Using Relationship Enhancement therapy with an adolescent with serious mental illness and substance dependence. .

Relationship Enhancement" (RE) therapy can be a useful intervention for adolescents with serious mental illness and their family members. The authors review the basic concepts and effectiveness of RE therapy and illustrate how it is implemented. Following 18 hours of RE therapy, a family--consisting of a mother, a father, and a son with serious mental illness and substance dependence--exhibited the ability to communicate and solve problems effectively. A discussion of the implications of this case example for research and mental health counseling are also included.

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Relationship Enhancement (RE) therapy is a family-based intervention that can be effective in treating families and their children with serious mental illness (SMI; Accordino & Guerney, 2001; Accordino & Herbert, 1997; Guerney, 1977). The authors describe the fundamental tenets of RE therapy and its effectiveness with various populations. They also offer an illustration of RE therapy with an adolescent diagnosed with SMI along with drug and alcohol problems. Although RE therapy has been conducted effectively with parents and adolescents (Guerney, Coufal, & Vogelsong, 1981; Guerney, Vogelsong, & Coufal, 1983; Haynes & Avery, 1979), the number of studies implementing RE therapy as a family intervention for adolescents with SMI has been limited. The authors hope that this case study will help contribute to the mental health counseling literature related to this population.

Having an adolescent with an SMI combined with a drug and alcohol problem is associated with severe dysfunctional behavior in the family (Clark, Neighbors, Lesnick, Lynch, & Donovan, 1998). According to clinical outcome studies, family-based interventions can be effective in improving the cohesion, communication, and coping skills of families and their children with SMI (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). Specifically, these interventions were found to improve (a) interpersonal effectiveness, (b) problem, solving, and (c) communication effectiveness (Falloon, Krekorian, Shanahan, Laporta, &McLees, 1993; Left et al., 1988,1990). Three major findings regarding the positive effects of family-based interventions were revealed in the literature: (a) the significant reduction and prevention of relapse of SMI in diagnosed family members with mental illness, (b) the greater cost effectiveness of treatment when compared to inpatient hospitalization, and (c) the overall greater efficacy when compared to educational-based assessments alone (Falloon et al.; Lam, 1991; Left et al.; Tarrier, Lowson, & Barrowclough, 1991).

RELATIONSHIP ENHANCEMENT THERAPY

RE therapy uses a psychoeducational approach that emphasizes strengths and skill building to achieve symptom reduction and to prevent interpersonal problems (Accordino & Guerney, 2001; Guerney, 1977; Guerney & Hardley, 1989). In addition, RE therapy synthesizes aspects of different theories including behavioral, client-centered, and social learning/reinforcement. One of the primary objectives of RE therapy is to help people create and strengthen intimate relationships and then maintain the quality of those relationships over time. RE therapy is a method that promotes positive change in self-differentiation and self-esteem and patterns of communication (Greene, 1986, Griffin & Apostal, 1993; Guerney).

RE therapy consists of teaching a structured set of nine skills that are effective in the treatment and prevention of interpersonal problems. In addition to the skills that improve relationship effectiveness, several skills enable regular practice of the skills to prevent deterioration of skill usage (see Guerney, 1991 for further description of the skills). Clients usually read of the RE program manual (Guerney), which describes the skills with examples. In addition, each skill is summarized in a set of brief guidelines that, like rules of a game, when followed lead to a skilled performance. Each guideline is spelled out usually in behavioral terms. For example, the guidelines recommend specific actions that participants should take in order to learn and use each skill effectively. Keep in mind the first four skills are considered the core of RE therapy and are taught first. When the core skills have been grasped, which is evident by the participants' ability to solve minor and major conflicts and exchange positive feelings in their relationships, the final five skills are then presented. Below, we provide a very brief statement of the purpose of each skill along with an example.

1. Empathic skill--helping others feel understood, safe, and involved enough to communicate openly, candidly, and less defensively, while simultaneously increasing understanding of other people, particularly their thoughts, feelings, and wishes. Mother demonstrates compassionate understanding by empathically responding to her daughter and better understands her daughter's fear of having a psychotic relapse.

2. Expressive skill--becoming aware of own thoughts, feelings, and wishes and expressing them in ways that are least likely to create defensiveness in others. Mother compassionately expresses to her daughter feelings of frustration and anxiety as the result of her daughter's unpredictable behaviors.

3. Discussion/Negotiation skill--discussing topics that are laden with strong emotions in a manner that is positive, and structuring the discussion in a way that reduces digression to other topics. Mother and father discuss appropriate ways to react when daughter experiences a psychotic relapse.

4. Problem/Conflict Resolution skill--promoting finding solutions to interpersonal problems by means of structured steps resulting in concrete, behaviorally oriented, constructive plans that are most likely to endure over time and best meet the needs of all family members. Mother and father develop with daughter specific responsibilities and goals (determining who will do what and when) with respect to the daughter finding volunteer or paid employment.

5. Facilitation skill--instructing others informally in the RE therapy skills learned to improve the interactions between them. By mutual agreement, father and daughter remind each other of the skills guidelines when they are involved in an argument.

6. Self-Change skill--modifying specific attitudes and behaviors through a structured set of steps that are most likely to result in prompt, constructive change. Daughter selects and places objects near her at the dinner table to remind her that she wishes to decrease the number of times that she raises her voice at the dinner table.

7. Other Change skill--aiding others involved in modifying their attitudes and behaviors by providing support, encouragement, and social reinforcement. Brother works with sister to help her to decrease the amount of times that she raises her voice at the dinner table.

8. Generalization skill--incorporating RE therapy skills when encountering different interpersonal life situations. Mother, father, and daughter employ the skills with mental health providers.

9. Maintenance skill--systematically practicing the RE therapy skills in order to prevent a deterioration in skill level. All family members schedule regular time intervals to practice the RE therapy skills.

RE therapy can be offered in a variety of formats. One format is called time-designated. It entails teaching all the skills and attempting to resolve the most important problems and conflicts in 10 to 20 hours or longer if needed. In this mode, compared to others, there is more time for the skills to be taught systematically so that participants can be proficient in skill usage before discussing minor and major problems. Another format is experiential and lasts 5 to 10 hours. The skills are taught as participants proceed, and major problems are addressed immediately. A third format is crisis intervention, which lasts one to 5 hours, and participants work on critical issues while learning the skills as they proceed (Guerney, 1997). When using the crisis intervention format, it may not be possible to teach all of the skills due to time constraints. Participants can still learn the skills, however, by reading the manual (Guerney, 1991) and listening to skill demonstration audiotapes (Guerney, 1994) both before and after the actual sessions.

In using RE therapy, the mental health counselor presents the background, rules, and specific goals of RE therapy and teaches the skills by modeling proper skill usage and by providing positive reinforcement whenever the participant performs appropriately. Techniques unique to RE therapy that the counselor employs include troubleshooting, which may be used with any type of problem situation and entails the mental health counselor using the RE therapy skills directly with participants. For an example of troubleshooting, consider the case where participant A is emotionally distraught and is unable to continue, and participant B is not skilled enough to be empathic. In such a situation, the mental health counselor uses the empathic skill to help participant A vent his or her strong thoughts, feelings, and wishes that impede participation until he or she feels able to resume using the skills with participant B. Another instance where troubleshooting may be used is when a participant is not willing to follow the RE therapy skills and procedures. In this event, similar to many other counseling interactions, the mental health counselor would use the empathic skill until the participant is ready to listen to the counselor's point of view. At that time, the mental health counselor would use the expressive skill. Both would take turns using each skill until the problem was resolved in a satisfactory manner to both people.

A second technique, becoming is used in crisis situations. When the participant is unable to continue an interaction due to emotions that are overwhelming, the mental health counselor assumes the role and speaks for a participant. This skill is best used when the counselor has a working knowledge of the family's problems and the thoughts, feelings, and wishes of each member. This method is especially effective when an adolescent is unwilling to participate in counseling due to strong resistance.

A third technique, laundering, is a very complex method where participants talk to the mental health counselor instead of each other. The mental health counselor employs the becoming technique for two participants while receiving statements, often unskilled, from both and uses empathy with both. For example, whenever speaking to participant A or addressed by A, the mental health counselor is viewed and addressed as if he or she were the other participant included in the interaction, that is, B; the interaction then proceeds conversely with B addressing the mental health counselor as A. The counselor may even suggest a solution to the problem while in the persona of a participant if that can potentially help the interaction.

SUMMARY OF RE THERAPY EFFECTIVENESS.

Research has revealed that RE therapy is a very effective approach (Accordino & Guerney, 2001). RE therapy has been demonstrated as effective with mental health populations including: (a) individuals with mental illness (Vogelsong, Guerney, & Guerney, 1983), (b) married couples with mental illness (Snyder, 1994; Waldo & Harman, 1993; Zahniser & Falk, 1993), and (c) community mental health agency staff (Accordino & Guerney, 1993). RE therapy has also been promoted as an effective intervention for families of adolescents in inpatient mental health facilities, but virtually no outcome studies have been conducted with the population (Vogelsong et al.). In comparing approaches, Giblin, Sprenkle, & Sheehan (1985) conducted a meta-analysis that investigated 85 studies with 3,866 couples or families, varying demographically in terms of age, income, education, and location. Within the studies, 16 marital and 4 family interventions were analyzed. RE therapy appeared to have the highest improvement effect size for both marital and family categories. Specifically effect sizes for marital and family RE programs averaged .96. Effect sizes of comparison marital and family programs ranged from .04 (Rational Emotive) through .42 (Marriage Encounter), and from .44 (Couples Communication) to .63 (Communications).

CASE EXAMPLE

Background

The adolescent, whose fictitious name is Bill, was a 15-year-old Caucasian male who was diagnosed, according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text rev.; American Psychiatric Association, 2000), with dysthymic disorder; attention deficit hyperactivity disorder (ADHD) mixed; oppositional defiant disorder; and cannabis dependence. He was prescribed Wellbutrin, an antidepressant medication. Bill's academic performance, according to his parents, was exemplary until the sixth grade, when he experienced increasing difficulty. He had a history of suicidal ideation and attempts; as early as the sixth grade, he made statements of wanting to take his own life. Bill also had experimented with satanic devil worship. He was committed to an inpatient facility after making homicidal threats toward his father and destroying property at home. This was Bill's second inpatient commitment in 4 months.

Bill's mother (Mary) and father (Tim), were also Caucasian, employed, married 20 years, and of middle socioeconomic status. They also had a 12-year-old son whom they prevented from taking part in the intervention despite encouragement from the mental health counselor. Their rationale was that they wanted to shield him from the pain that Bill's behavior had caused. Both parents reported that communication between Tim and Bill was very poor and often ended with Bill's shouting, making threats toward Tim, and breaking things. Mary and Bill, however, appeared to have a strong alliance. Often, Mary would mediate interpersonal problems between Tim and Bill.

Description of Sessions

The RE therapy sessions took place at a psychiatric hospital. The mental health counselor was a male who had 6 years of training and clinical supervision in RE therapy as well as 7 years of experience in community mental health counseling. The mental health counselor presented the RE therapy sessions in the experiential format over 18 hours (four 4-hour sessions and one 2-hour session).

Session one. This session consisted of introductions and elicitation of feelings and problems. Bill identified his feelings first and expressed that he could not trust his parents when they give him permission to spend time with friends. He went on to say that in the past his parents had given him permission to spend time with friends but had revoked that permission after a short time. Tim also expressed his feelings that related to trust. He reported feeling afraid of giving his son more trust at the present time due to the son's propensity to break that trust by becoming involved with drugs and exhibiting delinquent behavior. Mary conveyed her feelings that also dealt with trust. She, like Tim, was afraid to grant Bill more trust because he had made verbal threats to her in the past. Furthermore, she was constantly afraid that Bill would harm himself if she did not give in to his demands.

The session proceeded with Bill communicating to Mary while Tim served as an observer of how the skills were taught. Empathic, expressive, and discussion negotiation skills were taught first by the mental health counselor modeling skillful statements for the family members. Bill stated his point of view initially because he reported feeling in a vulnerable position. He stated that he desired to be with his friends and wanted more trust from his parents, his mother especially. Bill admitted abusing and selling illegal drugs. He also admitted that he bullied (yelled, screamed, threatened) in order to get what he wanted. Although he would rather not use these methods, he felt that they were effective. Furthermore, others had taken advantage of him in the past, and this behavior was employed to prevent such mistreatment in the future. Bill stressed that he enjoyed being in control. Mary, after being empathic, asked her son if he felt that it was worthwhile to desire being in control since such behavior had landed him in two inpatient institutions. Bill admitted that exhibiting threatening behavior to gain control, in retrospect, was not worth it. The session ended with Mary conveying anger that mental health professionals could not diagnose Bill's mental health problems sooner. Mary then stated that she understood Bill's desire to be with his friends, and she wanted him to be happy. She desired, however, that he spend more time on his school work and relate to her and her husband positively and without threats. At the end of the session, all three felt that what was expressed was enlightening to them. Furthermore, the son reported that he had minimal problems concentrating for the length of the entire session. As a result, all three participants wanted to keep the next session four hours long. Before the family departed, they were assigned homework consisting of each member reading about the RE therapy skills in the RE program manual (Guerney, 1991). In addition, the parents were to listen to several audiotapes (Guerney, 1994) demonstrating the RE therapy skills and then use them at mutually agreed times throughout the week.

Session two. Bill and Tim started session two with Bill discussing plans to see friends during a home visit over Thanksgiving. Tim then expressed that he understood his son's need to be with his friends but also requested that he help cut down a tree at his grandfather's. Bill initially refused, saying that such an activity would take away from time spent with friends. The mental health counselor then taught Bill and Tim the problem-solving skill, and they were able to solve the problem by choosing specific days for the son to cut down the tree and to be with friends. The next minor problem discussed was that of the Bill's desire to go with his friends to buy a coat. Tim was opposed to the idea and feared that Bill would spend the coat money on alcohol and illegal drugs. After Tim and Bill expressed their feelings and empathically responded to each other on this issue, the problem was solved with the plan that both parents would drive the son to the mall with one trusted friend and would stay in close proximity to him at the mall. In this way, he could still buy a coat, spend time with a close friend, and have a sense of freedom.

Mary proceeded to discuss with Bill a major problem: her concern with his peer group. After both discussed the issue at length, Bill expressed that he probably had the worst behavior of anyone in his peer group and admitted to manipulating and coercing his friends into buying drugs and alcohol and committing delinquent behaviors. Mary articulated that she had always thought that Bill was the instigator in his peer group. The discussion ended by Bill saying that he would do all that he could to not play the role of instigator by avoiding many of the people in his former peer group in order to prevent future problems. Specifically, Bill would keep his parents aware of peers with whom he was interacting.

Mary then expressed another major problem to Bill, which was related to his past problems with poor communication with his parents and her fear of how it would be when he was released from the facility. Bill expressed to Mary that he is often short with his parents because he feels he is being continually watched and fears being threatened with loss of privileges if he does not always complete his chores. Mary and Tim then took turns conveying to Bill that they had retracted privileges punitively and admitted that they may have overused that action at times, but simply did not know what other way to react at the time. All three family members then took turns discussing better ways to convey their feelings to each other, especially anger. Bill agreed that, in the future, when he experienced an interaction with parents where he felt enraged, he would go to his room in order to calm down and then return to interact with his parents using the RE therapy skills. Mary and Tim also agreed to give Bill verbal reminders to take a time out when he seemed extremely angry.

Session three. Session three started with Mary reporting to Bill her feelings about several problems that took place over the Thanksgiving visit. The major problem related to an incident where Bill and Tim got into an argument over Bill's choice of clothes and ended with Bill becoming very angry and withdrawn. Tim broke into Mary's interaction with Bill using the discussion negotiation skill. Tim stated that his intention was not to upset Bill but to get him to look at how other people dress. Bill expressed feeling hurt by Tim's comments. However, Bill said that he felt proud of himself during the visit because he did help to cut down the tree, obeyed a house rule of not being on the phone after 11 p.m., and showed some restraint, in his opinion, regarding how he dressed. Bill then sternly said that he believed he had compromised enough in how he dressed and would not budge on this issue. Tim became very upset at this point and said that he felt like walking out of the session. The mental health counselor then met with Tim alone using the troubleshooting technique. Tim expressed being very distraught with Bill's behavior and expressed despair that it would not change after he was released from the facility. Tim wept at one point and said that he wished the entire situation would "go away." When Tim felt composed enough to return to the family meeting, the discussion moved briefly to Bill and Mary. Bill reported feeling out of touch with his friends since being admitted to the facility. He also expressed feeling anxious when visiting at home and unable to enjoy himself due to the fear of returning to the facility. Mary, after responding empathically, returned to the issue of Bill's dress. It was then apparent that Mary and Tim had differing views on the appropriateness of the Bill's clothing. Mary expressed that she did not fully object to Bill's appearance. Mary and Bill then discussed the issue. Just before the session ended, Tim and Mary came to the agreement that they wished that their son would dress somewhat neater in terms of having at least clean clothing, with little or no holes in it, when he was at home.

Session four. At the beginning of session four, the family reported further solving the clothing issue. Bill was able to agree to wear clean clothing with few holes. Mary then stated appreciation to Bill for having had a positive visit on a recent one-day pass. She stated concern to Bill, however, that he still reacts angrily when she says "no" to any of his requests. She conveyed to Bill that she does not say "no" to purposely punish him but rather to look out for his welfare. Bill, while quite resistant to understanding his mother's point of view, was able to empathically respond to her statement with help from the mental health counselor. Mary then switched topics and expressed her concern and support for home aftercare services when her son was released from the facility. The son vehemently objected to the idea and became very angry and sullen. The mental health counselor then used the becoming technique with each family member since each had, by then, experienced trouble using the skills due to strong emotions. The son expressed himself first with the help of the mental health counselor by saying that he felt helpless, scrutinized, and punished in the facility and did not want to experience the same situation at home. Mary, with help of the mental health counselor who suggested several feeling words to reflect, was empathic of her son's views, but expressed that she firmly believed that the services would be beneficial to Bill. Furthermore, she added that, in her opinion, the family needed help because she could no longer act as mediator between Tim and Bill nor could she endure any longer Bill's past behavior of suicidal ideation, violence, and homicidal threats against the family. Bill then reluctantly conceded that he would be willing to meet with home-based professionals for up to 5 hours per week, but any more time would limit time with friends after school. He also expressed acceptance of seeing an outpatient mental health provider with whom he felt comfortable and a psychiatrist for medication monitoring. Bill expressed that he felt fully able, however, to control his own behavior without help. The becoming technique was terminated after Tim felt able to express himself independently by agreeing with Bill and voicing his opposition to excessive professional help at home due to feeling that it might be intrusive and unhelpful. The family then took turns sharing their remaining feelings regarding the issue of aftercare. Mary and Tim were able, by the end of the session, to express deeper feelings of love, appreciation, and acceptance to Bill. Bill, with the help of the mental health counselor, was also able to empathically respond to these feelings.

Session five. In session five, the family reported resolving the issue of aftercare in between sessions. Bill agreed to see a provider with whom he had worked well in the past as well as a psychiatrist. Aftercare would take place several hours per week. The mental health counselor then asked if any unresolved issues needed to be discussed. Mary offered to address Bill with her concern that he makes many racial slurs at home and her wishes that he would not be so prejudiced. Bill said that he disliked minorities because he felt they took advantage of affirmative action and often became involved in illegal activities. Tim then broke in using the discussion/negotiation skill and suggested to Bill that he try to empathize with minorities regarding how they had been oppressed in this country for many years. After each member expressed personal feelings on the issue, Bill agreed to refrain from using racial slurs, at least at home, for the time being.

The final issue that was discussed was that of Bill's poor academic work. Bill admitted that he has problems in school, but he does try. He added that he is reluctant to ask for help because he has a strong need to do things for himself. Furthermore, he often felt hurt in the past when he asked Tim for help and his father would become impatient and yell at him. Tim expressed that he understood Bill's feelings of anger and sadness but just did not know what else to do when he would get upset over Bill's inability to grasp a concept. Tim also added that he was not aware of Bill's ADHD diagnosis. Tim and Bill then used the problem-solving skill to remedy the schoolwork problem. Both eventually agreed that the best solution would be that Bill would try to learn things independently but would ask Tim if he had trouble. Tim agreed to try his best to help without becoming angry. Furthermore, Tim asked for a gentle reminder from Bill when, if at any time, he became angry. Tim also offered to pay for Bill's car insurance if he made the honor roll. The session ended with Tim expressing admiration to Bill for his sense of independence but unconditionally offered his help out of love.

Conclusion. After being involved in RE therapy, each person exhibited improvement regarding their: (a) empathy, (b) ability to listen to the other person and accept his or her points of view, (c) ability to express thoughts and feelings without creating defensiveness in the other person, and (d) problem-solving skills. Although the length of this intervention was probably insufficient to solve many of the problems of this family, the family was able to solve or at least structure methods for solving in the future a number of minor and major interpersonal problems. Furthermore, it was apparent that the family was able to learn and use the RE therapy skills competently. Specifically, each member reported being able to express feelings such as hurt, anger, love, and admiration more deeply than they had in the past. Bill, for the most part, seemed better able to communicate his own thoughts, feelings, and desires to his parents without becoming extremely agitated or withdrawn. He also showed some limited degree of empathy, which is a skill that he previously did not demonstrate. Both Tim and Bill were able to empathize with each other's feelings and points of view as well as modify certain personal behaviors that seemed to provoke the other. Mary, while fairly well-skilled at the onset of the training, was able to refine skills such as empathy and expressiveness via modeling the mental health counselor's statements. She also seemed able to step out of the role as mediator and to express her own thoughts, feelings, and desires.

IMPLICATIONS FOR MENTAL HEALTH COUNSELORS

With the promising results of this case, the next step would seem to be to replicate the outcome using a sound research design. Such a study might entail randomly assigning a large number of families to comparison and/or waiting list control groups to assess the actual clinical effects of RE therapy. Behavioral and self-report instruments could be used to measure variables such as empathy, expressiveness, problem-solving skill levels, and relationship and communication quality. Such measures could be administered at pre-, post-, and follow-up treatment periods. By researching RE therapy, it may be possible to use the method with greater confidence. Lastly, Ibrahim and Schroeder (1990) have discussed how RE therapy can be an effective intervention for families/couples of various ethnicities. Further research seems warranted in this area to assess the effectiveness of RE with multicultural families/couples.

One recommendation for practice would be to for mental health counselors to consider combining RE therapy methods with their current preferred methods of therapy/counseling. When combining RE therapy with another approach, however, it is important to consider two things: first, the role of the mental health counselor, and second, the uniqueness of the skills. In RE therapy, the mental health counselor takes on the role more akin to a teacher or a coach. Such a role may differ from the role assumed in another approach. The skills are also very distinct and, for the sake of continuity and comprehensiveness, should be presented together rather than intermittently. For example, RE therapy works best when empathy, expressiveness, discussion/negotiation, and problem/solving are taught concomitantly. Moreover, when integrated with other therapies, RE therapy should be offered in discreet and separate segments (Accordino & Guerney, 2001). By following these recommendations for research and practice, it is possible that mental health counseling practice may be enhanced and that RE therapy can be a useful and practical method to treat adolescents with serious mental illness and their family members.

REFERENCES

Accordino, M. P., & Guerney, B. G., Jr. (1993). Effects of the relationship enhancement program on community residential rehabilitation staff and clients. Psychosocial Rehabilitation Journal, 17(2), 131-144.

Accordino, M. P., & Guerney, B. G., Jr. (2001). The empirical validation of relationship enhancement couple and family therapies. In D. J. Cain & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 403-442). Washington, DC: American Psychological Association.

Accordino, M. P., & Herbert, J. T. (1997). Relationship enhancement as an intervention to facilitate rehabilitation of persons with severe mental illness. Journal of Applied Rehabilitation Counseling, 28, 47-52.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. Text rev.). Washington, DC: Author.

Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, A. D., & Stickle, T. R. (1998). Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology, 66, 53-88.

Clark, D. B., Neighbors, B. D., Lesnick, L. A., Lynch, K. G., Donovan, J. E. (1998). Family functioning and adolescent alcohol use disorders. Journal of Family Psychology, 12, 81-92.

Falloon I. R. H., Krekorian, H., Shanahan, W. J., Laporta, M., & McLees, S. (1993). A family-based approach to adult mental disorders. Journal of Family Therapy, 15, 147-161.

Giblin, P., Sprenkle, D. H., & Sheehan, R. (1985). Enrichment outcome research: A meta-analysis of premarital, marital, and family interventions. Journal of Marital and Family Therapy, 11, 257-271.

Greene, G. J. (1986). The effect of the relationship enhancement program on marital communication and self-esteem. The Journal of Applied Social Sciences, 1(1), 78-94.

Griffin, J. M., Jr., & Apostal, R. A. (1993). The influence of relationship enhancement training on differentiation of self. Journal of Marital and Family Therapy, 19, 267-272.

Guerney, B. G., Jr. (1977). Relationship enhancement: Skill training programs for therapy, problem prevention, and enrichment. San Francisco: Jossey-Bass.

Guerney, B. G., Jr. (1991). Relationship enhancement program manual. Bethesda, MD: National Institute of Relationship Enhancement.

Guerney, B. G., Jr. (1994). Relationship enhancement audio program. [Audio cassettes]. National Institute of Relationship Enhancement: Bethesda, MD.

Guerney, B. G., Jr. (1997, June). Advanced training program in relationship enhancement couple/family therapy. Symposium conducted at National Institute of Relationship Enhancement, Bethesda, MD.

Guerney, B. G., Jr., Coufal, J., & Vogelsong, E. (1981). Relationship enhancement versus a traditional approach to therapeutic/preventative/enrichment parent adolescent programs. Journal of Consulting and Clinical Psychology, 49, 927-939.

Guerney, B. G., Jr., & Hardley, G. (1989). A psychoeducational approach. In C. R. Figley (Ed.), Treating Stress in Families (pp. 158-181). New York: Brunner/Mazel.

Guerney, B. G., Jr., Vogelsong, E., & Coufal, J. (1983). Relationship enhancement versus a traditional treatment: Follow-up and booster effects. In D. Olson & B. Miller (Eds.), Family studies review yearbook (pp. 738-756). Beverley Hills: Sage.

Haynes, L. A., & Avery, A. W. (1979). Training adolescents in self-disclosure and empathy skills. Journal of Counseling Psychology, 26, 526-530.

Ibrahim, F. A., & Schroeder, D. G. (1990). Cross-cultural couples counseling: A developmental, psychoeducational intervention. Journal of Comparative Family Studies, 21(2), 193-205.

Lam, D. H. (1991). Psychosocial family intervention in schizophrenia: A review of empirical studies. Psychological Medicine, 21, 423-441.

Leff, J. P., Berkowitz, R., Shavit, N., Strachan, A., Glass, I., & Vaughn, C. (1988). A trial of family therapy versus a relatives group for schizophrenia. British Journal of Psychiatry, 153, 58-66.

Leff, J. P., Berkowitz, R., Shavit, N., Strachan, A., Glass, I., & Vaughn, C. (1990). A trial of family therapy versus a relatives group for schizophrenia. Two year follow-up. British Journal of Psychiatry, 157, 571-577.

Snyder, M. (1994). Couple therapy with narcissistically vulnerable clients: Using the relationship enhancement model. The Family Journal: Counseling and Therapy for Couples and Families, 2, 27-35.

Tarrier, N., Lowson, K., & Barrowclough, C. (1991). Some aspects of family interventions in schizophrenia. II: Financial considerations. British Journal of Psychiatry, 159, 481-484.

Vogelsong, E., Guerney, B. G., Jr., & Guerney L. F. (1983). Relationship enhancement therapy with patients and their families. In R. F. Luber & C. M. Anderson (Eds.), Family intervention with psychiatric patients (pp. 48-68). New York: Human Sciences.

Waldo, M., & Harman, M. J. (1993). Relationship enhancement therapy with borderline personality. The Family Journal: Counseling and Therapy for Couples and Families, 1, 25-30.

Zahniser, J. H., & Falk, D. R. (1993). Relationship enhancement marital therapy with a schizophrenic couple: A case study. The Family Journal: Counseling and Therapy for Couples and Families, 1, 136-143.

Michael P. Accordino D. Ed., CRC, is an assistant professor, Department of Rehabilitation and Disability Studies, Springfield College, Springfield, MA Email: Michael_P_Accordino@ Spfldcol.edu He is certified as a Relationship Enhancement (RE) Couple's Counselor and Program Leader. Donald B. Keat II, Ph.D., is a professor, Department of Counselor Education, Counseling Psychology and Rehabilitation Services, The Pennsylvania State University, University Park, PA. He is also a child psychologist in private practice. Bernard G. Guerney, Jr., Ph.D., is professor emeritus at The Pennsylvania State University, an adjunct professor of Psychology and of Family Studies at the University of Maryland, College Park, and director, National Institute of Relationship Enhancement, North Bethesda, MD.