her own negative feelings; her initial reaction had been disbelief. This
was followed by fear of “change of life,’’ as she had heard of so many unfortunate
things that could happen to a woman during this time. In common with other
women, she did not want to become old and unattractive and was angry that
it could be happening to her so soon. She thought that she would no longer be
an asset to her husband in his work because his clothes were not designed for
middle-age women.
Mrs. C had looked forward to traveling with her husband after their youngest
daughter’s marriage. They had planned such a future together enthusiastically, and
she felt proud to have contributed to his success but was now afraid that he would
not need her anymore and that all her plans were ruined.
Her expressed feelings of guilt and a fear of the loss of her feminine role
were thought to be the crisis-precipitating events. She was not seen as a suicidal
risk or as a threat to others, although she was depressed and expressed feelings
of worthlessness. She was highly anxious but could maintain control over her
actions.
Mrs. C had withdrawn from her previous pattern of social and family activities.
Her husband was frequently out of town, and the last of the daughters living at home
had transferred many of her dependency needs to her fiance. Mrs. C in the past 3
months had felt physically ill and had narrowed her social activities to infrequent
luncheons “‘when I felt up to it.” Her peer group was in the 35- to 40-year age level
and were all actively involved in community affairs, family activities, and so on.
Conversation with women friends still centered around problems of raising children,
and she believed that because her children were grown she no longer had much to
offer to the conversation.
Her goals for a role change from busy parenthood to active participation with her
husband in his business-social world were threatened, and she had no coping
experiences in this particular situation. Previous methods of coping with stress were
discussed. She related that she had always kept busy with their children and either
forgot the problems or talked them out with close friends or her husband. She could
not recall a close woman friend who had reached the menopausal stage and with
whom she could discuss her feelings, and she was too fearful of the reaction she
imagined her husband would have to discuss it with him. Her inability to
communicate her feelings and the loss of busy work with her children eliminated any
situational supports in her home environment, obviating the use of previously
successful coping mechanisms. The goal of intervention established by the therapist
was to assist Mrs. C to an intellectual understanding of her crisis.
Obvious to the therapist was that Mrs. C had little knowledge of the physiological
and psychological changes that occur in menopause. She had no insight into her
feelings of guilt and fear of the threatening loss of her feminine role. Unrecognized
feelings about her relationship with her husband would be explored. During the next
5 weeks, through the use of direct questioning and reflection of verbal and nonverbal
clues with Mrs. C, it became possible for her to relate the present crisis and its effect
to past separations from her husband (business trips) and her previous successful
coping mechanisms.
Mrs. C had married when she was 17 years old. She described herself as having
been attractive and popular in school, busy at all sorts of school activities. Mr.
C had been what everyone considered quite a catch. He came from a prosperous
family, had been a high school football captain and class president, and was sought
after by many of her girlfriends. At the time of their marriage he was a freshman
in college.
She always had a high regard for her physical attractiveness and her ability to
fulfill the social role Mr. C expected of her. Throughout the years when he traveled
alone, she felt left out of a part of his life and had looked forward with great
expectations to being able to be with him all of the time. Knowing that his business
brought him in frequent contact with attractive women buyers and models, she
regarded her own physical attractiveness as a prime requirement to “meet the
competition.”’ With Mr. C’s frequent trips away from home, she had magnified her
role in the husband-wife relationship to be more on the physical-social level than in
the shared role of parental responsibilities.
Mrs. C never questioned her physician after he informed her of his diagnosis of
early onset of menopause, and obviously her knowledge was inadequate and based
almost entirely on hearsay and myth rather than on fact. The physiological basis of
the process of aging was discussed, and much of her fear was allayed. This was an
important phase of anticipatory planning.
She was given situational support in which to talk out her feelings of insecurity
in her marriage and to view it in much more realistic terms. Relationships between
the precipitating events and the crisis symptoms were explored.
By the third week, Mrs. C had made significant progress toward reestablishing her
coping skills. She no longer feared “getting old overnight” and was able to tell her
husband that she was entering early menopause. His response was, “‘What the hell!
Is that why you have been acting so peculiar lately? You might have told me; the way
you ve been carrying on anyone would have thought you had just been told you had
6 months to live!”’ Although her first impulse was to interpret this as evidence of his
indifference to her as a woman, she later saw it as positive proof of her own
unrealistic fears. She returned to her medical doctor as advised for continuing care
and planning for physical problems that might arise in the future.
By the fifth week, she expressed confidence in her ability to meet the goals that
she and her husband had set for their future. Their daughter was married, and Mrs.
C was ready to leave town with her husband on a business trip. Before termination,
the adjustments she had made in coping with the crisis were reviewed and discussed
with her.
Mrs. C had been unable to cope with the combined stresses of early menopausal
symptoms and the need to change her family role. She avoided communicating her
fears to anyone who might have given her situational support for fear they would
confirm her own negative reactions. Increasing feelings of inadequacy, resulting in
anxiety and depression, led to a crisis level of disequilibrium.
Initial intervention focused on the exploration of Mrs. C’s knowledge of the
physical and psychological changes that could occur in menopause. As she was
CASE STUDY: MRS. C
Balancing factors present bs One or more balancing factors absent
PLUS AND
PLUS AND
RESULT IN RESULT IN
Figure 9-4
encouraged to explore and ventilate her feelings about her

relationship with her
husband, her perception of the stressful situation became more
realistic and her
coping skills were reintroduced successfully.
A fool at forty is a fool indeed.
—Edward Young
eee
SE Ee Doe et 2D Bite US
Old AgeLE
ET ON eT NeNS, cal OTE GE acl ialiii el tae a
Despite the fact that no clear line of demarcation exists between any of the phases
of adulthood in our society, the later phase of adulthood has been identified
chronologically as beginning at age 65. Decisions relating to autonomous functions
and activities; occupational changes; choice of marital partners; and concerns about
health, housing, and leisure activities take place throughout the whole of adulthood,
and many of the associated stressors have the same magnitude, frequency, and impact
on an individual’s lifestyle regardless of chronological age. Decrements in the
functioning of human organs or organ systems or in the psychosocial capacities of
people can and do occur at any age, since as yet no empirically predictable limits
related specifically to time of occurrence have been defined. What can be
documented, however, is that certain major events, such as enforced retirement and
loss of friends and intimate loved ones, become more likely with increasing age, and
that these negative life events are perceived as more stressful than events classified
as pleasant or positive. Coping with the confluence of physical, emotional, and social
factors, which might otherwise sufficiently exacerbate each other to produce
functional impairment, requires the ability to reintegrate one’s goals, self-image, and
life role. This ability to make such adjustments varies on an individual basis.
Seventy-five percent of the American population now lives to age 65, and 95%
of those 65 years and older reside in a noninstitutional setting. The proportion of older
persons has consistently increased more rapidly than that of younger persons; the 4%
of those 65 years and older in 1900 had increased to over 10% by 1975, and
projections show a continuation of this differential to at least 12% of the population
by the year 2000. A review of the gerontological literature suggests that persons
living beyond age 65 generally pass through three life stages: (1) Between ages 65
and 75, most people continue with normal activities unless they have a specific
illness, (2) most people also can carry out normal activities through age 85, although
many begin to show the effects of age even without an overt disease/illness condition,
and (3) after reaching the age of 85, however, only a relative few people are seen
as having the ability to carry on normal activities without some major assistance,
including institutionalization. Aside from the variable illness or disability factor,
differences between and within these stage-of-life cohort groups are often perceived
as being related to such other influences as previous lifestyle, adaptation to loss of
the work role, adjustment to minor ailments and stresses, openness to both feelings
and ideas, and maintenance of social activities and contacts.
The illnesses and disabilities of older persons are predominantly age- or

time-related, and tend to be chronic rather than acute. For the most part, chronic
diseases limit mobility and comfort and are the most frequent causes of
institutionalization. In general, despite the problems and hazards associated with
aging, the large majority of older persons remain well enough for many years to
participate in a variety of activities, are reasonably secure financially, and maintain
social ties with family and friends.
Nevertheless, and regardless of their life stage, older persons with multiple losses
(e.g., work role, mobility, health, vision, spouse, mental acuity, and home) are at
greater risk for requiring some form of institutional support than are those with single
or few losses. Probably the most compelling reason for institutionalization is that
these persons either outlive or overwhelm their support systems. What is not known,
however, is what those at risk of institutionalization actually do to remain in the
community. The functional status of older persons living in the community can be
quite high, despite the number and severity of their chronic disabilities. This high
level of functioning is based on the mechanisms the person has developed in the past
to cope with stressors and is now using to deal with the stressors accompanying
chronic illnesses and other losses of aging. ;
The author’s article on stressors in old age lists some of the needs of older persons
who continue to function in the community, for example, adequate income, suitable
housing, proper and adequate nutrition, and access to transportation. These persons
must also carry out certain responsibilities, such as establishing and continuing in a
range of physical and social activities, remaining flexible and adaptable in the face
of societal and community changes, seeking and accepting healthcare and other
helping services to ensure self-maintenance. Access to and use of social support
factors thus appear to be important determinants of whether older people are
relatively happy and self-sustaining. Certainly a strong need for companionship
exists, and most older people are interested in sex, have sexual feelings, and need
sexual outlets (Aguilera, 1980).
As is the case with people of any age, the healthcare needs of older persons
range from periodic evaluations to maintain wellness status, through the complexity
of services needed for acute care, to the supportive care needed for longer term
chronic health problems. Because persons may carry into their older years the
health problems of youth and early maturity, as well as being subject to health
stresses related to the aging process, the number of health problems afflicting
any one person may vary greatly. Although much can be done to alleviate or
control some of the effects of the aging process, the increased likelihood of
multiple health problems, combined with the slower recovery time associated with
aging, often leads to more frequent and prolonged hospitalizations. For older
persons who continue to need at least some medical surveillance and skilled
posthospitalization nursing care, a number of new problems arise. While theoretical
alternatives to institutionalization are available for many of the elderly, some form
of congregate living and continued healthcare may become a practical necessity.
Where family resources are inadequate, or where no suitable family substitute
is available, the person’s need for continued care may require placement in a
skilled nursing facility.
The predictors of morale, life satisfaction, satisfaction with treatment, and

survival were the patient’s subjective perceptions of the facility and their preferenc
e
and options for living in the facility itself or elsewhere. Loss of control among
the
institutionalized aged was at least partially responsible for depression, physical
decline, and early death. This suggests a need for increased attention to the patients’
cognitive and emotional status at application and entry periods, as well as throughout
their institutional stay.
Probably the most common problem in later adulthood is depression. Concomitant
with depression may be feelings of fatigue, lack of energy, low self-esteem, and
insomnia. Depression following bereavement is common. Loss of a spouse is usually
perceived as the single greatest loss that a person can experience throughout the life
cycle.
The dependency related to being ill, or to being ill and institutionalized, often
gives rise to fear of dependence and may be expressed in irritability, an unwillingness
to cooperate in treatment, and a general dissatisfaction with life. When an illness
brings into focus the probability of diminished life expectancy or impending death,
indirect or even direct self-destructive behavior may occur. This may take many
forms: active or passive, lethal or relatively innocuous, easily identified or obscure.
Behavioral examples include alcoholism and drug abuse, hyperobesity, disregard for
one’s health or safety, and withdrawal from the social environment. Behaviors that
appear to staff as uncooperative or belligerent and destructive to the patient’s health
may also serve a dual psychological purpose: that of being able to express anger and
frustration at circumstances related to medical condition and institutionalization and
of reestablishing some feelings of control and self-esteem.
A continuation of maturational stages of development would be more difficult to
define for the aged than for younger groups because the processes of decline and
growth occur concomitantly but not in equal balance. The process is highly
individualized in all cases, and the variability of physiological, psychological, and
sociological factors makes definite chronological relationships highly improbable.
When an elderly person seeks help, his symptomatology requires particularly
close scrutiny before an interpretation for intervention is undertaken. The therapist
must first be aware of his own tendencies to stereotype the client’s appearance and
symptoms as a normal aging syndrome. Determining which of the crisis symptoms
may be the result of organicity is particularly important because rapid onset of
behavioral changes is not infrequently caused by cerebrovascular or other organic
changes associated with longevity. A professional review of the current medical
history of the person must be part of the initial assessment phase.
Too often the person, because of organic changes, cannot gain an intellectual
understanding of the crisis or recognize his present feelings; or those who directed
him to the therapist may themselves be in crisis. If this is true, the therapist first may
have to resolve the feelings of the referrer that have been projected toward the elderly
person who seems to be in need of help.
In the aging process, the ego organization needs to withstand increasing
biopsychosocial threats to its integrity; unfortunately, the person’s coping abilities
may fail to adapt to meet the threats. The ability to accept new value systems
and adapt to necessary changes in the achieved maturational development of earlier
years without loss of achieved integrity may indeed be a developmental task for
the elderly. ,
The following case study concerns a couple who could be considered members
of the older age group.
Case Study Old Age

Sarah was accompanied to the crisis center by her husband, John, a former client who
had come there for help when in crisis following the death of their only son about
10 years ago. Sarah was 69 years of age, 3 years older than John. She was neatly
dressed, appeared to be slightly apprehensive, and walked with obvious difficulty,
supported by a Canadian crutch and her husband’s arm. After being assisted into a
chair in the therapist’s office, she quickly asked that John be allowed to remain with
her during the session. She stated that it “had really been John’s idea that we both
come here today. I’m sure that he can explain the problem better than I.” After a slight
pause and several hesitations John began to speak. Sarah sat tensely forward on her
chair, never taking her eyes from his face as he spoke.
According to John, their problem “‘probably first began” about 3 months ago,
when Sarah had fallen in the house and fractured her hip. After a month in the
hospital, she had been sent home in his care. The plan was for her to continue
physiotherapy as an outpatient. Despite all of the therapy and exercises at home, she
was apparently not making the progress they had expected. “‘Look at her, she still
can’t walk alone! She still needs someone to help her about or she might fall again,
and God knows what would happen to us then! It’s been a worry for both of us.”
As John continued to speak, it became quite obvious that he was avoiding any
direct references to himself. He described Sarah as having recent symptoms of
insomnia, anxiety, and depression and expressed the fear that she might be going into
the same crisis symptoms that he had been treated for at the center 10 years ago. “It
was sheer hell to feel the way I did then. She doesn’t deserve to go through what I
did then if she can be helped now.”’
As he spoke, he was becoming obviously more agitated. He avoided eye contact
with Sarah, kept moving about restlessly in his chair, and was becoming increasingly
tense and tremulous. His eyes frequently became tearful, and his voice broke on
several occasions. In almost direct contrast to his behavior, Sarah had assumed a very
supportive role, reaching out several times to pat his arm in a calming gesture and,
finally, holding his hand tightly.
At the point when it seemed he might begin to cry openly, he abruptly stood up
and said, “OK. Sarah, I’ve told her all about the problem. Now I’m going to go take
a walk for a while and let you do some of the talking, too.” With that, he said he would
be back in about 20 minutes and left the office.
As soon as John had left, Sarah began to cry quietly. Then she gave several deep
sighs and, for the first time, relaxed back into her chair. “*Please,’”’ she asked
the
therapist, “can you help him again like you did the last time?’ She stated that
for
the past week he had not slept more than an hour at a time during the night, paced
constantly, cried easily and often for no apparent reason, and had reached the point
where he now seemed too anxious and too preoccupied to make even the
simplest
of decisions.
According to Sarah, she and John had been married for 42 years. They had had
only one son, who had died, unmarried, 10 years ago. Although Sarah had never
held
a salaried job, she had always been very actively involved in both civic and church
organizations in their community. After John’s retirement from federal service, she
had withdrawn from several of these organizations in order to devote more time to
activities that they could participate in together. They had developed many new social
interests and maintained a fairly active social life. Sarah felt that the past 10 years had
included some of the best times in their life together. They had always seemed to be
planning something “for the future” and had acquired many new friends. Their home
was completely paid for; they had planned wisely for financial security ‘“‘in their old
age,” and, until her accident, they had had few health problems to worry about.
Even after her hip fracture, they had apparently been able to provide each other
with the situational support needed to cope adequately with the many new changes
arising in their daily lives. “After all,” Sarah said, “it wasn’t as though our world
was going to come to an end because of this—only that it might have to slow down
a bit until we could catch up again.”
After a month in the hospital, Sarah went home and arranged to continue therapy
as an outpatient. Despite regular visits to physiotherapy and John’s rigidly imposed
schedule of exercising at home, her recovery had been much slower than they had
anticipated. Last week her physician, also not satisfied with the rate of her progress,
recommended that she seriously consider admission as a full-time inpatient to a
well-known rehabilitation center in a nearby city. He was unable to guarantee how
long she might have to remain, estimating only that it would be a minimum of 1
month.
She stated that at the time John seemed to be as much in agreement as she with
the idea, although, she recollected, he had seemed a bit preoccupied on the drive
home. He took her out to dinner that night to celebrate her improved chances for a
full recovery. That same night she was awakened several times by John getting out
of bed and pacing about the house. When she mentioned it to him in the morning,
he quickly apologized for disturbing her and blamed it on “‘too much coffee and
food”’ the night before. She noticed, however, that he seemed very preoccupied that
day, even to the point of having to be reminded when it was time for her exercises.
Several times he asked if she felt confident that they were making the right decision,
or if they should try to find another physician for her who might suggest “better
treatments.”
His tension and anxiety continued to increase over the next few days. He seemed
unusually concerned with how she felt about the decision, and no amount of
reassurance from her could convince him that she really wanted to go into the hospital
for treatment. Several times yesterday, she found him looking at her sadly with tears
running down his face. His only explanation was that he felt “so sorry for you, having
to go to a strange place, and I might not be there when you need me!” Last night
he had not gone to bed at all but had sat in the living room. She had not dared go
to sleep for fear he would go outside and wander around.
Several times during the past few days, she had suggested he contact the crisis
center to speak to his former therapist. At first, he ignored her, then finally yesterday
he had countered with the proposal that they go together. “I’m sure,” he told her,
“that you must be feeling just as anxious as I am about all of this.” She said that she
agreed to this because she could think of no other way to convince him to come alone.
“Of course, I’m upset about having to go back to a hospital,” she told the therapist.
‘Anyone in my condition would like to have some sort of guarantee that they are
going to improve, but my greatest concern is what this all has done to John.” After
discussing her feelings a bit longer with her, the therapist determined that Sarah
appeared to be coping adequately with the recent events in her life and, although
anxious and concerned about them, was indeed not in crisis.
Finding that John had returned from his walk, the therapist arranged to have Sarah
wait outside and called him back into the office. He still appeared very tense, yet
when confronted with his evident symptoms of depression and anxiety, he at first
denied their severity. Then, after several evasive responses, he began to openly
describe just how frightened and overwhelmed he had been feeling for the past week.
“T just don’t know what’s going to happen to us next. I don’t think I'll be able to
handle much more. I was so sure she’d be back walking by this time. We did
everything that the doctors told us to do—I worked so hard with her to keep up with
the exercises and all of the appointments—and they haven’t helped. Now she has to
go back to the hospital. I feel that some of this is all my fault. Maybe I didn’t work
hard enough with her, or maybe I was doing the exercises the wrong way. She hates
being crippled like this. Sometimes I think she must hate me because she has to be
so dependent on me for doing everything.”
After Sarah had come home from the hospital 2 months ago, John had been
kept very busy and involved in driving her to appointments, arranging the
household schedules, and helping her exercise at home. He found many rewards
in this role, feeling that he was contributing greatly toward her eventual recovery.
However, as the weeks and months passed without much apparent improvement
in her condition, he was disturbed to find himself angry toward her, even at times
blaming her for not trying harder. Lately, he had been finding it increasingly
difficult to hide these feelings from her and found himself wishing that he could
just get away from the situation for a while, to take a trip like they used to,
even if it meant going off without her! Now, because of her decision to go into
the rehabilitation center for treatment, he was being given the opportunity to “get
away from it all” for a while, to turn the responsibility for her daily exercises
and care completely over to others, and he felt very guilty. Perhaps he had not
really tried hard enough to help her walk; maybe he should have found ways
to encourage her more. The more he ruminated on these thoughts, the more he
convinced himself that her lack of progress was entirely his fault. Therefore, it
was his fault that she had to go back to a hospital, and it would be completely
his fault if she were never able to return home again!
The goals of intervention were to help John obtain a realistic perception of the
situation, to assist him to ventilate his feelings about the effects of Sarah’s disability
on his life, and to provide him with situational support to help him cope with
the
pending loss of Sarah, albeit temporary at this point. Before the next session
and with
his consent, his personal physician was contacted to determine if there were any
organic bases for his behavioral changes. The physician’s report was negative.
During the next two sessions, through questioning and reflection, John was helped
to ventilate his feelings about his fears that Sarah might never recover beyond her
present level of functioning. With situational support supplied by the therapist, he
was able to begin to discuss openly the anger that he had felt toward Sarah for
“threatening the security of their future” with her accident. All of the careful
planning they had done for their “old age” seemed to be falling apart more each day.
“It wasn’t just the financial security,” he said, ‘“‘we have enough insurance to take
care of our illnesses. Our plans were all made for the two of us, together—not for
just one of us, alone!” His fears of losing her had been displaced into anger against
her for being the cause of his very unpleasant feelings.
It became quite apparent during the first session that John really did not have any
clear idea as to the nature of Sarah’s injury. To him, a broken bone was just that,
regardless of which one. It broke, therefore it should heal! He had never sat down
with her orthopedic surgeon to ask questions, leaving it to her to keep him informed.
He was advised to make an immediate appointment with this physician to get direct
information about Sarah’s expected progress rather than to continue to rely on his
own uneducated conclusions.
By the next session, he reported that he had followed through, kept the
appointment, and was relieved to learn that, although Sarah’s progress was a bit
slower than expected, the physician expected her to return to a fairly normal level
of functioning. He was advised that it would take time, however, and he would be
expected to help Sarah have patience. The recommendation that she enter the
rehabilitation center in the next city was made in an effort to speed up her progress
and was not to be construed by him as a sign that she might never recover. As John’s
anxiety and depression decreased, he began to view the events leading up to his crisis
in a more realistic manner. He realized that his anger was a normal response to his
situation with Sarah but that what he did with that anger was not normal. Rather than
openly discussing his feelings with Sarah as he would have at any other time in their
lives, he found himself “‘protecting” her from them, yet blaming her for all of his
misery. Because he lacked any other available situational support, his anxiety and
depression had increased, even further distorting his perceptions of the event.
When the suggestion was made that Sarah enter a rehabilitation center for further
therapy, John’s anxiety level interfered with his ability to perceive this as anything
other than the beginning of a final loss of Sarah from his life. As he later described
it to the therapist, “I guess this is always in the back of a person’s mind once they
get around my age. When you’re young, you go to a hospital and the odds are good
that you come home again, but when you get to be Sarah’s and my age, the odds
aren’t so good that you come home again! And she was asking me to help her make
the decision to go to that hospital—me, who was already mixed up in my feelings
about having to take care of her like this the rest of my life!”
By the end of the third session, John’s symptoms had lessened greatly, and he was
now able to help Sarah pack and move into the rehabilitation center without any
increase in anxiety. He realized now that, in overprotecting her from his true feelings,
he had only created anxiety for her as well as a crisis for himself. He planned to Visit
her three times a week. They agreed that this would give her full time to concentrate
on “‘being able to walk at home,” and he would begin to reestablish contact with their
old friends so that he would not feel so lonely while she was away.
Exploration with John about his feelings concerning the possibility that Sarah
might not improve beyond her current level of functioning helped prepare him for
this eventuality. He was able to begin to consider alternative modes of life for the
two of them. For example, he decided that they should seriously consider selling their
two-story home. ‘After all,” he said, “if it isn’t her broken hip, sure enough it’s
going to be my arthritis in the next few years that is going to make those stairs seem
like Mount Whitney!” Furthermore, John found himself faced with the realities of
what he would have to be able to do for himself if Sarah ever left him forever. While
she was in the rehabilitation center, he knew that he would have to begin learning
how to plan a life for himself. Although she might outlive him, he recognized that
this time without her was a sample for him of what life “‘might be for him—and only
a complete idiot would not recognize that I had better learn what to do and learn pretty
damned fast!”
Unprepared to assume his new role in caring for Sarah, John’s increased anxiety
distorted his perceptions of their stressful situation. When Sarah failed to make
the progress that he had expected, he became frustrated and angry and saw himself
as a failure in his new role. Unable to communicate these feelings appropriately,
he displaced his anger on Sarah. When asked to help her decide about reentering
a hospital, he felt threatened by a permanent role reversal and the eventuality
of her loss. He lacked adequate coping mechanisms to deal with the increasing
stresses of the situation; he became immobile and unable to make any decisions
for their future.
Intervention focused on helping John ventilate his feelings and obtain a realistic
perception of the event. As his anxiety and depression decreased, he became able to
anticipate and plan for their future. The major focus of the last session was to help
him recognize and accept that with increasing age future threats to his biopsycho-
social integrity could occur and that he should learn to seek help as problems arose
and not try to assume all of the responsibility himself.
Two months later, the therapist received a telephone call from John. Sarah had
come home from the rehabilitation center about 2 weeks before. Her progress,
unfortunately, was not what they had expected. However, according to John, she
was at least able to stand in the kitchen and make the “best damned dinner I
have eaten in a month” and that was ‘“‘good enough for me!” They had already
put their home up for sale and were looking for a large mobile home into which
they could move and then travel around the country to begin living the retirement
they had planned.
Pew de gens savent etre vieux.

Few people know how to be old.
—Duc de La Rochefoucauld
el rr Sede rie ee Reel oot Fe
Complete the paradigm in Figure 9-5 for this case study, then compare
it with the
completed one in Appendix D. Refer to the paradigms in Chapter
3 as needed.
JOHN
PLUS
PLUS AND
RESULT IN
Figure 9-5
REFERENCES
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Aguilera DC: Stressors in late adulthood, In Aguilera DC, editor: Coping with life stressors:
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Anderson CR and others: Managerial response to environmentally induced stress, Academy
Management J 20(2):260, 1977.
Baack D: The personal impact of company policies: a social penetration theory perspective,
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Cameron N: Personality development and psychopathology, Boston, 1963, Houghton Mifflin.
Cassell RN: The child ‘‘at risk” for drug abuse rating schedule (DARS), Psychol A J Human
Behav 28:52, 1991.
Cobb S: Social support as a moderator of life stress, Psychosom Med 38(5):300, 1976.
Dohrenwend BS, Dohrenwend BP, editors: Stressful life events: their nature and effects, New
York, 1974, John Wiley & Sons.
English O, Pearson: Emotional problems of living, New York, 1955, WW Norton.
Erikson EH: Growth and crises of the health personality. In Senn MJE, editor: Symposium on
the healthy personality, New York, 1950, Josiah Macy Jr Foundation.
Erikson EH: Identity and the life cycle. In: Psychological Issues, vol 1, No. 1, mono 1, New
York, 1959, International Universities Press.
Erikson EH: Childhood and society, ed 2, 1963, WW Norton.
Erikson EH: Maturational crisis. In Stantrock JW, editor: Life span development, ed 4,
Dubuque, 1992, WC Brown.
Hahn ME: Psychoevaluation: adaption, distribution, adjustment, New York, 1963, McGraw-
Hill.
Holmes TE, Rahe RH: Social readjustment rating scale, J Psychosom Res, vol 11, 1967.
Homonoff EE, Meltz P: Developing and maintaining a coordinated system of community
based services to children, Community Ment Health J 27(5):347, 1991.
Lau S: Crisis and vulnerability in adolescent development: erratum, J Youth Adoles 20:561,
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Peterson C and others: The attributional style questionnaire, Cognitive Therapy Res 6:287,
1972.
Piaget J: The child’s conception of the world, Totowa, NJ, 1963, Littlefield, Adams.
Piaget J: The life cycle. In Carter B, McGoldrick M, editors: The changing family life cycle,
ed 2, Boston, 1989, Allyn & Bacon.
Pruett H: Stressors in middle adulthood, Fam Community Health 2(47):53, 1980.
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s.
ADDITIONAL READING
Barabander CS: Alcohol and drugs in the workplace. In Ashenberg Straussner
SL, editor:
Clinical work with substance-abusing cliénts, New York, 1993, Guilford.
Cowger CD: Assessing client strengths: clinical assessment for client empowerm
ent, Soc Work
39:262, 1994. .
Goldmeier J: Intervention with elderly substance abusers in the workplace,
J Contemp Human
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Lewis JA and others: Substance abuse counseling, an individualized approach,
ed 2, Belmont,
Calif, 1994, Brooks/Cole.
~~ \
Ba
L
=
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2
AS,
ife is a never ending process in change. People change, fashions change—skirts

are long and flowing one year, and the next year women and young girls are
wearing microminiskirts. Men also change with “fashion,” from wide lapels to small
lapels, from cuffs on their trousers to no cuffs on their trousers. However, changes
in fashions that we wear cause no harm. But they do make money for the fashion
designers and retail stores.
A trend has occurred that is a danger to the youth and to those in the “Generation
X.” Designer drugs are now “‘in.’’ Who has heard of “‘roofies”’ or “Scoop?” Of
course, common to many are “pot,” “crack,” “sniffing,” “uppers,” and ““downers,”’
99 66
“Hf? and “smack.’’ How much is known about these street drugs? Who takes them
and why—where do they get them? What effect do some of them have? Is the effect
a temporary or a permanent state? Can they cause the death of the person who takes
them—or is given them?
California Attorney General Dan Lungren reported on the increased use of
drugs by American teenagers less than a week after Senator Bob Dole re-
leased a similar finding in the Federal Report (1996). Much like the na-
tional statistics released, a disturbing trend of growing drug use is seen among
students.
In the late 1980s, drug use among students decreased. In the early 90s, it mostly
leveled off, with some warning signs of small increases. Over the past 4 years,
a dramatic increase in drug use has occurred, back to levels that rival peaks of
10 years ago.
The federal study found drug use among 12 to 17 year olds escalated from
5.3% in 1992 to 10.9% in 1995. The state departments of alcohol and drug
221
programs, education, and health services surveyed nearly 6000 students in schools
scattered throughout California from November 1995 to March 1996. Among the
findings:
¢ Alcohol use in the last 6 months: 67.2% of 9th graders, down from 68.6%
reported in a 1993 to 1994 survey; 75.3% of 11th graders, up from 74.3%
in 1993 to 1994.
Marijuana use in the last 6 months: 34.2% of 9th graders, up from 30.4% in
1993 to 1994; 42.8% of 11th graders, up from 40% in 1993 to 1994.
Amphetamine use in the last 6 months: 10.8% of 9th graders, up from 7.5%
in 1993 to 1994; 10.4% of 11th graders, up from 10.1% in 1993 to 1994.
¢ LSD use in the last 6 months: 9.9% of 9th graders, up from 8.6% in 1993
to 1994; 10.8% of 11th graders, down from 12.2%, in the 1993 to 1994 survey.
* Heroin use in the last 6 months: 2.9% of 9th graders, up from 1993 to
1994; 2.2% of 11th graders, up from 1.4% in 1993 to 1994.
* Cocaine use in the last 6 months: 6.4% of 9th graders, up from 6.1% in 1993
to 1994; 7.2% of 11th graders, up from 4.9% in 1993 to 1994.
Marijuana
The danger has begun. Younger and younger students are drinking and getting
“high,” smoking cigarettes and pot to keep them high most of the time. Some
students see their parents, older siblings, and peers drinking and smoking pot and
apparently having a “good time.” This is how it begins. It seldom stops without a
great deal of help and strong self-discipline and self-motivation, or by accidental
overdose and death.
Young pot smokers light up for laughs and the rush of a good high, not because
of urban despair or lack of other pursuits (Ferrell, 1996). They tend to be articulate,
self-assured, and free of any great worries about the future. For many of these
teenagers, marijuana is nothing worse than a bit of spice—a secret ingredient in a
lifestyle meant to be fun, daring, a bit on the edge.
Some are second-generation pot smokers, the children of baby boomers who first
“blazed’’ in the 1960s. Others are influenced by friends, music, movies, and the
shifting tide of popular opinion. They claim few misgivings over the double lives
they lead, stashing “bud” in their closets and sock drawers, arranging deals over their
own telephones, and slipping away to get high in garages, backyards, or in their own
homes when their parents have stepped out for the night.
One 17-year-old senior, at a campus ranked among the top high schools
in the
nation said, ““You’ve got every type doing it .. . the jocks, the brainiacs, the
preppies,
the surfers, the hippies . . . 1know people who blow you away with their intelligen
ce,
and they’re snapping bongheads every night.” (Ferrell, 1996).
Some people manage to work marijuana into their lives without losing
control.
They pass their classes, hold down important jobs. This is part
of what makes
marijuana such an enigma—a reason why even many adults have
trouble deciding
how they feel about it.
Pot occupies a gray area in American thought. Scientific research
has found
evidence that pot is addictive and that it damages the lungs. But
its status as a health
Chapter 10: Substance Abuse 223
threat is murky and subject to widely differing opinions, even among scientists.
Tobacco and alcohol present some of the same problems, and these substances are
legal. A significant number of marijuana users go on to harder drugs, but a large share
do not. In January 1997, The American Medical Association announced their support
for the use of marijuana for medical uses (Shuster, 1997). At the same time the federal
government, represented by drug czar Barry McCaffrey, indicated its disagreement
with the AMA’s stance, saying that the change of a schedule status for marijuana was
“premature” (p. A20).
Not only are more teenagers using pot, but they are also starting at a younger age.
Ten years ago pot smokers seemed to begin at 17 or 18. Today they seem to start at
13 or 14. And 10 years ago the problem was limited to pot, alcohol, and some co-
caine, or LSD. But nowadays kids get into everything. They are not as selective as
they used to be and more are risk-takers (Ferrell, 1996).
While science is making progress toward understanding marijuana, science is also
making marijuana more potent. Hybridizing and special growing techniques have
enabled dealers such as Hemp BC, a cannabis store based in Vancouver, British
Columbia, to offer 70 or more varieties of marijuana seeds. Customers can purchase
them by catalog or over the Internet and grow pot that is far more potent than the
marijuana of the 1960s.
Heroin
Federal drug czar Barry R. McCaffrey (Greenberg, 1996) has warned that heroin use
is rising at an alarming rate nationwide and that dealers have found new and
increasingly more successful ways to market the drug.
The average street price for heroin is so low and the quality is so high that new
users can smoke or inhale it instead of injecting it, reported McCaffrey in releasing
the latest Pulse Check, a quarterly report on drug use compiled by the White House
Office of National Drug Control Policy.
The report also found that the increased availability and greater purity is aiding
heroin’s spread to blue-collar and suburban American. About three fourths of heroin
users inject the drug rather than inhale it, and this may show that inhalation is a
transition phase that switches to injection after a few years.
Some people who snorted cocaine during the mid-1980s are now using heroin.
Heroin is the kind of drug that always appears after a stimulant epidemic like that
we had with cocaine. Trends in illicit drug use in the United States are cyclical, with
drugs going in and out of fashion. After the cocaine-related deaths of a number of
athletes, actors, and musicians in the 1980s, cocaine use began to decline, and heroin
replaced it as the drug of choice.
McCaffrey’s survey also underscored the threat of methamphetamine (or
“‘speed,”), which has almost replaced cocaine as the illegal drug of choice. “It’s
being called ‘the poor man’s cocaine.’ It’s an enormously lethal threat to people’s
health and mental stability and their ability to operate machinery.” (Greenberg,
1996).
Most heroin in the United States came from Asia until about 1990, when
the Colombians began producing it along with cocaine and shipping it through the
southern U.S. border. Up to 70% of drug shipments now come through Mexico. The
Colombians are getting into heroin to diversify their market, and now they’re having
their street-level people handle both cocaine and heroin. Selling the two different
drugs through the same dealer, or ‘“‘double-breasted,” makes for a powerful
marketing combination.
The death of a backup musician for Smashing Pumpkins, one of the country’s
most successful alternative rock bands, has spawned a macabre surge in sales
of the very drug that killed him. Jonathan Melvoin, a 34-year-old keyboard player,
died from an apparent overdose of heroin (““Red Rum” brand) in a plush New
York hotel, and since, increasing numbers of users have been trying to buy the
“Red Rum, that the Melvoin used.’ Melvoin’s death has turned out to be a
commercial for the drug, and is attracting buyers. Police called a news confer-
ence to warn of the potential consequences of the use of Red Rum, which they
noted spelled “murder” backwards. They are trying to put out the word that it
is very dangerous. It has a high potency, and people should not shoot it (Goldman,
1996).
Methamphetamine
Methamphetamine, also called crystal or crank, is an amphetamine derivative
developed by a Japanese pharmacologist in 1919. Although it is prescribed to treat
attention-deficit disorder and obesity, like other amphetamines, it has been abused
since it came on the market in the 1930s.
An injectable, highly addictive form of “meth” used by “speed freaks” in the
1960s prompted the government to tighten controls on its manufacture in 1970.
Abuse of meth fell off during the 1970s as cocaine became increasingly available.
But “meth” has become more popular in recent years, especially in California—
now the nation’s center for clandestine meth labs. The drug is easy to make, cheaper
to buy than cocaine, and it produces a feeling of euphoria that lasts for hours—an
effect strongly alluring to workers trying to keep up (Marsh, 1996).
Workers take the drug anywhere they do not expect to be caught—the restroom,
a stairwell, a private office, in the car during break, and, for those who travel,
the airplane bathroom. In one common pattern of abuse, an employee snorts speed
before heading to work in the morning, takes it throughout the day as effects
wear off, downs alcohol at night to counteract the buzz, wakes up hung over,
and starts the cycle again.
When a speed user is in their midst, co-workers often sense that something is
wrong but cannot put their finger on it. The paraphernalia are easily concealed:
a
small plastic bag or vial for carrying the stuff; a business card holder,
mirror, or some
other flat surface to hold a hit; a razor blade for pulverizing the powder and
forming
it into lines; and a short straw for sniffing it.
One clue is that a person disappears into the restroom stall but does
not flush the
toilet, and then returns to the office or assembly line sniffing or playing
with the nose.
Some users maintain their personal hygiene. But other heavy users,
who stay awake
for long hours, skip needed showers and appear at work with
unkempt hair and
wrinkled clothes. They often pick at their skin, leaving sores
on the arms, legs, or
face known as “speed bumps.”
Normally, when people get very advanced into their use, you see them losing
weight, looking pale and somewhat frail. They are very irritable, nervous, and
anxious (Marsh, 1996). Normal situations, like going out to lunch with a group, are
often avoided. Relations with co-workers often deteriorate as users get edgy,
sometimes exploding at the slightest criticism and, in not-so-rare instances, lashing
out physically. People taking crystalmeth can become emotionally and physically
wrecked to the point where friends and neighbors cannot even recognize them
anymore.
The increasing number of police raids on meth labs, chemical explosions, and
emergency hospitalizations mark the rising epidemic of methamphetamine abuse; its
impact is increasingly being felt in the workplace. Of 300,000 drug tests performed
annually, about 15,000, or 5%, come up positive. Speed accounts for 35% of the
positive results, up from 20% 2 years ago, and it has edged out cocaine, which has
slipped about 5 percentage points to 30%, In virtually every industry, more people
are abusing meth, as they are often deluded into believing it can help them work
harder, better, faster, and longer.
Designer Drugs
ROHYPNOL
The drug Rohypnol, known among users as “roofies,”’ has allegedly been used in a
number of rape cases in which women reported their attackers slipped the small white
pills into their drinks before the women lost partial memory of the hours that followed
(Shuster, 1997). Los Angeles police say that they are seeing a great deal of it. They
see people with it but are unable to do anything about it. The state Senate passed a
bill by Senator Tom Hayden that makes the sale or possession of the hypnotic drug
a crime. ‘“We’d like to make the sale or possession of this dangerous drug—which
has an insidious threat of violence with it—a crime,” Hayden said. ““There’s a
delusion out there that this is a cheap relaxant. But Rohypnol is really 10 times the
power of Valium.”
The drug is sold in 64 countries as a sleeping aid, but the manufacturer has not
sought approval for sale in the United States. The pills gained notoriety when
Nirvana singer Kurt Cobain overdosed on Rohypnol that he took with champagne,
a month before killing himself. The pills, which can cause memory loss, are being
sold for $1.00 apiece on the street. Because they can cause memory loss, some rape
victims have trouble recalling the details of their attack, remembering just enough
to be traumatized. No rape goes without serious pain and serious damage. No rape
is forgotten.
Officials of Hoffman-LaRoche Inc., the firm that manufactures the 20-year-old
drug, oppose Hayden’s effort to place the drug in the same classification as
substances such as LSD, saying it does little to address abuse of the pills. Company
officials said they are working with authorities in Texas and Florida to develop a urine
test for Rohypnol. The company is making a weaker version of the drug, about half
the dosage, in Mexico and Colombia, where authorities believe traffickers are buying
the drug to smuggle into the United States.
Roofies are being used by heroin addicts to expand the effects of low- grade heroin
and by cocaine addicts to “cushion the crash” when the effects of that drug wears
off. Young adults and teenagers also are taking the pills to boost the effects of alcohol
and marijuana. This is not just a drug used for personal abuse. This is a drug used
as a weapon in a violent crime (Shuster, 1997).
Law enforcement officials in Los Angeles County announced new procedures to
collect evidence in sexual assault cases in which the use of disorienting and
sometimes /ethal “‘date-rape’’ drugs is suspected (Gold, 1996).
Beginning immediately, hospital caregivers are being asked to collect urine
samples from rape victims, and police officers are being trained to look for evidence
of these potent, invisible drugs when investigating sexual assaults.
GAMMA HYDROXYBUTYRIC ACID (“SCOOP” OR GHB)

Authorities are investigating whether four people who became ill in a bar—two of
them critically—had downed drinks spiked with a designer drug. Urine tests on two
of the victims showed the presence of an illegal drug known as Scoop. This liquid
drug, which is odorless and tasteless, is known for its purported aphrodisiac and
hallucinogenic properties (Tawa, 1996).
Drugs such as Rohypnol and GHB have drawn national attention as they circulate
through party and nightclub circuits. Six people were rushed to a hospital after they
consumed GHB at a club. The Los Angeles district attorney’s office is prosecuting
two rape cases involving these drugs, and the deaths of six people nationwide have
been attributed to their use. After ingesting the tasteless and odorless drug, the victim
feels dizzy and disoriented and may black out.
Beginning January 1, 1997, possession of Rohypnol (roofies), was illegal in
California. However, GHB, known on the street as ‘cherry meth” or “liquid X,”’
remains legal. Five to six sexual assaults a month involving the drugs have been
reported. This is just the tip of the iceberg. Most victims do not report the rape
because they feel shame and are uncertain about what happened.
Inhalants (The Silent Epidemic)

e e
In the culture of drug use, sniffing (or huffing) has traditionally been regarded as kid’s
stuff—a stunt pulled by adolescents and preteens using felt tip pens and tubes of
Elmer’s glue. But drug counselors and treatment professionals say a different
scenario is emerging nationwide—one of ignorant teenagers and parents, and
a
variety of readily available toxic substances (Brown, 1995):
Cutting across race and socioeconomic lines, huffing has evolved
into what the
National Inhalant Prevention Coalition has dubbed “the cocaine of the 90s.””
More
than 1000 people nationwide die annually from sniffing substances
found “right
under the kitchen sink.”
No longer a practice relegated to Third World slums, inhalants now
rank as the
third most used “drug” after alcohol and marijuana among students
in the United
States, grades 8 through 12. National surveys have found that 20%
of all 8th graders
have huffed toxic substances, with inhalants figuring prominently
in the drug use of
older teens.
More than 1000 household, office, and school product
s can be sniffed to get high,
with gasoline, glue, aerosol, butane, and solvents
such as toluene being the most
popular. The most knowledgeable huffers seek out containers labeled with a skull and
crossbones, which promises a bigger and better high.
Drug-treatment professionals tell of third graders sniffing “white-out” dabbed
under their fingernails. Canisters of air fresheners, bottles of nail polish remover, and
bags of moth balls all carry the potential for a cheap kick, without the stigma of being
illegal or the threat of being physically addictive.
Yet, these substances can be far more dangerous and damaging than heroin,
cocaine, or marijuana. Long-term and permanent neurological damage, akin to the
type that produces multiple sclerosis, can result from huffing. A 1986 study of 20
chronic toluene sniffers found that nearly two thirds suffered damage to their nervous
system. Toluene is generally found in lacquers and spray paints (Brown, 1995).
Because the fumes of sniffed substances pass directly to the brain, death can result
from just a single, overwhelming huff. Users can suffocate when they inhale
chemicals that coat their lungs, thereby preventing oxygen from entering the
bloodstream.
Huffing also has a high death rate among first-time users of 30%, according to a
British study. Some users suffered heart failure triggered by adrenaline surges while
under the influence of inhalants. Huffing gives pause for disbelief, just considering
the effectiveness of delivery (“faster than an IV’’) and the type of chemicals being
huffed.
This material is what people use to commit suicide. One will not know when a
dose will kill. Ignorance of inhalants exists on all fronts, from users to physicians to
law enforcement, and contributes to a wide-scale underreporting of usage. Few
physicians or police are attuned to looking for the effects of inhalant abuse, even
when faced with teen deaths resulting from automobile accidents or involving other
drugs. If one dies from butane, no one will know. No one will detect it unless
someone reports the deceased as a butane user.
Kids end up dead, and the death is labeled a suicide rather than an accident. A real
lack of awareness exists on the part of law enforcement and the medical profession.
Parents, too, are often in the dark and may not give a second thought to children with
paint stains on their mouths and hands, or red or runny eyes and noses. Other
symptoms of inhalant use include behaving dazed or drunk.
Because standard drug tests do not detect the presence of many inhalants,
users can appear to be clean. Given the gamut of available, sniffable products,
inhalant abuse experts are preferring to concentrate their efforts on education.
Inhalants are like Russian roulette. One puts the bullet in and asks, “Do I feel
lucky today?”
Substance Abuse in the Elderly

Behind the walls of sun-drenched retirement communities, the names of the latest
life-numbing wonder pills—and the physicians who dole them out—are quietly
swapped like favored formulas for hot toddies. This pill equals a pain-free afternoon.
Another, a sure night’s sleep (Weber, 1996).
If it is prescribed by the physician, how can it be wrong? Some senior citizens,
unwilling to bother far-off and busy children or grandchildren, stumble into trouble
self-medicating, and wind up hooked. The tablets they take for sleeplessness or
pain diminish the dread of losing control, of being poor or ill, of seeing friends
pass away.
Pill-taking becomes part of a comforting, physician-sanctioned ritual, part of a
daily routine with dwindling options. Addiction specialists and some geropsychia-
trists say physicians frequently do not have the time or the knowledge to diagnose
underlying emotional problems such as depression. Pressed for time, they too often
use pills as “bandages”’ for complaints of the elderly.
No one knows how many senior citizens might be abusing drugs. Usually retired,
often widowed and without friends, elderly addicts are easily invisible: no
co-workers to notice erratic behavior or absences; no brushes with the law over drugs
procured legally; no telltale smell on their breath. They are the “closet junkies.”’ They
are at home. They are alone. They are afraid. They are hiding. Their drug pusher is
their physician.
Shame and the fear of losing independence cause the many elderly abusers to deny
or hide their problem—dirty laundry no one should see. Most never make it into
treatment programs that cater to today’s “‘let-it-all-hang out’ therapy generation.
Family members in far-away cities, confident their aging parent is safely tucked
into a retirement community or living contentedly in the family home, often mistake
the fumblings, slurred speech, and memory loss of drug abuse for old age or senility.
Or they may aggravate the problem because they prefer a sedated grandparent, rather
than a cranky, complaining one. Drugs can cause or exacerbate depression in those
least able to cope, perhaps bringing death much sooner. There is something wrong
with the system for elderly. This is one of the great secrets of the geriatric community.
Certainly it is one of the taboo subjects of physicians.
Geriatric specialists and some physicians say the push toward HMOs is forcing
physicians to see more and more patients to make the same money. While such
managed-care plans can preclude “doctor-shopping” by members, they also allow
physicians less time to talk to patients and get to the real cause of aches and
pains—especially if the patient is cranky and demanding.
It is extremely time-consuming and emotionally upsetting to find out what is really
wrong. It takes 2 minutes to write a prescription, but it can take 2 years to convince
people to stop taking drugs (Weber, 1960). Table 10-1 presents drugs that
are
considered inappropriate for patients older than 65 because safer and
equally
effective drugs exist.
Cocaine
a
Cocaine is physically and psychologically addictive. It can damage the
liver, cause
malnutrition, and increase the risk of heart attacks. Coming down
from a high may
cause such deep gloom that the only remedy is more cocaine. Bigger
doses often
follow, and soon the urge may become a total obsession. This
pattern can lead to a
psychological dependence, the effects of which are not all that
different from physical
addiction. Growing clinical evidence shows that when cocaine
is taken in the most
potent and dangerous forms—injected in solution or chemica
lly converted and
smoked in a process called free-basing—it becomes addictiv
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Chapter 10: Substance Abuse
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Crack is not a new drug, but it does represent a new strategy in the sale and
marketing of street cocaine. Crack is ready-made, free-base cocaine sold in the form
of tiny pellets or “rocks,”’ which can be smoked with no further chemical processing.
The significance of this shift in cocaine vending patterns stems from the fact that it
makes the practice of smoking cocaine free-base more readily accessible to potential
users (Washton and Gold, 1987).
A cocaine high is an intensely vivid, sensation-enhancing experience; no evidence
exists, as Claimed, that it is an aphrodisiac. Indeed, evidence does suggest that the
sustained use of cocaine can cause sexual dysfunction and impotence. Even casual
sniffing can lead to more potent and potentially damaging ways of using cocaine and
other drugs. Many cocaine users take sedative pills such as quaaludes to calm them
down after the high and to take the edge off their yearning for more cocaine. A few
smoke marijuana for the same purpose or mix their cocaine with heroin in a process
called speedballing or boy-girl, which produces a tug-of-war wherein the exhilaration
of cocaine is undercut by the heroin.
A few middle-class users who dabble with heroin in conjunction with cocaine
smoke it rather than inject it; they believe this prevents addiction. This belief is false;
heroin, however it is used, is a fiercely addictive drug. Treatment centers are
receiving an influx of well-dressed, well-to-do men and women who have gravely
underestimated heroin’s effects. One of cocaine’s biggest dangers is that it diverts
people from normal pursuits; it can entrap and redirect a person’s activities into an
almost exclusive preoccupation with the drug.
New drugs and ways to get high appear at various times. Some remain for a length
of time because of being “‘new” and their effect on the person using them. Two “‘soft’’
drugs have been introduced in the 1990s. One is “blond hash,”’ which produces a
“giddy high”; the second is “dark hash,” which is used for a serious “zonking.”’
A newer illegal drug is “ice.” Ice originated in the Philippines; from there it
traveled to Hawaii, and from Hawaii to the mainland. It has at least three times
the
potency of speed, and has caused many deaths.
A second new drug is “cat,” a powder that is easily produced from household
chemicals such as battery acids and aerosols. Snorted like coke, it is relatively
inexpensive to make ($25), and the “high” from cat can last 3 days. This,
too, has
resulted in many deaths.
A recent method being used to get high is called ‘“autoerection ejaculati
on.” This
is done in a shower. The shower massage tubing is placed around the
person’s neck.
He then hangs himself until he is almost unconscious, and he has
a tremendous
ejaculation. Unfortunately, he may be too unconscious to release the
tubing and dies
of hanging.
In Somalia, six or seven men gather every afternoon to gossip and
to chew “qut”
(sometimes spelled khat or kat) until they are in a narcotic
euphoria. Qut is a pale
green plant that when chewed provides the user brief moment
s of a feeling of
well-being.
Qut is a way of life. The drug is cultivated in neighboring
Kenya. Qut is a boon
to dealers. It costs pennies to produce and abundant amount
s of qut are flown into
Somalia on charter planes costing $8000 a flight. No evidenc
e exists that U.S. troops
are bringing home any of Somalia’s qut. One American
civilian official said it might
happen in the future because the drug now is finding a market in the United States
(Freed, 1992).
Despite the influx of new uppers and downers, little likelihood exists that the
cocaine blizzard will soon abate. A drug habit born of a desire to escape the bad news
in life is not likely to be discouraged by bad news about the drug itself. Americans
will continue to succumb to the powder’s crystalline dazzle. Few are yet aware or
willing to concede that, at the very least, taking cocaine is dangerous to their
psychological health (Demarest, 1996).
Today’s drug was yesterday’s drug as well; we are now experiencing the third or
fourth cocaine epidemic. Historically, it dates back 5000 years. Its real claims to fame
occurred in the nineteenth century. Angelo Mariani, a Corsican chemist, may have
come the closest to “turning the world on” by inventing an elixir with coca and
alcohol. Numerous medical giants including Freud, Koller, Corning, Halsted, Crile,
and Cushing praised the merits of the “‘discovery of the age’’; cocaine’s benefit to
mankind would be incalculable. Its opponents labeled it the third scourge of mankind
(after alcohol and morphine). The New York Times stated that it wrecks its victim
more swiftly and surely than opium. CocaCola went “clean,” replacing coca with
caffeine. In the Harrison Tax Act (1914), cocaine was classified as a narcotic, and
since then debate has continued about its abuse and addictive potential.
In the United. States between 1982 and 1992, the number of people seeking
treatment for cocaine abuse increased fivefold, the number of emergency room
admissions fourfold, and the number of deaths fourfold. At least 1.5 million
Americans are now profoundly dependent on cocaine, a new corps more numerous
than heroin addicts. About 15% of high school seniors are regular users. Cocaine has
become a $50 billion business, ranking it in sales among the top 10 U.S. companies.
No longer is it the recreational drug of the affluent; 25% of blue-collar workers
engage in frequent cocaine misuse. Men users outnumber women by a 3:1 ratio, with
current profile remaining that of a white, college-educated man in his 30s with an
annual income of $45,000.
A survey conducted by the National Institute on Drug Abuse (1992) revealed that
31 million Americans had used cocaine at least once. A 1996 survey revealed that
19% of American high school seniors had tried cocaine. The rising population of
cocaine users has been accompanied by a similar increase in the number of heavy
abusers who have had to seek medical treatment because of cocaine-related
difficulties. The number of medical emergencies resulting from cocaine use increased
by 900% between 1990 and 1995, while cocaine-related deaths increased by over
1100%. Cocaine has become a widely prevalent drug that is being used by all levels
of our society, by men and women, adolescents, and adults, rich and poor (Statistical
Abstract of the United States, 1995).
Cocaine is readily absorbed from all mucous membranes, although concomitant
local vasoconstriction limits its rate of absorption. Despite this fact, absorption may
easily exceed the rate of detoxification and excretion, leading to high toxicity. Co-
caine undergoes rapid biotransformation in the body. Its two main metabolites,
ecgonine and benzoylecgonine, are excreted in the urine in amounts equivalent
to one fourth to one half the original dose within 24 to 36 hours. Depending
on urine acidity, 10% to 20% of cocaine is excreted unchanged. To avoid detection,
addicts attempt to enhance excretion by consuming large volumes of cranberry

juice or ingesting megadoses of vitamin C. Physicians attempt to increase
excretion by giving the patient intravenous ammonium chloride. After 100 mg
of intravenous cocaine has been taken, a plasma peak occurs at 5 minutes; the
distributional half-life is 20 to 40 minutes. The most popular routes for abuse
purposes are intranasal (snorting), intravenous (running), and free-basing inhalation
(smoking) (Hankes, 1984).
Cocaine is a beguiling drug that does not result in hangovers, lung cancer, or holes
in the arm. Instead, a user takes a snort, and for the next 20 to 30 minutes has an
increase in drive, sparkle, and energy without a feeling of being drugged. Reported
subjective effects include mood elevation to the point of euphoria, decrease in
hunger, increases in energy and sociability, indifference to pain, and significant
decrease in fatigue. Users experience a feeling of great muscular strength and
increased mental capacity, leading to an overestimation of their capabilities. The
powerful experience of the cocaine high can lead the user into a pattern of regular
and escalating use. The most commonly reported side effects of regular use include
anxiety, dysphoria, suspiciousness, disruption in‘eating and sleeping habits, weight
loss, fatigue, irritability, concentration difficulties, and perceptual problems.
Increasing use may lead to hyperexcitability, marked agitation, paranoia, hyperten-
sion, and tachycardia. As the person becomes more and more “‘strung out,” alcohol,
sedatives, or other narcotics are often taken to combat the overstimulation.
Paranoid psychoses are manifested by a variety of symptoms such as visual
distortion and hallucinations (geometric patterns such as “snow lights”’), tactile
hallucinations (sensation of insects on, in, or under the skin, called cocaine “bugs’’),
delusions (being chased by the police, or “bull horrors’), and violent behavior.
Cocaine interacts with the catecholamine neurotransmitters, norepinephrine and
dopamine, and alters normal interneuronal communication. It augments the effects
of these catecholamines, probably by blocking (or prolonging) reuptake at the
Synaptic junction, leaving an excess of these neurotransmitters to restimulate
receptors. Dopamine is a precursor of norepinephrine and is found in the corpus
striatum, which is part of the network governing motor functions, and in that portion
of the hypothalamus regulating thirst and hunger. Norepinephrine is the prime
neurotransmitter of the ascending reticular activating system (RAS), regulating
mechanisms of external attention and arousal. It acts as a vital transmitter as well
in
the hypothalamus, which regulates body temperature, sleep, and sexual
arousal and,
in general, mediates emotional depression. It also mediates neural
activation in the
median forebrain bundle of the hypothalamus, which is believed
to serve as a
person’s “pleasure center.”
When looking at a drug taken, but not prescribed, for a mood
or behavioral
change, one should consider the following: first, the potential for overdose
; second,
the potential for acute toxicity; third, physical derangements; fourth,
its effects on
mental status; and fifth, behavioral modification. That is, how much does it
incapacitate a person or hinder his ability to function in an environ
ment that was not
a preexisting problem? Acute consequences include hyperpyrexia;
hypertension with
possible cerebrovascular accident, arrhythmia, or myocardi
al infarct; accidents
because of impaired judgment and timing; and the dangers that
lurk around some less
than desirable purchase zones. Seizures are common and often progress to status
epilepticus. Chronic complications depend on purity, route of administration,
frequency of use, and sterility. All too often, users confuse cleanliness with sterility.
One of the frequent chronic medical complications is not strictly medical but
dental. Cocaine is a powerful local anesthetic, and users often neglect their teeth
because they are not aware of any discomfort or pain. They are often found to have
missing fillings, cavities, loose teeth, impaction with inflammation, and even
periodontal abscesses. A detailed oral examination is mandatory (Woods and Downs,
1973).
Malnutrition is common because food intake is ignored. Most patients are thin
(rarely are they obese), and some are emaciated; 73% have at least one major vitamin
deficiency, usually pyridoxine followed by thiamine and ascorbic acid. Intranasal
users develop rhinorrhea, nasal septal necrosis, and perforation; hoarseness;
aspiration pneumonia; and frontal sinusitis. Routine chest and frontal sinus x-ray
examinations are suggested. Free-basing often results in burns from explosion of the
volatile ether used in preparation of the base. Chronic users who prefer to smoke
cocaine should be evaluated for pulmonary function. Intravenous users are subject
to infections of the skin, lung, heart valves, brain, and eye by multiple unusual
bacteria and fungi. Some 86% of intravenous coke users have antibody evidence of
prior exposure to hepatitis B and human immunodeficiency virus (HIV). Talc and
silicone adulterants produce granuloma formation in the lungs, liver, brain, and eye.
Cocaine is metabolized by the liver and excreted by the kidney; any preexisting
dysfunction exacerbates most conditions previously discussed.
Patients often “tank up” just before admission, that is, use very large doses in
anticipation of “cold turkey’’ withdrawal. This increases the toxicity potential, and
some centers are reluctant to admit patients on weekends and nights unless medical
supervision is available. The lethal dose of cocaine is about 1.2 gm, but severe
toxicity has occurred with an average dose of 20 mg. Tolerance and route of
administration play an important role in the lethal dose. Sudden death from cocaine
is so sudden that the only medical person to see the patient is often the coroner. Death
occurs from status epilepticus, respiratory paralysis, myocardial infarction or
irritability, and rarely, anaphylaxis. Antiepileptic medications do not appear to reduce
or block cocaine-related seizures. The combined chronic lack of sleep and throat
anesthesia may interact to cause a deep “crash” (sleep), which is accompanied by
airway obstruction (suffocation) induced by a flaccid jaw or failure to remove
secretions (drowning). The number of deaths resulting from the combined use of
cocaine with other drugs has also rapidly increased but not as rapidly as the number
of cocaine-related homicide victims. Death can and does occur in people who drink
and use cocaine. The cocaine keeps the person awake enough to continue drinking
and try to drive home; the cocaine wears off before the alcohol, and the high blood
alcohol level oversedates, causing a fatal accident. Often only the blood alcohol level
is analyzed, which falsely attributes the death to alcohol alone. Concomitant use of
narcotics in an attempt to boost the cocaine high or to self-medicate its side effects
often results in disaster. Another factor involved in cocaine-related deaths is
cocaine-related suicides. These dependent people feel hopeless and helpless. Suicide
may be seen as the only solution to deteriorating health and personal, domestic, or
financial situations. However, fear of disability or disease from various sources does
not deter use because most users discount these medical reports or doubt that any
disability or disease will happen to them (Hankes, 1984).
The lifestyle generally accepted as normal involves major efforts to obtain and
enjoy food, water, shelter, friendship, and a sexual partner. Researchers assume that
a major function of the brain’s reinforcement centers is to make it possible for the
person to strive to achieve these goals despite the fact that their availability is limited.
Cocaine’s main danger is its bypassing of the normal reinforcement process. It
reprograms or reprioritizes the person so that getting cocaine is supreme and all
normal drives are subverted. People and their cocaine problems can be classified on
the basis of access. People who have a lot of disposable income have the different
problem of unlimited access; they can easily end up addicted. Cocaine is a drug of
disposable income: What you have, the drug will soon dispose of (Zinberg and
Robertson, 1972).
Many physicians and users debate whether cocaine is addicting, the underlying
premise being that if it is not addicting, it is not dangerous. The definition of
addiction encompasses three concepts: compulsive use, loss of control when using
the drug, and continued use despite adverse consequences. Using this definition,
cocaine is obviously very, very addicting. It lends itself to reinforcement. Toxic
manifestations do not curtail use; taking cocaine leads to taking more cocaine.
Drug-craving and drug-seeking behaviors are notable with cocaine, clearly
indicating a high level of psychological dependence. This effect, coupled with
cocaine’s property to reinforce its own abuse, leads to disaster. Regular users,
especially high-dose snorters, free-basers, and injectors, generally want to maintain
the elation. Cocaine’s price and pharmacology do not lend themselves to a
self-regulated maintenance program. Users may ‘“‘base” continuously for days or
inject intravenously every 10 minutes. For some, the anxiety, suspiciousness, and
hypervigilance become overwhelming. Even as the user comes down and recalls
the paranoid experience, he generally starts up again with the notion that this
time he will stop short of insanity. Success-oriented people who rarely use drugs
may discover cocaine and in less than 2 or 3 years find themselves hopelessly
involved in illicit activities or facing incarceration. Consistent use can result in
a severe depressive reaction, which may be the result of depleted norepinephrine
stores. This may lead to another temporary “cure,” or another dose, perpetuating
the habit. Others with mild depression self-medicate with cocaine. They
quickly
learn that they are nothing and that the drug is everything. Any subsequent
success
is misattributed to the drug, and these abusers come. to believe
that normal
functioning without the drug is nearly impossible (Garwin and Kepler,
1984).
Physicians who abuse drugs are a problem and are as dangerous
as physicians
who are severely neglectful or incompetent. Drug abuse experts say
that the culture
of the medical profession can lead physicians, more so than
the rest of the
population, not only to abuse drugs themselves, but also to overpres
cribe to others.
Fully 18% of physicians, or 14,000 of the 77,000 practicing
in California, will
develop dependency problems at some point in their lives.
And the percentage
is much higher among specialists whose work involves
treating patients with
narcotics (Bernstein, 1995).
The problems of physicians’ drug abuse and overprescription of mood-alt

ering
drugs like tranquilizers and amphetamines for their patients have their
roots in the
way physicians are trained. Medical students are taught that pharmaceuticals
often
can be the answer to patients’ problems, but remarkably little instruction is
given on
the nature of addiction. Many who develop dependency problems started in
medical
school or during grueling training periods as resident physicians in hospitals.
In 1994, 41 physicians were disciplined in California for Overprescribing drugs
to patients, and 23 for abusing drugs themselves. But those numbers are deceptivel
y
low. Most physicians who abuse drugs are “poly-drug abusers,” people who abuse
a variety of drugs. About half used alcohol, either in combination with drugs or alone.
Of 202 drug- and alcohol-abusing doctors, 134 used prescription narcotics, including
Demerol and Vicodin. Forty-three used cocaine, and 18 used marijuana.
Patients’ lives can be ruined, and physicians who are drug-addled while practicing
medicine can cause serious harm. Some physicians have admitted that they have
performed surgery and had blackouts (Bernstein, 1995).
The case study that follows depicts the tragic circumstances that occurred when
a young physician abused cocaine.
Case Study Substance Abuse

Late one Thursday afternoon, Steve D, an open-heart surgeon, called his friend, a
psychotherapist. He was quite concerned that no one hear their conversation; he
wanted to talk to his friend but not at the hospital where other staff members might
see him. They made arrangements for him to meet with the therapist at her home early
that evening. The therapist recalled that Steve had a very distinguished background:
his father, grandfather, and great-grandfather had been highly respected physicians;
and Steve was a Phi Beta Kappa from a well-known and distinguished eastern school,
had graduated magna cum laude, had married an intelligent and attractive woman,
had three lovely children, had finished at the top of his class, and had done his
residency with a famous cardiologist-surgeon. Everyone, including peers, nursing
staff, and patients, respected and liked him. In other words, he had everything going
for him.
When Steve arrived at his friend’s home, she immediately noticed that he was
tense and trembling. Then he lit a cigarette, which she had never seen him do before;
he had always disapproved of smoking. He seemed hesitant about telling the therapist
what was wrong. She reminded him that she could not help him if she did not know
what the problem was, and he obviously had a problem.
Steve began by telling her that he had been indefinitely suspended from the
hospital staff. His explanation started with his internship, when the hours were long
and the physical and emotional demands were constant. He had started using cocaine
then, “not every day or night, just when I was so tired I didn’t think I could keep
my eyes open from fatigue and complete exhaustion.”
The therapist was shocked and saddened by his confession, but she made no
outward sign of her feelings and told him to continue his story. His subsequent
residency had been difficult; Steve had felt that nothing he did pleased the surgeon.
However, when the residency was completed, the surgeon wrote a “glowing report,”
which stated that Steve had a “brilliant career” ahead of him and that he had been
the surgeon’s most outstanding resident. Steve told the therapist he had used cocaine
while he was a resident, maybe a little more than when he was an intern, but not
every day. ;
The therapist asked how he was using it and he replied, “I was just snorting
it—then.” She asked about the present, and he said, “Now I’m smoking
it—free-basing—and injecting it.” He also said that he was not combining heroin
with it when he injected it because he was “‘not that crazy.”’ He had been free-basing
for about 2'2 years and injecting for a little over a year.
She asked Steve who found out about his cocaine use and when. He started pacing
up and down and asked for a drink. Since he had admitted to smoking some coke
right before coming to see her, the therapist refused his request. She became very firm
with him and offered him a choice of answering her questions right then or leaving.
After only a moment’s hesitation, Steve started talking. He had scheduled a triple
bypass on a patient for the previous Monday morning. He explained that he never
injected himself for 3 days before surgery, but he did free-base. He made it a point
to be scrubbed early, before anyone else was around, and gowned so no one could
see his arms (with tracks from injecting the cocaine). He said everything was going
well in surgery on this particular morning until he accidentally cut his finger with a
scalpel. He added that he had been a little shaky that morning for some reason
(probably because of his heavy use of cocaine). One of his partners took his place
to continue the surgery, and he went out to rescrub. Unfortunately, Dr. A, the chief
of staff, was in the scrub room when Steve entered. Steve stripped his gloves and
gown off and started to rescrub at a basin as far from Dr. A as possible. Dr. A asked
him why he was rescrubbing, and Steve explained that he had cut his finger. Dr. A
asked to see his finger. Steve quickly held up his hand and said it was nothing.
However, the other physician apparently saw the tracks on Steve’s arm and quietly
but firmly asked him to hold out both his arms. Steve did as he was asked, and Dr.
A looked at his arms and told him to stay where he was. Dr. A then called for a resident
to replace Steve in surgery and told Steve to cancel all his appointments for the rest
of the week and wait for Dr. A in his office. Dr. A arrived at his office and asked Steve
what he had been shooting up on, how long, and why. After Steve related his story,
Dr. A told him he had no excuse; they were all dealing with human lives and could
not afford to make even one mistake. Dr. A called an emergency staff meeting of the
ethics committee for an hour later. He made it clear that he was doing nothing to help
Steve, who was to “try to explain” his behavior to the committee members.
Steve stopped talking at this point and had to be prodded into continuing. He said
the committee meeting was “‘horrible,”’ that the persons attending “‘stared at me as
if they had never seen me before.” All they had asked him was how much he was
using and where he got his supply (by writing prescriptions for nonexistent patients).
They informed him that he would have to enter a substance abuse facility and stay
there until he was determined “clean” by the discharge clinic staff. He was
automatically suspended from hospital privileges immediately. If he did not report
to a facility by the end of the week, they would notify the Board of Medical Quality
Assurance, and his license to practice medicine would be revoked.
The therapist asked him if he was going to do as the committee had told him by
the next day. He replied, “I don’t know. That’s why I had to talk to you. Can’t
you
work with me and get me over the need to use coke?” She answered firmly,
“Absolutely not, it can’t be done!’ She explained that the amount he used,
the
methods, and the length of time all made outpatient psychotherapy inappropriate and
dangerous. She told him he could die trying to get “clean” himself.
At that point, Steve said, “It would be better if I were dead.” His friend pointed
out to him that he would be leaving his wife and children a terrible legacy. She told
him that he could continue to be a surgeon, but that it would not be easy. She then
asked if he had discussed the matter with his wife, Jennifer, and he said ‘“‘no.” The
therapist sent Steve home to talk to his wife and told him to bring her back with him
that night. While he was gone, she would make some plans for him. He agreed to
do as she said.
The first step would be to talk with Steve and Jennifer together to determine if
his wife would stand by the decision that he enter a substance abuse facility. The next
step would be to contact the best facility the therapist knew to see if a private room
was available for Steve. She also needed to know if he could be admitted that night.
The facility under consideration was approximately 125 miles away. The therapist
did not think Steve would willingly accept a facility in the city.
The psychotherapist called the substance abuse facility and related her story to the
director, Mr. B, a friend of hers. Mr. B informed her that he had a room and suggested
that Steve might want to use an assumed name while there. He agreed that Steve and
Jennifer should come that night; he would make the train reservations and meet them
at the station.
Steve returned to the therapist’s home with his wife. Jennifer was shaken by what
her husband had told her, but she said they were very willing to do anything that the
therapist suggested to help her husband. The therapist told them to make
arrangements immediately to go to the facility that night. She told Steve that she
would talk to the chief of staff and inform him of Steve’s decision. Before leaving,
Jennifer requested therapy after she returned from the facility; she did not understand
how her husband could have become involved in using cocaine.
After they left, the therapist called Dr. A and told him what had happened that
evening. He asked her what she felt the chances were for Steve to come out of his
addiction really clean, with no desire to go back on cocaine. She responded that if
he could get through the first week, he might make it. The length of time he had been
using it and the methods he used made a more optimistic response impossible.
However, the therapist felt they had done all they could for him.
During the night, the therapist received a call from the director of the facility. He
informed her that Steve had died on the train; he had apparently “tanked up” and
died in his sleep. Jennifer had been admitted to the hospital in a state of shock.
Because nothing could be done for Steve, anticipatory planning would involve
helping his wife and children through the grief and mourning process. They would
have to rebuild their lives without him.
My salad days when I was green in judgment.
Complete the paradigm in Figure 10-1 for this case study, then compare it with
CASE STUDY: STEVE
Balancing factors present . One or more balancing factors absent
PLUS AND
RESULT IN RESULT IN
Figure 10-1
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2, 1995.
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in perspective, vol 1, Washington, DC, 1973, National Commission on Marijuana & Drug
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ADDITIONAL READING
Associated Press: Drug use among students up state poll finds, Los Angeles Times, August 27,
1996.
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results from three national surveys, Chicago, 1992, NCPCA.
Jones E and others: Substance abuse treatment programs for pregnant and parenting women:
a program guide, Chicago, 1992, NCPCA.
Newcomb MD, Bentler PM: Impact of adolescent drug use and social support on problems
of young adults: a longitudinal study, J Abnorm Psychol 97:64, 1988.
Sheehan M, Oppenheimer E, Taylor C: Why drug users sought help from one London drug
clinic, Br J Addict 81:765, 1986.
Shelowitz PA: Drug use, misuse, and abuse among the elderly, Med Law 6:235, 1987.
Snyder CA and others: “Crack smoke” is a respirable aerosol of cocaine base, Pharmacol
Biochem Behav 29:93, 1988.
Ventrua WP: Cocaine use: your choice now—no choice later, Imprint 35:28, 1988.
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Temporis ars medicine
The art of medicine is usually a
n December 22, 1996, the Associated Press announced in the Los Angeles
Times that Time Magazine’s 1996 Man of the Year was acquired immunode-
ficiency syndrome (AIDS) researcher Dr. David Ho, who pioneered a treatment for
human immunodeficiency virus (HIV) infection that has shown promise in beating
back the deadly disease. Time said that his work “‘might, just might, lead to a cure.”
In 1996, 3.1 million people became HIV-infected, bringing the worldwide total
to 22.6 million people living with HIV or AIDS. As long as HIV exists somewhere
in the world it threatens us all (Purvis, 1997). But at last there is a ray of hope; Dr.
Ho has given those with HIV and those who will be diagnosed in the near future a
chance for recovery.
AIDS is tightening its grip outside the United States and Western Europe. In India,
researchers estimate that by the year 2000, anywhere from 15 million to 50 million
people could be HIV-positive. Half of the prostitutes in Bombay are already infected,
and physicians report that the disease is spreading along major truck routes and into
rural areas, as migrant workers bring the virus home. In Central and Eastern Europe,
countries that had largely escaped the epidemic are seeing an explosion in the number
of cases, mainly among IV drug users and their heterosexual contacts.
Across much of Africa, the disease continues to rage unchecked. Already the
sub-Saharan region accounts for more than 60% of people living with HIV
worldwide, or some 14 million men, women, and children. As many people will die
there this year from the disease as were massacred 2 years ago in the Rwandan
holocaust. The social consequences of this die-off are catastrophic. By the year 2000,
nearly 2 million children in Kenya, Rwanda, Uganda, and Zambia will have
lost their
parents to the disease (Purvis, 1997).
The “cocktail” treatments are financially out of reach for those living in Central
and Eastern Europe and Africa. A more effective alternative is prevention,
through
240
Chapter 11: Persons with AIDS/HIV 241
public education and safe-sex programs. Such efforts have made some progress in
recent years. In Africa and in some parts of Asia, similar programs have stalled, due
to a combination of poverty, official indifference, and, at times, paranoia. As a result,
public understanding of even the most basic information of AIDS is still piecemeal.
Most of those dying from the disease in rural parts of Africa have no clear idea of
what is killing them, let alone how to prevent it.
Historical Background
The late twentieth century will be remembered as the time in which AIDS changed
attitudes and beliefs of people around the world. The world is faced with many
unknowns. When will a cure be discovered? Will scientists be able to create a vaccine
against it? How many men, women, and children will die from AIDS and its
opportunistic infections? No infectious condition of recent times has had the psy-
chosocial impact of HIV. A near “AIDS hysteria” has developed throughout the
world, as the informative as well as the sensationalist media have bombarded
the public with reports about AIDS. AIDS patients must cope not only with their own
adjustment to a terminal diagnosis, but also with discrimination caused by society’s
fear of them (Johnson, 1988).
As many as 40,000 Americans in 1996 who were defined only as HIV-positive
woke up on New Year’s Day, January 1, 1997, with a diagnosis of AIDS—the
consequence of a new and more inclusive official definition that is likely to place a
strain on already strapped social service agencies and add to the emotional trauma
of many who are infected.
The U.S. Centers for Disease Control and Prevention, which monitor the AIDS
epidemic, uses a so-called surveillance definition to determine when an HIV-positive
person has developed full-blown AIDS. Under the current definition, a person who
is infected with HIV is diagnosed as having AIDS when he or she develops one of
23 indicator illnesses. In 1993 the definition was expanded to include three diseases
common to HIV-infected women and IV drug users: cervical cancer, pulmonary
tuberculosis, and recurrent pneumonia. The expanded definition also included a
fourth new indicator: a drop in the level of CD4 immune cells, also called T-cells,
to 200/mm?° of blood, about one fifth the level of a healthy person. More so than most
other diseases, AIDS also has an emotional impact on physicians who are called on
to treat their AIDS patients’ social, emotional, and medical problems, many of which
can be overwhelming. Physicians frequently may have feelings to resolve about
caring for these patients because of their own fears of contagion, homophobia, or
other negative attitudes (Johnson, 1987).
Patients with AIDS, as well as those who perceive themselves to be at risk
(the “worried well’), face a range of fears and concerns about AIDS (Faulstich,
1987; Holland and Tross, 1985; Johnson, 1987; Nichols, 1985). HIV infection
can have devastating effects on a person’s interpersonal relationships, including
isolation, rejection, and overall loss of social support. Health consequences from
the virus can make the basic activities of daily life difficult by causing weakness,
physical debilitation, and dementia. Financial problems result from loss of job,
numerous hospital and medical bills, and exhausted medical insurance. The patient
may experience multiple psychological effects, including depression, anxiety, and

loss of hope for the future; issues of death and dying also surface (Perry and
Markowitz, 1986).
Physicians who care for these patients may feel beset by the medical, psychologi-
cal, social, and other problems and may not be able to address all of these issues in a
busy practice. Many communities, even smaller ones in rural areas, offer resources to
which the patient can be referred for specialized AIDS-related psychosocial support.
Local health departments and community mental health centers frequently can pro-
vide lists of these community services. Some health departments also provide AIDS
testing. These are usually termed alternate test sites, and the tests and results are
confidential and anonymous (AIDS Project Los Angeles, 1997).
Antibody Testing
HIV antibody testing was approved by the U.S. Food and Drug Administration in
1985 for the screening of donated blood (CDC, 1987). Since then, the test has also
been used to screen persons at risk for, and those showing signs of, HIV infection.
HIV antibody serological testing generally refers to a two or three test sequence. The
first is an enzyme-linked immunosorbent assay (ELISA) test; if this is reactive
(positive), a Western Blot test is indicated for more specificity. If this second test is
also reactive, the patient should be given the immunofluorescent assay (IFA) test. If
the IFA test is positive, the person is considered infectious and able to transmit the
disease (APLA, 1997).
To protect the patient’s confidentiality, some laboratories process HIV antibody
tests differently from other laboratory work. Frequently, specimens submitted with
the patient’s name are not accepted; only those specimens labeled with a code number
are accepted. To further protect the patient’s identity, many laboratories do not
directly bill insurance companies for the test. Many laboratories do not report test
results over the telephone, even to the physician who ordered the test. Physicians
should also direct their office or hospital practice (e.g., record keeping, staff attitudes)
so that patient confidentiality is maintained (Johnson, 1988).
AIDSSE
SE and HIV Counseling
een — eee en oan Pee ee Sh es Ay
Patient counseling, both before and after HIV antibody testing, has become the
standard medical practice in many clinical situations. This can be done by the
patient’s physician, a specially trained counselor, or, before the tests, in a group
setting (CDC, 1997b). All counseling involves educating the patient about HIV
antibody testing. In most situations, HIV testing should be performed with informed
consent, which means the patient understands that the testing is being done,
the
reasons for the test, and the possible implications (medical, social, and
legal) of both
positive and negative results. In addition, counseling should offer an environme
nt
that encourages the patient to discuss fears and feelings about AIDS. Test
results
should also be discussed. The clinician should assess the patient’s emotional
ability
to handle positive or negative results and then, together with the patient,
make a final
decision about whether to test (Johnson, 1987).
The functions of pretest counseling are to educate the patient about

AIDS and its
prevention and to help the patient decide whether the test is indicate
d and desired.
The primary purposes of posttest counseling are to inform the patient
of test results
and to provide emotional support. The patient should be encouraged to
express
feelings about the results but not be allowed to become so depressed that he
can no
longer function and pose a danger to himself. Some patients require a referral
to
mental health professionals to help them work out their feelings (Johnson, 1987).
In working with AIDS patients, therapists need to understand that the concept of
family has a broader meaning than is traditionally understood. On one hand the
traditional family composition is that of the nuclear family, the family of origin, or
both. On the other hand is the family of choice, who are also very significant and may
be included at different points in treatment. In working with the family of choice, the
definition of family may include lover or life partner and close friends who may be
the most significant relationships and source of support. Blending the family of
choice with the family of origin is therapeutic. In doing this blending, therapists serve
as models, showing that this is appropriate and needed (Appell and Blatt, 1992).
ROLE OF THE THERAPIST IN AIDS COUNSELING

In working with AIDS patients the therapist’s flexibility is crucial. For those who
have had more traditional training as therapists, AIDS can challenge their thinking.
In addition to working on relationship and family issues, both past and present,
therapists need to serve as educators, crisis counselors, and referral sources. Comfort
with moving between different roles helps patients.
Many families have no experience or prior knowledge about AIDS; the therapist
becomes their source of information in the beginning, educating families about
transmission and addressing their fears about risks of contagion. The families’ fears
are real. Validating those fears and concerns is an essential step in joining with the
family and helping them understand AIDS. As a therapist educates the family, AIDS
is demystified.
Being available to the family is critical. Every time AIDS is discussed openly and
nonjudgmentally, one serves as a role model to the family in a subtle, powerful way
about open communication. Referral to support groups, helpful books, and
AIDS-related agencies is part of the therapist’s job that often gives the family their
first connection to information about AIDS. For the therapists’ well-being, they need
to help their families find as many other forms of support as possible so that more
than one resource is available for them.
The therapist can also use his or her role to empower patients and enhance their
assertiveness or sense of control by allowing them to take the lead in bringing up
issues that need to be addressed. Although this would not be always appropriate, such
as in the case of unhealthy denial that created obstacles to needed treatment, generally
this attitude helps preserve the autonomy of the patient, an important issue in AIDS.
BOUNDARIES OF THE THERAPIST

Boundaries for a therapist need to be defined in a way that works both ethically and
therapeutically. When working with persons living with AIDS, the therapist needs to
be open to seeing the patient in the context of the family or subgroup within the
family. The therapist’s flexibility will often be challenged. At times, patients will
not be able to keep appointments and cancel at the last minute because of illness
or medical appointments. Will the therapist charge? Is the schedule open enough
to reschedule in the same week? Is the therapist willing to do home visits when
the patient becomes too ill to travel? It is a judgment call; one should not do
a house call out of one’s own anxiety, but rather out of the patient’s needs (Appell
and Blatt, 1992).
Working with AIDS patients can be integrated into most theoretical frameworks.
However, one should also focus on some of the specific issues regarding family
functioning to meet effectively the unique needs of those affected by AIDS. Some
family subgroups have issues that differ from those of other family subgroups.
Assessing family functioning can help to develop appropriate treatment plans and
goals.
Most patients wish for the family to be there and to be supportive. Therapists must
assess how realistic this hope is, and how likely it is that it will be fulfilled. For
instance, sometimes the disclosure of AIDS status is the first time the family has
heard that the person is gay. Disclosure needs to be tailored to the specific dynamics
of the family and the needs of the person (Appell and Blatt, 1992).
FAMILY SYSTEMS
When working with families, whether beginning with one person or a larger group,
looking at the boundaries in the family system, and understanding what those
boundaries are and how they have operated in the past as well as the present are
useful. People from enmeshed (overinvolved) families may have blurred boundaries.
In such families, premature disclosure of AIDS status may occur when family
members are not emotionally ready to deal with it. One can assist the HIV-positive
patient in containing anxiety long enough to think through the process of disclosure,
including each family member’s emotional preparedness and the appropriate timing
for disclosure. Members of an enmeshed family could become too involved too
quickly.
Understanding the style and makeup of the family system is vital for assessment
and treatment. In overinvolved or enmeshed families, unity is stressed and autonomy
is discouraged. Because autonomy is so important for the person who has AIDS,
family members need to resist a natural tendency to overprotect the patient. The more
they protect, the more helpless the patient may feel, and the less able to mobilize
strength and resources. One needs to teach family members the difference between
helping and rescuing. Rescuing behavior starts with the view that the patient is a
victim who is hopeless and helpless. Unattended, rescuing behavior has the effect of
infantilizing the client (Appell and Blatt, 1992).
If in a family few, if any, emotional connections exist, or if the family is
emotionally cut off, the family is referred to as disengaged. Often in this system,
AIDS disclosure may not have taken place. If it has, and if the AIDS-infected person
has historically been the identified patient in the family, this may be one more reason
for family members to see him or her as the identified patient and further blame the
person. Because of the shame connected with HIV, this could have a devastating
effect.
Depending on the level of dysfunction of the family and the emotional stability
of the patient, disclosure may or may not be appropriate. Therapists have to
pay
attention to their own need for clients to disclose. Therapists may hold a bias that
disclosure is helpful, but it may not be possible. The patients from this system are
more likely to erect rigid boundaries around themselves under the stress of an AIDS
diagnosis. They then might isolate themselves in unhealthy ways or may undermine,
distance, or cut off relationships prematurely. If a person in this type of system wants
to disclose, the therapist can help the patient prepare for disclosure by assisting in
gathering other support systems and creating a more positive image. Also, repeatedly
separating the virus from personhood helps take away the moral judgment that
contributes to shame. If the person who has been through this process decides to
disclose, he or she may be more emotionally able to handle the family’s response.
Sometimes in these situations, selective disclosure may work better: the person picks
the safest member in the family to tell first. As in the enmeshed system, timing of
disclosure is important (Appell and Blatt, 1992).
How families deal with stress and difficult news can be assessed in their level
of denial. Whether healthy or unhealthy, denial can be reflected in a family’s dif-
ficulty in taking in the reality of the situation, struggling with their many feel-
ings, and eventually accepting the roller coaster ride they are about to begin. Un-
healthy denial needs to be confronted, in a gentle and supportive way. Families do
not unlearn denial overnight. Communication is necessary for the family to overcome
their denial; otherwise, it can sabotage their chances of success in supporting one
another. For therapists, confronting denial is a walk on a tightrope at best. However,
not to pay attention to it is doing all a disservice.
The religious influences and beliefs of the patient and the family need to be taken
into consideration. Sometimes the family and the patient are in conflict about these
influences. Many gays have been cut off from their families of origin because of
religious differences. These families cannot always come together and accept their
differences.
Patients who are AIDS-infected sometimes want to reconnect with their original
faith or find a new sense of spirituality. Some may want to explore other avenues,
such as listening to meditation tapes, using crystals, or participating in other religious
or spiritual organizations. Therapists must guard against personal biases and help
patients define what is right for them and help the families to accept the patients’
perspective (Stribling, 1990).
ISOLATION
When evaluating family systems, one should look for isolation. This isolation can be
adaptive and part of the adjustment process of accepting and incorporating new
information. For example, after an AIDS disclosure, some family members may
distance themselves or withdraw for a short time. Therapists need to normalize this
reaction so that patients do not overreact and assume that this is a permanent state.
However, isolation and withdrawal by the family may not be adaptive. People
isolate for many reasons; one may be fear of contagion. Sometimes families
withdraw because they feel helpless. Often family members ask, “What do I do?
What do I say?” Fearing that they may make a mistake, they withdraw.
Family members may also withdraw from the AIDS member because they find
it difficult to be close when they fear losing someone. They may see AIDS as an
immediate death. A spouse or lover who also has AIDS may withdraw because of
fears about facing his or her own mortality. Finally, family members may experience
isolation and withdrawal in their own social circles because of the stigma of HIV.
This adds much stress at a time when support is especially important. In all of these
cases, therapists must educate, support, normalize, and validate feelings and fears.
The therapist should identify isolation and intervene when necessary, and encourage
Open communication among family members to increase intimacy and decrease
isolation (Appell and Blatt, 1992).
Grief is ongoing in working with AIDS. It is a constant adjustment process. The
losses are both real and symbolic. In addition to the many losses that the patient
suffers, the family experiences loss as well. Parents may be faced with losing a child.
Spouses and lovers face the potential loss of a life partner. These losses are
tremendous, particularly because HIV so often infects people who are quite young.
So these threatened losses also challenge the hopes and future dreams of the patient
and the family. Physical limitations caused by AIDS can also limit the activities the
family has shared in the past. The person with AIDS and family members may also
have lost other loved ones to AIDS, which decreases their support system and
compounds their loss. A therapist can help people grieve by assisting them in
expressing their feelings and normalizing their feelings. People often do not know
how to grieve or what is normal. People often feel angry during grief; without
knowing that this is normal, they may experience much guilt.
A therapist can help them talk about their feelings individually and together, as
well as express regrets and remembered joys when appropriate. Not only does this
help the ongoing grief process but also in the event death occurs the grief will be
much less conflicted. Guilt over things unsaid makes the grief process more difficult.
However, talking about loss as it occurs and death before it happens is important and
healthy (Aguilera, 1997b).
Therapists must not forget their own grief. As they work with people with HIV,
they care, they get attached, and they also have to let go. Therapists as caregivers
should give themselves permission to grieve and get support.
DEATH
We live in a death-phobic society. The person who may be dying does the family the
favor of not discussing it. The partners, in an attempt not to upset the person with
AIDS, do not talk about it either. Often both parties want to talk about their feelings
regarding death but are afraid. One of the most important things one can do is to help
people have a peaceful closure in life. If people are not able to acknowledge or
discuss death, saying good-bye when the time comes is very difficult. If one
successfully facilitates these discussions, people will have the Opportunity to stay
connected and to say a healthy good-bye. The value of this cannot be overestimated.
Psychiatric treatment must include psychological, biological, and social ap-
proaches. The psychological sequelae of AIDS affect all people at known risk, such
as homosexual men with generalized lymphadenopathy, as well as those
already
diagnosed with AIDS. In the AIDS patient, the impersonal aspects of the disease
may
be cruel and devastating. Malaise, fatigue, severe infection processes, and
loss of
control over excretory functions promote profound depression. This complements the
intrapsychic effects of AIDS, which promote depression and anxiety, and the
cognitive dysfunction, which occurs as delirious states resulting from febrile illness,
meningitis, and the toxic side effects of various chemotherapeutic agents (Wise,
1986).
AIDS in the United States

AIDS is not the disease of homosexuals or intravenous drug users alone; it threatens
millions of sexually active people regardless of age, gender, race, or place of
residence. The disease is insidious. Transmitted during sex or through the exchange
of blood (sharing needles, for example), it invades the genetic core of specific cells
in the immune system. Because it directly attacks the immune system, AIDS is both
daunting and deadly. Although the epidemic has spread worldwide, AIDS is an
especially acute problem for all, a social and medical crisis and, according to some
of the best scientific minds in the nation, a national catastrophe in the making
(Conant, 1997).
The official projections for the next 10 years of the epidemic—179,000 deaths and
270,000 cumulative cases of AIDS—have been widely publicized. By the year 2000,
an estimated 10 million Americans may be carrying the AIDS virus. What is less
known, but vitally important, is that these projections are almost certainly low. They
do not include any estimates of AIDS-related complex (ARC), a disease syndrome
that is sometimes fatal in itself and almost invariably a precursor of AIDS; by most
estimates, 10 times as many cases of ARC exist as cases of AIDS. Most experts in
the field believe that the government’s estimates of AIDS are skewed by pervasive
underreporting (Conant, 1997); the real total of AIDS cases will be as much as 75%
higher than the official figures. Another reason the 10-year projections may be low
is that they are based on estimates of the current extent of the epidemic. The
projections assume, perhaps unrealistically, that only those people who are already
infected will develop AIDS by the year 2000 (APLA, 1997).
Who will have AIDS 10 years from now? More than 90% of the victims will be
members of the two main groups, male homosexuals and intravenous drug users.
However, the nation’s heterosexual, drug-free majority cannot be reassured by that
fact because AIDS can be transmitted through conventional sex. Heterosexual
transmission is believed to have accounted for 1100 of the AIDS cases in 1986. By
the year 2000, that total will probably have risen to about 7000 cases, or 9% of the
epidemic caseload. Tragically, a total of 3000 infants will be born with AIDS. Babies
infected with the disease at or before birth will lead short and painful lives (Frierson
and Lippmann, 1987).
Many Americans have shrugged off the AIDS epidemic because it is primarily
identified with homosexuals and drug addicts, an attitude that is now changing.
Another reason for the nation’s general complacent attitude may be the belief that
science will quickly find a cure. That belief may not be warranted. Despite the
optimism of many researchers and despite gains against the disease, AIDS is one of
the most difficult challenges ever faced by modern medicine.
Apparently, many Americans remain confused about two key aspects of the
disease. One is the relationship between infections with the AIDS virus and the onset
of AIDS symptoms. For many reasons, not the least of which are human decency and
compassion, many of those who are infected with the virus are told that they have
a 1-in-10 to a 1-in-3 chance of contracting AIDS. The odds may be much worse;
experts now believe that half of all those infected eventually develop and die of
AIDS, and the actual percentage may be even higher (CDC, 1997a). The second
crucial issue is transmissibility. AIDS is not easily transmitted from one person to
another but it is transmitted through unprotected sexual contact, the sharing of
needles, and the transfusion of infected blood. Every person who has the virus is
capable of giving AIDS to someone else (Conant, 1997).
The present concern is that AIDS is on the verge of breaking out into the
population at large. The source of the contagion probably will be intravenous drug
users, a submerged and secretive subpopulation totaling about 1.5 million people
nationwide. Intravenous drug users, most of whom are heroin addicts, are least likely
to learn about controlling the spread of AIDS. Most addicts are young men with
limited education, a history of criminal behavior, and only tenuous ties to the
community or their families. In New York, which has the greatest concentration of
heroin addicts in the nation, 60% of those addicts are believed to be infected with
the AIDS virus. Assuming that most addicts are heterosexual, the next risk group will
be their lovers or spouses; the infection rate among women is rising and will pass
the rate of men by the year 2000 (Conant, 1997).
Those fighting against AIDS face two enemies: the epidemic itself and fear. AIDS
poses profound questions to American society, and it definitely tests the nation’s
reserves of compassion and common sense. It has already forced millions of people
to reconsider their sexual behavior and has brought the sexual revolution of the 1960s
and 1970s to an abrupt halt. AIDS is raising a host of difficult legal issues about
discrimination, and it may yet cause an upheaval in national politics.
The struggle against AIDS is evident daily within the nation’s homosexual
minority. With the disease toll mounting rapidly, homosexuals in New York, Los
Angeles, San Francisco, and other cities have rallied to fight the epidemic. They have
reduced their high-risk behavior—promiscuous anal sex—to a remarkable degree,
and they are providing important support for AIDS victims and the worried as well.
At the same time, the pall of death is omnipresent, and many homosexuals are
suffering from bereavement overload (Morganthau, 1986).
Canada is far ahead of the United States in recognizing gay rights. In recent years
and months, Canadian progress on homosexual rights has proceeded at such a clip
that some gay activists, as well as legal scholars, say the foundations are being laid
for a wholly new definition of “the family” under Canadian law, one in which men
may legally marry men and women marry women, one in which same-sex couples
may adopt children, receive spousal pension benefits, and generally be treated
the
same in all respects as traditional heterosexual couples.
“Canada is just light-years ahead of (gay-rights legal activities) in the United
States,” said David Pepper, an assistant to Svend Robinson, Canada’s only
openly
gay member of Parliament. Consider the following:
* Seven of Canada’s 12 provinces and territories have explicitly prohibite
d
sexual orientation as grounds for discrimination, a high percentage compared
with 7 of the 50 U.S. states that have done so.
At a national level, Justice Minister Kim Campbell said recently that she
would introduce a bill amending the Canadian Human Rights Act to proscribe
discrimination against gays and lesbians. (This act has already effectively
been amended by a federal court ruling.) No comparable proscription exists at
the federal level in the United States, although U.S. gay activists hope that
President Clinton’s election heralds a long-awaited amendment of the Civil
Rights Act of 1964.
A 1990 court ruling has apparently made Canada the first country in the world
to offer gays and lesbians antidiscrimination protection under national constitu-
tion.
* In October the Canadian military lifted its ban on homosexual bias in the
armed forces and provided sensitivity training sessions similar to those given
recruits on the sexual harassment of women.
By ending its ban on homosexuals in the military, Canada has come into step with
the vast majority of armies in the Western world. It also heightened the pressure on
President Clinton to make good on his campaign promise to end the Pentagon’s ban
on gays and lesbians in uniform (Walsh, 1992).
Homosexuals fear backlash as well. They are clinging to their gains in civil rights
against an anticipated wave of prejudice, scapegoating, and stigmatization. Acutely
conscious of the limits of the heterosexual majority’s tolerance in the best of times,
they are well aware that AIDS has reinforced their pariah status. However, the
homosexual community’s offensive against discrimination is going well: 33 states
now include AIDS victims under laws protecting the handicapped, and others are
moving in that direction. Legal experts foresee an explosion of AIDS-related lawsuits
in the next 5 years (Aguilera, 1997a).
AIDS undoubtedly will become politicized; in many respects, it is the ultimate
social issue, and the potential for demagogy is vast. In California, followers of the
extremist Lyndon La Rouche forced an AIDS issue onto the ballot as Proposition 54,
a referendum item that could have forced state public health officials to quarantine
some AIDS patients. The referendum failed by better than 2 to 1, a margin that left
AIDS activists cheering. However, the battle is not over. In 1988, Californians voted
on two propositions whose passage may have negated the progress made against
AIDS discrimination. Proposition 96, which passed, read:
Requires courts in criminal and juvenile cases, upon finding or probable cause to believe
bodily fluids were possibly transferred, to order persons charged with certain sex offenses,
or certain assaults on peace officers, firefighters, or emergency medical personnel to
provide specimens of blood for testing for AIDS. . .
Proposition 102, which was defeated, would have required the medical
community to report patients and blood donors believed to have been infected or
tested positive for AIDS virus to local health authorities.
Proposition 96 could cripple the efforts of physicians, researchers, and public
health officials to halt the spread of AIDS. It would only make the epidemic worse
(Conant, 1997). Raising the level of public concern is essential, but it must be done
without touching off hysteria.
THE AMERICANS WITH DISABILITIES ACT OF 1990

The Americans with Disabilities Act (ADA) addresses the concern that society has
been inclined to segregate persons with disabilities. The ADA is a mandate to
eliminate discrimination against those with physical and mental disabilities in all
aspects of their lives. An employer, program, or healthcare provider must evaluate
each person’s ability to perform a given task and make reasonable accommodations
that would allow the disabled person to perform.
Most healthcare institutions have had disability nondiscrimination. Nondiscrimi-
nation obligation can be found in Section 504 of the Vocational Rehabilitation Act
passed in 1973. The ADA is modeled after Section 504 and, for the most part, the
difference between Section 504 and the ADA is a change in terminology from
“otherwise qualified handicapped individual” to “otherwise qualified individual
with a disability.”
Every court case deciding on the HIV-AIDS discrimination issue has found that
people with AIDS are protected as handicapped under Section 504. Section 504 and
the ADA protect not only people with actual impairments but also those with a past
history of an impairment and those perceived by others as being impaired, despite
the fact that the person has no past or present impairment at all (Palm, 1992). To
demonstrate the extent of coverage in Section 504, Palm cites a recent AIDS
discrimination case against Beth Israel Hospital. A resident teaching physician of a
hospital refused to perform surgery on an HIV-infected patient. The court held that
because the hospital received Medicare and Medicaid funds for services rendered,
the hospital was liable under Section 504. However, the court dismissed the claim
against the physician because he could not receive federal funds as a resident teaching
physician. The ADA will eliminate such exclusions (Stine, 1993).
The ADA will eventually apply to all employers with 15 or more employees. It
will impact nearly every local government. For large cities, the impact began in 1992;
for smaller towns, in 1994. ADA will underscore the rights of the AIDS worker by
utilizing the same criteria for coverage that is currently used in Section 504 of the
1973 Vocational Rehabilitation Act, but ADA goes beyond existing legislation and
strengthens the rights of AIDS-infected employees in several ways. First, it is the
specific intent of Congress to include HIV and AIDS as a handicap covered by ADA.
Second, the legislation provides concrete examples of reasonable accommodation.
Third, with the exception of drug testing, ADA will also prohibit employers
from
using preemployment medical examinations as a screening device. Employers
will
still be able to impose job-related physical examinations, but only after they
have
extended job offers to applicants. Moreover, AIDS-infected people will
benefit from
the heightened stature of ADA in that its implementation and monitoring
will now fall
under the auspices of the Equal Employment Opportunity Commission
(Stine, 1993).
IMPACT OF AIDS ON THE HEALTHCARE SYSTEM
The expanding AIDS epidemic poses gargantuan challenges
for one American
institution in particular, the nation’s healthcare system. Even the
most conservative
estimate of the 5-year outlook for active AIDS cases proves
the need for changes in
the delivery, financing, and character of healthcare provide
d to the epidemic’s
victims. Virtually every big city hospital in America will
be treating AIDS cases by
2000, and major cities, such as New York, will
be compelled to restructure their
existing hospital systems to meet the rising need. At this point, real planning for the
crisis that lies ahead has barely begun (Hager, 1986).
AIDS is already taking a disproportionate toll among the estimated 35 million
Americans who have no medical insurance. Given the enormous expense of treating
AIDS patients in the terminal phase of the disease, this gap poses three unsettling
possibilities: (1) an explosive increase in billings to Medicaid, the federal safety net
for the medically indigent; (2) a budget crisis for the most severely affected
tax-supported big city hospitals; and (3) a drastic reduction in the level of care for
most, if not all, AIDS patients (Hager, 1986).
Healthcare planners foresee much wider use of alternative-care facilities by AIDS
patients, such as hospices, nursing homes, and in-home care by visiting nurses.
Hospital care would be reserved for AIDS patients in acute medical crises; the
epidemic’s other victims would receive less intensive care. Alternative care does
have its flaws. Few cities have yet established the elaborate outpatient system that
will be necessary; doing so will take time, money, and effort. Nursing homes offering
custodial care for the elderly are no place for young AIDS patients with Kaposi’s
sarcoma, and the visiting nurse programs in many cities are not equipped for the
immense needs of a patient dying of AIDS-related toxoplasmosis. Many AIDS
patients require 24-hour care by skilled professionals no matter where they are
housed; severe nervous system impairment and dementia are commonplace when the
AIDS virus invades the brain (Reese, 1986).
AIDS may well become the dominant social and political issue of the next decade,
but it is first and foremost a crisis in public health, an epidemic that may be out of
control. AIDS differs from other epidemic diseases in two important respects. First,
as far as is known, it is fatal in every case; it may remain dormant in the body from
5 to 15 years. Second, it utterly disables the human immune system, which has always
been the base of medical and public health strategies. If science cannot solve this
puzzle or cannot solve it fast enough, the death toll will be enormous. Thousands have
already died and thousands more will probably follow; very soon, millions of
Americans will know someone who has succumbed to the disease. Without a medical
miracle, tough decisions and a full measure of compassion are needed to fight this
disease (Ernsberger, 1986).
Sexual Transmission of AIDS

The proportion of HIV infection and AIDS cases among the heterosexual population
in the United States is now increasing at a greater rate than the proportion of HIV
infections and AIDS cases among homosexuals or intravenous drug users (Friedland,
1987). In 1985, fewer than 2% of AIDS cases were from the heterosexual population;
by 1989, 5% were from the heterosexual population. In 1991 7% of AIDS cases were
heterosexually transmitted; that is, AIDS was transmitted during heterosexual sexual
activities.
In contrast to these findings, studies in Africa, Haiti, and other Caribbean and
Third World countries indicate that AIDS transmission is most prevalent among the
heterosexual population. The number of men to women with AIDS in Africa is 1:1.
In late 1991 the World Health Organization stated that 75% of worldwide AIDS
transmission occurred heterosexually. By the year 2000, up to 90% will occur
heterosexually. Homosexuality and injection drug use occur in Africa, but the
incidence is reported to be very low. The high frequency of AIDS cases in Third
World countries is thought to be caused by poor hygiene, lack of medicine and
medical facilities, a population that demonstrates a large variety of sexually
transmitted diseases (STDs) and other chronic infections, unsanitary disposal of
contaminated materials, lack of refrigeration and the reuse of hypodermic syringes
and needles because of supply shortages.
Transmission from men to women in Nairobi has been shown to be facilitated by
common genital ulcers, the use of oral contraceptives rather than condoms, and the
presence of Chlamydia, which probably increases the inflammatory response in the
vaginal walls and increases the likelihood of having lymphocytes there that can attach
to the virus and allow transmission. The damage that sexually transmitted ulcerative
diseases cause to genital skin and mucous membranes may facilitate AIDS
transmission. If coexisting sexually transmitted infections increase the transmission
rate of AIDS, then populations with high rates of these infections are at higher risk
for AIDS. Prevention and early treatment of STDs could slow AIDS transmission in
the United States and in other countries.
VAGINAL AND ANAL INTERCOURSE

Among the routes of AIDS transmission, overwhelming evidence indicates that AIDS
can be transmitted via anal and vaginal intercourse. In vaginal intercourse,
male-to-female transmission is much more efficient than the reverse. This is believed
to be caused by (1) a consistently higher concentration of HIV in semen than in
vaginal secretions and (2) abrasions in the vaginal mucosa. Such abrasions in the
tissue allow HIV to enter the vascular system in larger numbers than would occur
otherwise, and perhaps at a single entry point.
The same reasoning explains why the receptive rather than the insertive
homosexual partner is more likely to become HIV infected during anal intercourse.
It appears that the membranous linings of the rectum are more easily torn than are
those of the vagina. In addition, recent studies indicate the presence of receptors for
HIV in rectal mucosal tissue.
Of all sexual activities, anal intercourse is the most efficient way to transmit AIDS
(De Vincenzi and others, 1989). Information collected from cross-sectional
and
longitudinal (cohort) studies has clearly implicated receptive anal intercourse as
the
major mode of acquiring AIDS. The proportion of new AIDS infection among
gay
males attributable to this single sexual practice is about 90%.
Major risk factors identified with regard to AIDS transmission among
gay
males include anal intercourse (both receptive and insertive), active
oral-anal
contact, number of partners, and length of homosexual lifestyle (Kingsle
y and
others, 1990).
Case Study
a AIDS (Heterosexual Female)
e)
Diane walked into a community mental health center and asked
to see a therapist.
She was given a brief chart to fill out and was assigned to a
therapist. The therapist
went out into the reception area, after reading Diane’s chart, with
a feeling of anger,
frustration, and hopelessness, and hoping that it would not
show.
She called Diane’s name, and a very attractive young woman wearing dark
glasses, approximately 5’7'” tall, slim, well dressed, with a lovely figure, stood up,
walked over to the therapist, and held out her hand. They shook hands; Diane’s hand
was cold and slightly limp. The therapist managed to maintain her composure
because she recognized her! She was a former well-known model who was doing a
few small but good parts in movies and television. She asked Diane to come to her
office. Diane followed her to her office.
In the office, the therapist asked Diane to have a seat. The therapist said to Diane,
“T have read your chart, and it makes me angry and sad. I must let you know that
I recognized you. Maybe another therapist might not know you. You may change to
another therapist now if you wish.”
Diane took off her dark glasses and sighed. “‘I really didn’t think anyone would
remember me. I haven’t done any modeling for years, and I have only had a few very
small parts in TV and a couple of movies.” The therapist answered with a smile, “‘But
you were my favorite model, your gorgeous green eyes, flowing streaked blonde hair
riding a horse down a beach. I love horses!”” They both laughed.
Remembering why they were there, they immediately sobered. The therapist
asked Diane again, ““Would you like to change to another therapist?”’ Diane looked
at the therapist and shook her head. “‘No, I feel very comfortable with you and I think
you like me. I don’t know if anyone can help me, but if anyone can I believe it would
be you.” The therapist nodded her thanks and said to Diane, “Just in case someone
at the clinic recognizes you we have a room upstairs where I lock your chart so no
one can ever see it but me, and don’t forget we have a fiduciary relationship.”’ Diane
smiled slightly and said, “Thanks.”
The therapist asked, ““How did you get AIDS? Didn’t you use protection? Surely
you know how it is transmitted.’ Diane said, ““Let me tell you how it happened. Then
maybe you won’t think I’m really stupid and careless.” She began talking.
She and Dave, who was also a model when they met, had been living together.
She said that it was really “hate” at first sight. She felt he was conceited, all the girls
chased him, and he dated first one and then another. They had a “‘shoot” in the
Caribbean for a well-known magazine that would involve many weeks. She was
thrilled that she was one of the three female models selected and Dave was one of
the two men selected to go. She smiled and said that from that trip came the shot of
her riding the horse on the beach. She said that when they were in the Caribbean Dave
seemed so different. He was very relaxed, and he teased her. They went swimming
and horseback riding, had dinner together, and were really getting to know each other.
Her “hate” turned to “like” and then to “love.’’ By the time they finished the
“shoot,” they were talking about living together. She said she was truly happy and
he seemed happy.
When they talked about where they would live, she wanted them to live in her
townhouse, but he wanted them to live in his townhouse. They were only about three
blocks apart. Finally, Dave said that they could live in her townhouse but that he
wanted to keep his townhouse. His reasons were that the “real estate market was
down” and “that occasionally he liked to have his privacy.” Diane said that she
accepted his conditions. They moved into her house, but occasionally he would spend
the night in his townhouse when he had an early morning “shoot” and she did not.
They lived together in what they had agreed upon, a monogamous relationship
(at least she thought they were), for a little over a year. They were both very happy.
He was working more than she was. (Men can model longer than women because
“they just get distinguished looking as they get older; women just get older.’’)
Diane said that she made an appointment with her physician because she had a
discharge and it was beginning to itch. Her doctor did several lab tests on her, told
her to use the suppositories he gave her, and said he would call her the next day. The
next day, his nurse called her and said that the physician wanted to see her. She said
that she went to his office and he told her as gently as he could that she had a yeast
infection but that her blood work showed that she was HIV positive. Diane said that
she could not believe it—she knew that she had been with only Dave.
She said she drove to her townhouse and then changed her mind and drove to
Dave’s. His car was in the garage, and she used her key to get in his townhouse. He
was in bed with one of the new young models. “‘I just looked at him. Then I said, ‘You
bastard, you gave me AIDS.’ I looked at the girl and said, ‘You better get tested too!’”’
She said Dave got out of bed and tried to talk to her, but she said all she could think of
was how stupid she had been to believe him. She said, “‘I really trashed his house,
screaming obscenities all the time. Then I went home and started crying. I knew I had
to know more about AIDS. I remembered this crisis center and I came here.”
Diane needed information on AIDS. She also needed to have a buddy. Because
she was probably better known than she realized, the therapist would delay getting
her in a support group. She would probably intimidate the other members. She would
continue seeing her in therapy until she stabilized more.
The case manager at the AIDS project was contacted and agreed to find a buddy
for Diane. He also agreed with the therapist that she would probably intimidate a
support group. He agreed to send all the new literature over so Diane could learn
about HIV and AIDS. The therapist would remain her situational support. The main
goal was to be a constant resource person to Diane, available through the exchange,
day or night. She had no family and, being so beautiful, it was not easy for her to
make friends.
Diane had a diagnosis of AIDS. She had been betrayed by her live-in lover. She
had no situational support, this was a new situation, and she had no coping skills.
She went into crisis.
Extreme remedies are very appropriate for extreme diseases.
—Hippocrates
EE PE EE
Complete the paradigm in Figure 11-1 for this case study, then compare it
with
the completed one in Appendix D. Refer to the paradigms in Chapter
3 as needed.
AIDS/HIV
So
e Pe
in Adolescence
e Sen SSS
A recent survey run by People magazine indicated that 96% of
high school students
and 99% of college students knew that HIV is spreading through
the heterosexual
population; but the majority of these students stated that they
continued to practice
unsafe sex. Combined data from surveys performed in 1993
and 1996 indicate that
among sexually active teenagers, only 15% used condoms
. Peter Jennings stated in
CASE STUDY: DIANE
PLUS ' AND
Figure 11-1
a 1991 “AIDS Update” television program that 26% of American teenagers practice
anal intercourse. Data such as these have prompted a number of medical and research
people to express concern for the next generation. If AIDS becomes widespread
among today’s teenagers, a real danger exists of losing tomorrow’s adults. Available
data suggest that teenagers have not appreciably changed their sexual behaviors in
response to HIV and AIDS information presented in their schools or from other
sources (Stine, 1993).
Teenagers at high risk include some 200,000 who become prostitutes each year
and others who become intravenous drug users. About 1% of high school seniors
have used heroin, and many from junior high on up have tried cocaine (Stine, 1993).
A large number of children from age 10 consume alcohol. Is it possible that too much
hope is being placed on education to prevent the spread of AIDS? Through the end
of June 1992, teenagers made up about 0.5% of 225,000 AIDS cases, or 1125 cases.
Teenagers must be convinced that they are vulnerable to AIDS infection and death.
Until then, it only happens to someone else. Jonathan Mann, past director of the
World Health Organization, estimates that between 1 and 2 million teenagers are
AIDS-infected worldwide. :
Teenagers, like adults, must be convinced of their risk of infection but not with
scare tactics. Behavior modification as a result of a scare is short-lived. However the
information is given, it must be internalized if it is to be of long-term benefit (Stine,
1993).
Teenagers feel invulnerable. Their hormones are flooding their systems, and they
are inclined to believe that they know it all. Too young to indulge legally in drinking,
smoking, and having sex, they still indulge in these behaviors. It makes them feel
mature, grown up, and very macho. They brag to their peers about how many beers
they had, how many cigarettes they have smoked, and how many girls they “made
it with.” Ironically, smoking is increasing in the younger population as it is
decreasing in the older population.
Statistics indicate that even though sex education classes in schools stress absti-
nence and the use of condoms, this education is ignored. Adolescents want to test
their limits in the forbidden areas of life to prove to themselves and their peers that
they are not afraid of anything (even AIDS) or anyone. The majority of teenagers
do
not use condoms. Why should they? After all, they know the people they are having
sex with; they have been going to school together for years. Even though they may
have a condom with them at the time, perhaps the last beer clouded their judgment,
and they do not use it. Then they develop strange and uncomfortable symptoms,
they
begin to miss school, and their friends tell them they are not looking too good.
The following case study is how Jack, age 14, contracted AIDS. He
trusted his
older brother, Bill, so he discussed his symptoms and asked
for his advice. Bill called
the AIDS hot line and got the address of an anonymous test
site. Jack was tested, and
the test came back HIV-positive. The test center sent him to the
crisis center for
assessment.
Case Study
$$
O N AIDS (Ole
(Adolescent)
SCENT)
The therapist was given Jack’s chart and went to the recepti
on area to meet him.
Jack’s brother Bill was with him. They both looked as if they
were ina complete state
of shock. The therapist introduced herself to Jack; he nodded and asked if his brother
Bill could go to her office with them. She replied, “Of course.” They walked to the
therapist’s office.
After Jack and Bill sat down, the therapist said to Jack, “I see that you were
referred to the crisis center by the AIDS hot line. Have you been tested?” Jack replied
that he had been tested for AIDS and he was HIV-positive. He was asked if he knew
the source of his infection. Jack answered, “It could only be one of three girls. I
haven’t been with any more.” He was told that they should be notified by the health
department so they could be tested for AIDS.
His brother Bill had been quiet, but he spoke up and in anger and sadness said
to Jack, “How many times have I told you to always protect yourself. That’s what
condoms are for! How are we going to tell Mom and Dad?”
Jack answered, “I know I have been stupid, but I’ve known all three of the girls
for years. I also always have a condom with me but I hate using the damn thing. Most
of the time, I’ve had a few beers and the girls don’t like me to use condoms anymore
than I like to—so I don’t.’ Bill replied in anger, “Yeah, and look where it got you!”
The therapist interrupted them and said to Jack, ““What do you know about being
HIV-positive?” He looked puzzled and said, ‘It means I’ve got AIDS and there is no
cure.” The therapist said, ‘““You are HIV-positive but you don’t have any of the ARC
symptoms. You could go 15 years and never get AIDS. This means you can pass the
AIDS virus to someone else so you will have to always use a condom or abstain.”
It was obvious that he had tuned out his sex education classes. He obviously
needed more in-depth knowledge of AIDS. Because Jack apparently had problems
believing “adults” or authority figures, the therapist believed he could learn and
relate better to his own peer group. His brother Bill was trusted by Jack, and he could
be an important supporter and mediator with their parents. She planned to meet with
their parents.
The therapist contacted the AIDS project and the case manager. She discussed
Jack’s situation and asked about informal classes with a peer support group for him.
The case manager told her that he had two ongoing support groups and one that
started the next day that sounded perfect for Jack. He added that they were all
approximately Jack’s age and all were still in a state of shock and disbelief.
The main goal was to maintain contact with Jack and Bill to determine if Jack was
following through with the peer group classes at the AIDS project. She would be
available to him if he had any questions. She would also meet with his family, have
them come for therapy, and be their situational support.
Jack was a 14-year-old adolescent with a recent diagnosis of HIV positive. He had
little knowledge of AIDS. He did not know anyone his age who had AIDS. This was
a totally new situation and he had no coping skills, his anxiety and depression
increased; and he entered a state of crisis.
Golden lads and girls all must

As chimney sweepers, come to dust.
Complete the paradigm in Figure 11-2 for this case study, then compare it with
CASE STUDY: JACK
Balancing factors present ; One or more balancing factors absent
PLUS AND
PLUS
RESULT IN RESULT IN
Figure 11-2
Common Questions About AIDS

AIDS is a frightening disease, but it is hard to catch and can be avoided. The
following questions and answers will provide a working knowledge of the disease
and how people can protect themselves, their families, and their friends from AIDS
(APLA, 1997).
WHAT IS AIDS?
AIDS is the acronym for acquired immune deficiency syndrome, which results from
a viral infection and most often causes death. The AIDS virus does its damage by
breaking down the body’s shield against disease, its immune system. Because they
have lost this natural shield against disease, people with AIDS contract diseases that
usually do not seriously harm those with intact immune systems. These diseases are
called opportunistic diseases. Some of the opportunistic diseases occurring most
often in people with AIDS include the following:
* Kaposi’s sarcoma (KS), a type of skin cancer
¢ Pneumocystis carinii (PC), an organism that causes a kind of pneumonia
* Toxoplasmosis, a disease caused by a parasite that infects the brain and the
central nervous system and can cause pneumonia
* Cryptosporidiosis, caused by an intestinal parasite that causes extreme diar-
rhea
* Candidiasis, caused by a fungus that coats the intestinal tract and is seen
most often in the throat as hard, white patches of growth
* Cytomegalovirus (CMV), a virus of the digestive tract
¢ Herpes simplex, a virus causing the ulceration of mucous membranes as
well as of the digestive and circulatory systems
¢ Lymphoma, a cancer that, in AIDS, affects the brain
* Cryptococcal meningitis
WHAT CAUSES AIDS?

The AIDS virus is a newly discovered type of virus called a retrovirus. Retroviruses
are difficult for scientists to understand because these viruses continually develop
new structures. This ability to change structure complicates the development of
medical treatment for AIDS and frustrates the search for a vaccine to prevent it.
Whether HIV is the direct cause of AIDS or if its ability to produce an AIDS infection
results from a damaged immune system is not yet known. One or both of these
possibilities may be true.
Scientists do not know why most of the people exposed to the AIDS virus have
not yet developed symptoms. In fact, scientists believe that most of those exposed
may never develop symptoms. However, scientists think that those who have no
symptoms (are asymptomatic) may carry the virus for many years following their
exposure to it. Some people who are exposed to the AIDS virus but do not develop
full-blown cases of AIDS may develop a less life-threatening condition of ARC.
HOW IS AIDS SPREAD?

The AIDS virus does not survive easily outside the human body, and it is
not transmitted through air, food, or water. People can contract the virus only
by having certain body fluids (blood and semen) that are contaminated with the
virus come into contact with their own bloodstreams. Infection most commonly
occurs by:
Having sexual intercourse with a person who carries the AIDS
virus (this includes anal intercourse, oral-anal contact, and oral-genital
contact).
Sharing hypodermic needles and syringes with people who carry the AIDS
virus.
Receiving transfusions of blood or blood products donated by someone who
carries the AIDS virus.
Being born to a woman who contracted the AIDS virus before or during
pregnancy.
Contaminating open wounds or sores with HIV-infected bodily fluids.
Receiving organs from an HIV-infected donor.
WHAT ARE THE SYMPTOMS OF AIDS?

Symptoms of the opportunistic diseases associated with AIDS may include:
Swelling or hardening of the glands located in the throat, groin, or armpit
The appearance of a thick, whitish coating on the tongue or mouth,
called thrush, which may also be accompanied by a sore throat
Increasing shortness of breath
Periods of continued deep, dry coughing that are not the result of other ill-
nesses or smoking
Periods of extreme and unexplainable fatigue that may be accompanied by
headaches, light-headedness, or dizziness
Rapid loss of more than 10 pounds of weight that is not the result of in-
creased physical exercise or dieting
Bruising more easily than normal
Unexplained bleeding from growths on the skin, from mucous membranes,
or from any opening in the body
Repeated occurrences of diarrhea
Whether or not such symptoms prove to be AIDS-related, a physician should be
consulted if any of these symptoms occur.
HOW IS AIDS DIAGNOSED?

Diagnosis is based on factors that include the state of a person’s immune
system, the
presence of AIDS antibodies, and the presence of opportunistic infection
s and
diseases associated with AIDS.
HOW CAN PEOPLE AVOID GETTING AIDS?

To avoid getting AIDS, the following precautions should be taken:
1. Abstain from having unsafe sex.
Ds When having sex, follow “safe sex”’ guidelines.
* Know your partner’s health status and whether he or she
has other sex
partners.
* Do not exchange blood and semen.
* Limit your number of sex partners (preferably to one person who has
also had no other sex partners).
* Use latex condoms.
3. Never share needles when using intravenous drugs (boiling does not guar-
antee sterility).
4. Do not share toothbrushes, razors, or other personal items that could be
contaminated with blood.
5. Maintain a strong immune system.
¢ Eat well.
* Get enough rest and exercise.
* Avoid recreational use of illicit drugs.
* Avoid heavy use of alcohol and tobacco.
* Have regular medical checkups.
People with AIDS, people who are at risk for AIDS, and people who carry
the AIDS virus must not donate blood, plasma, sperm, body organs, or other
tissues.
SHOULD MOTHERS EXPOSED TO THE AIDS VIRUS BREASTFEED THEIR

INFANTS?
No. Breastfeeding may spread AIDS from the mother to her child.
IS A TEST AVAILABLE TO DETERMINE IF A PERSON HAS BEEN EXPOSED

TO AIDS?
Blood tests that determine whether a person has been exposed to the AIDS virus
are available through private physicians, hospital clinics, and blood banks, as well
as most local, state, and federal health departments. The tests are designed to
detect antibodies to the AIDS virus. The presence of AIDS antibodies in a person’s
blood means that he or she has been exposed to the AIDS virus; it does not
mean that the person has or will have AIDS. Although they are highly accurate,
AIDS antibody tests are not reliable in detecting infections that have been present
for less than 4 months.
WHO SHOULD BE TESTED FOR ANTIBODIES TO AIDS?

Several things should be considered before deciding to be tested for antibodies to
AIDS. For example:
* Testing positive for AIDS antibodies does not mean that the person has or
will develop AIDS.
* Test results cannot distinguish persons who have developed an immunity to
AIDS from those who have not.
* Positive test results, if leaked to an employer or insurance company, can
lead to serious and prejudicial consequences.
* Use of birth control pills, alcoholism, and other factors may cause false-
positive results.
However, confidential testing may be appropriate for people at risk for AIDS
and/or for their partners who:
¢ Are considering parenthood
¢ Are considering enlisting in the armed forces

¢ Have been exclusively monogamous for a number of years and wish to dis-
regard safer sex guidelines
WHAT IS THE RISK OF GETTING AIDS BY DONATING BLOOD?

None. Blood banks and other blood collection centers use sterile disposable needles
and syringes that are used only once.
HOW IS AIDS TREATED?

Currently, no cure exists for AIDS and no vaccine can prevent it. Therapies are
available to treat each of the many opportunistic diseases affecting patients with
AIDS; success of these therapies varies from one patient to another.
It is possible to ease the burdens of this frightening, tragic, and often lengthy
illness. Many people with AIDS, their families, friends, neighbors, and healthcare
workers have made major strides by coming to terms with the feelings of fear,
helplessness, and inadequacy that surround AIDS. Learning to cope with the
overwhelming personal catastrophe of AIDS has also led to the recognition that other
nonmedical elements are essential in the treatment of AIDS victims.
People with AIDS require not only the most advanced medicines and chemical
therapies but also psychologically positive environments. The latest medical research
indicates a direct relationship between a person’s psychological outlook and the
function of his or her immune system. The ingredients for maintaining the healthy
outlook of a person with AIDS are those of any normal and healthy life. They include
the following:
* Companionship
* Access to a job
* Access to social, educational, and recreational facilities
* Access to a place of worship in the community
WHAT CAN ONE DO?

The first thing is abstinence. The second thing is to practice safer sex. Know one’s
partner’s health status and whether he or she has other sex partners. Limit the number
of sexual partners, and always use condoms. A wide range of lubricants commonly
used in conjunction with condoms—including Wesson Oil, Nivea hand cream,
Vaseline Intensive Care Lotion, and baby oil—can cause condoms to break
within
60 seconds. Safe lubricants include water-based preparations such as KY
jelly and
generic contraceptive gels that contain spermicide nonoxynol-9 (Parachini,
1989).
One can help prevent families, friends, and neighbors from contracting
AIDS by
making sure that they are informed about the disease and the way
in which it is
spread. If they already have AIDS, one can do everything possible
to make the rest
of their lives dignified and rewarding (APLA, 1997).
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ADDITIONAL READING
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rc
hoe
a
as
<q
.
eS.
B urnout syndrome and its effects have been extensively studied; however,
research has generally focused on individual response to people-based stimuli
in a care-giving environment. Although Freudenberger’s (1975) first definition of
burnout was failure, wearing out, or exhaustion from the demands of the or-
ganization on a person’s strength, energy, and resources, which suggest work
environment involvement, the focal point of the burnout syndrome became the
individual. His definition evolved to include loss of concern for the recipients
of one’s care, and emotional exhaustion (Maslach and Pines, 1977; Rogers, 1984).
These dimensions have been sustained through the theoretical development of the
burnout syndrome.
As many definitions of burnout have been proposed as are authors writing about
it. Freudenberger (1974), an authority on burnout, says it is “a depletion of energy
experienced by those in helping professions when they feel overwhelmed by other
problems.” Maslach’s Burnout Inventory is an excellent verifiable instrument
developed to test the degree of burnout that occurs when staff nurses show indications
that they are suffering from the burnout syndrome. Nurses who work in high-stress
areas such as the emergency room, intensive care unit, coronary care unit, AIDS
wards, and hospice facilities should be very aware of their vulnerability (Raphael,
1983).
More recently, burnout has been defined as a syndrome of emotional exhaustion,
depersonalization of others, and perceptions of reduced personal accomplishment,
resulting from intense involvement with people in a care-giving environment
(Garden, 1989; Maslach and Jackson, 1986; Pines and Aronson, 1981). The
environment in which the work is done has received far less attention in the literature
than either the individual response to pressures or job-specific aspects of the burnout
syndrome (Turnipseed, 1994).
265
Freudenberger (1974) has identified personality types most prone to burnout:

* The dedicated and committed worker who tends to take on too much for too
long and too intensely rat eeu
The staff member who is overcommitted to work and whose outside life is
unsatisfactory
¢ The authoritarian worker who relies on authority and obedience to control
others
¢ The administrator who is usually genuinely overworked but begins to view
himself as indispensable
- ¢ The professional who tends to overidentify with those he is working with
and for
Burnout and the Work Environment

Emotional exhaustion is negatively linked to peer cohesion and job structure and
positively related to work pressure in the work environment. The importance of
social support with respect to stress is widely acknowledged in the literature and
illustrates a negative impact of support (peer cohesion) on emotional exhaustion
and, thus, on burnout. Feelings of emotional exhaustion are a logical result of
working in an environment that has little camaraderie or feeling of mutual support.
This may be especially true for work characterized by close, constant peer
interaction, such as nursing. A workplace lacking in peer support may produce
emotional exhaustion whether or not it has other contributing factors, such as
people-care job stresses.
Job structure and communication are also negatively related to emotional
exhaustion. Constant uncertainty may contribute to emotional exhaustion. Poor or
conflicting communications regarding rules, policies, or other pertinent elements of
the job may aggravate the effects of the uncertainty or may themselves be
emotionally draining. An uncertain work environment and a lack of stabilizing
support (peer cohesion) may be sufficiently unsettling to cause exhaustion. Also, a
lack of peer cohesion may alter a person’s susceptibility to other negative stimuli in
the workplace (Tighe, 1991).
The influence of work pressure on emotional exhaustion may be explained by
mental preoccupation with the stress that is causing the pressure. A person will make
conscious and unconscious attempts to reduce or remove such stressors, and, that
failing, emotional exhaustion may result as time and mental resources are expended
combating the stress. Work pressure may directly cause emotional exhaustion
, or it
may reduce the ability to cope with other workplace stimuli, which
leads to
exhaustion.
The work environment stress considered here is not stress of the job, but the
degree to which the press of work and time urgency dominate the
work climate.
Consequently, for a given person, the contribution of work pressure
to emotional
exhaustion may be reduced or alleviated by changing jobs in
the same profession.
Pressure is an inescapable part of many jobs, but perhaps with
careful assessment,
some amount of that work pressure could be removed (e.g.,
reduce paperwork,
reassign nonessential job duties). Also, intervention attempts
to enhance coping
strategies may reduce emotional exhaustion. This suggests
that supervisory behavior
Chapter 12: Burnout Syndrome 267
is quite important in burnout, as supervisors have some degree of control

over clarity
and, albeit perhaps limited, overwork pressure in the organization.
The negative relationship of supervisor support and autonomy to burnout through
depersonalization bolsters the idea that supervisory behavior is a force in
the work
environment/burnout pathway. Employees may view any negative superviso
ry
behavior (or a lack of positive behavior) as a detriment to the work process. The
worker may react by depersonalizing the care recipient in a defense-type reaction to
insulate and protect the psyche from the person who, in the worker’s opinion, is
receiving suboptimal care from poor or inadequate management. Also, the worker
may depersonalize the care recipient because of a lack of acceptable ways to attack
the supervisor. A corollary explanation is that the workers feel a disequilibrium in
their personal input/output ratio, and purposefully reduce the patients’ outcomes by
depersonalizing to balance the perceived deficit in the inputs of the organization (the
poor supervision).
Supervisors have considerable control over the autonomy allowed; thus a lack of.
autonomy may be perceived as a lack of support, a lack of confidence, or a reluctance
by the supervisor to relinquish any control. Workers experiencing a lack of autonomy,
and attributing it to any of these reasons, may have negative feelings toward the
supervisor. Depersonalization of patients may result from displacement of their anger
or dissatisfaction (Turnipseed, 1994).
The importance of autonomy is explained by its positive linkage with personal
accomplishment, which is a contradimension in the burnout triad (increasing
amounts of personal accomplishment reduce burnout). The degree of autonomy
allowed is a partial function of supervisor decisions; other determinants may include
the training and competency of the worker. When management allows or fosters
autonomy, it communicates a message of personal worth and competency to the
worker, suggesting that at least part of any success experienced is a result of personal
abilities and efforts of the employee. Also, autonomy allows workers to pursue their
optimal approach to the job, with the possible benefit of increased quantity and
quality of output. Logically, feelings of personal accomplishment will follow.
With the exception of work pressure, the work environment factors linked to
burnout are those of job structure (clarity and autonomy) and relationships (peer and
supervisory relationships), which may be relatively easily altered. They are also
factors that a worker may believe should be present, positive, and supportive. When
they are lacking, emotional exhaustion and depersonalization may result, at least in
part, from attempts to cope with or to rationalize this difficulty.
Under the right conditions, anyone can experience burnout in his job situation. It
could be a staff nurse, supervisor, psychotherapist, social worker, or anyone in a
helping profession.
Stressors in Hospice and AIDS Care

HOSPICE CARE
Stressors include those factors that are part of the work environment as compared
with stressors that are a function of a person’s own experience. They include five
important facts: (1) all hospice patients are dying; (2) their disease process presents
staff with many distressful symptoms; (3) the work itself is physically and
emotionally demanding; (4) many aspects of care cannot be controlled in the home
because of the family; and (5) the process of integrating hospice into a healthcare
system can be difficult.
The most obvious stressor is the nature of terminal illness itself. Dying patients
and their families are under a tremendous amount of stress, which significantly
affects the hospice staff. Most families have little experience in caring for a gravely
ill person and are, therefore, apprehensive, unsure, anxious, and in need of a
tremendous amount of support and assurance from the hospice caregiver. In addition,
their own feelings about the impending death of a family member generates many
emotions and potential difficulties with interpersonal relationships.
Although death is the ultimate loss, in the course of a terminal illness the
patient and family experience many other losses. Coping with each successive
one often becomes increasingly difficult for the family, as well as for the patient.
Their emotional reactions are often exacerbated by previous experiences with grief
and loss that may or may not have been resolved (Friel and Tehan, 1980). The
needs of patients at the terminal stage are also great. Not only do they have physical
symptoms to alleviate but also psychological, spiritual, emotional, and financial
needs to meet.
Recognizing the impact of working with patients at only one end of the
health-illness continuum is essential. The staff know and interact with families at a
most difficult time in their lives. They have had no opportunity to participate in the
curative treatment phase when a more positive or hopeful atmosphere prevailed. In
short, the staff has no other perspective from which to work with this family.
Although many rewards are associated with this work, the pain and suffering of
patients and families occupy a significant portion of the staff’s day. Consequently,
the innumerable problems a staff member faces in caring for a terminally ill patient
become major contributors to burnout in hospice care.
Organizational factors may also be considered as stressors. Hospice care requires
the availability of 24-hour coverage, 7 days a week. The work is never predictable;
although a team member schedules regular visits, emergencies and crises are a way
of life. This translates into long workdays to accommodate unexpected needs.
Flexibility and adaptability are essential personal characteristics of hospice team
members.
In most home care situations, the patient is cared for by family members who, for
the most part, are inexperienced and untrained. Although hospice care is predicated
on the team approach, the nurse remains responsible for the coordination of care with
no other shift taking over after he leaves the home. All aspects of care, including
supplies and personnel, must be arranged by the staff.
The number of patients assigned to a hospice staff member, as well as the acuity
level of each patient-family unit, influences the amount of stress a hospice staff
member experiences. In short, the size of the caseload must be considered in relation
to the severity of the needs and problems of each particular family unit.
AIDS CARE
With the prevalence of AIDS in the United States today, healthcare providers are
at
great risk for experiencing burnout because of many stressors: (1) fear of contagion
and mortality, (2) the young age of those afflicted, (3) the inevitability of the patient’s
death, (4) deterioration of the patient’s physical condition and psychological state,
(5) the need for extra precautions, and (6) being the target of the patient’s anger. The
emotional and educational needs of the patient’s significant others also place a burden
on the health professional. Additional stress may be experienced if the healthcare
worker becomes placed in the role of mediator between the patient, the patient’s
family, and the patient’s lover (Salisbury, 1986).
Healthcare workers who have adverse feelings toward homosexuality, bisexuality,
or AIDS experience additional stress. The strain is compounded when the
professional tries to suppress personal feelings and attitudes to deliver care in a
nonjudgmental fashion. Healthcare providers may be shunned by their families,
friends, the community, and other professionals for their work with AIDS patients.
They may try to protect their personal and professional lives by concealing the nature
of their jobs from others. The combined stressors involved in working with AIDS
patients result in an increased potential for burnout among health professionals
(Nichols, 1985).
Indicators of Burnout
No one stressor is apt to cause burnout. One must look instead at the number of
stressors experienced by a staff member and the extent to which individual stressors
impact the caregivers. One does not suddenly “‘burn out’’; rather, he undergoes a
process marked by physical, emotional, and behavioral indicators that can be easily
recognized. Physically, the staff member may describe a never-ending sense of
exhaustion and fatigue; often, he shows symptoms of frequent headaches,
gastrointestinal disturbances, respiratory problems, loss of appetite, weight changes,
sleeplessness, and continual colds. He may also increase the normal use of alcohol,
cigarettes, or drugs.
Emotionally, the staff member may be described as depressed, irritable, or
paranoic, often with a negative self-image because he does not like what is happening
or how he feels. A person may describe a sense of powerlessness and a lack of
appreciation. An overall feeling of negativity prevails about changes that may be
occurring within the job or about the work in general. Overall, job satisfaction is
decreasing because the rewards do not nearly balance the problems.
Observable behavioral changes occur that include increased absenteeism,
inability or unwillingness to be as productive as previously, irritability with patients
and other staff members, and an attitude of omnipotence or “I can do it alone,”
accompanied by increasing isolation from co-workers. Nightmares about patients or
about the job may occur to the point where it interferes with sleep. In the staff
member’s personal life, spouse, friends, or children may complain about being
ignored; a major change may precipitate in these relationships. Often, the burned-out
person complains about not being able to relax (Friel and Tehan, 1980).
BURNOUT PROGRESSION
Two factors are most likely to create conditions under which burnout may progress.
First, therapists are vulnerable when they fail to adhere to the psychological
boundaries that separate their lives from their patient’s lives or when these
boundaries are poorly or unrealistically defined. When boundaries fail, therapists
adopt into their personal lives the emotional responses—grief, anger, fear—that
patients bring to the counseling session. Although identifying with their work is often
productive for therapists, psychological boundaries also protect their personal lives
from being substituted by work (Tighe, 1991).
Second, unrealistic goals and expectations set the stage for frustration and
burnout. Therapists are limited in what they can achieve at antibody test sites during
one session; for example, if they see success as entirely changing a person’s
risk-taking behaviors or totally eliminating the transmission of AIDS, they will fail.
A related factor is the perception that an inadequate healthcare system can never fully
satisfy patient needs and therefore leaves them to therapists to resolve. By contrast,
expectations of failure—for example, thinking that patients will not be able to get
appropriate treatment despite referrals offered by therapists—may lead therapists to
feel hopeless and powerless (Stine, 1993).
A therapist’s emotional state and job performance may offer warning signs of
burnout. During the early stages of burnout, therapists often report that outside work,
they are listless and inactive, inclined to meet only minimal responsibilities imposed
on them by friends and family, and apt to sleep longer. They are more likely to
participate in addictive behaviors, such as eating, smoking, drinking, and recreational
drug use.
STAGES OF DISILLUSIONMENT
The most definitive work on burnout syndrome is the text by Edelwich and Brodsky
(1980). According to the authors, the four stages of disillusionment that occur are (1)
enthusiasm, (2) stagnation, (3) frustration, and (4) apathy. Each of these stages of
disillusionment is discussed briefly, and a fifth stage, that of hopelessness, is
included, as well as some intervention techniques.
Enthusiasm. Enthusiasm is the initial period of high hopes, high energy, and
unrealistic expectations. During this period, the person does not need anything in life
but the job because the job promises to be everything. Overidentification with clients
and excessive and inefficient expenditure of one’s own energy are the major hazards
of this stage.
People go into the human services to make a living but not to make money.
Although the full extent of the inequities in salaries between publicly funded
Service positions and jobs in the private sector may become apparent only after
a person has invested years of training and work in a helping profession, the
person is generally aware that such professions do not pay especially well. The
motivation is a desire to “help” people. These workers become “helpers” because
they really enjoy working with people and they want to make a difference
in
people’s lives. Those who are genuinely involved far outnumber those who
are
cynical and self-seeking.
An important factor in bringing people into the human services is the example of
others in the field. People want to be like those who have helped them.
This is
especially common in teaching and medicine because every young person is
exposed
to teachers and physicians, some of whom are inspiring models.
In other human services fields, the experience of being a patient often engenders
the desire to be a helper (Edelwich and Brodsky, 1980). The experience of being
helped provides the strongest demonstration of the value of helping. At the same time,
it creates expectations of what it would be like to assume the role of helper.
People who have been counseled unsuccessfully do not become counselors. The
people who become counselors are those who have been counseled successfully, and
their experiences as cooperative patients who have benefitted from the services
offered them may give them unrealistic expectations. They may expect all patients
to be as receptive and resourceful as they were and all counselors to be as competent
and caring as those who counseled them.
Enthusiasm comes not only from high initial motivation but also from early
successes and satisfactions on the job. The new counselor or social worker, needing
a certain amount of structure and supervision, tends to be put to work in
environments that are safer and more rewarding than those they will face later.
When the social worker has moved out into tougher, more demanding envi-
ronments and has exhausted the capacity for self-reinforcement as well, he tends
to look back on those halcyon days with a certain wistful nostalgia. In the stage
of enthusiasm, it is commonly believed that the job is the person’s whole life
and that all gratifications are coming from the job. This unbalanced existence
comes about by a kind of vicious cycle. On the one hand, an inflated conception
of the job tends to obliterate personal needs and concerns. On the other hand,
glorification of work may arise from deficiencies in a worker’s personal life. The
cycle of overcommitment is self-fulfilling because the longer the personal life is
neglected, the more it deteriorates. The helper is thus left in a highly vulnerable
position when the job ceases to furnish the rewards it once did (Edelwich and
Brodsky, 1980).
Overidentification with patients is a major link in the chain that stretches from
enthusiasm to burnout, both because it leads the helper to act in ways that are
detrimental to patients and because it makes the helper’s emotional well-being
dependent on the patient’s living up to unrealistic expectations. Overidentification
stems from an excess of energy and dedication, a lack of knowledge and experience
in the field, and a confusion of personal needs with those of patients. It manifests
itself as a lack of clarity in role definitions between patient and helper. It leads
well-meaning professionals and paraprofessionals to make themselves available to
receive telephone calls at home at all hours of the night, a degree of accessibility that
can have damaging effects on the helper’s life.
The problem facing those who are dedicated to human services is to be realistic
enough to cope with discouraging conditions without suffering a total loss of idealism
and concern. This is also the lesson that needs to be conveyed to students and trainees.
This is the area where intervention is the most crucial, especially when a person
reflects that an initial lack of realism is what leaves him most vulnerable to eventual
disillusionment.
Stagnation. According to Edelwich and Brodsky (1980) stagnation refers to the
process of becoming stalled after an initial burst of enthusiasm. It is the loss of the
momentum of hope and desire that originally brought the person into the helping
professions.
No sharp distinction can be drawn between stagnation and frustration or, indeed,
between any two of the four stages of burnout. The progression through the four
stages cannot be traced in precise chronological sequence in any given instance.
When accomplishments are reduced to a human scale, minor annoyances such as
low pay and long hours begin to be noticed. The frustrations that occur at this point
are not enough to question doing the job, but they are enough to question doing
nothing but the job. In stagnation a person is still doing the job, but the job can no
longer make up for the fact that personal needs—to earn a decent living, to be
respected on and off the job, to have satisfying family and social relationships, and
to have some leisure time in which to enjoy them—are not being met. If those needs
remain unmet, that person will not be able to keep on doing the job for very long.
Stagnation often begins with the discovery that one cannot as easily as anticipated
see, let alone assess, the results of one’s labors. Initially, it is experienced not as a
source of active discontent but as a kind of bewilderment that leaves a person
wondering why the job is not quite what it appeared to be. At the heart of stagnation
lies the feeling that one’s career is at a dead end (Edelwich and Brodsky, 1980).
Frustration. In the stage of frustration, helpers who have set out to give others
what they need find that they themselves are not getting what they want. They are
not doing the job they set out to do. In essence, they are not really “helping.” Besides
the low pay, long hours, and low status, a more basic frustration in the helping
professions becomes evident: people are extremely difficult to change, especially
under negatively perceived working conditions.
The sensation of powerlessness is felt at many levels by people in the helping
professions. Most obvious is the powerlessness felt by front-line workers who occupy
the lowest positions in the decision-making hierarchy, for example, the therapist who
has no way to compel his crisis patients to keep their appointments with him.
Powerlessness is relative to a person’s position. A frequent complaint of supervisors
is that their subordinates credit them with more power than they actually have
(Larson and others, 1978).
The feeling of powerlessness is universal; it goes beyond hierarchical status. Its
broader implications are the inability to change the system and the inability to control
patients, subordinates, superiors, or the agency. This is the frustration that leads
directly to burnout.
Notwithstanding the idealism that motivates people to enter the helping
professions, issues of power and control are central to the helping relationship. Some
people complain that they do not have enough power; others complain that they have
too much power. The unresponsiveness of the system to the people working in it is
seen as a lack of appreciation. Workers who are not given responsibility, are not
consulted about decisions, and are generally overlooked by the bureaucratic system
will certainly believe they are not appreciated by their supervisor or by the
organization as a whole.
Appreciation from patients is what enables the worker to go on despite lack of
institutional support. A person can take the stress from the supervisor when
appreciated and receiving positive feedback from patients. When patients,
too,
become unappreciative, a worker begins to question the whole purpose
of being
there.
The effects of frustration and of stagnation on the quality of services rendered to

patients are all too evident. Implicit and explicit in the accounts of overwork,
inadequate funding, staff polarization, bureaucratic sluggishness, and other sources
of discouragement and demoralization among staff members is the almost inevitable
conclusion that the patient is the one who suffers.
The importance of frustration in burnout lies in what a person does with it.
Reaction to frustration has a great deal to do with whether the worker will fall deeper
into burnout and, ultimately, leave the field. A person can respond to frustration in
three ways: (1) use it as a source of negative energy, (2) use it as a source of positive
energy, or (3) just withdraw from the situation.
Frustration no doubt creates energy. When it is an energy of willful denial, a frenzy
of activity aimed at evading the reality of frustration or doing away with the causes
of frustration that are among the givens of the situation, then it is a self-destructive,
negative energy. The energy of frustration can also be directed into a constructive
effort. By taking responsibility, confronting issues, and taking actions that may bring
about change, a person can release some of the emotional tension created by
frustration. Frustration can be a major turning point in the progression through the
stages. A person who misses this turn is likely to descend into apathy.
Probably the most common response to frustration is to not express it at all, but
to internalize it and withdraw from the threatening situation. The helper avoids
patients, disliking or resenting them, despairs of being unable to do anything for
them, or is physically exhausted. Some walk away from their jobs and from their
idealism and concern. Then they may get angry, assert themselves, and get back into
the center of things. Others, unfortunately, drift into the fourth and last stage of
burnout—apathy (Edelwich and Brodsky, 1980).
Apathy. Apathy takes the form of a progressive emotional detachment in the
face of frustration. The starting point is the enthusiasm, the idealism, and
overidentification of the beginner. If one is to come down from the clouds and work
effectively, some detachment is desirable and inevitable, but most people do not have
ideal learning conditions and sympathetic guidance to help them reach an optimum
level of detachment. Frustration comes as it will, sometimes brutally, and the
detachment that develops in its wake is less a poised emotional distancing than a kind
of numbness. In turning off to frustrating experiences, a person inay well turn off to
people’s needs and to his own caring. Apathy can be felt as boredom. The once
idealistic helper can trace the erosion of a previous desire to help and the feeling of
involvement with patients. People who started out caring about others end up caring
mainly about their own health, sanity, peace of mind, and survival.
The most severe and saddest form of apathy is experienced when a person remains
at a job for one reason only—because the job is needed for survival. The person has
seen what is going on but has no inclination to try to change it. Certainly, no risks
are taken when the worker can just go along, protecting the position while doing as
little as possible. Security has become the prime concern. Of all the stages of burnout,
apathy is the hardest to overcome and the one against which intervening successfully
is most difficult. It is the most settled and the most deep-seated stage, the one that
takes the longest to arrive at, and it lasts the longest. It stems from a decision, reached
over a period of time and reinforced by one’s peers, to stop caring. In the absence
of a major personal upheaval, vastly changed conditions on the job, or a concerted

intervention, it can last forever.
Hopelessness. Edelwich and Brodsky (1980) did not discuss hopelessness as a
stage in the process of disillusionment; it is, however, implicitly evident in their
stages of stagnation, frustration, and apathy. According to Horney (1967), hopeless-
ness is the ultimate product of unresolved conflicts. It is a looking forward to an event
or an occurrence with the deeply held belief that the anticipated will not occur.
When hope is lost, a person may be in the stage of stagnation, frustration, or
apathy. Hopelessness may fluctuate throughout the stages, diminishing at times and
then returning full force to make the person feel like giving up the role of helper. With
hopelessness, the helper has a tendency to deny or to avoid revealing any personal
thoughts or feelings that could be considered ‘“‘unprofessional” and to behave instead
as if in control of the situation and doing well. Failing to share true feelings with
others leads to the erroneous assumption of being the only one having such problems.
This error is further enhanced by the fact that the helper who believes he is alone in
having these feelings will be especially careful not to reveal this response to others
and will maintain the facade of professionalism (McConnell, 1982).
Avoiding Burnout
A first useful step in managing or avoiding burnout is to acknowledge the difficulties
and limitations of the therapist’s job: seeing patients for short periods of time,
soliciting information that many consider private, and being charged with providing
risk-reduction education and counseling as well as emotional support. The second
step is to acknowledge the complexity of patient’s lives, the fact that all of their needs
and emotional concerns cannot be resolved during a single session, and the fact that
therapists cannot compensate for all of the inadequacies of the healthcare and social
service systems. Therapists should not excessively scrutinize themselves about what
they are unable to do. Instead, they should give themselves credit for the positive
work they can accomplish (Miller and others, 1990).
Therapists state that “taking care of yourself” is the most important way to
maintain a healthy approach to work. This requires satisfying personal needs, which
may include independence, acceptance, support, and emotional expression, as well
as feeling good about oneself and one’s work. Patients’ needs for social services,
emotional support, and information are important during therapy, but therapists
should not carry their patients’ burdens away from the test site. To accomplish this,
therapists must set explicit psychological boundaries and review their work
and
behavior to make sure that they are not exceeding these boundaries.
Institutions and organizations that deal with AIDS patients have a responsib
ility
to be aware of these stressors and to take action to prevent burnout. Weekly
meetings
with the staff can assist in stress management by encouraging members
to express
their feelings. The meetings can decrease anxiety, provide for an exchange
of mutual
support, and allow acceptance of the situation. The sessions can
occur in the form
of staff meetings or support groups. Other techniques that may
prove useful in
preventing burnout include relaxation exercises, assignment rotation,
and scheduled
time off for “‘mental health days.”
Educational needs of healthcare workers should be strongly considered. Access

to current information about AIDS and instructions on mental status examinations
should be readily available. Institutions and organizations caring for AIDS patients
can provide optimal care only when they take optimal care of their health
professionals (Salisbury, 1986).
INTERVENTION
Intervention may be self-initiated, or it may occur in response to an immediate
frustration or threat. It may be fueled in part by a person’s own strength and in part
by support and guidance from peers, supervisors, family and friends, or whoever else
is important in his life. It may be a temporary stopgap or a real change. Intervention
can and should occur at any of the four stages of disillusionment. One of the major
tasks of trainers and supervisors should be to help staff members experience the four
Stages with greater awareness and thus be less subject to violent swings of emotion.
In reality, however, intervention most often takes place at the stage of frustration,
when it is almost too late. In the stage of enthusiasm, people are having too. good a
time to see any need for intervention. Stagnation does not usually provide the energy
required to change course, although interventions in the areas of further education,
skill development, and career advancement are sometimes initiated at this stage. As
for apathy, that stage is already a long way toward disillusionment, and the road back
up is a long, hard one that some people negotiate successfully but many never
attempt.
More often, frustration moves a person off center and impels changes. Frustration
is effective when it gets people angry enough to break out of a bad situation instead
of becoming apathetic.
Nothing is more important in handling burnout than to know what respon-
sibilities the worker does and does not have. Professionals are not responsible
for patients or for the institution but are responsible for themselves. This does
not mean that professionals do not become involved with patients or do not try
to change the way the institution is run. It simply means that they are responsible
for their own actions and remain responsible for their own actions regardless of
what patients do or do not do.
When other systems in life are strengthened, the worker gains strength for coping
with work as well. The things people do to strengthen their outside lives and create
a larger world to live in vary from individual to individual. An important first step
is to make a clear separation between work and other areas of life by limiting
off-hours socializing with co-workers or others in the same field and controlling the
tendency toward extracurricular preoccupation with job-related issues. The number
of hours required at work is usually set, but the rest of the day is controlled by the
person. The professional can, however, refuse to give friends and relatives free
professional assistance with their personal problems. The benefits of giving a home
telephone number to clients to be available to them in an emergency must be weighed
against the costs.
Probably the most important way of enlarging a person’s world is through close
personal and family relationships. Developing and maintaining these relationships
requires and, in turn, creates time commitments and emotional commitments that
keep the person from being devoured by the job. It may take a lot of work to negotiate
with family and close friends the space needed for commitment to the job and the
space all concerned need to be together and to be away from constant reminders of
the job, but by making this effort, an identity independent of the job is created. Of
course, many other reasons exist for wanting to have a fulfilling personal life. With
regard to burnout, however, the importance of close personal ties is clear and crucial.
When one is loved and appreciated by the family, whether one is loved and
appreciated by patients or supervisors is no longer a life-or-death matter. When deep
and constant support of family and friends is enjoyed, a person’s whole self is not
put on the line every morning.
Other interventions could include the technique of planned, temporary social
isolation. At a minimum, professionals need times when they can get away from those
who are often the direct source of job stress—the recipients and, in some cases, the
administrators. This can be accomplished through physical and psychological
withdrawals and long vacations (Edelwich and Brodsky, 1980).
Another alternative is a “decompression routine’ between leaving work and
arriving home, a time in which they can engage in some solitary activity, preferably
physical and noncognitive, in order to unwind and relax. By being alone for a while,
they are then more ready to be with people again, especially with those people who
are close to them. }
Some helping professionals deliberately use some of their off-duty hours to
engage in activities with people who are normal, healthy, and functioning well. By
having pleasant and successful interactions with these people, professionals can
counteract the development of negative attitudes about clients and about their ability
to work well with clients.
Case Study Burnout

Sabrina, a 34-year-old registered nurse, came to a community mental health center.
She completed the brief chart and was told she would be able to see a therapist later
that afternoon, in approximately 3 hours. Sabrina told the volunteer she would go out
for coffee and come back later—maybe. The volunteer told the therapist assigned to
Sabrina that she seemed “very angry.”
Sabrina did return and leafed through every magazine, throwing them on the
table carelessly; if they fell, she just let them lay. The therapist came out and
called Sabrina. Sabrina stood up rather defiantly and looked at the therapist. The
therapist introduced herself, and they shook hands. The therapist looked at the
magazines on the floor and then at Sabrina, smiled, and asked, “Did you throw
those magazines on the floor?” Sabrina put her chin up and said, ‘“‘Yes, I did.”
The therapist smiled again and said firmly, “Then please pick them up and
we can go to my office and begin therapy. We only have an hour and you
are
wasting my time.” Sabrina looked slightly shocked and began to pick up
the
magazines. When she was through, she looked at the therapist, smiled
slightly,
and said, “My friends call me Bree. You can call me Bree.” They walked to
the therapist’s office.
The therapist asked Bree to sit down, and picked up her chart. The therapist had
read Bree’s chart. She knew that she was 34, married, had a 6-year-old son, Brian,
and was a registered nurse. Until 3 days ago she had worked as a charge nurse at a
hospice. She was of average height and weight and attractive, with large gray eyes
and auburn hair. In answer to the question “Why are you here?” she had written on
her chart, “J can’t take it anymore!!!”
The therapist told Bree that she had read her chart and asked, “What can’t
you take anymore?” Bree looked up with tears in her eyes and said, “I can’t
take the dying... not anymore, I just can’t!” The therapist asked Bree to tell her
what had happened 3 days ago. Bree answered angrily, “It was more than 3 days
ago. I don’t know when it began. I just walked out 3 days ago and told them
I would not be back!”
The therapist asked Bree how long she had worked at the hospice. Bree said
that she had been the first nurse to go to the hospice when it had opened 3 years
ago. The therapist asked her how she had liked working at the hospice. Bree
answered, “‘It was wonderful. I really felt like a nurse, not just a paper pusher!
It was so rewarding to be able to be in that lovely hospice. The rooms were
just like a bedroom in a home, not at all like a cold, sterile hospital room! The
families and friends, even pets, could visit any time they wanted to; I truly loved
working there. It was sad when someone died, but all the staff supported each
other; we never felt that we were grieving alone.’’ She paused and then said,
“T am a good nurse, a very good nurse. I honestly think no one is a better nurse
than me.” She started to cry. The therapist handed her a tissue and let her cry.
She finally stopped and apologized for crying. The therapist said there was no
need to apologize.
Bree looked at the therapist and began talking again. She said that she did
not know what was wrong with her. Lately, she had been so irritable. She said
that at home “‘she wasn’t fit to live with’ and that a week ago her husband asked
her to take some time off so they could go away for a few days. She said that
she had lost her temper and told him that she could not take any time off because
she was needed. She said he became angry and said, ““We need you, too. Do
you realize that we haven’t had a single day to ourselves since you started at
the hospice?”’
The therapist asked if this was true, and Bree reluctantly said that she had been
too busy. So much needed to be done at the hospice, and a charge nurse was the only
one who could do it.
The therapist asked Bree, “Why do you think you are the only nurse that can take
care of everything at the hospice? Are you omnipotent? Everyone can be replaced
in their job, even you or me. Don’t you care about your family? Bree, surely you have
heard of burnout. It sounds to me as if you are in burnout now. No job is worth the
happiness and love you have with your husband and son.”
Bree had listened to the therapist quietly and thoughtfully. She then said, “I know
you are right. I am so exhausted, I’ve been having nightmares. I wonder if I gave
Mr. A or Mrs. C their pain medication so I go back to the hospice to check, and I
had given them their meds. It’s just that I hate to fail! I have never failed before.”
The therapist said, ‘Bree, you have not failed. I doubt if many nurses could
work in a hospice as long as you did; 3 years is a long time. I know J couldn’t.
Bree, could you take a 3-month leave of absence from nursing, and that includes
the hospice? You need a good rest, and you need to get to know your family.
You are young, and you need to have some fun in your life. Would you go home
and talk to your husband about it? Call me and let me know what he says, and
I'll see you next week. Try taking a brisk 2-mile walk every day to relieve your
excess energy.”
Bree said, “I don’t know what I would do with 3 months off. I’ll talk to Patrick
and then call you.” The therapist said, ‘““Good, let’s make an appointment for next
week!” They walked out of the office together, talking as they went, to schedule an
appointment for Bree.
Bree was apparently suffering from burnout. She needed time off from the
hospice and nursing. She was concerned that no one could take her place. It was
felt that meeting and talking with her husband to get feedback from him was
important. It was essential to find out how he felt about her taking a 3-month
leave of absence.
Bree called the therapist and said that she had talked with Patrick and that
he wanted to talk to the therapist. The therapist said, “Fine, Bree, put him on
the telephone.” Patrick took the phone and said hello to the therapist. He then
said, “‘I can’t believe that anyone could convince Bree that the hospice would
not fall apart without her. I have got to meet you!” The therapist laughed and
replied, ““You read my mind. Could you come in with Bree next week?’ Patrick
said, ““You can bet on it!”
The therapist continued to see Bree and Patrick together for the remaining
sessions. Patrick had been very concerned about Bree and agreed with the therapist
that she was suffering from burnout. Eventually, Bree began to relax. She began
spending more time with their son, Brian, and he began to bloom with her attention,
as did Patrick. At their last session, Bree said happily, “I have asked for a transfer
out of the hospice—and I’m going to be working a ‘normal’ shift in pediatrics. I told
my supervisor that I would work in the hospice for 1 week at a time—if I was needed
and only if I was needed.”
Both Bree and Patrick were told that they could return to the center around any
future crisis. The therapist cautioned Bree about becoming so involved with her work
that it controlled her life completely. Bree agreed and said that she loved going into
pediatrics. She was reminded to continue taking her 2-mile walks, as often as
possible, to help her burn off her excess energy.
Bree did not recognize her symptoms of burnout. She refused the support of her
husband. Her coping mechanisms were ineffective in this situation. Her anxiety
and
depression increased. She had burnout and went into a crisis.
Take rest; a field that has rested gives a bountiful crop.
—Ovid
——————
E ——— E en ee
Complete the paradigm in Figure 12-1 for this case study, then compare
it with
the completed one in Appendix D. Refer to the paradigms in
CASE STUDY: SABRINA
PLUS AND
PLUS AND
RESULT IN RESULT IN
Figure 12-1
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ADDITIONAL READING
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in sex role orientation: correlates of
work satisfaction and burnout among women in special
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Kruger LJ, Botman HI, Goodenow C: An investigation of social support and burnout among
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Leiter M: The dream denied: professional burnout and constraints of human service
organizations, Can Psychology 32(4):547, 1991.
Naisberg-Fennig S and others: Personality characteristics and proneness to burnout: a study
among psychiatrists, Stress Med 7(4):201, 1991.
Revenson TA, Cassel BJ: An exploration of leadership in a medical mutual help organization,
Am J Community Psychol 19(5):683, 1991.
Rosse JG and others: Conceptualizing the role of self-esteem in the burnout process, Group
Organization Stud 16(4):428, 1991.
Seidman SA, Zager J: A study of coping behaviours and teacher burnout, Work Stress 5(3):205,
1991.
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POSTSCRIPTUM
P atients and mental health professionals in the next century can look forward to
not only bright hopes but also many challenges and confrontations. No, I do not
have a crystal ball. What I do have are some solid predications from impeccable
sources—Harvard University and the World Health Organization.
Richmond and Harper (1996)* state that the following needs for child and
adolescent psychiatry will be priorities for the next generation of professionals. First,
a commitment to equity is necessary so that all children and families have access to
services. Second, a greater emphasis on health promotion and prevention is in order.
Professional activities that apply knowledge are needed to influence not only
healthcare policy but also social policy recommendations as well, since much of
prevention and health promotion requires improving the environments of children
and families. Third, an awareness of resource limits will be needed by those who
seek to improve the lives of children. Fourth, research support must continue if
interventions are to improve. Research is the engine of change.
Professional organizations will have to reaffirm their social responsibilities by
emphasizing priorities and social roles:
¢ The maintenance of professional standards and ethics
* Social conscience; individual strategies must become essential to preserve
professional ethical standards
Advocacy for the whole child, for an integrated biopsychosocial approach,
and for community interventions
* Partnership in advocacy; alliances with groups that represent the public in-
terest will make for more effective advocacy
Our Children Are Our Future

A 5-year study by an international team at Harvard University School of Public
Health stated that the causes of death and disability will change dramatically by the
year 2020 (Maugh, 19967). The study is called “The Global Burden of Disease”’ by
the World Health Organization. When the study is completed, they are projecting ten
volumes. The first two volumes of results compares the statistics of death in 1990
with the projected statistics of 2020.
eee ee eeearn nnn TEnEEEE EEE

Dene
first century, Harvard Rev
*Richmond J, Harper G: Child and adolescent psychiatry: toward the twenty
ba
Psychiatry 4(2):51, 1996.
of death, Los Angeles
+Maugh TH II, Times medical writer: World-wide study finds big shift in causes
Times, September 16, 1996.
283
284 Postscriptum
For comparison the first two diseases are listed below.
1990 2020
RANK DISEASE OR INJURY RANK DISEASE OR INJURY
1 Lower respiratory infections 1 Ischemic heart disease
Ms Diarrheal disease 2 Unipolar major depression
It should be apparent why only two comparisons were necessary. Unipolar major
depression is the number two disease predicted for future professionals to work with.
Let us not forget our hopes: the gene theories and therapies that are even now
being discovered and utilized in identifying and preventing multitudes of diseases
and the brain that rules the body in finally giving up its secrets. Pharmaceutical
companies are working day and night to find medications that will prevent, cure, or
inoculate against every known illness.
Our challenges and confrontations will occur when as mental health professionals
we become entrepreneurs and have our own offices and care for patients with
minimal supervision of physicians. We will be collaborators; we will work with them
not for them. It is possible to work together with other professionals; we do research
with them now on equal terms.
Our major confrontation will be managed healthcare providers. They will either
be the only providers or the public will demand that we return to individual care from
our physicians. They will either continue to proliferate and function as a closed
“union” or they will be eliminated because of lack of care and financial abuses. It
is strongly anticipated that the public will begin to demand that payment for mental
healthcare be equated with that for physical healthcare.
We will eventually be accepted by managed healthcare providers. We will receive
not only acceptance but also recognition that our expertise is worthy of a quality
standard salary.
O magic sleep! O comfortable bird,

That broodest o’er the troubled sea of the mind
Till it is hush’d and smooth!
—John Keats
APPENDIX”
ACCUSATION
refers to the formal document or pleading that officially initiates the licensing board’s
action against the respondent and specifies the unprofessional conduct alleged. The
accusation is served on the respondent after an investigation by the Department of
Consumer Affairs’ Division of Investigation and after a review of the investigative
report by the board and the attorney general’s office.
DECISION
refers to the written decision of the administrative law judge who decides the case
and imposes the discipline, if any, after the hearing has been held and the testimony
of all witnesses have been received.
DEFAULT DECISION
refers to the situation whereby the respondent, after being served with the accusation,
fails to respond by filing the required notice of defense, therefore resulting in a
decision by the administrative law judge. Additionally, a default decision can also
occur when the respondent, after filing the notice of defense, fails to attend the
administrative hearing.
NO CONTEST
refers to the response to an accusation that neither admits nor denies the charges but
simply says that the respondent does not wish to contest or argue with the charges.
No contest usually results in the imposition of disciplinary action through a stipulated
agreement. The major purpose of entering a no contest (nolo contendere) response
is to avoid future civil liability based on the board’s action.
NON-ADOPTED DECISION
refers to the situation whereby the administrative law judge has rendered a decision,
but the board later votes not to adopt the judge’s decision. The board may thereafter
decide the case and impose the penalties that they believe are appropriate under the
circumstances.
PUBLIC REPROVAL
of
refers to the situation where the board has not imposed any period of suspension
the license but has decided to make public the fact that the respondent has been
285
286 Appendix A
disciplined for some usually minor form of unprofessional conduct or for misconduct
that is mitigated by other facts and circumstances.
RESPONDENT
refers to the licensee or registrant who is charged with unprofessional conduct.
REVOCATION
refers to the most severe action that can be taken by the licensing board. Once a
license is revoked, the respondent may get the license back only by petitioning the
board for reinstatement after the passage of a specific amount of time and with a
sufficient showing of rehabilitation.
STAYED (STAY)
refers to an action that puts the imposition of the penalty on hold, provided that the
respondent complies with certain probationary terms. “Revocation stayed” therefore
means that the license is not actually revoked, but if the respondent violates the terms
or conditions of probation, the stay can be lifted and the imposition of the revocation
can then occur.
STIPULATION
refers to a written agreement between the respondent and the licensing board that
settles the matter. The stipulation typically includes an admission of wrongdoing by
the respondent to one or more charges and also includes the specific disciplinary
action (punishment) to be imposed.
SURRENDER OF LICENSE
refers to the situation whereby a licensee decides to surrender the license. The
surrender of license usually results in the licensing board dropping the charges before
any hearing is held. Surrendered licenses cannot be restored through the petition
process, and generally, once surrendered, the license is gone forever.
SUSPENSION
refers to the temporary loss of license or registration for the time specified
. Once the
period of suspension has expired, the license or registration is automati
cally restored.
The respondent does not have to petition the board for reinstatement.
APPENDIX
Characteristics Normal Abnormal
APPEARANCE AND BEHAVIOR

Posture Normal Rigid, limp, ill-at-ease, bizarre
Gestures Appropriate Hyperactive, agitated, fidgeting, hand-
wringing, picking, touching, violent,
purposeless, tics, twitches, clumsy,
bizarre
Grooming Neat and Slovenly, meticulously clean
(hair, nails) well groomed
Dress Appropriate, Careless, seductive, dirty, inappropriate,
casual but clean bizarre
Facial expression Appropriate Dazed, perplexed, grimacing, poor eye
contact, staring, lip smacking
Speech
Pace Normal Pressured, retarded, halting, blocking,
mute, stuttering
Volume Normal Very loud or soft, monotonous
Form Logical, coherent Illogical, rambling, incoherent, tangential,
circumstantial
Clarity Clear Slurred, garbled
Content Normal, Flight of ideas, word salad, loose associa-
unremarkable tions, rhyming, echolalia neologisms,
obscene
ATTITUDE AND SENSORIUM

Attention Normal span, Short span, hyperalert, fluctuating,
alert drowsy, easily distracted
Mood Cheerful, Elated, euphoric, agitated, fearful, anx-
friendly, happy ious, panicky, hostile, apathetic, sad
Affect Appropriate Inappropriate, intense, shallow, flat,
blunted, labile, indifferent
PERCEPTION AND THOUGHT

Hallucinations
Auditory Own voice, another’s, many; talking to/
about patient; flattering, accusatory,
directive
ee EEE TSE
Continued
287
288 Appendix B
Characteristics Normal Abnormal
PERCEPTION AND THOUGHT—CONT’D

Hallucinations—cont’d
Visual Shadows, lights, halos, forms, figures
Tactile/
Somatesthetic
Gustatory
Olfactory
Delusions Paranoid/persecutory, grandeur, reference,
alien control, guilt, nihilism, thought
insertion/broad cast/withdrawal
Illusions Visual, auditory
Other Derealization, autistic thinking, phobias,
ambivalence, obsessions, compulsions,
ruminations, suicidal/homicidal ide-
ation or plans
ORIENTATION Oriented x 3 Disoriented to time, place, and person

(others, familiar others, self)
JUDGMENT Intact Impaired
COGNITION
Memory, Intact Impaired
short-term
Immediate recall Good Poor (digit span of 5 or less)
Reversals Good Poor (digits backward of 4 or less)
Concentration Good Poor
Calculations Good Poor
ABSTRACTION
Similarities Handled well Poor, bizarre responses
Absurdities Recognized Not recognized, poorly handled
Proverb Good, Literal, semiconcrete, concrete, bizarre
interpretation appropriate
INSIGHT Good, excellent Fair, poor, absent
APPENDIX
Parent Support Groups

National Self-Help Clearinghouse
CUNY Graduate Center, 1206A
33 West 42nd Street
New York, NY 10036
(212) 840-1259
Provides the best means of finding national self-help, mutual-aid groups.
SHARE, c/o Sister Jane Marie Lamb

Saint John’s Hospital
800 East Carpenter Street
Springfield, IL 62769
(217) 544-6464, ext. 5275
Provides a list of national groups for parents who have experienced miscarriage,
stillbirth, or newborn loss.
The Compassionate Friends, Inc.

PO Box 3696
Oak Brook, IL 60522-3696
(313) 323-5010
Provides a list of self-help groups for bereaved parents who can help each other after
the loss of an infant or an older child.
Pregnancy-Loss Peer-Support Program

National Council of Jewish Women (New York Section)
9 East 69th Street
New York, NY 10021 (212) 535-5900, ext. 16
A nonsectarian support service for parents who have suffered pregnancy loss or
by
stillbirth. Parent support groups meet weekly for 6 weeks and are facilitated
trained volunteers who have also experienced pregnancy loss. Telephone counseling
is also available.
289
290 Appendix C
Bereavement Clinic
c/o Sharon Pentel
Downstate Medical Center
450 Clarkson Avenue
Brooklyn, NY 11203
Offers monthly support groups, led by a professional, for parents who have suffered
stillbirth.
Pastoral Care
c/o Sister Mary Alice
Mercy Hospital
North Village Avenue
Rockville Center, NY 11570
A bereavement group that meets twice monthly for 8 to 10 weeks for parents who
have suffered miscarriage or stillbirth.
Pregnancy and Infant Loss Center

1415 East Wayzata Blvd, #2
Wayzata, MN 55391
(612) 473-9372—24-hour Help Line (612) 292-1184
A nonprofit organization offering support, resources, and education on miscarriage,
stillbirth, and infant death; publishes a newsletter, “Loving Arms.”
Reach Out to Parents of an Unknown Child

c/o Health House
555 North Country Road
Saint James, NY 11780
(516) 862-6743
Offers voluntary support groups of parents who have experienced
unexpected loss
through miscarriage, stillbirth, or infant death. Groups are also
available for a
subsequent pregnancy. Telephone contacts are also available.
RESOLVE, Inc.
5 Water Street
Arlington, MA 02174
(617) 643-2424
A nonprofit organization offering counseling, referral, and
support groups to people
with problems of infertility and miscarriage. Telephone
counseling is available.
Based in Boston, RESOLVE has 46 affiliated chapter
s nationwide.
Appendix C 291
COPING)
Santa Barbara Birth Resource Center
2255 Modoc Road
Santa Barbara, CA 93101
(805) 682-7529
Their goal is to offer comfort to people suffering from intrauterine and neonatal grief;
they also provide support for those who are experiencing a loss and for those planning
or going through a subsequent pregnancy.
UNITE (Understanding Newborns in Traumatic Experiences)

Jeannes Hospital
7600 Central Avenue
Philadephia, PA 19111
(215) 728-2082, or -3777
Offers support groups for parents within the area who have experienced miscarriage
or infant death. For copies of their quarterly newsletter, send $5 to Department of
Social Services at the address above.
ICU (Intensive Caring Unlimited)

c/o Diane Sweeney
1844 Patricia Avenue
Willow Grove, PA 19090
Offers support groups for parents of children born premature or at high risk or for
those who have lost a child. They publish a newsletter and send out a packet of reprint
articles for parents who have experienced miscarriage, stillbirth, and loss of a baby
or child.
DAD (Depression after Delivery)

Contact: Nancy Berchtold
PO Box 1282
Morrisville, PA 19067
(215) 295-3994
Offers parent support groups for those experiencing postpartum depression or
depression after miscarriage or infant loss. A nationwide referral service and
telephone counseling are available.
Grieving Process Group

Booth Maternity Center
6051 Overbrook Avenue
Philadelphia, PA 19131
(215) 878-7800, ext. 658
292 Appendix C
Other Related Support Groups and Services

Sudden Infant Death Syndrome (SIDS)
Regional Center
School of Social Welfare
HSC L2 Room 099
SUNY at Stony Brook
Stony Brook, NY 11794
(516) 246-2582
SIDS Counseling Program

520 First Avenue
New York, NY 10016
(212) 868-8854
National SIDS Clearinghouse

1555 Wilson Boulevard, #600
Rosslyn, VA 22209
(703) 528-8480
Bereavement and Loss Center of New York

170 East 83d Street
New York, NY 10028
(212) 879-5655
Perinatal Loss
2116 NE 18th Avenue
Portland, OR 97212
(503) 284-7426
Hot Lines
ee eee
Pregnancy/Environmental Hot Line National Birth Defects Center
Kennedy Memorial Hospital
Boston, Massachusetts
They will accept calls from practitioners nationally: 800-322-5014
(Massachusetts only) 617-787-4957
Pregnancy Exposure Information Service

University of Connecticut Health Center
Farmington, Connecticut only: 800-325-5391
Washington State Poison Control Network
University of Washington
Seattle: 800-732-6985
(Washington only) 206-526-2121
APPENDEX®
Having difficulty Living in

in meeting people a large city
PLUS
PLUS AND
Corresponds with Figure 4-1
293
294 Appendix D
CASE STUDY: ANN
Spouse not at home Earthquake
PLUS AND
PLUS AND

Appendix D 295
CASE STUDY: ALICE
Birth of Isolation
é fom
from u
usual
Bob’s son available situational
supports
PLUS AND
PLUS AND
RESULT IN RESULT IN

296 Appendix D
CASE STUDY: SUZAN
Feeling inadequate Feeling that she

as wife and mother deserves beatings
PLUS AND
RESULT IN RESULT IN

Appendix D 297
CASE STUDY: RICARDO
baie Did not want to Had possession of

jeopardize his friend dangerous
information
PLUS AND
PLUS AND
RESULT IN

298 Appendix D
CASE STUDY: HATTIE
Isolated from others Beaten by husband
PLUS AND
PLUS AND
RESULT IN RESULT IN

Appendix D 299
CASE STUDY: ANGELA
New to the area Two miscarriages
PLUS AND
PLUS AND
RESULT IN RESULT IN

300 Appendix D
CASE STUDY: MR. E
Threat of lawsuit Loss of job
PLUS AND
PLUS AND
RESULT IN

Appendix D 301
CASE STUDY: ANN
Fear of rejection
from fiancé Rape
RESULT IN RESULT IN

302 Appendix D
CASE STUDY: MR. Z

Diagnosis of
Fear of impending
invalidism myocardial
infarction
PLUS AND
PLUS AND
RESULT IN RESULT IN

Appendix D 303
CASE STUDY: FRANK
Perceives loss Fear of loss of

of wife daughter
PLUS AND
PLUS AND
RESULT IN RESULT IN

304 Appendix D
CASE STUDY: CAROL
Fear of loss of Past rejection by

significant other significant other
PLUS AND
PLUS AND
RESULT IN RESULT IN

Appendix D 305
CASE STUDY: BILLY
Perceives rejection Fear of rejection

by father by mother
TER
_
~_

306 Appendix D
CASE STUDY: MARY

Need for Need for father’s
identification permission to
with peer group go to prom
>
PLUS AND
RESULT IN RESULT IN

Appendix D 307
CASE STUDY: MYRA
Strong ambivalence Feelings of

toward parent role rejection by
husband
RESULT IN

308 Appendix D
CASE STUDY: MRS. C
Forced role change Onset of menopause
PLUS AND
PLUS AND
RESULT IN RESULT IN

Appendix D 309
CASE STUDY: JOHN

Feelings of
inadequacy in Fear of loss of wife
caring for wife
PLUS AND
PLUS AND
RESULT IN RESULT IN

310 Appendix D
CASE STUDY: STEVE

Discovery of
Heavy use drug use by
of cocaine chief-of-staff
PLUS AND
PLUS AND
RESULT IN RESULT IN

Appendix D 311
CASE STUDY: DIANE
Betrayed by lover Diagnosis of AIDS
PLUS AND
PLUS AND
RESULT IN
Corresponds with Figure 11-i

312 Appendix D
CASE STUDY: JACK
14-year-old; lack of
knowledge of AIDS Diagnosis of AIDS
’
PLUS AND
PLUS AND
RESULT IN RESULT IN

Appendix D 313
CASE STUDY: SABRINA

Felt she was
irreplaceable; worked Worked in a hospice;
overtime as an RN burnout
PLUS AND
PLUS AND
RESULT IN RESULT IN

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APPEINIDEXS
Addison, Joseph 1672-1719

Bierce, Ambrose Gwinett 1842-1914
Byron, George Gordon (6th Baron: Byron of Rochdale, called Lord
Byron) 1788-1824
Cicero, Marcus Tullius 106-43 Bc
Dickinson, Emily Elizabeth 1830-1886
Disraeli, Benjamin 1804-1881
Duc de La Rochefoucauld, Francois 1613-1680
Emerson, Ralph Waldo 1803-1882
Epictetus circa ‘ap 55-circa 135
Franklin, Benjamin 1706-1790
Gandi, Mohandas K. 1869-1948
Gilbran, Kahil 1883-1931
Goethe, Johann Wolfgang von 1749-1832
Goldsmith, Oliver 1728-1774
Hippocrates 460-377 Bc
Holy Bible, King James Version
Horace (Quintus Horatius Flaccus) 65-8 Bc
Houseman, Alfred Edward 1859-1936
Keats, John 1795-1821
Kennedy, John Fitzgerald 1917-1963
Ovid, P. Ovidius Naso 43 Bc-17 aD
Retz, Cardinal de 1614-1679
Roux, Joseph 1834-1905
Saki (pseudonym of HH Muno) 1870-1916
Shakespeare, William 1564-1616
Sophoceles 496-406 Bc
Stevenson, Robert Louis 1850-1894
Wordsworth, William 1770-1850
Wylie, Elinor 1885-1928
Young, Edward 1623-1765
315
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INDEX
A Acquired immunodeficiency syndrome

‘‘A Nation’s Shame: Fatal Child Abuse and (AIDS)—cont’d
Neglect in the United States,” 78 biood donations and, 242, 260, 262
Absolute thinking in cognitive theory of de- breastfeeding and, 261
pression, 23 burnout syndrome and, 268-269
Abstinence, AIDS and, 256, 262 causes of, 259
Abstraction cocktail treatments for, 240-241
mental status examination and, 288 cognitive dysfunction and, 247
selective, in cognitive theory of depres- counseling for; see Counseling, AIDS/HIV
sion, 23 definition of, 241, 259
Abuse diagnosis of, 241, 260
child; see Child abuse and neglect in Europe, 240-241
elder; see Elder abuse and neglect heterosexuals and, 251-254
financial, elder abuse and neglect and, case study involving, 252-254
110-111 historical background of, 241-242
marital; see Spouse abuse homosexuals and, 251-252
past, elder abuse and neglect and, 114 hot line for, 8
physical; see Physical abuse impact of, on health care system, 250-251
psychological, elder abuse and neglect and, in India, 240
110 intrapsychic effects of, 247
sexual; see Sexual abuse opportunistic diseases and, 259
spouse; see Spouse abuse prevention of, 240-241, 260-261, 262
substance; see Substance abuse psychological sequelae of, 246-247
Abusive caregivers, characteristics of, elder questions about, 259-262
abuse and neglect and, 111-115 sexual transmission of, 251-252
Abusive men, self-help group for, 97 suicide and, 175
Abusive-dynamic model, child abuse and symptoms of, 248, 260
neglect and, 82-83 testing for, 242, 261-262
Accident neurosis, 62 transmission of, 248, 251-252, 259-260
Accusation, definition of, 285 treatment for, 262
Acquired immunodeficiency syndrome in United States, 247-251
(AIDS), 240-264 vaginal intercourse and, 252
in adolescence, 254-256 Acute stress disorder (ASD), 62, 63, 66-68
case study involving, 256-258 ADA; see Americans with Disabilities Act
in Africa, 240-241, 251, 252 Adaptation
coping mechanisms and, 38
Americans with Disabilities Act of 1990
and, 250 principle of, 3-4
anal intercourse and, 252, 256 Adaptational psychotherapy, 4
antibody testing and, 242, 261-262 Addiction
in Asia, 240, 241 definition of, 234
Internet, 8-10
avoidance of, 260-261, 262
317
318 Index
Adjustive reactions, coping mechanisms Alzheimer’s disease—cont’d

and, 38 initial symptoms of, 161-162
Adjustment, outward, rape and, 147 American Medical Association (AMA),
Adolescence, 193-199 112-113, 223
AIDS/HIV in, 254-256 American Psychiatric Association, 51, 62
case study involving, 256-258 American Psychological Association, 8, 51
case study involving, 196-199 Americans with Disabilities Act (ADA), 250
normative crisis of, 4 Amitriptyline (Elavil), avoidance of, in
suicide in, 172-174 elderly, 229
Adrenaline surges, huffing and, 227 Ammonium chloride, cocaine and, 232
Adulthood, 199-211 Amphetamines, 222, 224, 235
later phase of, 211-219 Anal intercourse, transmission of AIDS and,
case study involving, 214-219 252, 256
menopause, case study involving, 207-211 Analysis of transference in brief psycho-
motherhood, case study involving, 202-205 therapy, 16
Advanced age Anger, infertility and, 124
case study involving, 214-219 Antibody testing, AIDS/HIV, 242, 261-262
elder abuse and neglect and, 114, 211-219 Anticipatory planning in crisis intervention,
Aerosol, sniffing and, 226-227 PN Bye
Affective stages of infertility, 124-126 Anti-elitism, ethical concerns and, 48
Affective symptoms, acute stress disorder Antiepileptic medications, cocaine-related sei-
and, 67 zures and, 233
Africa, AIDS in, 240-241, 251, 252 Anxiety
African-Americans, suicide and, 175 Age of, 48
Age in crisis intervention, 21
abuse and neglect and; see Child abuse and fight or flight reaction and, 37
neglect; Elder abuse and neglect physical illness and, 152-161
of Anxiety, 48 in problem-solving approach to crisis inter-
of Ethical Crisis, 48 vention, 27
infertility and, 131 stress and, 27
old, 211-219 Apathy, stages of disillusionment in burnout
case study involving, 214-219 and, 273-274
suicide and, 175 Appearance, mental status examination and,
Aggression, tension-reducing mechanisms
287
and, 38 Appraisal, coping behaviors and, 35-37
AIDS; see Acquired immunodeficiency Arbitrary inference in cognitive theory of de-
syndrome pression, 23
AIDS Hotline, 256 ARC; see AIDS-related complex
AIDS hysteria, 241 Armed forces, homosexuals in, 249
AIDS-related complex (ARC), 247, 259 Arteriosclerosis, physical illness and, 152-161
Air freshener canisters, sniffing and, 227
Ascending reticular activating system (RAS),
Alcohol, 222, 223, 226, 231, 256
232
abuse of, by physicians, 235 ASD; see Acute stress disorder
roofies and, 226
Asia, AIDS in, 240, 241
Aldosterone, stress and, 28
Assault, sexual, 146
Alexander, 15
Assessment
Alliance of mental health law and care, thera-
in crisis intervention, 20
peutic jurisprudence and, 46-47 of individual and problem, 29-31
Alzheimer’s disease, 161-172
Assignment rotation, burnout syndrome and,
case study involving, 167-172
274
Index 319
Association, free, 14, 16 Bladder incontinence, Alzheimer’s disease

Attention-deficit disorder, methamphetamine and, 164
for, 224 Blame
Attitude infertility and, 130
Alzheimer’s disease and, 166 internalizing, elder abuse and neglect and,
in crisis intervention, 19-20 114
mental status examination and, 287 Blond hash, 230
Autoerection ejaculation, 230 Blood donations, AIDS and, 242, 260, 262
Autonomy, burnout syndrome and, 267 Board of Behavioral Science Examiners, 51
Autopsy, stillbirth and, 128 Border crossing, violence in schools and, 105
Avoidance phenomena, posttraumatic stress Bowel incontinence, Alzheimer’s disease
disorder and, 64 and, 164
Boy-girl, 230
B Breastfeeding, AIDS and, 261
Baby oil, condoms and, 262 Breuer, 13
Balancing factors affecting equilibrium, 32, Brief psychotherapy, 16-18
35-41 Bronx Mental Health Center, 7
Battered child syndrome, 80-81; see also “Bugs,” cocaine, 232
Child abuse and neglect Bull horrors, cocaine and, 232
Battered spouse; see Spouse abuse Burnout Inventory, 265
Battered Women’s Task Force of New York Burnout syndrome, 265-281
State Coalition Against Domestic AIDS care and, 268-269
Violence, 94 avoidance of, 274-276
Batterers, 93-102, 146 case study involving, 276-279
Battery, sexual, 93-102, 146 definition of, 265
Battle fatigue, 62 hospice care and, 267-268
Beater, spouse, 96-97 indicators of, 269-274
Beck, cognitive theory of depression of, intervention in, 275-276
21-23 progression of, 269-270
Behavioral indicators, child abuse and neglect stages of disillusionment and, 270-274
and, 83 apathy, 273-274
Behavioral symptoms, acute stress disorder enthusiasm, 270-271
and, 67 frustration, 272-273
Behaviors hopelessness, 274
burnout syndrome and, 269 stagnation, 271-272, 273
confusional, Alzheimer’s disease and, work environment and, 266-267
163 Butane, sniffing and, 226-227
coping; see Coping mechanisms Butazolidin; see Phenylbutazone
mental status examination and, 287
C
rescuing, AIDS/HIV counseling and, 244
supervisory, burnout syndrome and, 267 California Community Mental Health Act, 6-7
Benjamin Rush Center for Problems of California Department of Mental Hygiene,
Living, 7 6-7
Campbell, Kim, 249
Benzodiazepines, stress disorders and, 68
Benzoylecgonine, 231-232 Canada, gay rights in, 248-249
Bereavement and Loss Center of New York, Canadian Human Rights Act, 249
292 Candidiasis, AIDS and, 259
Bereavement Clinic, 290 Caplan, G., 4-5, 26, 32
Cardiac disease, physical disease and,
Bereavement reactions, 2, 18
Beth Israel Hospital, 250
152-161
320 Index
Caregivers Child abuse—cont’d

abusive, characteristics of, elder abuse and and neglect, 77-93
neglect and, 111-115 case study involving, 85-93
perceptions of, Alzheimer’s disease and, 166 definition of, 80, 81
Carisoprodol (Rela; Soma), avoidance of, dynamics of, 79-85
in elderly, 229 homicide by, 78
Case law, therapist malfeasance and, 51 incidence and prevalence of, 78-79, 80
Case study indicators of child’s potential need for
adolescence, 196-199 protection and, 83
adulthood, 202-205, 207-211 seven steps to stamp out, 80
advanced age, 214-219 Child Abuse Prevention and Treatment
AIDS Act, 81
in adolescent, 256-258 Child neglect; see Child abuse and neglect
in heterosexual female, 252-254 Children
Alzheimer’s disease, 167-172 future of, 283-284
battered spouse, 97-102 good, child abuse and neglect and, 84
burnout syndrome, 276-279 neglect of; see Child abuse and neglect
child abuse and neglect, 85-93 uniqueness of, child abuse and neglect
completed paradigms for, 293-303 and, 84
elder abuse, 115-118 Children’s Hospital in Los Angeles, 7
elderly, 214-219 Children’s reactions, posttraumatic stress syn-
heart attack, 157-161 drome and, 65
infertility, 132-136 Chlamydia, AIDS and, 252
latchkey children, 188-193 Chlordiazepoxide (Librium), avoidance of,
menopause, 207-211 in elderly, 229
motherhood, 202-205 Chronic diseases, old age and, 212
old age, 214-219 Cigarette smoking, 223, 256
physical illness, 157-161 City Hospital of Elmhurst, New York, 6
posttraumtic stress disorder, 71-74 Civil Rights Act, 54, 249
prepuberty, 188-193 Clinton, Bill, 249
rape, 148-152 Cliques, adolescence and, 195
spouse abuse, 97-102, 115-118
Closet junkies, 228
status and role changes, 141-144 CMV; see Cytomegalovirus
substance abuse, 235-238 Cobain, Kurt, 225
suicide and, 179-183 Coca, 231
therapist-patient involvement, 55-59
CocaCola, 231
violence at school, 106-109
Cocaine, 222, 223, 227, 228-235, 256
Cat, 230 abuse of, by physicians, 235
Catastrophic reaction, Alzheimer’s disease
consequences of, 232-233
and, 164
heroin and, 230
Categorizing data, critical thinking and, 29
lethal dose of, 233
Cathartic hypnosis, 13, 14
roofies and, 225
Causality, principle of, 3
suicide and, 233-234
CD4 immune cells, AIDS and, 241
toxicity of, 233
Centro de Hygiene Mental del Bronx, 7
Cocaine “bugs,” 232
Chat rooms, dependent users of Internet and, 9
Cocktail treatments for AIDS, 240-241
Cherry meth, 226 Coconut Grove fire of 1942, 2
Child abuse
Cognition
Domestic Violence, Adoption, and Family
mental status examination and, 288
Services Act, 81 perception of event and, 35
Index 321
Cognition—cont’d Coping mechanisms—cont’d

problem solving and, 29 in problem-solving approach to crisis inter-
Cognitive style, perception of event aiid, 35 vention, 32, 37-41
Cognitive symptoms, acute stress disorder stress disorders and, 68-69
and, 66-67 Coronary heart disease, physical illness and,
Cognitive theory of depression, 21-23 152-161
Cognitive therapy, 21-23 Corpus striatum, 232
cognitive triad in, 22 Corticoids, stress and, 28
faulty patterns of processing information Cortisol, stress and, 28
in, 22-23 Counseling
schemas in, 22 AIDS/HIV, 242-247
Cognitive triad in cognitive therapy, 22 Americans with Disabilities Act of 1990
Cognitive/behavioral therapy, stress disorders and, 250
and, 69 boundaries of therapist in, 243-244
Cohesion, peer, burnout syndrome and, death and, 246-247
266 family systems in, 244-245
Cold turkey withdrawal from cocaine, 233 impact of, on healthcare system, 250-251
Communication isolation and, 245-246
burnout syndrome and, 266 role of therapist in, 243
suicide and, 175 in United States, 247-251
Community, therapeutic, 6 Alzheimer’s disease and, 166-167
Community Mental Health Program at Countertransference, therapist malfeasance
Harvard University, 4 and, 51
Community psychiatry, evolution of, 5-8 Crack, 230; see also Cocaine
Compassion, special teacher and, 105 Cranberry juice, cocaine and, 232
Compassionate Friends, Inc., 289 . Crank, 224-225
Computers, crises related to, 8-10 Crashing, cocaine and, 233
Concrete operations, prepuberty and, 187 Criminal sexual penetration, 146
Condoms, 252, 254, 256, 262 Crisis
Confidentiality, legal and ethical issues in danger and, 1
psychotherapy and, 49-50 definition of, 4-5
Conflict, ego functions and, 3 developmental phases, 32
Conflict resolution programs, violence in emotional, 2
schools and, 103 of infertility, 122, 129
Confusional behavior, Alzheimer’s disease normative, of adolescence, 4
and, 163 opportunity and, 1
Congruence, absence of, therapeutic jurispru- psychological, 1
dence and, 45 related to technological advances, 8-10
Consent, informed, AIDS/HIV counseling resolution of, 21
and, 242 situational; see Situational crises
Contraceptives, oral, 254 Crisis intervention, 18-23, 21, 52
COPING, 291 anticipatory planning in, 21
Coping assessment in, 20
Alzheimer’s disease and, 164 cognitive therapy in, 21-23
definition of, 154 community psychiatry and, 5-8
maladaptive, 154 crises related to technological advances,
8-10
recovery process in heart disease and,
generic approach to, 18-19
154-155, 156
historical development of, 1-12
Coping mechanisms, 30-31, 38, 68-69
individual approach to, 19-20
posttraumatic stress syndrome and, 65
322 Index
Crisis intervention—cont’d Dependency—cont’d

Internet addiction and, 8-10 elder abuse and neglect and, 114
intervention in, 21 in later adulthood, 213
methodology of, 18-20 Depersonalization, burnout syndrome and,
planning therapeutic intervention in, 20 267
problem-solving approach to; see Problem- Depression, 21-22, 141-144
solving approach to crisis intervention after Delivery (DAD), 291
resolution of crisis in, 21 cognitive theory of, 21-23
steps in, 20-21 in crisis intervention, 21
Critical thinking, 29 in later adulthood, 213
Cryptococcal meningitis, AIDS and, 259 suicide and, 176
Cryptosporidiosis, AIDS and, 259 unipolar major, 284
Crystal, 224-225 Desensitizing, stress disorders and, 69
Culture, violence in schools and, 105, 106 Designer drugs, 221, 225-226
Cyberspace, crises related to, 8 Determinism, psychic, 3
Cyclobenzaprine (Flexeril), avoidance of, Developmental psychology, 3
in elderly, 229 Dewey, John, 29
Cytomegalovirus (CMV), AIDS and, 259 Diabetes, physical illness and, 152
Diagnostic and Statistical Manual of Mental
D
Disorders (DSM-IV)
DAD; see Depression after Delivery Diazepam (Valium), 225
Daily attendance in schools, 104 avoidance of, in elderly, 229
Dalmane; see Flurazepam Didi Hirsch Community Mental Health
Danger, crisis and, 1 Center, 7
Dark hash, 230
Disciplinary key, 51, 285-286
Darvon; see Propoxyphene Discipline, violence in schools and, 106
Date rape, 146 Disclosure
Day hospitals for psychiatric patients, 6 AIDS/HIV counseling and, 244, 245
Dear Abby, 79 legal and ethical issues in psychotherapy
Death, AIDS counseling and, 246-247
and, 49-50
Decision, definition of, 285 Disease; see also Physical illness
Decision making, problem solving and, 28 Alzheimer’s; see Alzheimer’s disease
Decompression routine, burnout syndrome
chronic, old age and, 212
and, 276 Disengaged family, AIDS/HIV counseling
Default decision, definition of, 285
and, 244
Defense mechanisms; see Coping mechanisms Disequilibrium, period of, infertility and, 123
Delusions, cocaine and, 232 Disillusionment, stages of, burnout syndrome
Dementia, early, Alzheimer’s disease and, 163
and, 270-274
Demerol, abuse of, by physicians, 235
apathy and, 273-274
Denial
enthusiasm and, 270-271
AIDS/HIV counseling and, 245
frustration and, 272-273
Alzheimer’s disease and, 166
hopelessness and, 274
infertility and, 124 stagnation and, 271-272, 273
Dental complications of cocaine, 233
Disorganization phase, rape and, 147
Deontological approach, therapeutic jurispru-
Dissociative symptoms, acute stress disorder
dence and, 44, 46
and, 66
Department of Consumer Affairs’ Division of
Distinguishing, critical thinking and, 29
Investigation, 285
Dole, Bob, 221
Dependency
Domestic violence, child abuse and neglect
Alzheimer’s disease and, 164
and, 78
Index 323
Dopamine, cocaine and, 232 Elderly—cont’d

Down sizing, 140 substance abuse in, 227-228, 229
Drug addiction, definition of, 234 Electromagnetic field (EMF), Alzheimer’s dis-
Drugs ease and, 161
antiepileptic, cocaine-related seizures and, ELISA test; see Enzyme-linked immunosor-
233, bent assay test
in brief psychotherapy, 17 e-mail, nondependent users of Internet and, 9
designer, 221, 225-226 EMF; see Electromagnetic field
overprescription of, 228, 234-235 Emotional crisis, 2
psychotropic, 5 Emotional exhaustion, burnout syndrome and,
soft, 230 266, 269
stress disorders and, 68 Emotional maltreatment, child abuse and
DSM-IV; see Diagnostic and Statistical neglect and, 83
Manual of Mental Disorders Emotional state of infertile couple, 123-126,
Duty to warn, legal and ethical issues in psy- 130
chotherapy and, 49-50 Emotions
adolescent talking of suicide and, 174
E repressed, 14
Earthquake, posttraumatic stress disorder and, Endocrinologist, reproductive, infertility and,
case study involving, 71-74 131
Ecgonine, 231-232 Endometriosis, infertility and, 131
EEOC; see Equal Employment Opportunity Enthusiasm, stages of disillusionment in burn-
Commission out and, 270-271
Ego Environment
functions of, 3 manipulation of, in brief psychotherapy, 17
in later adulthood, 213-214 work, burnout syndrome and, 266-267
primary autonomous functions of, 3 Enzyme-linked immunosorbent assay
state of, 2-3 (ELISA) test, HIV infection and,
Ego psychology, 4 242
Ego-analytic theorists, 3 Epigenetic development, 4
Ejaculation, autoerection, 230 Epinephrine, stress and, 28
Elavil; see Amitriptyline Equal Employment Opportunity Commission
Elder Abuse: The Hidden Problem, 112 (EEOC), 53-54, 250
Elder abuse and neglect, 109-118 Equilibrium, balancing factors affecting, 32,
case study involving, 115-118 35-41
characteristics of abusive caregivers, Equinal; see Meprobamate
111-115 Erikson, Erik H., 4, 187
documentation of, 111 Ethical Crisis, Age of, 48
financial, 110-111 Ethical issues; see Legal and ethical issues in
indicators of, 112 psychotherapy
physical, 109-110 Ethics, definition of, 47-48
physical neglect, 110 Europe
psychological, 110 AIDS in, 240-241
psychological neglect, 110 psychotherapists in, 52
types of, 109-111 European Federation of Professional Psy-
violation of rights of, 111, 112 chologists’ Associations, 51
Elder mistreatment, 109-118 Evaluation, problem solving and, 29
Event, perception of, in problem-solving ap-
Elder neglect; see Elder abuse and neglect
proach to crisis intervention, 80932:
Elderly, 5, 211-219
case study involving, 214-219 35-36
324 Index
Excessive loyalty, elder abuse and neglect- Force, violence in schools and, 106
and, 114 Formal operations, adolescence and, 196
Executive suicides, 175 Free association, 14, 16
Exercises, relaxation, burnout syndrome and, Free-basing, 228, 232, 233
274 Freedom to innovate in jobs, 140
Exhaustion Freud, Sigmund, 3, 4, 13, 231
emotional, burnout syndrome and, 266, 269 Frustration, stages of disillusionment in burn-
physical, burnout syndrome and, 269 out and, 272-273
F G
False accusations, therapist malfeasance Gamma hydroxybutyric acid (GHB), 226
and, 51 Gang rape, 146
Family Gangs, 107-109, 195
adulthood and, 206 Gasoline, sniffing and, 226-227
AIDS counseling and, 244-245 Gay domestic violence, 95-96
Alzheimer’s disease and, 164-165, 166 Gay rights in Canada, 248-249
disengaged, 244 Gender, suicide and, 175
elder abuse and neglect and, 113 General adaptation syndrome, 186
emancipation from, adolescence and, 193 Generic approach to crisis intervention, 18-19
two-income, 5 Genetic psychology, 3
Fatigue, battle, 62 Genital ulcers, AIDS and, 252
Faulty patterns of processing information in “Get-tough” approach, violence in schools
cognitive therapy, 22-23 and, 103
Fear, fight or flight reaction and, 37 GHB; see Gamma hydroxybutyric acid
Feelings; see Emotions “Global Burden of Disease,” 283
Felony murder, child abuse and neglect Glucocorticoids, stress and, 28
and, 78 Glue, sniffing and, 226-227
Females; see Women Good child, child abuse and neglect and, 84
Fertility, infertility and, 122-137 Granny bashing, 109
Fiduciary relationship between patient and Grief
therapist, 49 AIDS/HIV counseling and, 246
Field dependent style, perception of event Alzheimer’s disease and, 166
and, 35 infertility and, 126
Field independent style, perception of event of therapist, 246
and, 35 Grief process, 2, 18
Fight or flight reaction, 28, 37-38 Grieving Process Group, 291
“Fighting violence,” violence in schools and, Guilt, infertility and, 125-126
103
Fights in school, on-the-spot demotion of one H
full academic year and, 104 Hallucinations
Filtering, problem solving and, 29 Alzheimer’s disease and, 163
Financial abuse, elder abuse and neglect and,
cocaine and, 232
110-111 Harassment, sexual; see Sexual harassment
Firmness, special teacher and, 105
Harrison Tax Act, 231
First Psychiatric Hospital in Moscow, 6
Hartmann, Heinz, 3
Flashback, posttraumatic stress disorder and,
Harvard University, 283
63-64 Community Mental Health Program at, 4
Flexeril; see Cyclobenzaprine
School of Public Health, 283
Flurazepam (Dalmane), avoidance of, in
Hash
elderly, 229
blond, 230
Index 325
Hash—cont’d HSG; see Hysterosalpingogram

dark, 230 Huffing, inhalants and, 226-227
Hayden, Tom, 225 Human immunodeficiency syndrome (HIV),
Head trauma, child abuse and neglect and, 78 240-264
Health insurance, lack of, AIDS and, 251 in adolescence, case study involving,
Health maintenance organizations (HMOs), 254-256
drug prescriptions and, 228 AIDS and; see Acquired immunodeficiency
Healthcare needs of older persons, 212 syndrome
Healthcare system, impact of AIDS on, antibody testing and, 242
250-251 counseling for; see Counseling, AIDS/HIV
Heart attack, physical illness and, 152-161 in heterosexual female, case study in-
Heart disease, physical illness and, 152-161 volving, 252-254
Heart failure, huffing and, 227 historical background of, 241-242
Help, adolescent talking of suicide and, 174 Human immunodeficiency virus (HIV)
Hemp BC, 223 hot line for, 8
Heroin, 222, 223-224, 227, 256 rape and, 144, 147
AIDS and, 248 Hypertension, physical illness and, 152
cocaine and, 230 Hypnosis, cathartic, 13, 14
roofies and, 225 Hypodermic needles, transmission of
Herpes simplex, AIDS and, 259 AIDS and, 247, 248, 251, 252, 256,
Heterosexuals, AIDS and, 251-254 260, 261
case study involving, 252-254 Hysterosalpingogram (HSG), infertility and,
HIV; see Human immunodeficiency virus 131
HIV antibody testing, 242, 261-262
HIV status, revealing, gay domestic violence I
and, 95-96 Ice, 230
HMOs; see Health maintenance organizations ICU; see Intensive Caring Unlimited
Ho, David, 240 Identity
Hoffman-LaRoche Inc., 225 adolescence and, 193, 195
Home, violence in, 93-102 occupational, 196
case study involving, 97-102 IFA test; see Immunofluorescent assay test
dynamics of, 96-97 Illness, physical, 139, 152-161
“new” families and, 95-96 case study involving, 157-161
Homicide, 20, 31 Immediate physiologic processes, problem-
by child abuse, 78 solving approach to crisis intervention
Homophobia, 95-96, 241 and, 27-28
Homosexuals, 95-96, 241, 248-249 Immune system, AIDS and, 251, 256
AIDS and, 247, 251 Immunofluorescent assay (IFA) test, HIV in-
Honesty, adolescent talking of suicide and, fection and, 242
174 Imprint, mothering, child abuse and neglect
Hopelessness, stages of disillusionment in and, 83-84
burnout and, 274 Incest, 81; see also Child abuse and neglect
Hospice care Incontinence, bowel and bladder, Alzheimer’s
AIDS and, 251 disease and, 164
burnout syndrome and, 267-268 India, AIDS in, 240
Hospital, day, for psychiatric patients, 6 Individual
assessment of, in crisis intervention, 29-31
Hot lines, 8
AIDS, 256 situational crises and, 138
infertility, 292 Individual approach to crisis intervention, 18,
House Select Committee on Aging, 112 19-20
326 Index
Indomethacin (Indocin), avoidance of, in el- Internal pelvic examination, infertility and,
derly, 229 131
Inference, arbitrary, in cognitive theory of de- Internalizing blame, elder abuse and neglect
pression, 23 and, 114
Infertile couple, emotional state of, 123-126, International Union of Psychological Science,
130 51
Infertility, 122-137 Internet, crises related to, 8-10
affective stages of, 124-126 Interpretation, in brief psychotherapy, 16
blame and, 130 Intervention
case study involving, 132-136 in burnout syndrome, 275-276
crisis of, 122, 129 crisis; see Crisis intervention
definition of, 122 paradigm of, 32-35
determining cause of, 131 in problem-solving approach to crisis inter-
emotional state of couple in, 123-126 vention, 31-32
groups and services, 292 social work, Alzheimer’s disease and, 166
hot lines, 292 therapeutic, 20, 31
as life crisis, 123 Intravenous drug users, AIDS and, 247, 248,
miscarriage and, 126-128, 131-132 251, 252, 256, 260, 261
parent support groups, 289-291 Invisible kids, child abuse and neglect and,
as problem of couple, 130 78
psychological trauma of, 122-137 Irritability in later adulthood, 213
psychosocial therapy and, 129-131 Isolation
psychotherapy, 128-131 AIDS counseling and, 245-246
resources for information about, 289-292 elder abuse and neglect and, 114
stillbirth and, 126-128, 131-132 infertility and, 125
Infertility specialist, 130-131 social, child abuse and neglect and, 84
Information, faulty patterns of processing, in
cognitive therapy, 22-23 J
Informed consent, AIDS/HIV counseling and, Job structure, burnout syndrome and, 266
242 Job transfer, 140
Inhalants, 226-227 Judgment
In-home care, visiting nurses and, AIDS and, mental status examination and, 288
251 problem solving and, 29
Inner-directed rage reaction, child abuse and
Junkies, closet, 228
neglect and, 82 Jurisprudence, therapeutic; see Therapeutic
Innovation, role, self-esteem and, 140
jurisprudence
Inpatient treatment, stress disorders and, 70
Input, problem solving and, 29 K
Insight, mental status examination and, 288 Kaposi’s sarcoma (KS), AIDS and, 251, 259
Institutionalization Kat, 230-231
Alzheimer’s disease and, 164 Kempe, C.H., 80-81, 82-83
elder abuse and neglect and, 113
Kennedy, John F, 1
old age and, 212, 213 Khat, 230-231
Insurance, lack of, AIDS and, 251
Koop, C. Everett, 93
Integration, rape and, 147 KS; see Kaposi’s sarcoma
Intensive Caring Unlimited (ICU), 291 KY jelly, condoms and, 262
Intercourse, transmission of AIDS and, 252,
256, 260 L
Intermediate response, problem-solving ap-
La Rouche, Lyndon, 249
proach to crisis intervention and, 28 Lacquers, sniffing and, 227
Index 327
Language, Alzheimer’s disease and, 163 Lungren, Dan, 221

Latchkey children, case study involving, Lymphoma, AIDS and, 259
188-193
Law; see Legal and ethical issues in psycho- M
therapy Magnification in cognitive theory of depres-
Legal, definition of, 47 sion, 23
Legal and ethical issues in psychotherapy, Major depression, unipolar, 284
43-61 Maladaptive coping, 154
confidentiality, 49-50 Males; see Men
consequences of therapist malfeasance in, Malfeasance, therapist
50-55 case study involving, 55-59
definitions of, 47-48 ethical and legal consequences of, 50-59
disclosure statements, 49-50 Malnutrition, cocaine and, 233
duty to warn, 49-50 Malpractice laws, therapeutic jurisprudence
privilege, 49-50 and, 46
sexual harassment, 52-55 Manipulation, environmental, in brief psycho-
therapeutic jurispudence, 44-47 therapy, 17
therapist-patient involvement, case study Mann, Jonathan, 256
involving, 55-59 Mariani, Angelo, 231
Legal Realist movement, therapeutic jurispru- Marijuana, 222-223, 226, 227, 230
dence and, 44 abuse of, by physicians, 235
Lesbians, violence against, 95-96 roofies and, 226
Librium; see Chlordiazepoxide Marital abuse; see Spouse abuse
License, surrender of, definition of, 286 Marlborough Experiment, 6
Life crisis, infertility as, 123 Marriage, stress and, 18
Life cycle, definition of, 186 Maslach, 265
Life cycle stressors, 186-220 Mastery, coping mechanisms and, 38
adolescence, 193-199 Maturity, adulthood and, 202
case study involving, 196-199 McCaffrey, Barry R., 223
adulthood, 199-211 Medicaid, 250, 251
case study involving, 202-205, 207-211 Medical insurance, lack of, AIDS and, 251
menopause, case study involving, 207-211 Medicare, 250
motherhood, case study involving, 202-205 Medications; see Drugs
old age, 211-219 Melvoin, Jonathan, 224
prepuberty, 187-193 Memories, repressed, 14
case study involving, 188-193 Memory loss, Alzheimer’s disease and, 163
Lifestyles Men
cocaine and, 234 abusive, self-help group for, 97
coping mechanisms and, 37-38 midlife symptoms of, 206
suicide and, 175 suicide and, 175
Lindemann, Eric, 2, 4, 18 Menopause, 206
Liquid X, 226 case study involving, 207-211
Listening, adolescent talking of suicide and, suicide and, 175
174 Mental health, 2-3
Long-term response, problem-solving ap- Mental health days, burnout syndrome and,
proach to crisis intervention and, 28 274
Los Angeles Gay and Lesbian Center, 95 Mental health law and care, alliance of, thera-
peutic jurisprudence and, 46-47
Loyalty, excessive, elder abuse and neglect
and, 114 Mental health services, legal and ethical is-
LSD; 2225275 sues and, 47
328 Index
Mental status examination, terms applicable Neglect—cont’d

to, 287-288 physical—cont’d
Mentoring programs, violence in schools and, elder abuse and, 110
103 psychological, elder abuse and, 110
Meprobamate (Equinal; Miltown), avoidance Nembutal; see Pentobarbital
of, in elderly, 229 Neuroendocrinology, infertility and, 122
Meritor Savings Bank y. Vinson, 54 Neurosis
Meth, 224-225 accident, 62
Methamphetamine, 223, 224-225 transference, 14
Methocarbamol (Robaxin), avoidance of, New York State Coalition Against Domestic
in elderly, 229 Violence, Battered Women’s Task
Midlife, suicide in, 174-175 Force of, 94
Military, homosexuals in, 249 Nirvana, 225
Miltown; see Meprobamate Nivea hand cream, condoms and, 262
Mineralocorticoids, stress and, 28 No contest, definition of, 285
Minimization in cognitive theory of depres- Nolo contendere
sion, 23 Non-adopted decision, definition of, 285
Miscarriage, 126-128, 131-132 Nonoxynol-9, condoms and, 262
Morality, definition of, 47 Nonphysical battering, battered women
Morphine, 231 and, 94
Moth balls, sniffing and, 227 Norepinephrine
Motherhood, case study involving, 202-205 cocaine and, 232
Mothering imprint, child abuse and ne- stress and, 28
glect and, 83-84 Norflex; see Orphenadrine
Motivation, principle of, 3-4 Normality, adult, 202
Mourning, Alzheimer’s disease and, 166 Normative crisis of adolescence, 4
Multiple sclerosis, 227 Nursing homes
Murder, felony, child abuse and neglect AIDS and, 251
and, 78 spouse abuse among elderly and, 114
Nussbaum, Hedda, 93
N
Nail polish remover, sniffing and, 227 O
Narcotics, prescription, abuse of, by physi- Obesity
cians, 235 methamphetamine for, 224
National Committee to Prevent Child
physical illness and, 152
Abuse, 79 Objective events, situational crises and, 139
National Inhalant Prevention Coalition, 226 Observing, critical thinking and, 29
National Institute on Drug Abuse, 231 Occupational identity, adolescence and, 196
National Self-Help Clearinghouse, 289 Occupational structure, burnout syndrome
National SIDS Clearinghouse, 292
and, 266
Needles, hypodermic, transmission of Oklahoma City bombing, 70
AIDS and, 247, 248, 251, 252, 256,
Old age, 114, 211-219
260, 261 case study involving, 214-219
Neglect Olympics, 1996, bombing at, 70
child; see Child abuse and neglect
Omen formation, posttraumatic stress disorder
definition of, 110
and, 64
elder; see Elder abuse and neglect On-the-spot demotion of one full academic
passive, 110 year, fighting in school and, 104
physical Operations, formal, adolescence and, 196
child abuse and neglect and, 83
Opium, 231
Index 329
Opportunistic diseases, AIDS and, 259 Perception—cont’d

Opportunity, crisis and, 1 mental status examination and, 287-288
Oral contraceptives, 254 Perinatal Loss, 292
Oral sex, AIDS transmission and, 252 Personal computers, crises related to, 8-10
Organic brain syndrome; see Alzheimer’s Personality types prone to burnout, 266
disease Personalization in cognitive theory of depres-
Organizing data, critical thinking and, 29 sion, 23
Orientation, mental status examination and, PET; see Psychiatric Emergency Team
288 Phenylbutazone (Butazolidin), avoidance of,
Orphenadrine (Norflex), avoidance of, in in elderly, 229
elderly, 229 Physical abuse
“Outing” victims, gay domestic violence and, battered women and, 93-102
95-96 child abuse and neglect and, 83
Outward adjustment, rape and, 147 elder abuse and neglect and, 109-110, 111
Overcommitment, burnout syndrome and, 271 Physical examination, infertility and, 131
Overgeneralization in cognitive theory of Physical exhaustion, burnout syndrome and,
depression, 23 269
Overidentification with patients, burnout syn- Physical illness, 139, 152-161
drome and, 271 case study involving, 157-161
Physical neglect
P child abuse and, 83
Panic attacks, posttraumatic stress disorder elder abuse and, 110
and, 65 Physicians
Paranoid psychoses, cocaine and, 232 AIDS and, 241-242
Parent support groups, infertility and, 289-291 drug abuse by, 234-235
Parental reactions, posttraumatic stress syn- Physiological processes, immediate, problem-
drome and, 65 solving approach to crisis intervention
Passive neglect, definition of, 110 and, 27-28
Past abuse, elder abuse and neglect and, 114 Physiological reactions
Pastoral Care, 290 acute stress disorder and, 67
Patients to stress disorders, 70-71
involvement of, with therapist, case study Piaget
involving, 55-59 adolescence and, 196
overidentification with, burnout syndrome prepuberty and, 187
and, 271 Planning, anticipatory, in crisis intervention,
PC; see Pneumocystis carinii DN, BY?
Peer cohesion, burnout syndrome and, 266 Pleasure center, 232
Peer group, adolescence and, 193 Pneumocystis carinii (PC), AIDS and, 259
Pelvic examination, internal, infertility and, Poddar, Prosenjit, 49
131 Poly-drug abusers, 235
Pentazocine (Talwin), avoidance of, in Positive transference, 16
elderly, 229 Post rape syndrome, 62
Pentobarbital (Nembutal), avoidance of, in Postcoital test, infertility and, 131
elderly, 229 Posttraumatic stress disorder (PTSD), 62-66
Pepper, David, 248 acute, 65
Perception versus acute stress disorder, 63
case study involving, 71-74
of event in problem-solving approach to
crisis intervention, 30, 32, 35-36 chronic, 65
delayed onset, 65
hallucinatory types of, Alzheimer’s disease
and, 163 special needs of children with, 65-66
330 Index
Posttraumatic stress disorder (PTSD)—cont’d Proposition 96, 249

symptoms of, 63-65 Proposition 102, 249
Pot, 222-223 Propoxyphene (Darvon), avoidance of, in
Powerlessness, burnout syndrome and, 272 elderly, 229
Pregnancy Prostitutes, AIDS and, 256
and Infant Loss Center, 290 Pseudodeveloped, suicide and, 175
infertility and; see Infertility Psychiatric Emergency Team (PET), 8
Pregnancy Exposure Information Service, 292 Psychiatric interview, screening, infertility
Pregnancy/Environmental Hot Line National and, 128-129
Birth Defects Center, 292 Psychiatric patients, day hospitals for, 6
Pregnancy-Loss Peer-Support Program, 289 Psychiatry, community, 5-8
Premature baby, stress and, 18 Psychic determinism, 3
Preparation, problem solving and, 29 Psychoanalysis, 13-16, 23
Prepuberty, 187-193 Psychoanalytic psychotherapy, 13-16, 23
case study involving, 188-193 Psychoanalytic technique of Freud, 3, 4
Prescription narcotics, abuse of, by physi- Psychodynamic psychotherapy, stress disor-
cians, 235 ders and, 69
Pretest AIDS/HIV counseling, 242-243 Psychological abuse, elder abuse and neglect
Primary appraisal, coping behaviors and, 36 and, 110
Primary autonomous functions of ego, 3 Psychological crisis, 1
Primitive thinking in cognitive theory of de- Psychological neglect, elder abuse and, 110
pression, 22 Psychology
Privilege, legal and ethical issues in psycho- developmental, 3
therapy and, 49-50 ego, 4
Problem, assessment of, in crisis intervention, genetic, 3
29-31 Psychopathology, elder abuse and neglect
Problem-solving approach to crisis interven- and, 111
tion, 26-42 Psychoses, paranoid, cocaine and, 232
anticipatory planning in, 32 Psychosocial development, stages of, 4
assessment of individual and problem in, Psychosocial therapy, infertility and, 129-131
29-31 Psychotherapeutic techniques, 13-25
balancing factors affecting equilibrium in, brief psychotherapy, 16-18, 23
35-41 crisis intervention; see Crisis intervention
coping mechanisms in, 37-41 psychoanalysis, 13-16, 23
factors affecting, 27-28 psychoanalytic psychotherapy, 13-16, 23
immediate physiologic processes in, Psychotherapists, 50-51
27-28 infertility and, 128-129
intermediate response in, 28 in United States and Europe, 51-52
intervention in, 31-32 Psychotherapy
long-term response in, 28 adaptational, 4
paradigm of intervention in, 32-35 brief, 16-18
perception of event in, 35-36 infertility and, 128-131
problem solving in, 29-32 legal and ethical issues in: see Legal and
reproductive, 27 ethical issues in psychotherapy
situational supports in, 36-37 psychoanalytic, 13-16, 23
therapeutic intervention in, 31 psychodynamic, stress disorders and, 69
Production, problem solving and, 29 Psychotic states, suicide and, 177
Project on the Status and Education of
Psychotropic drugs, 5
Women, 53, 54 PTSD; see Posttraumatic stress disorder
Proposition 54, 249 Puberty; see Prepuberty
Index 331
Public reproval, definition of, 285-286 Resolution, infertility and, 126

Pulse Check, 223 RESOLVE, Inc., 290
Resources of patient, suicide and, 175
Q Respondent, definition of, 286
Quaaludes, 230 Retrovirus, AIDS and, 259
Qut, 230-231 Revocation, definition of, 286
Revocation stayed, definition of, 286
R
Rights, violation of, elder abuse and neglect
Rado, Sandor, 3-4 and, 111
Rape, 144-152 Robaxin; see Methocarbamol
case study involving, 148-152 Robinson, Svend, 248
date, 146 Rohypnol, 225-226
definition of, 146-147 Role
depression and, 147-148 definition of, 139-140
fears and anxiety and, 147 sick, 156
gang, 146 Role changes, status and, 139-144
Rape trauma syndrome, 147 case study involving, 141-144
Rapists, self-concept of, 148 Role innovation, self-esteem and, 140
RAS; see Ascending reticular activating Role modeling, sexual harassment and, 52
system Role reversal
Rationalization, coping mechanisms and, 38 Alzheimer’s disease and, 165
Reach Out to Parents of an Unknown child abuse and neglect and, 84
Child, 290 Roofies, 225-226
Reappraisal, coping behaviors and, 36 Rotation, assignment, burnout syndrome and,
Recovery process in heart disease, 154-155, 274
156 Roy v. Hartogs, 51
Red Rum brand of heroin, 224
Regression, tension-reducing mechanisms S
and, 38 Safe sex, AIDS and, 260-261, 262
Rela; see Carisoprodol San Francisco General Hospital, 7
Relationships Scapegoating, child abuse and neglect and, 82
acute stress disorder and, 67-68 Schemas in cognitive therapy, 22
fiduciary, between patient and therapist, 49 Schools
stress disorders and, 69 daily attendance in, 104
Relaxation exercises, burnout syndrome and, violence in, 102-109
274 alternative approaches to prevention of,
Religious beliefs, AIDS/HIV counseling and, 105-106
245 case study involving, 106-109
Relocation, 140 discipline and, 103-105
Reorganization phase, rape and, 147 Scoop, 226
Repressed emotions, 14 Secobarbital (Seconal), avoidance of, in el-
Repressed memories, 14 derly, 229
Repression, tension-reducing mechanisms Secondary appraisal, coping behaviors and, 36
and, 38 Selective abstraction in cognitive theory of
Reproductive endocrinologist, infertility and, depression, 23
131 Self-concept, appraisal of self and, 37
Reproductive problem solving, 27 Self-esteem
Reproval, public, definition of, 285-286 appraisal of self and, 37
Rescuing behavior, AIDS/HIV counseling prepuberty and, 187
and, 244 role innovation and, 140
332 Index
Self-help group for abusive men, 97 Situational crises—cont’d

Self-medication, stress disorders and, 70 status and role changes, 139-144
Self-neglect, definition of, 110 case study involving, 141-144
Selye, 186 suicide, 172-183
Semen analysis, infertility and, 131 in adolescence, 172-174
Sensorium, mental status examination and, 287 case study involving, 179-183
Serotonin re-uptake blockers, stress disorders in midlife, 174-175
and, 68 Situational supports in problem-solving ap-
Sex, safe, AIDS and, 260-261, 262 proach to crisis intervention, 30, 32,
Sex offenders, plea bargaining by, 46 36-37
Sexual abuse, 81 Skills, coping, 30-31
child abuse and neglect and, 83 Sleeplessness, stress disorders and, 68
elder abuse and neglect and, 109-110, 111 Smashing Pumpkins, 224
Sexual assault, 146 Smoking, 223, 256
Sexual battery, 146 Sniffing, inhalants and, 226-227
Sexual harassment “Snow lights,” cocaine and, 232
definition of, 53 Social club, therapeutic, 6
legal and ethical issues in psychotherapy Social isolation, child abuse and neglect
and, 52-55 and, 84
Sexual intercourse, transmission of AIDS and, Social Readjustment Rating Scale (SRRS),
252, 260 199
Sexual involvement, therapist-patient, 50-59 Social support, definition of, 201
case study involving, 55-59 Social work intervention, Alzheimer’s disease
Sexual transmission of AIDS, 251-252, and, 166
259-260 Society
Sexually transmitted diseases (STDs), rape for the Prevention of Cruelty to Children, 80
and, 144 violence in; see Violence
Shaken baby syndrome, child abuse and Soft drugs, 230
neglect and, 78 Solvents, sniffing and, 226-227
SHARE, 289 Soma; see Carisoprodol
Sharing feelings, adolescent talking of suicide Specialness of child, child abuse and neglect
and, 174 and, 84
Shell shock, 62 Speed, 223, 230
Shelters for battered women, spouse abuse Speed bumps, 224
among elderly and, 114 Speed freaks, 224
Shock Speedballing, 230
rape and, 147, 148-152 Spermicide, condoms and, 262
shell, 62 Spouse abuse, 93-102, 146
Sick role, 156 case study involving, 97-102
SIDS; see Sudden Infant Death Syndrome elder abuse and neglect and, 114-118
SIDS Counseling Program, 292 case study involving, 115-118
Significant other, suicide and, 178 Spouse beating, 96-97
Situational crises, 138-185 Spray paints, sniffing and, 227
Alzheimer’s disease, 161-172 SRRS; see Social Readjustment Rating Scale
case study involving, 167-172 Staff meetings, burnout syndrome and, 274
defining, 138-139 Stagnation, stages of disillusionment in burn-
physical illness, 152-161, 162 out and, 271-272, 273
case study involving, 157-161, 162 Startle reactions, posttraumatic stress disorder
rape, 144-152, 153 and, 64-65
case study involving, 148-152, 153 Statistical Abstract of the United States, 172
Index 333
Status Substance abuse—cont’d

definition of, 139-140 methamphetamine, 224-225
and role changes, 139-144 Sudden Infant Death Syndrome (SIDS), 292
case study involving, 141-144 Suggestion, waking, 13-14
Stay, definition of, 286 Suicidal plan, 175
Stayed, definition of, 286 Suicide, 20, 31, 172-183
STDs; see Sexually transmitted diseases in adolescence, 172-174
Steinberg, Joel, 93 African-Americans and, 175
Stillbirth, 126-128, 131-132 age and, 175
Stipulation, definition of, 286 AIDS and, 175
Stress case study involving, 179-183
anxiety and, 27 cocaine and, 233-234
immediate physiologic processes and, communication and, 178
27-28 depression and, 176
intermediate response and, 28 executive, 175
life cycles and, 186-220 gender and, 175
long-term response and, 28 inhalants and, 227
suicide and, 175 lifestyle and, 177-178
Stress disorders men and, 175
acute, 62, 63, 66-68 menopausal women and, 175
observations in, 70 in midlife, 174-175
physiological reactions and, 70-71 pseudodeveloped and, 175
posttraumatic; see Posttraumatic stress psychotic states and, 177
disorder rape and, 147
relationship to emotions in, 71 related factors and, 175-178
subjective reports in, 70 resources of patient and, 177
treatment of, 68-71 significant other and, 178
Stressors stress and, 176
in hospice and AIDS care, burnout syn- suicidal plan and, 176
drome and, 267-269 symptoms relating to, 176-177
life cycle; see Life cycle stressors women and, 175
in old age, 212 Supervisory behavior, burnout syndrome and,
Stroke, physical illness and, 152 267
Students Support groups, burnout syndrome and, 274
AIDS/HIV and, 254-256 Supportive category of psychoanalytic
substance abuse and, 221 psychotherapy, 15
Subjective events, situational crises and, Supports
138-139 situational, in problem-solving approach to
Substance abuse, 221-239 crisis intervention, 30, 32, 36-37
case study involving, 235-238 social, definition of, 201
cocaine, 228-235 Surprise, infertility and, 124
designer drugs, 221, 225-226 Surrender of license, definition of, 286
gamma hydroxybutyric acid, 226 Suspension, definition of, 286
GHB, 226 Suspiciousness, child abuse and neglect and,
Rohypnol, 225-226 84-85
Scoop, 226 Syndrome
in elderly, 227-228, 229 battered child; see Child abuse and neglect
heroin, 223-224 organic brain; see Alzheimer’s disease
inhalants, 226-227 Syringes, transmission of AIDS and, 247,
marijuana, 222-223 248, 260
334 Index
T Tranquilizers, 235
Tactile hallucinations, cocaine and, 232 Trans World Airlines flight 800, 70
“Tailhook” Navy reunion, 53 Transference
Taking care of yourself, burnout syndrome analysis of, in brief psychotherapy, 16
and, 274 positive, 16
Talwin; see Pentazocine Transference neurosis, 14
Tanking up with cocaine, 233 Transference phenomena, 14
Tarasoff, Tatiana, 49 Transfers of jobs, 140
Tarasoff v. Regents of University of Califor- Trauma, head, child abuse and neglect
nia, 48-49 and, 78
T-cells, AIDS and, 241 Trouble-Shooting Clinic, 6
Technological advances, crises related to, Two-income families, 5
8-10
Tension-reducing mechanisms, 38; see also U
Coping mechanisms Ulcers, genital, AIDS and, 252
Terror of degradation, violence in schools Uncovering category of psychoanalytic psy-
and, 104 chotherapy, 15
Testing, AIDS/HIV antibody, 242, 261-262 Underclass, child abuse and neglect and,
Therapeutic community, 6 78-79
Therapeutic intervention in crisis intervention, Understanding Newborns in Traumatic Expe-
20,31 riences (UNITE), 291
Therapeutic jurisprudence, 44-47 Unipolar major depression, 284
alliance of mental health law and care, Uniqueness of child, child abuse and neglect
46-47 and, 84
limits of, 45-46 United States
Therapeutic social club, 6 AIDS in, 247-251
Therapist psychotherapists in, 51-52
in AIDS counseling, 243-244 UNNITE; see Understanding Newborns in
grief of, 246 Traumatic Experiences
Therapist malfeasance U.S. Advisory Board on Child Abuse and
case study involving, 55-59 Neglect, 79
ethical and legal consequences of, 50-59 U.S. Centers for Disease Control and Preven-
Therapist-patient involvement, case study in- tion, 241
volving, 55-59 U.S. Food and Drug Administration, 242
Thinking
absolute, 23 vV
critical, 29 Vaginal intercourse, transmission of AIDS
primitive, 22 and, 252
Thomas-Hill, 53 Validating data, critical thinking and, 29
Thought, mental status examination and, Valium; see Diazepam
287-288 Van Buren, Abigail, 79
Thrush, AIDS and, 260 Vaseline Intensive Care Lotion, condoms and
>
Thyroxine, stress and, 28 262
Time, recovery process in heart disease and,
Vasopressin, stress and, 28
154-156 Vicodin, abuse of, by physicians, 235
Time off, burnout syndrome and, 274 Violation of rights, elder abuse and neglect
Title VII of 1964 Civil Rights Act, 54 and, 111
Tobacco, 223, 256 Violence, 76-121
Toluene, sniffing and, 226-227 battered spouse and, case study involving,
Toxoplasmosis, AIDS and, 251, 259
97-102
Index 335
Violence—cont’d White House Office of National Drug Control

child abuse and neglect and, 77-93 Policy, 223
case study involving, 85-93 White-out, sniffing and, 227
cocaine and, 232 Withdrawal
domestic, child abuse and neglect and, 78 AIDS/HIV counseling and, 245-246
elder abuse and neglect, 109-118 tension-reducing mechanisms and, 38
case study involving, 115-118 Women
in home, 93-102 battered, 93-102
case study involving, 97-102 elder abuse and neglect and, 114
in “‘new” families, 95-96 employment of, outside home, 5
in schools, 102-109 heterosexual, AIDS in, case study involv-
case study involving, 106-109 ing, 252-254
Visiting nurses, in-home care for AIDS and, menopausal, suicide and, 175
251 suicide and, 175
Visual hallucinations, cocaine and, 232 Work environment, burnout syndrome and,
Vitamin C, cocaine and, 232 266-267
Vitamin deficiencies, cocaine and, 233 World Health Organization, 154-155,
Vocational Rehabilitation Act, 250 251-252, 256, 283
Volunteers, violence in schools and, 106 World Wide Web, nondependent users of
Internet and, 9, 10
WwW
Waking suggestion, 13-14 Y
Washington State Poison Control Network, Youth suicide, 172-174
292
Wellesley Human Relations Service, 2-3 Z
Wesson Oil, condoms and, 262 Zero tolerance policies, violence in schools
Western Blot test, HIV infection and, 242 and, 102
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ABOUT THE AUTHOR
| ISBN 0-8151-2604-2
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CRISIS.

NAM SAYING WO)

1. Historical Development of Crisis Intervention Methodology, 1

6 . Violence in Our Society, 76

- ABOUT THE COVER

DONNA C. AGUILERA, PHD, FAAN, FIAEP

Vice President and Publisher: Nancy L. Coon

All rights reserved. No part of this publication may be reproduced,

Permissions may be sought directly from Elsevier’s Health Sciences

Printed in the United States of America

05 06 07 08 / 109 87 Co, Maxoud,

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Chapter 4 discusses the legal and ethical issues inherent in psychotherapy.

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eel to Gade tiavila perniiekoy

1. Historical Development of Crisis Intervention

2. Differentiation Among Psychotherapeutic

3. Problem-Solving Approach to Crisis Intervention, 26

4. Legal and Ethical Issues in Psychotherapy, 43

. Posttraumatic Stress Disorder and Acute

_ Violence in Our Society, 76

. The Psychological Trauma of Infertility, 122

8. Situational Crises, 138

. Life Cycle Stressors, 186

LO: Substance Abuse, 221

Ee Persons With AIDS/HIV, 240

1 Burnout Syndrome, 265

ren Dequites AA of (GR, TD

, afeel tat nine Li —a, 9 te a

(ss 14 Teimiscine (eee EAP | x: x

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psychological crisis refers to an individual’s inability to solve a problem. We

2. The degree of reality recognized and faced in solving problems

methods of problem solving. A period of disorganization ensues, a period of upset,

Evolution of Community Psychiatry

community who were unfamiliar with established forms of psychiatric treatment.

Crises Related to Technological Advances

SIGNS OF AN ON-LINE ADDICT

Uses the Internet as a way of escaping from problems or relieving a poor

Kaplan H, Sadock B: Synopsis of psychiatry, ed 6, Baltimore, 1994, Williams & Wilkins.

P sychotherapy as a form of treatment has had many definitions, some conflicting

Psychoanalysis and Psychoanalytic Psychotherapy

repressed, conflictual emotional events through this approach. He next devised an

5. Confinement of the analyst’s activity essentially to interpretation or other

Diagnostic evaluation is extremely important in short-term therapy. Its aim is to

Crisis intervention extends logically from brief psychotherapy. The minimum

*These studies are also discussed in Chapters 8 and

plan is directed toward an adaptive resolution of the crisis. Specific intervention

... direct encouragement of adaptive behavior, general support, environmental manipula-

20 Crisis Intervention: Theory and Methodology