Academic literature on the topic 'Time-limited marital therapy'

Marital dissatisfaction is the most common presenting problem in adults seeking psychological services and is rated as the second most severe stress adults can experience after a death in the family. Almost every married couple is, at some time, at risk for marital distress, conflict, separation, and divorce and for the resulting stress on themselves and their children. Traditionally, theory and practice have focused on tertiary prevention of marital distress (i.e., marital therapies). However, marital therapy has limited efficacy and accesses only limited numbers of couples. Poor communication and dissatisfaction with interactions, assessed premaritally, are strong predictors of marital distress. Several marital distress prevention programs have been developed which generally or specifically target communication behaviour of pre- and early married couples. Outcome evaluations suggest such programs can lead to improved communication and problem-solving skills, improved relationship satisfaction, lower levels of marital violence, and diminished probability of marital dissolution. Suggestions for future research include a more fine-grained analysis of situation-specific cognition, affect, and psychophysiological responses during communication, incorporation of a self-regulatory model within prevention work, and the use of longitudinal research designs.

BACKGROUND: Mortality rates among immigrant patients undergoing rehabilitation for musculoskeletal backache are unknown. OBJECTIVE: To study the association between marital status, severe psychosocial strain, receiving long-term time-limited sickness allowance (TLSA) and all-cause mortality (ACM) in a cohort of immigrants aged 20–45 years with long-standing backache in Sweden. METHODS: We studied 318 patients (92% foreign-born, 76% non-European) of known marital status on sick-leave for musculoskeletal backache. They were followed up for ACM until 2015. Socio-demographic data, TLSA and psychosocial strain, including major depression, severe psychosocial stressors and pessimistic thoughts, were analysed using multiple-imputation Cox regression. RESULTS: Over a mean (standard deviation) follow-up time of 15 (5.0) years, 11 (3.5%) participants died. At baseline, 34% were unmarried, 19% were receiving TLSA, and 71% had ⩾ 1 psychosocial strain component (38% depression; 47% severe stressors; 35% pessimistic thoughts). After concomitant risk factors were adjusted for, being unmarried and receiving TLSA were associated with higher mortality by factors of 6.2 (p= 0.005) and 5.8 (p= 0.006), respectively. Psychosocial strain was only significantly associated with higher mortality in the unadjusted analyses. CONCLUSIONS: Being unmarried and receiving TLSA were associated with significantly higher ACM in this highly marginalized group of immigrant patients.

Research suggests that physical activity (PA) has many health benefits for an aging population. Evidence exploring the association between PA and vision is limited. This study includes the measures of self-reported PA (International Physical Activity Questionnaire) and self-rated vision at three points in time over a 6-year period used in the Irish Longitudinal study of Ageing, a cohort of community-dwelling older adults (50 years or older). A path analysis found that PA was indirectly associated with vision over 6 years controlling for age, sex, marital status, employment, education, depression (Centre for Epidemiologic Studies Depression Scale), self-reported general health, cardiovascular disease (e.g., heart attack), high blood pressure, diabetes, eye disease (e.g., glaucoma, diabetic eye disease, macular degeneration, cataract), and disabilities associated with activities of daily living. Further research is needed to fully understand the relationship over time and generalize the findings.

256 Background: Data on age-specific comparisons in metastatic prostate cancer (MPC) is limited. This analysis evaluated socio-demographic and clinical characteristics among men with MPC aged <65 years versus ≥65 years. Methods: Eighty-four US men aged ≥18 years with self-reported MPC completed a cross-sectional survey in January-February 2011 which collected data on socio-demographic and clinical characteristics including treatment history and source of care. Results: Forty-nine men were aged <65 years; 35 men were ≥65 years. There were no differences (all P>0.05) between groups for marital status (80% of those <65 years and 83% of those ≥65 years were married), race/ethnicity (94% of both groups were white), education (88% of those <65 years and 77% of those ≥65 years had attended college), and annual household income (29% of those <65 years and 31% of those ≥65 years had incomes of $35,000-$54,999). Time since diagnosis differed between groups with 12%, 84%, and 4% of those aged <65 years and 3%, 69%, and 29% of those aged ≥65 years having been diagnosed <1, 1-9, and ≥10 year(s) ago, respectively (P<0.001). Respondents aged <65 years and ≥65 years reported similar experience with chemotherapy (37% in both groups had received chemotherapy), no anemia in last 4 weeks (80% and 83%, respectively), no bone fractures or spinal cord compression in last 4 weeks (90% and 94%, respectively), receiving previous radiation therapy (69% and 66%, respectively), receiving previous surgery (63% and 66%, respectively), and utilizing hormonal treatments previously or currently (86% and 90%, respectively) (all P>0.05). In addition, those <65 years versus ≥65 years did not differ regarding their self-reported source of primary care for prostate cancer (51% and 54% reported receiving their care from oncologists, respectively; 47% and 43% from urologists; 2% and 3% from family physicians/internists). Conclusions: In this study of men with MPC, those aged <65 years and those ≥65 years reported similar prostate cancer treatment utilization as well as socio-demographic and clinical characteristics with the exception of a difference in time since diagnosis. Further research in larger populations is warranted.

5024 Background: Quality of life (QOL) assessments in early stage (stage I and II) ovarian cancer survivors (CS) are limited and have to date not focused on CS who have received adjuvant platinum- and taxane-based chemotherapy (CT). Methods: 55 early stage ovarian patients (pts) were identified from patient logs from the Dana-Farber Cancer Institute and Massachusetts General Hospital. 54 pts. received CT. QOL and long-term medical sequelae were measured in pts who were > 3 years from diagnosis and had no evidence of recurrent cancer. Pts were interviewed by phone, and the following surveys were administered: EORTC QLQ-C30 (EORTC) and QLQ-OV28 (OV-28), MHI-17, CALGB sexual functioning, GOG Neuropathy, FACT Fatigue, Beck’s Hopelessness, Fear of Recurrence (FOR), Dyadic Adjustment Scale (DAS), PCL-C post-traumatic stress disorder (PTSD), Unmet Needs, FACT-Spirituality (FACT-Sp), complementary therapy use, and MOS Social Support (MOS). Results: 55 pts were interviewed (mean age 58 yrs, range 34 to 77 yrs). Mean time between diagnosis and interview was 5.6 yrs. CS reported significantly higher MHI-17 scores than the population norm, and higher MHI-17 scores were associated with better overall QOL (EORTC, r = 0.57, p < 0.0001), increased social support (MOS, r = 0.54, p < 0.0001), and better marital relationships (DAS, r = 0.42, p < 0.001). Sexual problems (1.57 out of 6) and unmet needs (1.5 out of 14) were minimal. FOR was correlated with lowered overall QOL (EORTC, r = −0.63, p < 0.0001), increased abdominal symptoms (OV-28 abdominal scale, r = 0.48, p < 0.0002), increased hopelessness (Beck’s, r = 0.46, p < 0.0005), and increased spirituality (FACT-Sp, r = −0.57, p < 0.0001). CS were using 5.4 complementary therapies for QOL purposes and 5.8 for cancer treatment. Minimal negative socioeconomic impact was observed in CS (0.16 out of 4). However, 12.5% of pts had scores indicative of a diagnosis of PTSD. Conclusions: Long-term QOL follow-up of early stage ovarian cancer survivors demonstrated minimal long-term symptoms, excellent mental health, minimal unmet needs, and minimal socioeconomic impact. No significant financial relationships to disclose.

Abstract Background: There is limited information about socioeconomic factors effect on survival in veterans with acute myeloid leukemia (AML). Some studies suggested higher risk of leukemia mortality among veterans who were smokers [1, 2, 3, 4]. Few studies investigated socioeconomic factors like insurance status, care at private or academic center, marital status and median household income effect on outcomes in adults with AML [5, 6, 7]. Methods: Medical records of AML patients at the Oklahoma City VAHCS between 2010 and 2017 were reviewed. Information collected included home distance from treatment center (≤ 40 miles vs > 40 miles), marital status at diagnosis, tobacco use in the 3 months preceding diagnosis, history of alcohol abuse, level of college education (college education vs less than college education). Fisher-exact test was used for differences in survival rates. Kaplan-Meier analysis was used to estimate the survival and log-rank test to determine differences among groups. Results: Total number of Veterans were 28. Fifteen patients (56%) had poor risk disease, 8 (30%) had intermediate risk disease, and 4 (15%) had good risk disease. Median survival for the whole group was 9.3 months. Patients with poor and intermediate risk cytogenetic/molecular status had median survival of 5.5 and 37.7 months, respectively (p=0.0066). There was insufficient number of deaths in the good risk group at the time of this analysis. Median survival for veterans with history of alcohol abuse vs none was 66 vs 7 months (p= 0.15). Median survival for veterans who had some college education vs less than college education was 26.1 vs 6.9, (p=0.14). Median survival for veterans with history of tobacco use within 3 months of diagnosis vs others was 6.9 vs 26.1 (p= 0.11). Median survival for veterans who were married at diagnosis vs non married was 14 vs 7.89 (p=0.29). Median survival for veterans who lived > 40 miles from treatment center vs ≤ 40 miles was 7.43 vs 37.7 months (p=0.5). Conclusions: In our retrospective single institute study, poor risk cytogenetic/molecular risk group was associated with inferior survival. While there appeared to be a trend towards worse survival in association with lower education, smoking, non-married status, and longer distance from treatment center, none of these factors had a statistically significant effect. Larger studies are needed to confirm such observations. References: 1. Austin H, Cole P. Cigarette smoking and leukemia. Journal of chronic diseases. 1986; 39: 417-421. 2. Kahn HA. The Dorn study of smoking and mortality among US veterans: Report on 8.5 years of observation. Bethesda, MD: US Department health, Education and Welfare, 1966; 1-125. 3. Rogot E, Murray JL. Smoking and causes of death among US veterans. 16 years of observation. Public Health Rep. 1980; 95: 213-222. 4. McLaughlin JK, Hrubec Z et al. Cigarette smoking and leukemia. J Natl Cancer Inst 1990; 81: 1262-1263. 5. Luciano Costa, Uma Borate et al. Non Biological factors affecting survival in Younger patients with acute myeloid leukemia. Blood 2014; 124:1273; 6. Gaurav Goyal, Lata Nawal et al. Impact of socioeconomic, demographic and health system factors on therapy in Acute myeloid leukemia. Blood 2015; 126: 3316; 7. Lene Sofie Granfeldt et al, Effects of Education and income on treatment and outcome in patients with AML in tax supported health care system: A national population based cohort study. J Clin Oncol Nov 2017; 35: 3678-3687. Disclosures No relevant conflicts of interest to declare.

e18658 Background: Adolescent and young adults (AYAs) experience poorer outcomes, including lower survival improvements, compared to younger and older patients. As higher compliance with National Comprehensive Cancer Network (NCCN) guidelines has been associated with improved outcomes, we sought to understand the influence of psychosocial factors on receipt of care concordant with NCCN guidelines in AYAs with bone sarcomas. Methods: Retrospective chart review was performed on adult AYA patients (18-39 years) with localized Ewing sarcoma (ES) or high-grade conventional osteosarcoma (OS) seen at least once between 2015-2019 at the University of Wisconsin (UW). These tumor types were selected given uniform guideline-based care recommendations. Chart review identified receipt of standard care as per NCCN Bone Cancer guidelines, defined as neoadjuvant chemotherapy, local therapy (surgery/radiation), and adjuvant chemotherapy with receipt of at least 75% of recommended chemotherapy cycles, and compared to interpersonal relationships (marital status and presence of children at cancer diagnosis), changes in school or work following cancer diagnosis, substance use, and residential location. Results: We identified 21 AYA patients with localized ES (10/21, 48%) or OS (11/21, 52%), with 67% (14/21) receiving NCCN guideline concordant care. Receipt of guideline concordant care was associated with interpersonal relationships, with only 33% (1/3) of patients with children versus 72% (13/18) of patients without children receiving guideline concordant care. Additionally, the one patient noted to divorce following cancer diagnosis did not receive guideline concordant care (0/1, 0%) as compared with 67% (10/15) of single patients and 80% (4/5) of married patients. Vocational changes also affected care, with only 56% (5/9) of patients with work change following cancer diagnosis receiving guideline concordant care versus 75% (9/12) without work changes. Guideline concordant care was less common in patients with alcohol use (5/10, 50%) as compared with patients without alcohol use (9/11, 82%). Residential distance to UW was also associated with receipt of guideline concordant care, which was more common in patients living 0-20 miles from UW (86%, 6/7) as compared with those 21-100 miles from UW (60%, 6/10) or > 100 miles from UW (50%, 2/4). Conclusions: Given the occurrence of cancer during a complex developmental time, AYAs have a relatively high occurrence of psychosocial changes and needs, which we found to be associated with receipt of NCCN guideline concordant care in patients with localized ES and OS. While a limited sample size, as the first study to define specific psychosocial factors that affect receipt of guideline concordant care, these finding suggest the need to improve identification and support of these discrete patient factors.

Abstract Introduction: The use of allogeneic HSCT is considered a potential cure for AML but its use is limited in older patients because of significant comorbidities and increased transplant-related morbidity and mortality. However, there is evidence to suggest that older patients up to 80 years old may tolerate and benefit from intensive treatment, despite deteriorating organ function. This real-world analysis compared outcomes of Medicare-aged, chemotherapy-treated AML patients with or without HSCT. Methods: We performed a retrospective cohort analysis of 4,772 patients with a first primary AML in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Patients were diagnosed between January 1, 2000 and December 31, 2013, were aged > 66 years, continuously enrolled in Medicare Part A and B with no health maintenance organization (HMO) coverage in the year prior to diagnosis, and had received chemotherapy treatment within 3 months of diagnosis. Demographic and clinical characteristics were compared between patients who received HSCT and those who did not, using chi-square test for categorical variables and analysis of variance (ANOVA) or t-test for continuous variables. Unadjusted Kaplan-Meier survival plots were used to assess overall survival. Cox proportional hazards regression modeling evaluated the independent effects of covariates on overall survival, including receipt of HSCT, age, sex, race, prior myelodysplastic syndromes (MDS), poor performance indicators (PPIs), comorbidity burden, income, education, marital status, year of diagnosis, and geographic region. Date of last follow-up was December 31, 2015, permitting a minimum 2-year follow-up. Results: Of 4,772 patients with a first primary AML in the linked SEER-Medicare database, 403 (8%) underwent HSCT therapy after chemotherapy and 4,369 (92%) did not. Rates of HSCT increased over the study time period from 7% in 2000 to 12% in 2012 (P = 0.0033). Of the 403 patients who underwent HSCT, the majority (82%) were aged ≤ 75 years. Overall, patients in the HSCT group were younger at diagnosis (71 vs 75 years), more likely to be male (63% vs 54%), be married (66% vs 60%), less likely to have high-risk disease (11% vs 15% with prior MDS) or PPIs (4% vs 8%), and had lower comorbidity burden (59% vs 53% with a comorbidity score of 0) versus patients treated with chemotherapy only. In a subset analysis stratified by age, the relationships observed between patient characteristics and HSCT receipt persisted in the younger cohort of patients (≤ 75 years) but not in the older cohort (> 75 years). The unadjusted median overall survival was higher for the HSCT group (14.2 months) versus the non-HSCT group (4.8 months; log-rank P < 0.0001). In multivariate survival analysis, patients who underwent HSCT had a 40% lower risk of death versus those who did not undergo HSCT (hazard ratio [HR] 0.60; 95% CI 0.53-0.67). Advanced age, male sex, higher comorbidity score, prior MDS, and PPIs were significantly associated with higher risk of mortality. Stratifying by age, the survival benefit with HSCT was only demonstrated in the younger cohort aged ≤ 75 years (HR 0.53; 95% CI 0.46-0.60); no difference in mortality risk was noted in the older cohort aged > 75 years (HR 0.85; 95% CI 0.67-1.08). Conclusions: Overall, only 8% of patients receiving antileukemic therapy underwent subsequent HSCT therapy, and 82% of patients who did undergo HSCT were aged ≤ 75 years. HSCT was associated with a 40% reduction in mortality risk versus patients receiving chemotherapy only, and the survival benefit was more pronounced among the younger cohort aged ≤ 75 years, with a 47% reduction in mortality risk. Chronologic age appears to be the driving factor in HSCT receipt and prognosis, and these findings provide important new information on real-world outcomes on the benefit of HSCT in an elderly population. Disclosures Satram-Hoang: Celgene Corp.: Research Funding; Genentech: Research Funding. Parisi:Celgene Corp.: Employment, Equity Ownership.

Abstract Background Eliminating mother-to-child transmission of HIV (MTCT) in sub-Saharan Africa is hindered by limited understanding of HIV-testing and HIV-care engagement among pregnant and breastfeeding women. Methods We investigated HIV-testing and HIV-care engagement during pregnancy and breastfeeding from 2014 to 2018 in the Agincourt Health and Demographic Surveillance System (HDSS). We linked HIV patient clinic records to HDSS pregnancy data. We modelled time to a first recorded HIV-diagnosis following conception, and time to antiretroviral therapy (ART) initiation following diagnosis using Kaplan-Meier methods. We performed sequence and cluster analyses for all pregnancies linked to HIV-related clinic data to categorise MTCT risk period engagement patterns and identified factors associated with different engagement patterns using logistic regression. We determined factors associated with ART resumption for women who were lost to follow-up (LTFU) using Cox regression. Results Since 2014, 15% of 10,735 pregnancies were recorded as occurring to previously (51%) or newly (49%) HIV-diagnosed women. New diagnoses increased until 2016 and then declined. We identified four MTCT risk period engagement patterns (i) early ART/stable care (51.9%), (ii) early ART/unstable care (34.1%), (iii) late ART initiators (7.6%), and (iv) postnatal seroconversion/early, stable ART (6.4%). Year of delivery, mother’s age, marital status, and baseline CD4 were associated with these patterns. A new pregnancy increased the likelihood of treatment resumption following LTFU. Conclusion Almost half of all pregnant women did not have optimal ART coverage during the MTCT risk period. Programmes need to focus on improving retention, and leveraging new pregnancies to re-engage HIV-positive women on ART.

The rise of expertise in the lives of women is a complex and prolonged process that began when the old networks through which women had learned from each other were being discredited or destroyed (Ehrenreich and English). Enclosed spaces of expert power formed separately from political control, market logistics and the pressures exerted by their subjects (Rose and Miller). This, however, was not a question of imposing expertise on women and forcing them to adhere to expert proclamations: “the experts could not have triumphed had not so many women welcomed them, sought them out, and … organised to promote their influence” (Ehrenreich and English 28). Women’s continuing enthusiasm for self-help books – and it is mainly women who buy them (Wood) – attests to the fact that they are still welcoming expertise into their lives. This paper argues that a major factor in the popularity of self-help is the reversal of the conventional ‘priestly’ relationship and ethic of confession, in a process of conversion that relies on the enthusiasm and active participation of the reader.Miller and Rose outline four ways in which human behaviour can be transformed: regulation (enmeshing people in a code of standards); captivation (seducing people with charm or charisma); education (training, convincing or persuading people); and conversion (transforming personhood, and ways of experiencing the world so that people understand themselves in fundamentally new ways). Of these four ways of acting upon others, it is conversion that is the most potent, because it changes people at the level of their own subjectivity – “personhood itself is remade” (Miller and Rose 35). While theories of conversion cannot be adequately discussed here, one aspect held in common by theories of religious conversion as well as those from psychological studies of ‘brainwashing’ is enthusiasm. Rambo’s analysis of the stages of religious conversion, for example, includes ‘questing’ in an active and engaged way, and a probable encounter with a passionately enthusiastic believer. Melia and Ryder, in their study of ‘brainwashing,’ state that two of the end stages of conversion are euphoria and proselytising – a point to which I will return in the conclusion. In order for a conversion to occur, then, the reader must be not only intellectually convinced of the truth, but must feel it is an important or vital truth, a truth she needs – in short, the reader must be enthused. The popularity of self-help books coincides with the rise of psy expertise more generally (Rose, "Identity"; Inventing), but self-help putatively offers escape from the experts, whilst simultaneously immersing its readers in expertise. Readers of self-help view themselves as reading sceptically (Simonds), interpretively (Rosenblatt) and resistingly (Fetterly, Rowe). They choose to read books as an educational activity (Dolby), rather than attending counselling or psychotherapy sessions in which they might be subject to manipulation, domination and control by a therapist (Simonds). I have discussed the nature of the advice in relationship manuals elsewhere (Hazleden, "Relationship"; "Pathology"), but the intention of this paper is to investigate the ways in which the authors attempt to enthuse and convert the reader.Best-Selling ExpertiseIn common with other best-selling genres, popular relationship manuals begin trying to enthuse the reader on the covers, which are intended to attract the reader, to establish the professional – or ‘priestly’ – credentials of the author and to assert the merit of the book, presenting the authors as experienced professionally-qualified experts, and advertising their bestseller status. These factors form part of the marketing ‘buzz’ or collective enthusiasm about a particular author or book.As part of the process of establishing themselves in the priestly role, the authors emphasise their professional qualifications and experience. Most authors use the title ‘Dr’ on the cover (Hendrix, McGraw, Forward, Gray, Cowan and Kinder, Schlessinger) or ‘PhD’ after their names (Vedral, DeAngelis, Spezzano). Further claims on the covers include assertions of the prominence of the authors in their field. Typical are DeAngelis’s claim to being “America’s foremost relationships expert,” and Hendrix’s claim to being “the world’s leading marital therapist.” Clinical and professional experience is mentioned, such as Spezzano’s “twenty-three years of counseling experience” (1) and Forward’s experience as “a consultant in many southern California Medical and psychiatric facilities” (iii). The cover of Spezzano’s book claims that he is a “therapist, seminar leader, author, lecturer and visionary leader.” McGraw emphasises his formal qualifications throughout his book, saying, “I had more degrees than a thermometer” (McGraw 6), and he refers to himself throughout as “Dr. Phil,” much like “Dr Laura” (Schlessinger). Facts and SecretsThe authors claim their ideas are based on clinical practice, research, and evidence. One author claims, “In this book, there is a wealth of tried and accurate information, which has worked for thousands of people in my therapeutic practice and seminars over the last two decades” (Spezzano 1). Another claims that he “worked with hundreds of couples in private practice and thousands more in workshops and seminars” and subsequently based his ideas on “research and clinical observations” (Hendrix xviii). Dowling refers to “four years of research … interviewing professionals who work with and study women.” She went to all this trouble because, she assures us, “I wanted facts” (Dowling, dust-jacket, 30).All this is in order to assure the reader of the relevance and build her enthusiasm about the importance of the book. McGraw (226) says he “reviewed case histories of literally thousands and thousands of couples” in order “to choose the right topics” for his book. Spezzano (7) claims that his psychological exercises come from clinical experience, but “more importantly, I have tested them all personally. Now I offer them to you.” This notion of being in possession of important new knowledge of which the reader is unaware is common, and expressed most succinctly by McGraw (15): “I have learned what you know and, more important, what you don't know.” This knowledge may be referred to as ‘secret’ (e.g. DeAngelis), or ‘hidden’ (e.g. Dowling) or as a recent discovery. Readers seem to accept this – they often assume that self-help books spring ‘naturally’ from clinical investigation as new information is ‘discovered’ about the human psyche (Lichterman 432).The Altruistic AuthorOn the assumption that readers will be familiar with other self-help books, some authors find it necessary to explain why they felt motivated to write one themselves. Usually these take the form of a kind of altruistic enthusiasm to share their great discoveries. Cowan and Kinder (xiv) claim that “one of the wonderful, intrinsic rewards of working with someone in individual psychotherapy is the rich and intense relationship that is established, [but] one of the frustrations of individual work is that in a whole lifetime it is impossible to touch more than a few people.” Morgan (26) assures us that “the results of applying certain principles to my marriage were so revolutionary that I had to pass them on in the four lesson Total Woman course, and now in this book.”The authors justify their own addition to an overcrowded genre by delineating what is distinctive about their own book, or what other “books, articles and surveys missed” (Dowling 30) or misinterpreted. Beattie (98-102) devotes several pages to a discussion of Dowling to assert that Dowling’s ‘Cinderella Complex’ is more accurately known as ‘codependency.’ The authors of another book admit that their ideas are not new, but claim to make a unique contribution because they are “writing from a much-needed male point of view” (Cowan and Kinder, back cover). Similarly, Gray suggests “many books are one-sided and unfortunately reinforce mistrust and resentment toward the opposite sex.” This meant that “a definitive guide was needed for understanding how healthy men and women are different,” and he promises “This book provides that vision” (Gray 4,7).Some authors are vehement in attacking other experts’ books as “gripe sessions,” “gobbledegook” (Schlessinger 51, 87), or “ridiculous” (Vedral 282). McGraw (9) writes “it is amazing to me how this country is overflowing with marital therapists, psychiatrists and psychologists, counselors, healers, advice columnists, and self-help authors – and their approach to relationships is usually so embarrassing that I want to turn my head in shame.” His own book, by contrast, will be quite different from anything the reader has heard before, because “it differs from what relationship ‘experts’ tell you” (McGraw 45).Confessions of an Author Because the authors are writing about intimate relationships, they are also keen to establish their credentials on a more personal level. “Loving, losing, learning the lessons, and reloving have been my path” (Carter-Scott 247-248), says one, and another asserts that, “It’s taken me a long time to understand men. It’s been a difficult and often painful journey and I’ve made a lot of mistakes along the way in my own relationships” (DeAngelis xvi). The authors are even keen to admit the mistakes they made in their previous relationships. Gray says, “In my previous relationships, I had become indifferent and unloving at difficult times … As a result, my first marriage had been very painful and difficult” (Gray 2). Others describe the feelings of disappointment with their marriages: We gradually changed. I was amazed to realize that Charlie had stopped talking. He had become distant and preoccupied. … Each evening, when Charlie walked in the front door after work, a cloud of gloom and tension floated in with him. That cloud was almost tangible. … this tension cloud permeated our home atmosphere … there was a barrier between us. (Morgan 18)Doyle (14) tells a similar tale: “While my intentions were good, I was clearly on the road to marital hell. … I was becoming estranged from the man who had once made me so happy. Our marriage was in serious trouble and it had only been four years since we’d taken our vows.” The authors relate the bewilderment they felt in these failing relationships: “My confusion about the psychology of love relationships was compounded when I began to have problems with my own marriage. … we gave our marriage eight years of intensive examination, working with numerous therapists. Nothing seemed to help” (Hendrix xvii).Even the process of writing the relationship manual itself can be uncomfortable: This was the hardest and most painful chapter for me to write, because it hit so close to home … I sat down at my computer, typed out the title of this chapter, and burst into tears. … It was the pain of my own broken heart. (DeAngelis 74)The Worthlessness of ExpertiseThus, the authors present their confessional tales in which they have learned important lessons through their own suffering, through the experience of life itself, and not through the intervention of any form of external or professional expertise. Furthermore, they highlight the failure of their professional training. Susan Forward (4) draws a comparison between her professional life as a relationship counsellor and the “Susan who went home at night and twisted herself into a pretzel trying to keep her husband from yelling at her.” McGraw tells of a time when he was counselling a couple, and: Suddenly all I could hear myself saying was blah, blah, blah. Blah, blah, blah, blah. As I sat there, I asked myself, ‘Has anybody noticed over the last fifty years that this crap doesn’t work? Has it occurred to anyone that the vast majority of these couples aren’t getting any better? (McGraw 6)The authors go to some lengths to demonstrate that their new-found knowledge is unlike anything else, and are even prepared to mention the apparent contradiction between the role the author already held as a relationship expert (before they made their important discoveries) and the failure of their own relationships (the implication being that these relationships failed because the authors themselves were not yet beneficiaries of the wisdom contained in their latest books). Gray, for example, talking about his “painful and difficult” first marriage (2), and DeAngelis, bemoaning her “mistakes” (xvi), allude to the failure of their marriage to each other, at a time when both were already well-known relationship experts. Hendrix (xvii) says: As I sat in the divorce court waiting to see the judge, I felt like a double failure, a failure as a husband and as a therapist. That very afternoon I was scheduled to teach a course on marriage and the family, and the next day, as usual, I had several couples to counsel. Despite my professional training, I felt just as confused and defeated as the other men and women who were sitting beside me.Thus the authors present the knowledge they have gained from their experiences as being unavailable through professional marital therapy, relationship counselling, and other self-help books. Rather, the advice they impart is presented as the hard-won outcome of a long and painful process of personal discovery.Peace and PassionOnce the uniqueness of the advice is established, the authors attempt to enthuse the reader by describing the effects of following it. Norwood (Women 4) says her programme led to “the most rewarding years of my life,” and Forward (10) says she “discovered enormous amounts of creativity and energy in myself that hadn't been available to me before.” Gray (268) asserts that, following his discoveries “I personally experienced this inner transformation,” and DeAngelis (126) claims “I am compassionate where I used to be critical; I am patient where I used to be judgmental.” Doyle (23) says, “practicing the principles described in this book has transformed my marriage into a passionate, romantic union.” Similarly, in discussing the effects of her ideas on her marriage, Morgan (26) speaks of “This brand new love between us” that “has given us a brand new life together.” Having established the success of their ideas and techniques on their own lives, the authors go on to relate stories about their successful application to the lives and relationships of their clients. One author writes that “When I began implementing my ideas … The divorce rate in my practice sharply declined, and the couples … reported a much deeper satisfaction in their marriages” (Hendrix xix). Another claims “Repeatedly I have heard people say that they have benefited more from this new understanding of relationships than from years of therapy” (Gray 7). Morgan, describing the effects of her ‘Total Woman’ classes, says: Attending one of the first classes in Miami were wives of the Miami Dolphin football players … it is interesting to note that their team won every game that next season and became the world champions! … Gals, I wouldn’t dream of taking credit for the Superbowl … (Morgan 188)In case we are still unconvinced, the authors include praise and thanks from their inspired clients: “My life has become exciting and wonderful. Thank you,” writes one (Vedral 308). Gray (6) talks of the “thousands of inspirational comments that people have shared” about his advice. Vedral (307) says “I have received thousands of letters from women … thanking me for shining a beam of light on their situations.” If these clients have transformed their lives, the authors claim, so can the reader. They promise that the future will be “exceptional” (Friedman 242) and “wonderful” (Norwood, Women 257). It will consist of “self fulfilment, love, and joy” (Norwood, Women 26), “peace and joy” (Hendrix xx), “freedom and a lifetime of healing, hope and happiness” (Beattie), “peace, relief, joy, and passion that you will never find any other way” (Doyle 62) – in short, “happiness for the rest of your life” (Spezzano 77).SummaryIn order to effect the conversion of their readers, the authors seek to create enthusiasm about their books. First, they appeal to the modern tradition of credentialism, making claims about their formal professional qualifications and experience. This establishes them as credible ‘priests.’ Then they make calculable, factual, evidence-based claims concerning the number of books they have sold, and appeal to the epistemological authority of the methodology involved in establishing the findings of their books. They provide evidence of the efficacy of their own unique methods by relating the success of their ideas when applied to their own lives and relationships, and those of their clients and their readers. The authors also go to some lengths to establish that they have personal experience of relationship problems, especially those the reader is currently presumed to be experiencing. This establishes the ‘empathy’ essential to Rogerian therapy (Rogers), and an informal claim to lay knowledge or insight. In telling their own personal stories, the authors establish an ethic of confession, in which the truth of oneself is sought, unearthed and revealed in “the infinite task of extracting from the depths of oneself, in between the words, a truth which the very form of the confession holds out like a shimmering mirage” (Foucault, History 59). At the same time, by claiming that their qualifications were not helpful in solving these personal difficulties, the authors assert that much of their professional training was useless or even harmful, suggesting that they are aware of a general scepticism towards experts (cf. Beck, Giddens), and share these doubts. By implying that it is other experts who are perhaps not to be trusted, they distinguish their own work from anything offered by other relationship experts, thereby circumventing “the paradox of self-help books’ existence” (Cheery) and proliferation. Thus, the authors present their motives as altruistic, whilst perhaps questioning the motives of others. Their own book, they promise, will be the one (finally) that brings a future of peace, passion and joy. Conversion, Enthusiasm and the Reversal of the Priestly RelationshipAlthough power relations between authors and readers are complex, self-help is evidence of power in one of its most efficacious forms – that of conversion. This is a relationship into which one enters voluntarily and enthusiastically, in the name of oneself, for the benefit of oneself. Such power enthuses, persuades, incites, invites, provokes and entices, and it is therefore a strongly subjectifying power, and most especially so because the relationship of the reader to the author is one of choice. Because the reader can choose between authors, and skip or skim sections, she can concentrate on the parts of the therapeutic diagnosis that she believes specifically apply to her. For example, Grodin (414) found it was common for a reader to attach excerpts from a book to a bathroom mirror or kitchen cabinet, and to re-read and underline sections of a book that seemed most relevant. In this way, through her enthusiastic participation, the reader becomes her own expert, her own therapist, in control of certain aspects of the encounter, which nonetheless must always take place on psy terms.In many conversion studies, the final stage involves the assimilation and embodiment of new practices (e.g. Paloutzian et al. 1072), whereby the convert employs or utilises her new truths. I argue that in self-help books, this stage occurs in the reversal of the ‘priestly’ relationship. The ‘priestly’ relationship between client and therapist, is one in which in which the therapist remains mysterious while the client confesses and is known (Rose, "Power"). In the self-help book, however, this relationship is reversed. The authors confess their own ‘sins’ and imperfections, by relating their own disastrous experiences in relationships and wrong-thinking. They are, of course, themselves enthusiastic converts, who are enmeshed within the power that they exercise (cf. Foucault History; Discipline), as these confessions illustrate. The reader is encouraged to go through this process of confession as well, but she is expected to do so privately, and to play the role of priest and confessor to herself. Thus, in a reversal of the priestly relationship, the person who ‘is knowledge’ within the book itself is the author. It is only if the reader takes up the invitation to perform for herself the priestly role that she will become an object of knowledge – and even then, only to herself, albeit through a psy diagnostic gaze provided for her. Of course, this instance of confession to the self still places the individual “in a network of relations of power with those who claim to be able to extract the truth of these confessions through their possession of the keys to interpretation” (Dreyfus and Rabinow 174), but the keys to interpretation are provided to the reader by the author, and left with her for her own safekeeping and future use. As mentioned in the introduction, conversion involves questing in an active and engaged way, and may involve joy and proselytising. Because the relationship must be one of active participation, the enthusiasm of the reader to apply these truths to her own self-understanding is critical. Indeed, the convert is, by her very nature, an enthusiast.ConclusionSelf-help books seek to bring about a transformation of subjectivity from powerlessness to active goal-setting, personal improvement and achievement. 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The present study investigates the role of attachment in a time-limited marital therapy. The study explores Brief Contextual Modular Psychotherapy (BCMT). This approach to practice provides a model that integrates principles and techniques from the major psychotherapies. BCMT can be distinguished from other brief therapies by its theoretical integration, its six-session time limit, its specific clinical focus, and its techniques for dealing with dissatisfaction and distress. The therapy sets out practice modules—six-session treatment plans—for a diverse range of presenting issues such as the anxiety disorders, depression, trauma, loss and grief, marriage and the phobias. BCMT emphasises the collaboration of the therapist and the client. A community-based psychological counselling centre has practised BCMT for over ten years, applying it in cases of wide diversity and maladjustment. Prior to this research, a comprehensive analysis of the theory underlying the BCMT model or the theory of change it endorses had not been carried out. The study provides a detailed description of the conceptual and treatment elements of the marital module developed in the treatment manual for BCMT. The study explores how the construct of attachment provides an organising framework or metaperspective for theory construction and therapeutic intervention in the clinical application of this time-limited marital therapy. To achieve this objective, one de-facto and four married couples participated in the time-limited therapy. They completed a questionnaire on adult attachment and also a self-report questionnaire to assess the effectiveness of the therapy. Narrative analysis was used to assess the praxis or the experience of participating in the therapy. The results show that the integrated model provided a treatment method for differing expressions of marital disturbance and psychopathology. Three of the five couples and eight of the ten participants reported positive treatment outcomes. The research sample included the paraphilias, a major depressive episode with postpartum psychosis, the narcissistic borderline syndrome and childhood sexual abuse. The study supports the association between the role of adult attachment styles and intrapsychic responses in conflicted intimate relationships. From the point of view of clinical applications of attachment theory, the research highlights how theoretical ideas can be integrated, specific clinical methods can be incorporated and certain treatment perspectives can be derived from one another. Several implications for the treatment process flow from this integration. The integration of attachment theory in BCMT demonstrates how the therapeutic process progressed through three separate yet interrelated stages: past, present and future. In addition, it led to the identification of three stage-related mourning processes associated with the time-limited therapeutic process: protest, despair and detachment. From a clinical perspective, the research finds that the theoretical and treatment model does not need to be restricted to marital therapy. The findings suggest that the integrated model could be applied across a wide range of presenting issues. By defining the theory of personality and psychopathology and the therapeutic change processes associated with it, the integration of attachment theory results in BCMT taking its place in the literature as a theory of psychotherapy.