Coping with mysterious symptoms

The July/August article "When symptoms are a mystery" is important. I have treated several children and adults who endured numerous emergency room visits and medical procedures with nothing physically wrong being discovered, only to have their symptoms disappear as their psychotherapy progresses. But, to be less judgmental, some children perform hypochondriacal dramas that would terrify anyone. I have also treated children with mothers who report continuing, long-term physical distress and receive numerous diagnoses relating this to the arthritis/rheumatism family of disorders with no treatment ever being effective. These women have disastrous intimacy lives, although they function well at work and reliably bring their child to therapy, but are unwilling to consider it for themselves. Two bits of advice that adult patients benefit from: Check the accuracy of their prescribed medication online and, except in an emergency, get a second or even third opinion when an invasive procedure is advised.

Stanley Goldstein, PhD
Middletown, N.Y.

Breaking free from addiction

The June Monitor article "Breaking free from addiction" makes many worthwhile points. There is, however, a missing element therein. No mention is made of the extensively documented importance of family members and significant others (SOs) regarding such matters as a) the typical close ties between adult substance abusers and their parents or the people who raised them; b) family-couple interactional patterns and life events are often key to the onset and continuation of substance use disorders; c) SOs can be instrumental in getting adult substance abusers to enter treatment/self-help and remain in it longer; and d) there is substantial evidence regarding the effectiveness — and longer-lasting results — of family couples treatment approaches for substance use disorders.

Per the last, the absence of that category in the article's "what works" list is unfortunate given that results for at least 113 family couples randomized controlled trials with adult substance abusers have been published, along with a number of systematic reviews and meta-analyses. Further, at least seven such models now qualify as well-established treatments for substance use disorders. Relatedly, David Sheff, in his new book "Clean," devotes several pages to family therapy, including mention of the SAMHSA/CSAT Treatment Improvement Protocol No. 39, which has concluded that "family therapy (as distinguished from family education programs or visiting programs) has a place in all treatment modalities" (p. 66).

In sum, being informed about the above can be of help both to psychologists and their clients.

M. Duncan Stanton, PhD
Spalding University

I was quite pleased to see coverage of addiction treatment in the June Monitor. This area of psychology has been neglected and this population seriously underserved. However, I was disappointed to note that your list of evidence-based practices included such valuable modalities as cognitive-behavioral therapy and motivational interviewing, without any mention of twelve-step facilitation. Despite rumors to the contrary, there is abundant evidence of the efficacy of 12-step interventions. In fact, in Project MATCH, a large multi-site study of these three modalities, there was little difference noted in outcome among them. There is often a bias in our field against AA and its descendants (perhaps due to its "unscientific" origins) and I feel this is reflected in their omission from this article. However, this bias should not deter our use or investigation of this approach, which has provided recovery support for millions of suffering alcoholics and addicts.

Mark Schenker, PhD
Blue Bell, Pa.

As a psychologist working in outpatient substance abuse treatment, the "Breaking free from addiction" article was initially curious in title and then in content — curious in content given the waste of space in explaining why treatments in "the community" don't work as well as those in "the lab." Did we really need a mention of individual differences as the parsimonious explanation for all (not just in addiction treatment) implementation glitches between research and practice? The commentary on the apparent value and importance of training notwithstanding given much data questioning such a need for effective practice (e.g., practitioners and interns have as good or better outcomes than seasoned professionals), the primary solution titled "measurement-based practice" is an excellent one. It is the same as what has been proposed for quite some time now in the outcome literature as "practice-based evidence" (a literal twist to the more politically correct version — i.e., evidence-based practice) with which we as a profession are now obsessed. Here's to real-time feedback via engagement of clients in their care.

Rafael S. Harris Jr, PsyD
St. Petersburg, Fla.

The "Breaking free from addiction" article presents long-term (and deeply needed) solutions for changing the U.S. addiction treatment system, but the article is mostly silent about what a family or drug user might do now if treatment is needed. As Morganstern states in the final paragraph, "I can tell you that every day I have a family with a young person who has no place to go." However, there are places to go (many of them run by psychologists) if one knows where to look and what to ask. I was surprised Anne Fletcher's recently released "Inside Rehab: The Surprising Truth about Addiction Treatment —And How to Get Help That Works" was overlooked in this article. "Inside Rehab" provides the information treatment seekers need to increase the quality of the treatment they receive. 

Tom Horvath, PhD
La Jolla, Calif.

Please send letters to Sara Martin, Monitor editor. Letters should be no more than 250 words and may be edited for space and clarity.


The caption in the July/August story "Activists for change" should have said that Dr. Pamela Reid was pictured on the right. Reid was chair of APA's Committee on Women in Psychology in 1984; Dr. Hortensia Amaro chaired it in 1985.