Important Literature References in the Behavioral Health Sciences

This column is for the professional behavioral health practitioner who is seeking more information to enhance competence in daily clinical practice. The general public may also find it useful as a source of information to be used in their consultations with Behavioral Health Science professionals. It will contain a primary source reference with a comment or quote about the source material. (We would welcome hearing from others who may know of some source material they feel is important for practitioners. We will gladly share that information with our readers.)

This first series of articles highlights the need to be sensitive to the consumer of service when treatment programs are involved. This perspective is sometimes lost in the demands of a daily practice.

  1. Weingourt, Rita, Ph.D., RN, CS. Using Margaret A. Newman’s Theory of Health With Elderly Nursing Home Residents. Perspectives in Psychiatric Care, Vol. 34, #3, July-Sept. 1998. ("If the elderly are to thrive in Nursing homes, efforts must be made to understand the concerns that make them vulnerable to loneliness, anxiety and depression. In particular, attention must be paid to the losses that lead to loneliness and sense of deconnection from the world.")

Author's e-mail address:

(Comment: Care in nursing homes is a highly volatile issue. Adjustment to a new surrounding is a major factor for the elderly. Systems which help individuals cope with their new environment would slow the deconnection from the world felt by the elderly, but allowing them time to grieve for the loss of independence is also important for long term adjustment.)

  1. Davidson L., & Strauss J.S. (1995) Beyond psychosocial model: Integrating disorder, health & recovery. Psychiatry, 58, 44-55.

Recovery dependent upon the rediscovery, reconstruction and use of a more functional sense of self. Involves four basic aspects:

a. discovering the possibility of possessing a more active sense of self
b.taking stock of the strengths and weaknesses of this self and assessing possibilities for change
c.putting into action some aspects of the self and integrating the results
d.using the enhanced sense of self to provide some degree of refuge from ones illness.

(Comment: Psychological steps to strengthen the process of recovery from illness are always needed as an adjunctive treatment., but is easier said then done. It calls for a lot of support from the environment, something that is not always forthcoming from those around us.)

3. Slack W. V. (1997) Cybermedicine. San Francisco, Jossey Bass.

"A must read for anyone interested in clinical computing."

  1. Gould RA, & Clum GA (1993). A meta-analysis of self-help treatment approaches. Clinical Psychology Review. 13:169-186. (Comment: When two media, such as audiotapes or a videotape plus a booklet, are employed, self-help treatment program affect size more than doubles.)

  2. Roberts RE, Kaplan GA, Shema SJ, Strawbridge WJ. (1997). Does growing old increase risk for depression? Am. J. Psychiatry 154:1384-1390. (Comment: Study follows a 50+ year old population for one year looking for symptoms of depression as related to age. The results indicate that the only apparent age effect on depression were caused by chronic health problems and functional impairment. Healthy, normal functioning adults were at no greater risk for depression than were younger adults. Depression in the elderly is a highly treatable disease if identified early on.)

  3. McCrum, Robert (1998). My Year Off: Recovering Life After a Stroke. W.W.Norton ("…a meticulous and highly literate account,, written by a gifted storyteller, of that harrowing night ( suffered a stroke) and its aftermath. It is a book difficult to lay aside until its final sentence has been read.")

  4. (Comment: Should be read by all behavioral health professionals to enable them to better empathize with the consumers of their services.)

  5. Kapur, Narinder (Ed.) (1997). Injured Brains of Medical Minds: Views from within. Oxford University Press. (Comment: Dr. Kapur’s collection of first- and third-party accounts of physicians and psychologists who suffered brain damage concludes with lessons for patient management and staff education and information about the process of recovery from brain surgery that is a must read for everybody.)

This is the second of a continuing series of summarizing/quoting articles that could be useful in the treatment process.

Improving the treatment repertoire in rehabilitation is not a sophisticated pastime but a clinical need. Finding ways to promote healthy behaviors and practice is a major management, clinical and administrative policy objective.

Exercise is considered by most health experts as an essential part of any wellness program. Studies show the robust positive effect of an exercise regimen on health, rehabilitation, and longevity. Management of pain also rears its head in any exercise program geared to restoring individuals to the mainstream of life.

A sample of articles on exercise, back injury and self-efficacy follows:

Emtner M, Finne M, Stalenheim T. High-intensity physical training in adults with asthma. A comparison between training on land and in water. Scand. J Rehab Med 30:201-209, 1998.

"…Many persons with asthma perceive their disease as a factor limiting their chances of improved fitness and lack adequate knowledge about asthma and exercise. For this reason, asthmatic individuals often avoid physical activity and choose an inactive lifestyle. Rehabilitation, including physical training, has been shown to improve physical fitness, reduce anxiety about physical condition, alleviate asthma symptoms and reduce the number of emergency room visits and days absent from school." This study showed that "all patients irrespective of training form were able to exercise to maximal intensity (80-90% of estimated heart rate). No asthmatic attacks occurred in connection with training sessions. The asthmatic symptoms declined during the rehabilitation period and the subjects needed less acute asthma care after the rehabilitation."

(Comment: The incidence of asthma, despite the wide range of treatment modalities available, continues to increase. Exercise may become an important part of a treatment protocol for this disorder but is not a magic bullet. Better attention to vectors of this disease is still needed to stop the growth in incidence of asthma.)

Sarno, John E. The Mind Body Prescription: Healing the body, healing the pain. Warner Books, 1997.

Deyo, Richard A. Low Back Pain. Scientific American. August 1998.

"Low back pain is at epidemic levels. Although its causes are still poorly understood, treatment choices have improved, with the body’s own healing power often the most reliable remedy.

"Up to 80% of all adults will eventually experience back pain, and it is a leading reason for physician office visits, for hospitalization and surgery and work disability.

"The good news is that most back-pain patients will substantially and rapidly recover, even when the pain is severe. The prognosis holds true regardless of treatment method or even without treatment…Most patients who do leave work return within six weeks, and only a small percentage never return to their jobs. (at a given time, about 1% often work force is chronically disabled because of back problems.)

The bad news is that recurrences are common, a majority of patients will experience them. Fortunately, these recurrences tend to play out much as the original incidents did, and most patients recover again quickly and spontaneously.

"Only a weak association exists between symptoms, imagery results and anatomical or physiological changes.

Sarno concludes "that unresolved emotionally charged states produce physical tension that in turn causes pain. He asserts that a variety of back pain actually serves to distract patients from the potential distress of confronting their psychological conflicts.

"An exhaustive review of clinical studies of exercise and back pain found that structured exercise programs prevented recurrences and reduced work absences in patients with acute pain who regularly took part soon after an episode of back pain had subsided. The preventive power of exercise was stronger than the effect of education (for example, how to lift) or of abdominal belts that limit spine motion. Patients experiencing chronic pain also benefited from exercise…even with their pain."

(Comment: Treatment repertoire for back pain needs to become more sophisticated if we are to help individuals return to economic mainstream. Modified exercise with some pain may carry weight in restoring individuals to work. Pain tolerance is an important factor in a rehabilitation process. It means dealing with the underlying cognitive distortions.)

Butterfield, Patricia G., Spencer, Peter S., Redmond, Nadia, Feldstein, Adrianne & Perrin, Nancy. Low Back Pain: Predictors of Absenteeism, Residual Symptoms, Functional Impairment and Medical Costs in Oregon Workers’ Compensation Recipients. American Journal of Industrial Medicine 34:559-567 (1998).

"Survival curves revealed significantly longer claim duration among workers who discontinued physical fitness activities post injury compared with workers who did not; these differences remained significant even after controlling for severity of the initial injury"

They conclude "continuation of physical fitness activities during the recovery process was found to be a significant predictor in three of four regressive models, providing evidence on behalf of a relationship between fitness and positive health outcomes.

"The relatively weak association between injury severity, at time of presentation and the study outcome provides evidence that factors beyond the magnitude of the injury play significant roles in lower back pain recovery.

In this study "older age was predictive of greater functional impairment but younger age was predictive of greater medical costs. Older workers may be more likely to have functional impairments based on an accumulation of back problems over many years superimposed on other health problems.

(Comment: Workers’ Compensation rehabilitation programs have to reorient the way they approach dealing with those disabled at work, with much attention needed in dealing with motivation, a very complex issue both internally and externally. See Geelen and Soons below)

Hammer, Niklas, Alfredsson, Lars, Johnson, Jeffrey V. Job strain, social support and evidence of myocardial infarction. Occupational and Environmental Medicine 1998. #55:548-553.

"The combination of high psychological job demand and low decision latitude (high job strain) has been associated with an increased risk of coronary heart disease. It has been proposed that this may also be the case for low social support at work. The aim of this study was to analyze the relationship between psychosocial factors and incidence of myocardial infarction. (Used a case-controlled study design)

"Our results indicate that jobs characterized by low decision latitude, high job strain or low social support at work may be associated with an increased risk of acute myocardial infarction.

(Comment: Biopsychosocial factors are important in formulating a plan to return disabled individuals to the working world. The idea has been around for quite a while, yet Workers’ Compensation continues to be a problem that has not found a solution.)

McAuley, E (1993). Self-efficacy and maintenance of exercise participation in older adults. J of Behavioral Medicine 16(1), 103-113.

(Comment: Beliefs, social supports, pain, fatigue and verbal encouragement were related to motivation to participate in exercise activities in sedentary older adults. More and more studies indicate that sedentary life is detrimental to personal health.)

Geelen, R., & Soons, P. (1996) Rehabilitation: an "everyday" motivation model. Patient Education and Counseling 28, 69-77.

(Comment: Exposure to role models, receiving verbal encouragement and reinforcement, feeling cared for and cared about, and decreasing unpleasant sensations during an activity influenced motivation to perform functional activities. Putting this all together in a program is the challenge for the professional.)

December `1998

This third series of articles takes a look at Alzheimer’s Disease. There are about 78 million baby boomers and starting in June of 1996 about 10,000 of these baby boomers will turn 50 years old everyday. The fastest growing segment in our population is the over 75 years of age, a cohort group especially vulnerable to Alzheimer’s Disease.

  1. Morris, Robin (Ed.) The Cognitive Neuropsychology of Alzheimer-type Dementia. Oxford England: Oxford University Press. 1996

(Comment: Check out the chapters in the section headed "Implication for Treatment and Rehabilitation in Dementia" that look at the area of assessment, management and pharmacological intervention. Thesis of book is that different patterns of cognitive decline in Alzheimer’ patients suggests that subtypes of Alzheimer’s Disease exist and must be treated differently. Use of regional Single Photon Emission Computed Tomography (SPECT) scans will pinpoint impaired neurophysiological functioning.)

This fourth series of research articles looks at illness representation and attempts to show that illness representation predicts return to work.

Levental H., & Nerenz RD, (1985) in Karoly, P (Ed.) Measurement Strategies in Health Psychology. New York, Wiley, 517-554.

Lau RR, & Hartman KA (1983) Commonsense representations of common illness. Health Psychology. 2:163-185.

Lacroix JM, Martin B, Avendano M, & Goldstein R (1991). Symptoms schemata in chronic respiratory patients. Health Psychology. 10:268-273.

Comment: The above articles investigate seriously ill individuals, revealing common themes of how these individuals think about their illness. The five common themes are: identity, or the label assigned to the illness and the knowledge of the symptoms associated with it; time-line, or the course the illness takes; the perceived cause of the illness; the consequences of the illness for a person’s life; and the possible cure, or beliefs about the controllability or curability of an illness. Cognitive bias serve to maintain and exacerbate symptomatology. For example, anxious individuals seem to attend selectively to threatening stimuli and can interpret the nature of their illness in a bias fashion thus making it hard to effect a cure or rehabilitation. The magnitude of the cognitive bias will increase as a function of the state anxiety.


by Harold Rubin BA, CRC, ABD, Guest Lecturer


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