VOL 15, NO. 1, 1989
Social Problem Solving
in Schizophrenia
by Alan S. Bellack, Randall L.
Morrison, and Kim T. Mueser
Abstract
The recent literature on social
skills training has placed an
increasing emphasis on the role of
cognitive factors in social failure,
as opposed to deficits in motoric
skills. It has been hypothesized
that schizophrenic patients are
markedly deficient in social
problem-solving abilities, and several programs have been developed
to teach problem-solving skills.
Despite high face validity, there is
little empirical support for these
training programs or the problemsolving model on which they are
based. Research on information
processing and problem solving in
nonpatient populations is discussed, and it is concluded that the
model used in these treatment programs is not a good representation
of the problem-solving process. In
particular, means-ends analysis is
not an appropriate strategy for
dealing with most interpersonal
problems and conflicts. The difficulties experienced by schizophrenic patients in social situations
might be due to a number of factors other than deficits in problemsolving skill, including sensitivity
to negative affect and disordered
communication. It is concluded
that further research on problemsolving training programs is clearly
warranted but that the validity of
the problem-solving model and the
utility of the training is uncertain.
Severe impairment in social functioning is a hallmark of
schizophrenia. Deterioration of
social relations is one of the defining characteristics of the disorder
specified by DSM-111 (American
Psychiatric Association 1980). Social
isolation and withdrawal are frequently among the most prominent
prodromal symptoms, as well as
101
characteristic markers of the negative syndrome or defect state
(Andreasen 1982). This pattern of
social disability appears to be exacerbated by the chronic course of the
disorder, but there are considerable
data suggesting that many adult
schizophrenic patients exhibited
maladaptive patterns of interpersonal functioning beginning in
childhood (Lewine et al. 1978,
1980). Poor premorbid competence
has been related to the etiology of
the disorder and remains one of the
best prognostic indicators (Strauss
et al. 1977; Wallace 1984). Inability
to deal effectively with the social
environment is thought to be a
major source of stress for patients
and thus contributes to relapse
(Falloon et al. 1984). At the same
time, their social impairment prevents them from developing the
supportive relationships that could
provide a buffering effect. The pattern of interpersonal difficulties is
not simply a byproduct of debilitating positive and negative symptoms. Schizophrenic patients with
and without negative syndrome
manifest marked social skill deficits
even when other symptoms are
pharmacologically controlled or in
remission (Wallace 1984; Bellack
and Morrison 1987).
Social Skills Training
The breadth and significance of
interpersonal problems experienced
by schizophrenic patients has
sparked considerable interest in
possible remediation strategies. The
most promising approach is social
skills training (Liberman et al. 1985;
Bellack 1986). An effective technolReprint requests should be sent to
Dr. A.S. Bellack, The Medical College of
Pennsylvania at EPPI, 3200 Henry Ave.,
Philadelphia, PA 19129.
102
ogy for improving social skills has
been developed through a long
series of single-case and small-scale
demonstration studies (Hersen and
Bellack 1976b; Morrison and Bellack
1984). More recently, several largescale clinical trials have documented
that schizophrenic patients can
acquire and maintain new skills,
and that social skills training can
have a significant effect on relapse
(Bellack et al. 1984; Hogarry et al.
1986; Wallace and Liberman 1985).
As a result of this accumulating
body of research, social skills training is now widely regarded as one
of the most important psychosocial
components of a comprehensive
treatment program for
schizophrenia.
Motor Skills Model. Despite the
positive data and widespread
acceptance of the model, relatively
little is known about precisely how
social skills training works, and
there are a number of important
questions about the most effective
content and structure for training.
Initial training programs were based
primarily on a motor skills, or topographic, model of social functioning
(Liberman 1982; Morrison and
Bellack 1984). According to this
model, social performance depends
on the smooth integration of a set
of specific behavioral elements,
including verbal production, paralinguistic features (e.g., voice tone
and volume), and nonverbal features (e.g., kinesics, proxemics, and
gaze). The appropriate use of these
elements varies across situations.
For the most part, social behaviors
(effective or ineffective) are thought
to be elicited by situational cues in
a relatively automatic manner. It is
assumed that persons with social
skills deficits (including schizophrenic patients) either failed to
learn requisite skills, lost them as a
SCHIZOPHRENIA BULLETIN
function of long periods of hospitalization or social isolation, or are
unable to use skills in their repertoire because of high levels of
negative affect. Social skills training
programs based on this model
emphasize repeated rote rehearsal
of targeted behaviors. The goal is to
produce overlearning, so that
appropriate behaviors are emitted
in a relatively automatic manner.
This model was developed, in part,
to accommodate to the learning and
performance deficits associated with
schizophrenia, including problems
in sustaining effortful attention and
hypersensitivity to negative affect
and stress (Hersen and Bellack
1976b).
The motor skills model has
received extensive empirical support. A large series of single case
studies has demonstrated that
patients can learn to maintain eye
contact, decrease the latency of
their responses, vary their voice
intonation, and emit appropriate
statements of appreciation and
assertion (Hersen et al. 1973;
Bellack et al. 1976; Hersen and
Bellack 1976a). Holmes et al. (1984)
showed that patients could learn
more complex conversational skill.
Finally, Bellack et al. (1984) and
Hogarty et al. (1986) demonstrated
that motoric skills training could
have a significant effect on core
symptoms and vulnerability to
relapse.
The motor skills model, as originally conceived, does not address
the role of cognitive factors in interpersonal behavior. This is now
widely regarded as a significant
omission, and increasing attention
has been paid to such factors as
social perception (Morrison and
Bellack 1981, 1987) and information
processing (Liberman et al. 1986).
At some level, effective interpersonal behavior requires attention to
appropriate social cues, processing
of the input (e.g., evaluation of the
incoming stimuli and comparison to
social standards, needs, and goals),
and selection of a response alternative. However, there is considerable
disagreement about the automaticity of such cognitive processes and
the role of conscious thought and
decisionmaking in social interaction.
We have argued that most social
interactions unfold so rapidly and
automatically as to preclude
planned cognitive activity, even for
nonschizophrenic patients. People
often plan strategies for those
important or threatening interactions that can be anticipated, and at
times they also rehearse specific tactics. For example, an employee
might rehearse how to ask an
employer for a raise either by imagining the interaction or by role
playing with a spouse. The vast
majority of social exchanges are not
planned, however, and even when
a general interaction can be anticipated, the specific ebb and flow
cannot be predicted in advance
(e.g., we generally do not know
when we are going to be frustrated
or presented with an angry
response). Most social behaviors
seem to be elicited by the interpersonal cues emitted by the partner in
a relatively automatic, stimulusresponse manner. Goals, needs,
beliefs, expectancies, and affect
clearly provide a backdrop that
determines the specific stimulusresponse linkages which are initiated. Nevertheless, people who are
socially adept do not stop and think
before every response to form a
plan or evaluate possible outcomes
of their next response.
Problem-Solving Model. A contrasting view is provided by McFall
(1982), Liberman et al. (1985, 1986),
and others, who have argued that
VOL. 15, NO. 1, 1989
controlled cognitive processes play
a central role in social interactions.
For example, McFall (1982) has
hypothesized that social skills consist of three subsidiary processes:
decoding skills, decision skills, and
encoding skills. Decoding skills
include what we have previously
referred to as social perception: the
reception, perception, and interpretation of incoming stimuli.
Encoding skills consist of those
parameters typically categorized as
motoric skills (e.g., speech content
and nonverbal behavior). Decision
skills include more complex and
effortful information-processing elements, such as identification of
response alternatives, evaluating
the alternatives in light of specific
task demands, selecting the most
effective response, and evaluating
the risks and rewards associated
with implementation of the best
alternative.
Liberman et al. (1986) have proposed a very similar model. They
conceptualize social behavior as
consisting of four components:
social schemata, social skills, coping
efforts, and social competence.
Social schemata are "psychobiological" information structures that
include
the individual's assumptions
about the qualities that define a
competent performance in the
general class of situations, the
skills required for that performance, and the responses that can
be expected of the environment,
[p. 6&]
Social skills are thought to include
three subcomponents: (1) social perception skills, or the ability to
perceive incoming messages accurately; (2) social problem-solving
skills, which involve a variety of
information-processing tasks,
including identification and evaluation of response options and
103
selection of an appropriate response
strategy; and (3) performance of the
desired response. While motoric
responses are recognized as essential for effective performance, they
are viewed as subsidiary to the
antecedent cognitive operations.
Both the motor skills and cognitive models acknowledge the
importance of social perception for
effective social interactions. Both
models recognize that the problems
experienced by schizophrenic
patients in this area may result
from attentional deficits and other
neurological impairments endemic
to the disorder instead of from deficits in learned abilities (this issue
will be discussed later). The most
important difference between the
motor skills and cognitive models,
as represented by McFall and
Liberman et al., is the primacy
given to social problem-solving
processes. According to the cognitive (problem-solving) model, the
critical problem for many schizophrenic patients is their inability to
process social input and engage in
effective problem-solving operations. Thus, skills training focuses
primarily on enhancing such cognitive skills as generating multiple
response alternatives and evaluating their respective utility before
emitting a response.
Social Problem Solving
The antecedents of the current
social problem-solving literature can
be found in the work of Goldfried
and D'Zurilla, and Platt and
Spivack and their colleagues in the
early 1970's. Almost all current
training programs are based on the
problem-solving models they
developed. D'Zurilla and Goldfried
(1971) defined problem solving as
"a behavioral process, whether
overt or cognitive in nature, which
(a) makes available a variety of
potentially effective response alternatives for dealing with the
problematic situation and (b)
increases the probability of selecting
the most effective response from
among these various alternatives"
(p. 108). They reviewed the information-processing literature extant
at the time and abstracted a set of
cognitive operations that they
believed to be central to effective
problem solving. They then proposed a heuristic model that
contained five components: general
orientation or "set," problem definition and formulation, generation of
alternatives, decisionmaking, and
verification.
The problem-solving "set" lays
the groundwork for subsequent
problem-solving efforts by first
identifying that a problem exists,
some adaptive action is needed,
and action is likely to be effective.
Problem solving cannot proceed if
the. person either does not view a
situation as problematic, or does
not think that he or she can cope
with the situation. Problem definition and formulation involves
concretizing the situation causing
distress and identifying a specific
issue or situation that needs to be
resolved. The specific factors causing conflict or frustration are
frequently clouded by heightened
levels of negative affect and nonproductive information-processing
styles such as overgeneralizarion
and arbitrary inference (D'Zurilla
and Nezu 1982). For example, an
initial disagreement between
spouses about who will watch the
children on a particular night when
both have social obligations may
evolve into an argument about love
and selfishness, an issue that cannot be resolved. Effective problem
solving requires recognition of the
SCHIZOPHRENIA BULLETIN
104
initial source of conflict and reformulation of the disagreement into
concrete, manageable terms.
Once the problem is adequately
defined, the next step is to generate
alternative solutions. It is generally
thought to be desirable to generate
multiple possible solutions to maximize the likelihood of identifying
the "best" alternative. The process
of solution generation is a form of
"brainstorming." The fourth step in
the problem-solving process is decisionmaking, in which each possible
solution is evaluated and the most
desirable strategy is selected. This
process "is based on the utility
model of human choice, where the
effectiveness of a given alternative
is based upon the value and likelihood of anticipated consequences"
(D'Zurilla and Nezu 1982, p. 218).
These two stages (generating and
evaluating solutions), which form
the core of the problem-solving
approach, emphasize a form of reasoning referred to as "means-ends
analysis." As is discussed later, this
particular logical strategy is quite
limited and useful only for solving
circumscribed types of problems.
The final stage in the problemsolving process is verification. In
this stage, the solution selected in
the previous steps is evaluated by
implementing it and examining its
effectiveness in solving the problem. Most training programs
incorporate motor skills training in
this stage for patients who are not
able to implement the desired solution effectively.
Problem-Solving Training. As the
problem-solving model has gained
increasing acceptance in the field, it
has led to the development of a
number of highly similar training
programs. There is an accumulating
body of literature suggesting that
these programs can be effective in
teaching the component skills.
However, the studies are uniformly
marked by serious methodological
flaws that limit the conclusions
which can be reached about the
value of the training.
Siegel and Spivack (1976) published one of the earliest reports of
a problem-solving program for
chronic patients. They developed a
highly structured program in which
patients were taught to analyze and
identify appropriate responses to
standard social stimuli presented on
slides, in photographs, and on
audiotapes, as well as in structured
games with the therapist. They conducted two uncontrolled pilot
studies on chronic patients in an
aftercare program. The data were
primarily subjective and based on
small samples; thus, they did not
allow any firm conclusions to be
drawn about the efficacy of the
procedure.
Coche conducted two studies
(Coche and Flick 1975; Coche and
Douglas 1977) in which a semistructured problem-solving training
program was compared to no-treatment groups and control conditions
in which patients read and discussed plays. The program
appeared to be effective in the former study and ineffective in the
latter. Neither study included adequate measures of problem-solving
behavior, social competence, or
psychiatric functioning, and neither
included a followup assessment. A
study by Bedell et al. (1980) suffers
from the same limitations. They
evaluated a program that was very
similar in content to the D'Zurilla
and Goldfried model. Subjects were
hospitalized psychiatric patients
with a variety of diagnoses. Subjects in the problem-solving
condition improved significantly
more than a control group on a
series of self-report measures
developed for the study. The validity of these instruments is
questionable, and there were no
other measures of problem solving,
social competence, or psychopathology.
Edelstein et al. (1980) and Hansen
et al. (1985) also developed and
tested training programs based substantially on the D'Zurilla and
Goldfried model. Training was conducted in a small group format, and
used didactic instruction, role playing, and rehearsal. Subjects in the
two studies were 12 and 7 chronic
psychiatric patients, respectively.
The effectiveness of the training
was evaluated with single-subject
research methodology (multiple
baseline). Subjects in both studies
were able to learn the skills targeted
for training, and they showed some
generalization to novel situations.
Neither study evaluated the effects
of training on psychiatric functioning or community adjustment,
however, and neither included a
followup to evaluate maintenance
of effects. Consistent with other
investigations in thit area, neither
study evaluated the validity of the
specific problem-solving behaviors
targeted for training or assessed
changes in actual problem situations in the environment.
Brenner et al. (in press)
developed a comprehensive program to remediate basic cognitive
deficits, as well as to teach problem
solving, per se. Their program
covers five general subareas of cognitive/behavioral functioning: (a)
cognitive differentiation, which
includes such functions as concept
formation, recall, and recognition;
(b) social perception, including
stimulus discrimination and interpretation; (c) verbal communication,
which focuses on increasing the
coherence of communication and
decreasing idiosyncratic linkages;
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VOL. 15, NO. 1, 1989
(d) social skills, targeting such cognitive response parameters as
cognitive rehearsal, self-evaluation,
and self-reinforcement; and (e)
interpersonal problem solving.
Brenner et al. have conducted a
series of semicontrolled pilot studies and a large-scale clinical trial to
evaluate various components of the
program on hospitalized patients.
The training has generally resulted
in improvements in symptomatology and overall functioning.
However, the patients have not
shown improvement in the specific
cognitive skills targeted for treatment, casting doubt on the utility of
the cognitive training. Moreover,
this series of studies has not effectively controlled for other (i.e.,
noncognitive) aspects of treatment,
such as attention and social reinforcement, making it impossible to
evaluate the specific contribution of
the cognitive training.
Wallace and Liberman (1985) conducted the most systematic
investigation of problem-solving
training with schizophrenic
patients. They compared a problemsolving skills condition to "holistic
health therapy," a control treatment
that emphasized physical exercise
and meditation. The skills training
was administered in a small group
format. Subjects engaged in extensive role playing, during which
they were taught to attend to the
interpersonal partner and evaluate
their own response alternatives
before responding. Subjects were 28
carefully diagnosed inpatients at a
State psychiatric hospital. Patients
in the skills condition improved significantly more on a variety of
social skills, psychopathology, and
adjustment measures both at the
conclusion of the 9-week treatment
period and at a 24-month followup.
However, patients in the two conditions also received different forms
of family therapy, and the holistic
health group is at best an imperfect
control for the various elements of
the social skills training procedure.
As with the studies discussed
earlier, there was no evaluation of
the validity, utility, or in vivo utilization of the specific problemsolving skills that were taught.
Thus, it cannot be concluded that
the problem-solving training was
effective or necessary.
Validity of the Problem-Solving
Model. D'Zurilla and Goldfried
(1971) developed their model to
deal with the broad range of problems people experience in their
everyday lives, from "trying to
decide what tie to wear in the
morning to more significant issues,
such as dealing with an unreasonable employer" (p. 107). Interpersonal problems make up only a
subset of the situations for which
the model may be applicable. Moreover, interpersonal problems
themselves are quite diverse, ranging from short-term face-to-face
conflicts to ongoing relationships
that may not even involve direct
contact (e.g., surreptitiously competing with a coworker for
promotion). It seems unlikely that
any single model or intervention
would fit every type of problem situation. Social skills training
programs (cognitive or otherwise)
have generally focused on relatively
discrete face-to-face interactions,
such as standing up for one's
rights, asking for favors, and initiating conversations. Such situations
clearly present difficulties for
schizophrenic patients in their dayto-day lives. In keeping with that
focus, our discussion of the validity
of the problem-solving model and
our use of the term "social problem
solving" will pertain primarily to
such circumscribed face-to-face
interactions, although it may apply,
in part, to nonsocial problems and
diffuse relationship issues as well.
The widespread acceptance of
both the problem-solving model
and the associated treatment strategies seems to be based more on
face validity than on empirical data.
There is little documentation that
schizophrenic patients have differential deficits in problem-solving
skill, let alone the specific parameters targeted in most extant
treatment programs. To the contrary, there are data to suggest that
these programs may be misdirected
both in their conceptualization of
the problem-solving process and in
the treatment needs of schizophrenic patients.
The most widely cited support for
the validity of the model for schizophrenia is a series of studies
conducted by Platt, Spivack, and
their colleagues in the early 1970's.
They hypothesized (analogously to
D'Zurilla and Goldfried) that the
central component of problem solving is means-ends analysis and
developed an assessment device,
the Means-Ends Problem-Solving
Procedure (MEPS), to evaluate the
ability of subjects to generate alternative solutions to problem
situations (Platt and Spivack 1975).
Subjects are presented with the
beginning and ending of 10 problem situations, and they are
directed to make up the middle of
the story. Responses are scored on
a variety of dimensions, including
number of relevant and irrelevant
means (i.e., ways in which the
actor can reach the goal identified
in the story) and absence of means.
The primary measures reported in
the literature are the number of
means and the ratio of relevant to
irrelevant means. The MEPS has
been the primary dependent variable in research by the Platt and
Spivack group, as well as in most
SCHIZOPHRENIA BULLETIN
106
other research on the problem solving of schizophrenic patients.
Platt and Spivack and their colleagues have found a number of
differences in MEPS performance
between chronic psychiatric patients
and nonpatient controls. Patients
do not generate as many alternative
solutions to problems as nonpatients (Platt and Spivack 1972a,
1974), and the solutions they do
propose are qualitatively different
(Platt et al. 1975). Their solutions
are less relevant and not as reflective (i.e., they are less likely to
anticipate and evaluate consequences or to see connections
between events). In addition, those
patients who perform more poorly
on the MEPS tend to have lower
premorbid social competence (Platt
and Spivack 1972b) and more pathological Minnesota Multiphasic
Personality Inventory (MMPI) profiles (Platt and Siegel 1976).
Unfortunately, this series of studies is marked by numerous
methodological flaws that severely
limit the significance of the work.
The diagnostic makeup of the psychiatric groups is not clearly
specified, and where diagnoses are
reported, the criteria and reliability
of diagnosis are not indicated. In
most studies, psychiatric patients
were compared to nonpatient
groups with no controls for hospitalization, medication, education, or
socioeconomic status. The most
serious problem is that the sole
dependent measure of problemsolving ability in these studies is
the MEPS. This instrument was not
developed empirically and suffers
from a variety of psychometric
shortcomings (Butler and
Meichenbaum 1981). The 10 stories
were developed on an ad hoc basis,
and the content is neither representative of the range of social
problem situations nor suited to the
living situations of most chronic
patients (e.g., story 5 deals with a
man who kills a Nazi storm trooper
who murdered his family during
World War II). The procedure has
low test-retest reliability, and criterion validity has never been
established (i.e., it has never been
correlated with any other measure
of problem-solving ability or social
competence). The instructions to
subjects identify the MEPS as a test
of imagination rather than a
problem-solving task, and subjects
are not directed to generate as
many solutions as possible. Scoring
focuses solely on number of solutions generated, not the quality of
solutions. In fact, Platt et al. (1975)
found that while psychiatric
patients generated fewer solutions
to MEPS stories, they were not deficient in the ability to recognize
effective solutions. These data suggest that other MEPS findings
might represent a lack of effort on
the part of patients or an inability
to identify multiple response
options spontaneously, rather than
an inability to solve the problems.
Information Processing and
Problem Solving
The literature on social problem
solving has used a relatively global
model of the problem-solving process. Aside from general reference to
means-ends analysis and an
expected utility heuristic for weighing alternatives, little attention has
been paid to the specific cognitive
operations involved. The literature
describing treatment programs has
been particularly vague on the precise cognitive operations that are
taught and how the teaching is conducted. For the most part, training
appears to consist primarily of
prompting patients to generate and
evaluate alternative solutions,
rather than any specific strategies
for altering information processing.
Edelstein et al. (1980) have argued
that this is a pragmatically useful
strategy and that more precise
knowledge about how problemsolving operates is not necessary to
teach an effective algorithm. That
might be true for populations that
do not have fundamental deficits in
information processing but does not
seem supportable for schizophrenia.
Schizophrenic patients may well
have deficits that prevent them
from using means-ends analysis
effectively, or their inability to solve
problems effectively may be due to
other factors.
Components of Problem Solving.
The most systematic analyses of the
information-processing components
of problem solving have been conducted by Simon and his colleagues
(Simon 1978, 1979) and by Greeno
(1978). Simon has conceptualized
problem solving as a serial search
process in which the individual
makes successive steps to secure
information that will gradually
move him closer to the goal. The
operation depends on a number of
cognitive processes, including the
following components: perception
or representation of the problem;
short-term memory, especially recall
of steps already taken or evaluated;
long-term memory, both for information stored in the course of the
problem-solving process and the
fund of information available about
the particular situation and problem
solving in general; and ability to
sustain attention on the task.
The specific processes required to
solve any particular problem vary
according to the nature of the problem. Greeno (1978) has categorized
problems into the following three
types: problems of inducing structure, problems of transformation,
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VOL 15, NO. 1, 1989
and problems of arrangement. In
problems of inducing structure, the
individual knows some elements of
a situation and must determine
how they are related. A common
example is analogies, of the form A
is to B as C is to
Solving this
type of problem depends on
developing an understanding of the
relations between elements and
constructing an integrated representation of the commonality.
In problems of transformation,
the person is faced with a situation
and a goal. The task is to determine
the steps required to achieve the
goal. A typical transformation problem is a water jug problem (e.g., a
boy is to pour 8 gallons of water
when he has a 5-gallon and a 2-gallon jug). The basic cognitive
operation to solve this type of problem is means-ends analysis. Greeno
has hypothesized that this operation has three major components:
the capacity to conduct a comparative analysis, the ability to perform
complex operations that integrate
several substeps (e.g., long division
is a complex operation that subsumes multiplication and
subtraction), and the ability to infer
relationships between behaviors
and goals (e.g., if I do x, y will
occur).
The third type of problem identified by Greeno is problems of
arrangement, such as anagrams
(e.g., form a word out of the letters:
KRMA). This type of problem
places a premium on constructive
search operations (generating and
testing successive solutions). Cognitive processes used in such tasks
include flexibility in the process of
generating solutions, ability to
retrieve information from memory,
ability to constrain the search process to avoid excessive trial and error
behavior, and ability to generate
and employ algorithms that speed
the search process (e.g., if there is
only one vowel, place it second or
third).
The three types of problems
described above have numerous
corollaries in everyday life (e.g.,
determining how to circumvent a
traffic jam on the way home from
work is a transformation problem;
determining how to pack a suitcase
for a trip is a problem in arrangement). Together, they encompass a
large segment of our everyday
problem-solving efforts and illustrate the range of cognitive
processes involved. However, these
problems have several unique features that make them different from
many of the interpersonal problems
encountered in commonplace social
situations. Accordingly, several
important parameters of social
problem solving are not included in
Greeno's conceptualization.
The types of problems categorized by Greeno are often
referred to as "puzzles" and contrasted to "ill-structured" or
"wicked" problems (Kitchener 1983,
1986). Puzzles are specialized problem situations in which most of the
key elements involved in reaching a
solution are known in advance and
the task is simply to derive the
solution: the goal is clear-cut, legal
moves are specified, the effectiveness of every move is quickly
determined, and it is clear when
the goal is reached. In ill-structured
problems, one or more critical elements are unknown.
First and foremost, in many problematic social situations the person
does not understand the nature of
the problem or even that a problem
exists—only that he or she is frustrated or under stress. Aside from
the vague goal of stress reduction,
it is not clear what the person
wants to achieve or what type of
action would be effective. More-
over, goals may change during the
course of the encounter in response
to the partner's behavior or an
altered perspective of the situation.
In many everyday interactions the
process of problem "finding" is
more difficult than problem "solving" (Simon 1979; Arlin 1986).
Often, the solutions to problems
become obvious once they have
been adequately conceptualized.
Many interpersonal conflicts are
dialectical (Kitchener 1983) in that
both sides have valid but incompatible goals. The "best" solution
might entail compromise or concession as new data are presented and
the partner's position becomes
clear. Similarly, real life goals often
have both positive and negative
consequences (e.g., the interpersonal partner concedes but remains
angry), making it difficult to determine what the best solution is and
when it has been achieved. Ill-structured problems also frequently
provide little guidance about what
moves are legal (i.e., the possibilities are endless), and the effect
of moves often cannot be determined for some time. For example,
a sarcastic comment at a meeting
may temporarily quiet a coworker
but produce surreptitious hostility
and resistance in the future.
The difficulty posed by ill-structured social problems is illustrated
by a prototypical family argument.
Many arguments begin over minor
differences in opinion or desires
(e.g., what television show to
watch and requests for help with
some chore). Nonemotional conversation gradually evolves into
disagreement and then into argument as the participants
overgeneralize ("You never help"),
emit emotionally loaded nonverbal
responses (e.g., a certain sarcastic
"look"), or bring up heated old
issues. Before long, the original
SCHIZOPHRENIA BULLETIN
108
area of disagreement is forgotten or
irrelevant. At the beginning of the
discussion, neither participant is
aware that an argument is developing, and after it becomes heated,
neither knows precisely what the
argument is about. Consequently,
neither partner has specific goals in
the discussion, and it is not possible to determine when someone has
"won" (i.e., achieved the goal). The
couple might have broad rules
about legal moves (e.g., no physical
violence, no one leaves the house),
but the range of response alternatives is immense and is not clearcut. At the same time, it is difficult
(if not impossible) to determine the
effect of any particular response. As
indicated above, the partner might
not react to a particular response
until some time afterward and, at
any one time, might be reacting to
something that was said on a previous occasion. Also, the goals
oscillate between hurting the partner, changing the partner's opinion,
securing an apology or concession
of defeat, simply ending the argument, and achieving some
functional end (e.g., one's original
preference).
Just as the parameters of ill-structured problems differ from puzzles,
there are important differences in
the reasoning process used in solving the two types of problems. The
predominant theory of decisionmaking in situations involving risk
(as is the case in social problem
solving) is the expected utility
model (Tversky and Kahneman
1981). As indicated above, this
model plays a central role in
D'Zurilla and Goldfried's (1971)
conceptualization of means-ends
analysis. Research on decisionmaking in ill-structured problems
indicates, however, that people do
not always make choices on the
basis of expected utility. Estimates
of value (i.e., expected utility) and
the types of risk one is willing to
take vary dramatically with the perspective from which the problem is
viewed. Tversky and Kahneman
(1981) have demonstrated that very
subtle differences in the way problems are phrased alter the way they
are perceived, and produce very
different types of decisions. When
people focus on possible gains associated with alternative choices, they
are averse to risk and choose the
safer alternative (i.e., a bird in the
hand ...). Conversely, if they focus
on potential losses in precisely the
same situation, they become risk
takers and opt for choices that
might minimize loss even though
they entail risks of greater loss. Risk
taking also varies with the degree
of certainty associated with outcomes. For example, certainty tends
to exaggerate the perceived aversiveness of losses in comparison to
losses that are uncertain.
In a question dealing with the
response to an epidemic, for
example, most respondents found
"a sure loss of 75 lives" more
aversive than "80% chance to lose
100 lives" but preferred "10%
chance to lose 75 lives" over "8%
chance to lose 100 lives," contrary
to expected utility theory.
[Tversky and Kahneman 1981,
p. 455]
One additional aspect of problem
solving in everyday social interactions warrants mention. Meansends analysis and puzzle solving in
general involve a relatively formal
set of logical operations. Yet, Rogoff
(1984) points out:
what is regarded as logical problem solving in academic settings
may not fit with problem solving
in everyday situations, not
because people are "illogical" but
because practical problem-solving
requires efficiency rather than a
full and systematic consideration
of all alternatives. In everyday situations, thought is in the service
of action. Rather than employing
formal approaches to solving
problems, people devise satisfactory opportunistic solutions,
[p- 7]
Arguing the same point from a
slightly different perspective,
Einhorn and Hogarth (1981) indicate that judgment (based on logic)
does not necessarily determine the
choices people make. Logic serves
to reduce uncertainty and provide
guidance in selecting among alternatives. However, many problems
cannot be resolved solely by logic
(e.g., whether to ask for a raise
or what to say in response to an
insult). Even in situations that
could be decided logically, the
options people select often are
determined by such illogical factors
as emotion, "hunches," impulse,
and the desire simply to escape the
conflict associated with decisionmaking. That is not to say that logic
is never used in solving wicked
problems. Skill in thinking logically
and solving puzzles may well enter
the process indirectly. Nevertheless,
it seems clear that formal logical
operations are neither necessary nor
sufficient for solving wicked problems and often are not used at all.
Delimiting Factors on Social
Problem Solving
This overview of the problem-solving literature raises serious
questions about the validity of the
social problem-solving model and
associated treatments discussed
earlier. Instead of being a universal
strategy, means-ends analysis is
used primarily to solve only one
type of problem (transformations),
and it may not be useful for solving
the ill-structured problems commonplace in everyday social
interactions. Decisionmaking often
is not based on an expected utility
VOL 15, NO. 1, 1989
model, as proposed by D'Zurilla
and Goldfried (1971). In fact, derisionmaking and choice apparently
do not always depend on formal
logical operations. Of course, as
suggested by Edelstein et al. (1980),
means-ends analysis may be a
heuristic method for training even if
it is not the basis of problem solving by nonschizophrenic
populations. However, schizophrenic patients suffer from a
number of other handicaps that
may be more germane to the problems they experience in social
conflict situations and may militate
against their use of means-ends
analysis. In the following sections,
we highlight two of those handicaps: sensitivity to negative affect
and disordered communication.
Sensitivity to Negative Affect.
Familial expressed emotion (EE) is a
dichotomous construct that reflects
family attitudes about the patient.
Family members are characterized
as high or low EE. High-EE relatives tend to be critical and hostile,
overinvolved and intrusive, or both,
in their interactions with the patient
(Miklowitz et al. 1984; Strachan et
al. 1986). EE has become one of the
most robust and reliable predictors
of posthospitalization adjustment
among schizophrenic patients.
Patients returning to homes characterized by high levels of EE have a
dramatically increased risk of
relapse, and high EE apparently can
even mitigate the effects of neuroleptics (Vaughn and Leff 1976;
Vaughn et al. 1984). While there is
an extensive body of research on
the effects of high EE, relatively little attention has been paid to
precisely how it affects the patient.
The most widely accepted hypothesis is based on the general stressdiathesis model. It is assumed that
patients living with high-EE parents
109
are regularly exposed to affectively
intense interactions that create
excessive levels of stress, pushing
the patient beyond his or her tolerance level and eventuating in
relapse. This hypothesis seems
especially germane to patients living with parents who manifest
excessive criticism and hostility—a
pattern of interactions that appears
to be much more pernicious than
overinvolvement, as it is associated
with significantly higher relapse
rates (Hogarty et al. 1986). Overinvolvement is not associated with
intense affect and does not fit the
model as well. It has been suggested, instead, that overinvolvement is a response to longstanding incapacity or negative
symptoms on the part of the
patient; as such, it is viewed as
more a marker of patient psychopathology than is the overly critical
pattern (Miklowitz et al. 1983).
The stress-diathesis hypothesis
does not explain why parental criticism has so much impact on the
patient. It is unclear, for example,
why patients do not habituate to
the criticism over time. One possible explanation is that (at least
some) schizophrenic patients are
differentially vulnerable to intense
affect, especially intense negative
affect such as hostility and criticism
(Rabin et al. 1979). They may be
hypersensitive to such negative
input or lack the specific social
skills to deflect or reduce it. This
possibility is certainly consistent
with anecdotal clinical observations.
It has also been a fundamental
assumption underlying motoric
social skill training programs, which
have been systematically designed
to avoid the use of negative
response feedback and have characteristically included assertion
training as a fundamental part of
the curriculum. A recent treatment
study by Hogarty et al. (1986)
provides indirect support for this
hypothesis. They evaluated a variation of social skills training that
attempted to teach patients specifically how to avoid or reduce highEE type interactions with their relatives. This intervention was as
effective as a family treatment
designed to alter relative's behavior.
Of special note, the combination of
family therapy and social skills
training was the only condition that
was effective in preventing relapse
when the family maintained a high
level of EE.
Another line of research suggesting that schizophrenic patients may
have special difficulty in dealing
with affective cues has focused on
the perception of affect. We have
found significant differences in the
perception of negative affect
between schizophrenics and both
other psychiatric patients and nonpatients (Morrison et al., in press).
The schizophrenic patients seem to
be less sensitive to negative cues or
to underestimate the intensity of
such cues. Other studies have
reported that at least some schizophrenic patients are deficient in the
ability to identify correctly and
draw inferences from affective displays, particularly those involving
negative affect (Pilowsky and
Bassett 1980; Cutting 1981).
A related line of research has
focused more narrowly on possible
schizophrenic deficits in affect
recognition, especially affect
expressed by facial cues (Morrison
et al. 1988). It has been suggested
that disturbances in affect recognition may be one of the most
pervasive and serious aspects of
schizophrenic patients' interpersonal problems (Feinberg et al. 1986).
A number of studies have found
that schizophrenic patients have
differential deficits in the ability to
SCHIZOPHRENIA BULLETIN
110
recognize or discriminate affective
states communicated solely by facial
expression (Novic et al. 1984;
Walker et al. 1984). These deficits
are especially marked in the case of
negative affective states. It has
alternately been hypothesized that
these deficits result from focal right
hemisphere impairment, generalized deficits in attention and
information processing, or social
learning (see Morrison et al. [1988]
for a fuller discussion). Unfortunately, this literature is marked
by numerous methodological shortcomings and does not allow for
clear conclusions. However, the
existence of some notable impairment in this vital social function
seems clear.
The discussion above suggests
that schizophrenic patients have
significant difficulties in dealing
with affective expressions by interpersonal partners, especially in the
area of negative affect. They
seemingly have problems in accurately perceiving negative affect and
in coping with it when they do perceive it. The precise nature and
etiology of their handicaps are not
central to this discussion. What is
more critical is that these deficits
likely play a key role in the ability
of patients to resolve interpersonal
problems. While some social problems can be discussed and
evaluated dispassionately, most
involve heightened emotions and
conflict. If schizophrenic patients
cannot accurately evaluate the affective cues emitted by their partners,
or if they experience excessive levels of autonomic arousal in the
presence of moderate negative
affect, their coping responses will
be inadequate. Moreover, their deficits in social perception might lead
to increased negative affect from
interpersonal partners. For example, high-EE parents might resort to
highly critical and hostile responses
in frustration when the patient
proves unresponsive to mild
complaints.
Problem-solving training would
not seem to be a suitable strategy
for ameliorating these difficulties.
Moreover, these handicaps would
seem to preclude the effective use
of problem-solving strategies. The
first, and possibly most critical,
stage of problem solving is problem
definition. If schizophrenic patients
are unable to identify the affective
cues emitted by their interpersonal
partners, they would be unable to
define the problem situation and
initiate the problem-solving process.
Second, the heightened levels of
arousal stimulated by negative
affect would interfere with information processing, thereby preventing
schizophrenic patients from engaging in the modulated attention,
recall, and reasoning required for
the subsequent stages of cognitive
analysis.
It should also be underscored
that most research on information
processing and social problem-solving processes in schizophrenia have
been conducted within a framework
of "cold cognition" and have not
examined the influence of affect,
arousal, or effort on these processes
(Gjerde 1983). Yet, one of the critical processing dysfunctions in
schizophrenia may actually be a
phenomenon relating to deviant
arousal and not a specific pattern of
cognitive deficit (Knight and Russell
1978; Gjerde 1983). Given the similarity between operations that have
been posited to constitute social
problem solving, per se, and those
outlined in more general cognitive
models of information processing
(e.g., Steinberg 1969), the role of
arousal in problem-solving behavior
cannot be discounted.
Disordered Communication. One
of the foremost manifestations of
schizophrenia is a severe disruption
in the ability to engage in meaningful conversations and communicate
effectively with others. Schizophrenic speech is often marked by a
variety of anomalies, such as odd
use of words, abrupt shifts of topic,
confusion, and disorganization.
Consequently, schizophrenic
patients are difficult to understand,
and conversations with them are
often uncomfortable and unfulfilling
for the interpersonal partner. Consistent with the early writings of
Bleuler (Andreasen 1979), these distortions in speech and language
have generally been assumed to be
a manifestation of disordered thinking processes, such as loose
associations and autistic logic
(Andreasen 1979; Hotchkiss and
Harvey 1986). However, communication problems and language
pathology have been shown to
occur in the absence of florid
thought disorder (e.g., use of neologisms and clang associations,
gross derailment) and during periods of remission (Harrow et al.
1983; Harvey et al. 1986; Spohn et
al. 1986). There is a growing body
of evidence to suggest that disordered communication is a
significant symptom of schizophrenia in its own right, instead of
being secondary to faulty logic or
bizarre thinking patterns.
Communication is a reciprocal
process in which the speaker and
the listener provide an ongoing
series of cues to one another to
ensure adequate comprehension
and a smooth exchange. For example, the listener may register
confusion, boredom, or disagreement by subtle changes in facial
expression, gaze, and posture. The
speaker must monitor the listener
as well as his or her own speech to
111
VOL. 15, NO. 1, 1989
make necessary adjustments. A
number of investigators have
hypothesized that the communication impairment in schizophrenia
results from an inability or disinclination to consider adequately
what information interpersonal
partners require to decode messages. Cohen and his colleagues
have conducted a series of studies
which demonstrate that schizophrenic patients are markedly
deficient in "referent communication" (Cohen et al. 1974;
Kantorowitz and Cohen 1977). They
have used a variety of experimental
tasks in which subjects are required
to provide hints or cues that enable
a partner to identify a targeted
stimulus (as in the game "Password"). Schizophrenic patients fail
to provide adequate cues or "referents," thus making it difficult for
their partners to interpret the information they provide. Conversely,
when they are in the listener's role,
schizophrenic patients are not deficient in picking up the cues
provided by the partner. Cohen has
hypothesized that this one-sided
communication deficit occurs
because schizophrenic patients fail
to engage in sufficient self-editing
to screen out inappropriate descriptors and generate the most
informative response (Kantorowitz
and Cohen 1977). As a result, they
respond impulsively with prompts
that are not useful to the partner.
Harrow and his colleagues have
reported similar findings in their
research on intermingling (Harrow
and Prosen 1979; Harrow and Miller
1980). They have found that
schizophrenic patients mix or
"intermingle" highly personal material into their communications
without providing adequate referents to allow the interpersonal
partner to understand the chain of
associations. The logical association
between ideas is not necessarily
bizarre or "loose." But, the schizophrenic patient fails to provide the
linguistic ties between ideas to
make the connections comprehensible to the partner. Similar to the
results reported by Cohen, the difficulty appears to be in the expression
of ideas, not in the nature of the
ideas or in the decoding of cues
provided by others. When asked to
evaluate their own speech, schizophrenic patients are unaware that
the connections between clauses
(ideas) are inappropriate or bizarre.
However, they are not deficient in
the ability to judge bizarreness in
the speech of other subjects
(Harrow and Miller 1980). Harrow
and Miller (1980) have suggested
that the pathology results from:
an impairment in schizophrenics'
judgments about themselves or in
their ability to maintain a broad
sense of perspective about their
own speech and behavior and, to
a lesser extent, to monitor their
own speech and behavior as
these emerge on a moment-bymoment basis, [p. 725]
Harvey (1983), Rochester and her
colleagues (Rochester 1976; Rochester et al. 1977), and Rutter (1985)
have come to similar conclusions
based on different research methodologies. Harvey (1983) and
Rochester et al. (1977) conducted
lexical analyses of schizophrenic
speech. They found that the syntactical structure of individual
sentences was adequate, but that
schizophrenic patients failed to use
enough appropriate cohesive ties
(e.g., conjunctions) between sentences (ideas) to allow the listener
to grasp the flow of the discourse.
Rutter (1985) made transcriptions of
the sentences in the conversations
of schizophrenic patients and presented them to judges in random
order. The judges were unable to
determine the order in which they
were actually expressed, presumably because there were insufficient
links between ideas. Rutter (1985)
concludes
the problem for schizophrenics
was much less the cognitive processes of regulating and organising
their thoughts than the social
processes of expressing and communicating those thoughts in a
way in which the listener could
understand and follow. Where
their difficulty really lay was in
taking the role of the other and it
is that which seems to be the
key. [p. 403]
This body of research on disordered communication does not
permit definitive conclusions about
the source of the difficulty. The
problem may be one of attention,
motivation, or impaired information-processing ability, as well as a
distinct deficit in speech, perspective, or self-editing. The differentiation of thought disorder and
speech disturbance is especially
thorny. As speech is the primary
behavioral indicant of thinking
processes, it is virtually impossible
to determine whether any particular
speech anomaly is a manifestation
of a linguistic problem or an underlying dysfunction in thought
(Andreasen 1979; Hotchkiss and
Harvey 1986). Yet the precise differentiation of these parameters is
not central to our discussion.
Regardless of the specific etiology,
the data consistently document that
schizophrenic patients have a signal
impairment in their ability to communicate and make themselves
understood. The evidence for this
impairment is much stronger than
the evidence for a deficit in problem-solving skill. Paralleling the
discussion in the previous section
about schizophrenic patients' difficulties with affect, it would appear
that (1) the communication impair-
SCHIZOPHRENIA BULLETIN
112
ment is more central to their
interpersonal difficulties than deficits in problem-solving ability; (2)
the current problem-solving curricula do not adequately address this
problem; and (3) the inability to
make their desires and reasoning
understood would seriously compromise the ability of schizophrenic
patients to use the strategies taught
in problem-solving training.
Conclusions
The model of D'Zurilla and Goldfried (1971) which underlies current
social problem-solving programs
has considerable heuristic value,
but it does not adequately account
for the problem-solving process in
normal populations, let alone in
schizophrenic patients. Considerable work is required to provide an
understanding of how problem
solving occurs naturally before we
can develop an effective technology
to correct deficits. Means-ends analysis does not seem to be a viable
foundation upon which to base our
efforts. A great deal of effort is also
required to develop an adequate
assessment methodology. The
MEPS procedure is neither methodologically nor conceptually
sound. Other ad hoc procedures
used in individual studies (e.g.,
repeatedly questioning subjects
about their goals and how they may
be achieved) are similarly flawed.
The process of developing better
assessment methods is intimately
tied to an increased understanding
of the problem-solving process. We
must empirically determine what to
assess before we can determine how
to conduct the assessment.
Any knowledge acquired about
how problem solving occurs in normal populations must be evaluated
in light of the range of other
impairments accompanying schizo-
phrenia. We have highlighted two
areas of difficulty that might underlie the apparent deficits in problemsolving ability: sensitivity to negative affect and disordered
communication. There are a number of other problems that could
have been addressed as well. For
example, schizophrenic patients
have been shown to have deficits in
most of the cognitive operations
required for effective reasoning,
problem solving, and decisionmaking, including: short-term memory,
ability to focus and sustain attention, information-processing
capacity, ability to engage in controlled information processing
(Schneider and Shiffrin 1977), and
ability to screen out irrelevant stimuli (Liberman et al. 1984;
Nuechterlein and Dawson 1984;
Harvey et al. 1986; Mirsky and
Duncan 1986). An effective problem-solving program must either
directly address these various deficits, accommodate for them, or
provide some supplemental treatment for them. For example, if
schizophrenic patients cannot
provide sustained attention under
load (e.g., as in a stressful conversation), instructing them to engage
in a means-ends analysis during a
social interchange might exacerbate
their difficulties rather than alleviate
them. They might be better advised
to leave stressful interchanges and
conduct a problem-solving analysis under less demanding
circumstances.
We must also recognize the possibility that problem-solving
behavior might not be trainable.
Research on nonpsychiatric populations suggests that there is little
transfer of training from one type of
problem to another or even across
different versions of the same
problem type (Simon 1979). Schizophrenic patients may be even less
responsive to training. Goldberg et
al. (1987) attempted to teach schizophrenic subjects how to improve
their performance on the Wisconsin
Card Sort Test (Heaton 1981). The
subject's task on this test is to
determine a categorical rule linking
a series of stimuli (e.g., color, size).
In Greeno's (1978) terminology, this
is a prototypical problem of inducing structure. As found in other
studies, subjects performed very
poorly on baseline trials. When
given card-by-card feedback (e.g.,
"You should be sorting by color"),
they showed markedly improved
performance. However, there was
no transfer of training once prompting ceased. Subjects showed an
immediate return to baseline on the
next set of trials. Thus, subjects
were able to alter their behavior in
response to temporally adjacent
prompts but were unable to learn
the logical rule for the task or generalize from their correct responses.
Weinberger and colleagues (Goldberg et al. 1987; Weinberger 1987)
suggest that this deficit results from
a diffuse lesion in the dorsolateral
prefrontal cortex. Weinberger (1987)
hypothesizes that this lesion
impedes higher level cognitive functioning (e.g., reasoning and
problem solving), especially under
stress. In discussing the implications of this dysfunction, he
suggests that (motoric) social skills
training may be particularly
appropriate and effective for schizophrenic patients because it reduces
"the demand for autonomous prefrontal function" (p. 667).
Weinberger's hypothesis about the
neurological basis of schizophrenia
is far from definitive, but it raises
significant questions about the
viability of the relatively higher
level training used in current
problem-solving programs. Schizophrenic patients may lack the
113
VOL. 15, NO. 1, 1989
neurological capacity to learn the
cognitive operations, even if the
problem-solving model is otherwise
valid.
Our discussion has referred to
"schizophrenic" patients as if they
were a homogeneous population,
all of whom have identical cognitive
and social impairments. It is clear
that schizophrenic patients as a
group show marked deficits in social
competence in comparison to normal individuals and patients with
other chronic disorders (Bellack et
al. 1988). However, it is also clear
that not all schizophrenic patients
have persistent social impairments.
Type I (i.e., positive syndrome)
patients, in particular, are thought
to have adequate social functioning
between episodes (Andreasen
1985). Similarly, many patients do
not have a history of interpersonal
difficulties in childhood (Lewine et
al. 1978, 1980) or poor premorbid
functioning (Andreasen 1985).
Thus, it should not be assumed that
all schizophrenic patients have
equivalent social skill deficits, be
they motoric or cognitive. Any analysis of social-skills or problemsolving training should address the
heterogeneity of the disorder.
There is a pressing need to
develop effective treatment programs for schizophrenic patients.
Regardless of any new developments in pharmacotherapy, there
will probably be a continued need
for new and better psychosocial
treatments. It seems particularly
unlikely that pharmacological
developments in the next 10 years
will correct the severe social impairment experienced by schizophrenic
patients. In that context, further
research on social problem-solving
training is clearly warranted. As
indicated above, there is compelling
face validity to the problem-solving
model, and existing problem-solv-
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Behavior therapy's forgotten child.
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Bellack, A.S.; Hersen, M.; and
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schizophrenics: An experimental
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Bellack, A.S., and Morrison, R.L.
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May 10-13, 1987.
Bellack, A.S.; Morrison, R.L.;
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Acknowledgment
The preparation of this manuscript
was supported in part by NIMH
grants MH-39998 and MH-38636.
The Authors
Alan S. Bellack, Ph.D., is Professor
of Psychiatry, Director of Adult
Psychology, and Director of the
Behavior Therapy Clinic; Randall L.
Morrison, Ph.D., is Assistant Professor of Psychiatry and Assistant
Director of the Behavior Therapy
Clinic; and Kim T. Mueser, Ph.D.,
is Assistant Professor of Psychiatry,
Medical College of Pennsylvania/
Eastern Pennsylvania Psychiatric
Institute, Philadelphia, PA.