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Affect-Focused Body Psychotherapy in Patients With Generalized Anxiety Disorder: Evaluation of an Integrative Method

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The aim of this study was to explore the long-term effects of affect-focused body psychotherapy (ABP) for patients with generalized anxiety disorder (GAD). A group of 61 consecutive patients, 21–55 years old, were randomized to ABP and psychiatric treatment as usual (TAU). The patients were assessed before treatment and followed up 1 and 2 years after inclusion. The ABP patients received one session of treatment per week during 1 year. Three self-report questionnaires were administered; Symptom Checklist—90, Beck Anxiety Inventory, and the WHO (Ten) Well-Being Index. In both groups, there was a significant improvement. On termination, the ABP group had improved significantly more on the SCL-90 Global Symptom Index than the TAU group, whereas the differences were short of significance on the other two scales. The integration of bodily techniques with a focus on affects in a psychodynamically informed treatment seems to be a viable treatment alternative for patients with GAD. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Thesis for doctoral degree (Ph.D.)
2009
Aect-focused Body Psychotherapy
for patients with Generalised
Anxiety Disorder
Adrienne Levy Berg
Thesis for doctoral degree (Ph.D.) 2009 Adrienne Levy Berg
AFFECT-FOCUSED BODY PSYCHOTHERAPY FOR
PATIENTS WITH GENERALISED ANXIETY DISORDER
DEPARTMENT OF NEUROBIOLOGY, CARE SCIENCES
AND SOCIETY
Karolinska Institutet, Stockholm, Sweden
AFFECT-FOCUSED BODY
PSYCHOTHERAPY FOR
PATIENTS WITH GENERALISED
ANXIETY DISORDER
Adrienne Levy Berg
Stockholm 2009
Affect-focused Body Psychotherapy
for patients with
Generalised Anxiety Disorder
DEPARTMENT OF NEUROBIOLOGY, CARE SCIENCES
AND SOCIETY
Karolinska Institutet, Stockholm, Sweden
AFFECT-FOCUSED BODY
PSYCHOTHERAPY FOR
PATIENTS WITH GENERALISED
ANXIETY DISORDER
Adrienne Levy Berg
Stockholm 2009
Affect-focused Body Psychotherapy
for patients with
Generalised Anxiety Disorder
All previously published papers were reproduced with permission from the publisher.
Published by Karolinska Institutet. Printed by EPRINT, www.eprint.se
Oxtorgsgatan 9-11, 111 57 Stockholm.
© Adrienne Levy Berg, 2009
ISBN 978-91-7409-375-9
All previously published papers were reproduced with permission from the publisher.
Published by Karolinska Institutet. Printed by EPRINT, www.eprint.se
Oxtorgsgatan 9-11, 111 57 Stockholm.
© Adrienne Levy Berg, 2009
ISBN 978-91-7409-375-9
That if real success is to attend the effort to bring
a man to a definite position, one must first of all take
pains to find him where he is and begin there. This is the
secret of the art of helping others (Kierkegaard [1848]
1962, p.27.)
That if real success is to attend the effort to bring
a man to a definite position, one must first of all take
pains to find him where he is and begin there. This is the
secret of the art of helping others (Kierkegaard [1848]
1962, p.27.)
ABSTRACT
Introduction and aims: This thesis investigates Affect-focused Body Psychotherapy
(ABP) for patients with Generalised Anxiety Disorder (GAD). ABP has demonstrated
good results in patients with chronic pain, but its effect has not been empirically tested
in psychiatric disorders. The aim of the present thesis was to evaluate ABP for GAD
from several angles. Study I was an outcome trial comparing ABP to Psychiatric
treatment as usual (TAU). Study II investigated whether ABP influenced affect
consciousness (AC), and how AC was related to psychiatric symptoms. Study III
explored the relationship of treatment preferences and experiences to outcome. Study IV
investigated how patients with GAD experienced ABP.
Methods: A group of 61 consecutive referrals with GAD, 21-55 years old, were
randomised to ABP (n=33) or TAU (n= 28). Patients were assessed before treatment and
followed-up one and two years after inclusion. ABP patients received treatment once a
week for one year. Five self-report questionnaires were administered to both groups:
SCL-90, Beck Anxiety Inventory, WHO (Ten) Well-Being Index, SCID screen, and
Treatment Preferences and Experiences Questionnaire (TPEX). Patients in ABP were
interviewed at the end of treatment and one year afterwards concerning their treatment
experiences. ABP patients were also assessed with the Affect Consciousness Interview
prior to and at termination of treatment.
Results: Both groups showed significant clinical improvement. At termination ABP had
improved significantly more on the SCL-90 Global Symptom Index than TAU, whereas
differences were non-significant on the BAI and WWBI. Affect consciousness increased
after ABP, and patients with high levels of anxiety at treatment start as measured with
the BAI increased their affect-consciousness most. However, it was not possible to
conclude that affect consciousness had an effect on outcome, directly or as a mediator.
ABP patients reported being helped by supportive and reflective treatment interventions
to a greater extent than controls, but it was found that differences in outcome were
considerably more marked for patients who had mainly positive treatment experiences
compared to those who had mainly negative ones independent of treatment form.
Treatment expectations appeared to be based on patients’ perception of their bodies. A
key aspect concerning shame and control emerged in the interview material. Patients
who approached the body with curiosity and interest tended to reformulate anxiety, and
could see such reactions as conveying meaningful information about their life situation.
Conclusions: The integration of body-based techniques and a focus on affects into a
body psychotherapy framework, such as ABP, may constitute an effective treatment for
GAD, especially among patients who are interested in exploring the questions of mind-
body unity. However, the results indicate that interpersonal aspects of therapy need to be
more fully explored. Paying closer attention to treatment preferences and body attitudes
may increase the potential of ABP and improve outcome.
Key words: Affect-focused Body Psychotherapy, affect consciousness,
Generalised Anxiety Disorder, lived body, physiotherapy, preferences
ABSTRACT
Introduction and aims: This thesis investigates Affect-focused Body Psychotherapy
(ABP) for patients with Generalised Anxiety Disorder (GAD). ABP has demonstrated
good results in patients with chronic pain, but its effect has not been empirically tested
in psychiatric disorders. The aim of the present thesis was to evaluate ABP for GAD
from several angles. Study I was an outcome trial comparing ABP to Psychiatric
treatment as usual (TAU). Study II investigated whether ABP influenced affect
consciousness (AC), and how AC was related to psychiatric symptoms. Study III
explored the relationship of treatment preferences and experiences to outcome. Study IV
investigated how patients with GAD experienced ABP.
Methods: A group of 61 consecutive referrals with GAD, 21-55 years old, were
randomised to ABP (n=33) or TAU (n= 28). Patients were assessed before treatment and
followed-up one and two years after inclusion. ABP patients received treatment once a
week for one year. Five self-report questionnaires were administered to both groups:
SCL-90, Beck Anxiety Inventory, WHO (Ten) Well-Being Index, SCID screen, and
Treatment Preferences and Experiences Questionnaire (TPEX). Patients in ABP were
interviewed at the end of treatment and one year afterwards concerning their treatment
experiences. ABP patients were also assessed with the Affect Consciousness Interview
prior to and at termination of treatment.
Results: Both groups showed significant clinical improvement. At termination ABP had
improved significantly more on the SCL-90 Global Symptom Index than TAU, whereas
differences were non-significant on the BAI and WWBI. Affect consciousness increased
after ABP, and patients with high levels of anxiety at treatment start as measured with
the BAI increased their affect-consciousness most. However, it was not possible to
conclude that affect consciousness had an effect on outcome, directly or as a mediator.
ABP patients reported being helped by supportive and reflective treatment interventions
to a greater extent than controls, but it was found that differences in outcome were
considerably more marked for patients who had mainly positive treatment experiences
compared to those who had mainly negative ones independent of treatment form.
Treatment expectations appeared to be based on patients’ perception of their bodies. A
key aspect concerning shame and control emerged in the interview material. Patients
who approached the body with curiosity and interest tended to reformulate anxiety, and
could see such reactions as conveying meaningful information about their life situation.
Conclusions: The integration of body-based techniques and a focus on affects into a
body psychotherapy framework, such as ABP, may constitute an effective treatment for
GAD, especially among patients who are interested in exploring the questions of mind-
body unity. However, the results indicate that interpersonal aspects of therapy need to be
more fully explored. Paying closer attention to treatment preferences and body attitudes
may increase the potential of ABP and improve outcome.
Key words: Affect-focused Body Psychotherapy, affect consciousness,
Generalised Anxiety Disorder, lived body, physiotherapy, preferences
SAMMANFATTNING
Introduktion och syfte: I denna avhandling presenteras data om Affektfokuserad
kroppspsykoterapi (ABP) för patienter med generaliserad ångest (GAD). ABP har utvärderats
med goda resultat för patienter med kronisk smärta. Emellertid har metoden inte testats för
patienter med psykiska störningar. Syftet med denna avhandling var att utvärdera ABP från olika
perspektiv. I studie I som är en utfallsstudie, jämfördes ABP med sedvanlig psykiatrisk
behandling (TAU) inom öppenvårdspsykiatrin. I studie II var syftet att utvärdera om
affektmedvetenheten (AM) påverkades av ett års behandling med ABP och hur AM var relaterat
till symptom nivå. I studie III jämfördes patienternas behandlingspreferenser och erfarenheter
med behandlings resultatet. I studie IV undersöktes hur patienterna upplevde ABP behandlingen.
Metod: 61 konsekutiva patienter med GAD, 21-55 år gamla, randomiserades till ABP (n=33)
och TAU (n=29). Data för utvärdering samlades in vid tre tidpunkter; före behandlingen samt ett
och två år efter behandlingsstart. Patienterna i ABP gruppen erhöll behandling en gång per vecka
under ett år. Fem självskattningsformulär användes; SCL-90, Becks ångest skala (BAI), WHO’s
välbefinnande index (WWBI), SCID screen, och frågeformulär om patienternas behandlings
förväntningar och erfarenheter (TPEX). Patienterna i ABP intervjuades vid avslutad behandling
samt efter ytterligare ett år rörande deras upplevelser av behandlingen. Vidare deltog patienterna
i en affektmedvetenhetsintervju före och direkt efter ABP behandlingen.
Resultat: Patienterna i båda grupperna förbättrades signifikant över tid. Emellertid var
förbättringen i ABP gruppen signifikant större beträffande symptomreduktion mätt med SCL-90,
däremot var skillnaderna inte signifikanta beträffande BAI och WWBI. I studie II framkom att
Affektmedvetenheten ökade signifikant, det var patienter med hög ångest, mätt med BAI, som
ökade sin affektmedvetenhet mest. Det var dock ej möjligt att visa att affektmedvetenheten
påverkade utfallet varken direkt eller indirekt. I studie III framkom att ABP patienter, i högre
grad än kontrollgruppens patienter, upplevde att de hade fått hjälp av interventioner som var
inriktad på stöd och reflektion. Skillnader i behandlingsresultatet var mer beroende på
patienternas upplevelse av behandlingen än behandlingsformen, d.v.s de som huvudsakligen
hade positiva behandlingserfarenheter förbättrades mer än de som huvudsakligen hade negativa
erfarenheter, oberoende av interventionsmodell. I studie IV framkom att patienternas
förväntningar på terapin var relaterade till hur de uppfattade sin kropp. Skam och kontroll var
viktiga faktorer som trädde fram vid analysen av intervjumaterialet. Patienter som förmådde
möta sin kropp med nyfikenhet och intresse lyckades omformulera ångest signalerna. Dessa
kunde då förändras från att vara skrämmande till att förmedla meningsfull information om den
egna livssituationen.
Konklusion: Integrationen av kroppsliga tekniker och fokus på affekter i en kroppspsyko-
terapeutisk metod så som i ABP tycks vara ett möjligt behandlingsalternativ för patienter med
GAD, i synnerhet för patienter som är intresserade av att närmare undersöka enheten kropp-
psyke. Emellertid tyder resultaten på att de interpersonella aspekterna i terapin måste studeras
närmare. En ökad uppmärksamhet på patienters behandlingspreferenser och inställning till den
egna kroppen kan höja behandlingspotentialen och förbättra resultatet.
Nyckelord: Affektfokuserad kroppspsykoterapi, affektmedvetenhet, den levda kroppen,
Generaliserad ångest, sjukgymnastik, psykoterapi, preferenser
SAMMANFATTNING
Introduktion och syfte: I denna avhandling presenteras data om Affektfokuserad
kroppspsykoterapi (ABP) för patienter med generaliserad ångest (GAD). ABP har utvärderats
med goda resultat för patienter med kronisk smärta. Emellertid har metoden inte testats för
patienter med psykiska störningar. Syftet med denna avhandling var att utvärdera ABP från olika
perspektiv. I studie I som är en utfallsstudie, jämfördes ABP med sedvanlig psykiatrisk
behandling (TAU) inom öppenvårdspsykiatrin. I studie II var syftet att utvärdera om
affektmedvetenheten (AM) påverkades av ett års behandling med ABP och hur AM var relaterat
till symptom nivå. I studie III jämfördes patienternas behandlingspreferenser och erfarenheter
med behandlings resultatet. I studie IV undersöktes hur patienterna upplevde ABP behandlingen.
Metod: 61 konsekutiva patienter med GAD, 21-55 år gamla, randomiserades till ABP (n=33)
och TAU (n=29). Data för utvärdering samlades in vid tre tidpunkter; före behandlingen samt ett
och två år efter behandlingsstart. Patienterna i ABP gruppen erhöll behandling en gång per vecka
under ett år. Fem självskattningsformulär användes; SCL-90, Becks ångest skala (BAI), WHO’s
välbefinnande index (WWBI), SCID screen, och frågeformulär om patienternas behandlings
förväntningar och erfarenheter (TPEX). Patienterna i ABP intervjuades vid avslutad behandling
samt efter ytterligare ett år rörande deras upplevelser av behandlingen. Vidare deltog patienterna
i en affektmedvetenhetsintervju före och direkt efter ABP behandlingen.
Resultat: Patienterna i båda grupperna förbättrades signifikant över tid. Emellertid var
förbättringen i ABP gruppen signifikant större beträffande symptomreduktion mätt med SCL-90,
däremot var skillnaderna inte signifikanta beträffande BAI och WWBI. I studie II framkom att
Affektmedvetenheten ökade signifikant, det var patienter med hög ångest, mätt med BAI, som
ökade sin affektmedvetenhet mest. Det var dock ej möjligt att visa att affektmedvetenheten
påverkade utfallet varken direkt eller indirekt. I studie III framkom att ABP patienter, i högre
grad än kontrollgruppens patienter, upplevde att de hade fått hjälp av interventioner som var
inriktad på stöd och reflektion. Skillnader i behandlingsresultatet var mer beroende på
patienternas upplevelse av behandlingen än behandlingsformen, d.v.s de som huvudsakligen
hade positiva behandlingserfarenheter förbättrades mer än de som huvudsakligen hade negativa
erfarenheter, oberoende av interventionsmodell. I studie IV framkom att patienternas
förväntningar på terapin var relaterade till hur de uppfattade sin kropp. Skam och kontroll var
viktiga faktorer som trädde fram vid analysen av intervjumaterialet. Patienter som förmådde
möta sin kropp med nyfikenhet och intresse lyckades omformulera ångest signalerna. Dessa
kunde då förändras från att vara skrämmande till att förmedla meningsfull information om den
egna livssituationen.
Konklusion: Integrationen av kroppsliga tekniker och fokus på affekter i en kroppspsyko-
terapeutisk metod så som i ABP tycks vara ett möjligt behandlingsalternativ för patienter med
GAD, i synnerhet för patienter som är intresserade av att närmare undersöka enheten kropp-
psyke. Emellertid tyder resultaten på att de interpersonella aspekterna i terapin måste studeras
närmare. En ökad uppmärksamhet på patienters behandlingspreferenser och inställning till den
egna kroppen kan höja behandlingspotentialen och förbättra resultatet.
Nyckelord: Affektfokuserad kroppspsykoterapi, affektmedvetenhet, den levda kroppen,
Generaliserad ångest, sjukgymnastik, psykoterapi, preferenser
LIST OF PUBLICATIONS
I.
Levy Berg, A., Sandell, R., & Sandahl, C. (2009). Affect-focused body
psychotherapy in patients with generalized anxiety disorder: evaluation of an
integrative method. Journal of Psychotherapy Integration, 19, 67-85.
Reproduced with permission from Journal of Psychotherapy Integration
Copyright © 2009 by the American Psychological Association.
II.
Levy Berg, A., Sandell, R., & Sandahl, C. Is there a relationship between
affect-consciousness and distress in patients with Generalised Anxiety
Disorder before and after treatment with affect-focused body psychotherapy?
Psychotherapy Research. (Submitted)
III.
Levy Berg, A., Sandahl, C., & Clinton, D. (2008). The relationship of
treatment preferences and experiences to outcome in generalized anxiety
disorder (GAD). Psychology and Psychotherapy: Theory, Research and
Practice, 81, 247-59. Reproduced with permission from the Psychology and
Psychotherapy: Theory, Research and Practice, © The British Psychological
Society.
IV.
Levy Berg, A., Sandahl, C., & Bullington, J. Patients’ perspective of change
processes in Affect-focused Body Psychotherapy. (Manuscript).
LIST OF PUBLICATIONS
I.
Levy Berg, A., Sandell, R., & Sandahl, C. (2009). Affect-focused body
psychotherapy in patients with generalized anxiety disorder: evaluation of an
integrative method. Journal of Psychotherapy Integration, 19, 67-85.
Reproduced with permission from Journal of Psychotherapy Integration
Copyright © 2009 by the American Psychological Association.
II.
Levy Berg, A., Sandell, R., & Sandahl, C. Is there a relationship between
affect-consciousness and distress in patients with Generalised Anxiety
Disorder before and after treatment with affect-focused body psychotherapy?
Psychotherapy Research. (Submitted)
III.
Levy Berg, A., Sandahl, C., & Clinton, D. (2008). The relationship of
treatment preferences and experiences to outcome in generalized anxiety
disorder (GAD). Psychology and Psychotherapy: Theory, Research and
Practice, 81, 247-59. Reproduced with permission from the Psychology and
Psychotherapy: Theory, Research and Practice, © The British Psychological
Society.
IV.
Levy Berg, A., Sandahl, C., & Bullington, J. Patients’ perspective of change
processes in Affect-focused Body Psychotherapy. (Manuscript).
CONTENTS
1 INTRODUCTION .......................................................................................... 1
1.1 Mind-body relationship in psychotherapy ......................................................... 2
1.2 Psychomotor physiotherapy ................................................................................. 3
1.3 Body awareness ...................................................................................................... 4
1.4 Affect-focused body psychotherapy .................................................................... 4
1.4.1 ABP according to Wampold’s levels of abstraction of psychotherapy ............. 5
1.4.1.1 Theoretical approach .................................................................................. 5
1.4.1.2 Technique .................................................................................................... 7
1.4.1.3 Strategies - the therapist’s role ................................................................... 8
1.4.1.4 Meta-theory ................................................................................................. 8
1.5 Generalised anxiety disorder ............................................................................. 10
1.5.1 Prevalence and incidence .................................................................................. 10
1.5.2 Etiology .............................................................................................................. 11
1.5.2.1 Genetic explications .................................................................................. 11
1.5.2.2 Childhood experiences .............................................................................. 11
1.5.3 Understanding the worry in GAD ..................................................................... 12
1.5.4 Therapeutic treatment ........................................................................................ 12
1.6 Patient’s preferences and experiences related to outcome ............................. 13
1.7 Locating myself .................................................................................................... 14
1.8 Rationale ............................................................................................................... 15
1.9 Aim of the thesis ................................................................................................... 16
2 METHOD ..................................................................................................... 17
2.1 Research design .................................................................................................... 17
2.2 Patients .................................................................................................................. 18
2.3 Procedures ............................................................................................................ 19
2.4 Instruments and measures ................................................................................. 20
2.4.1 Self-rated instruments ........................................................................................ 20
2.4.1.1 Socio-demographic data ........................................................................... 20
2.4.1.2 Severity of psychiatric symptoms .............................................................. 20
2.4.1.3 Severity of anxiety symptoms .................................................................... 21
2.4.1.4 Well being .................................................................................................. 22
2.4.1.5 SCID II screen ........................................................................................... 22
CONTENTS
1 INTRODUCTION .......................................................................................... 1
1.1 Mind-body relationship in psychotherapy ......................................................... 2
1.2 Psychomotor physiotherapy ................................................................................. 3
1.3 Body awareness ...................................................................................................... 4
1.4 Affect-focused body psychotherapy .................................................................... 4
1.4.1 ABP according to Wampold’s levels of abstraction of psychotherapy ............. 5
1.4.1.1 Theoretical approach .................................................................................. 5
1.4.1.2 Technique .................................................................................................... 7
1.4.1.3 Strategies - the therapist’s role ................................................................... 8
1.4.1.4 Meta-theory ................................................................................................. 8
1.5 Generalised anxiety disorder ............................................................................. 10
1.5.1 Prevalence and incidence .................................................................................. 10
1.5.2 Etiology .............................................................................................................. 11
1.5.2.1 Genetic explications .................................................................................. 11
1.5.2.2 Childhood experiences .............................................................................. 11
1.5.3 Understanding the worry in GAD ..................................................................... 12
1.5.4 Therapeutic treatment ........................................................................................ 12
1.6 Patient’s preferences and experiences related to outcome ............................. 13
1.7 Locating myself .................................................................................................... 14
1.8 Rationale ............................................................................................................... 15
1.9 Aim of the thesis ................................................................................................... 16
2 METHOD ..................................................................................................... 17
2.1 Research design .................................................................................................... 17
2.2 Patients .................................................................................................................. 18
2.3 Procedures ............................................................................................................ 19
2.4 Instruments and measures ................................................................................. 20
2.4.1 Self-rated instruments ........................................................................................ 20
2.4.1.1 Socio-demographic data ........................................................................... 20
2.4.1.2 Severity of psychiatric symptoms .............................................................. 20
2.4.1.3 Severity of anxiety symptoms .................................................................... 21
2.4.1.4 Well being .................................................................................................. 22
2.4.1.5 SCID II screen ........................................................................................... 22
2.4.1.6 Treatment preferences and experiences ................................................... 22
2.4.2 Interviews .......................................................................................................... 23
2.4.2.1 Affect Consciousness interview ................................................................ 23
2.4.2.2 Qualitative interviews ............................................................................... 24
2.5 Treatment and therapists ................................................................................... 24
2.6 Patients and methods of analysis ....................................................................... 25
2.6.1 Paper I-III .......................................................................................................... 25
2.6.2 Paper IV ............................................................................................................. 28
3 RESULTS ................................................................................................... 30
3.1 Primary outcome study (I) ................................................................................. 30
3.2 The relationship between affect-consciousness and distress (II) ................... 32
3.2.1 Additional analysis: Description of positive changes in affect consciousness 32
3.2.2 Affect consciousness in relation to other variables .......................................... 36
3.3 Relationship of patients preferences and experiences to outcome (III) ........ 38
3.4 Patients’ perspective of change processes in ABP (IV) .................................. 39
4 DISCUSSION ............................................................................................. 40
4.1 Reflections on main findings .............................................................................. 40
4.2 Revised meta theory ............................................................................................ 43
4.3 Methodological considerations .......................................................................... 44
4.4 Clinical implications ............................................................................................ 48
4.5 Suggestions for future research ......................................................................... 49
4.6 Conclusions .......................................................................................................... 50
5 ACKNOWLEDGEMENTS .......................................................................... 51
6 REFERENCES ........................................................................................... 53
2.4.1.6 Treatment preferences and experiences ................................................... 22
2.4.2 Interviews .......................................................................................................... 23
2.4.2.1 Affect Consciousness interview ................................................................ 23
2.4.2.2 Qualitative interviews ............................................................................... 24
2.5 Treatment and therapists ................................................................................... 24
2.6 Patients and methods of analysis ....................................................................... 25
2.6.1 Paper I-III .......................................................................................................... 25
2.6.2 Paper IV ............................................................................................................. 28
3 RESULTS ................................................................................................... 30
3.1 Primary outcome study (I) ................................................................................. 30
3.2 The relationship between affect-consciousness and distress (II) ................... 32
3.2.1 Additional analysis: Description of positive changes in affect consciousness 32
3.2.2 Affect consciousness in relation to other variables .......................................... 36
3.3 Relationship of patients preferences and experiences to outcome (III) ........ 38
3.4 Patients’ perspective of change processes in ABP (IV) .................................. 39
4 DISCUSSION ............................................................................................. 40
4.1 Reflections on main findings .............................................................................. 40
4.2 Revised meta theory ............................................................................................ 43
4.3 Methodological considerations .......................................................................... 44
4.4 Clinical implications ............................................................................................ 48
4.5 Suggestions for future research ......................................................................... 49
4.6 Conclusions .......................................................................................................... 50
5 ACKNOWLEDGEMENTS .......................................................................... 51
6 REFERENCES ........................................................................................... 53
LIST OF ABBREVIATIONS
ABP Affect-focused body psychotherapy
AC Affect consciousness
ACI
ANOVA
Anx
Affect consciousness interview
Analysis of variance
The anxiety subscale of SCL-90
BAI
DSM IV
Beck’s anxiety inventory
Diagnostic and Statistical Manual of Mental
Disorders, fourth edition
GAD
GSI
GSI-anx
GSI_anx
MANCOVA
MANOVA
Generalised Anxiety Disorder
Global Severity Index (the mean across the 90 items
on the SCL-90)
Global Severity Index without the anxiety scale
Global Severity Index without the anxiety scale
Multivariate analysis of co-variance
Multivariate analysis of variance
PD
RCI
SCL-90
SCLAnx
SCID
Personality Disorder
Reliable Change Index
Symptom check list 90
The anxiety subscale of SCL-90
Structured Clinical Interview for DSM disorders
TAU
TPEX
Treatment as usual
Treatment Preferences and Experiences scale
WWBI WHO’s Well Being Index
LIST OF ABBREVIATIONS
ABP Affect-focused body psychotherapy
AC Affect consciousness
ACI
ANOVA
Anx
Affect consciousness interview
Analysis of variance
The anxiety subscale of SCL-90
BAI
DSM IV
Beck’s anxiety inventory
Diagnostic and Statistical Manual of Mental
Disorders, fourth edition
GAD
GSI
GSI-anx
GSI_anx
MANCOVA
MANOVA
Generalised Anxiety Disorder
Global Severity Index (the mean across the 90 items
on the SCL-90)
Global Severity Index without the anxiety scale
Global Severity Index without the anxiety scale
Multivariate analysis of co-variance
Multivariate analysis of variance
PD
RCI
SCL-90
SCLAnx
SCID
Personality Disorder
Reliable Change Index
Symptom check list 90
The anxiety subscale of SCL-90
Structured Clinical Interview for DSM disorders
TAU
TPEX
Treatment as usual
Treatment Preferences and Experiences scale
WWBI WHO’s Well Being Index
1
1 INTRODUCTION
The affect-focused body psychotherapy (ABP) is a method that was created by Monsen
in the end of the 80’s (Psychodynamic body therapy, 1989) and so far its effect has not
been tested regarding patients suffering from Generalised Anxiety Disorder (GAD).
In ABP anxiety is considered a natural emotion, it is the persons way of
avoiding anxiety signals that may become neurotic (Malan, 1999; McCullough &
Andrews, 2001). Affects, which are not accepted, or play a much too prominent role
(such as shame and fear), will cause anxiety problems for the individual. The patient
uses conscious or unconscious mental and bodily manoeuvres to defend him/herself
from experiencing the unwanted emotions, thus worsening the problem by getting
secondary difficulties such as muscular stiffness, pain, vertigo, nausea, sleeplessness,
and phobias.
GAD is characterized by uncontrollable worry (Appendix 1; APA, 1994) and is
associated with a wide range of somatic symptoms as well as impaired social
functioning (Kubzansky et al., 1997). GAD is also associated with cardiac events (Shen
et al. 2008), poor glycemic control in diabetes (Frasure-Smith & Lespérance, 2008), as
well as chronic obstructive pulmonary disease (Brenes, 2003). Furthermore, patients
with muscle pain, headache, or stomach pain are likely to have GAD, panic anxiety, or
depression (Anderson et al., 2002). High rate of psychiatric co-morbidity, primarily
depressive episodes, social anxiety, and sometimes self-medication with alcohol is also
associated with GAD (Dyck et al., 2001; Wittchen, Zhao, Kessler, & Eaton, 1994). In
a review of 34 studies, it was found that impairment in quality of life from GAD was of
similar magnitude to that seen in depression. Substantial costs were incurred as a result
of GAD, due to reduced work capacity (Hoffman, Dukes, & Wittchen, 2008).
Patients with GAD often seek primary health care because of muscular pain
caused by anxiety-provoked tension. This is one reason why patients with GAD are
often referred to physiotherapeutic treatment. However, this patient group is a
challenge to physiotherapists because symptomatic treatment generally only achieves
short-term relief. The patients tend to seek help because of their physical problems over
and over again, with a high risk of becoming frustrated and disappointed. This pattern
also causes high costs in the health care system. Therefore we wanted to explore if the
ABP method that integrates bodily interventions with a focus on affect awareness could
be a viable way of dealing with the problems presented by patients suffering from
GAD.
1
1 INTRODUCTION
The affect-focused body psychotherapy (ABP) is a method that was created by Monsen
in the end of the 80’s (Psychodynamic body therapy, 1989) and so far its effect has not
been tested regarding patients suffering from Generalised Anxiety Disorder (GAD).
In ABP anxiety is considered a natural emotion, it is the persons way of
avoiding anxiety signals that may become neurotic (Malan, 1999; McCullough &
Andrews, 2001). Affects, which are not accepted, or play a much too prominent role
(such as shame and fear), will cause anxiety problems for the individual. The patient
uses conscious or unconscious mental and bodily manoeuvres to defend him/herself
from experiencing the unwanted emotions, thus worsening the problem by getting
secondary difficulties such as muscular stiffness, pain, vertigo, nausea, sleeplessness,
and phobias.
GAD is characterized by uncontrollable worry (Appendix 1; APA, 1994) and is
associated with a wide range of somatic symptoms as well as impaired social
functioning (Kubzansky et al., 1997). GAD is also associated with cardiac events (Shen
et al. 2008), poor glycemic control in diabetes (Frasure-Smith & Lespérance, 2008), as
well as chronic obstructive pulmonary disease (Brenes, 2003). Furthermore, patients
with muscle pain, headache, or stomach pain are likely to have GAD, panic anxiety, or
depression (Anderson et al., 2002). High rate of psychiatric co-morbidity, primarily
depressive episodes, social anxiety, and sometimes self-medication with alcohol is also
associated with GAD (Dyck et al., 2001; Wittchen, Zhao, Kessler, & Eaton, 1994). In
a review of 34 studies, it was found that impairment in quality of life from GAD was of
similar magnitude to that seen in depression. Substantial costs were incurred as a result
of GAD, due to reduced work capacity (Hoffman, Dukes, & Wittchen, 2008).
Patients with GAD often seek primary health care because of muscular pain
caused by anxiety-provoked tension. This is one reason why patients with GAD are
often referred to physiotherapeutic treatment. However, this patient group is a
challenge to physiotherapists because symptomatic treatment generally only achieves
short-term relief. The patients tend to seek help because of their physical problems over
and over again, with a high risk of becoming frustrated and disappointed. This pattern
also causes high costs in the health care system. Therefore we wanted to explore if the
ABP method that integrates bodily interventions with a focus on affect awareness could
be a viable way of dealing with the problems presented by patients suffering from
GAD.
2
1.1 MIND-BODY RELATIONSHIP IN PSYCHOTHERAPY
Freud stated in the Ego and the Id (1927) that the ego is “first and foremost a body-ego
(p 26)”…”the ego is ultimately derived from bodily sensations, chiefly from those
springing from the surface of the body” (p 27). Freud fought throughout his earlier
career with the integration or lack of integration between body and mind. As Freud’s
psychoanalytic theory and technique developed it became more trapped in the mind-
body dualism prevalent in European culture of the time. One of Freud’s associates,
Wilhelm Reich, has contributed to our understanding of the body’s role in
psychotherapy. He developed a theory of muscular armour, which sought to understand
the ways in which we inhibit our “libidinal flow” by means of muscular defences
mostly seen in the thorax. Reich’s (1948) work is the basis for many approaches to
body psychotherapy that exist today, and it has influenced the ABP. Reich used touch
to accompany the talking cure, taking an active role in sessions, feeling his patients'
chests to check their breathing, repositioning their bodies and sometimes requiring
them to remove their clothes, so that men were treated wearing shorts and women in
bra and panties.
Another of Freud’s associates was Franz Alexander, a Hungarian psychoanalyst
and physician, who investigated the dynamic interrelation between mind and body.
Alexander observed that patients with certain illnesses had corresponding personality
styles. He concluded that addressing the personal style of the patient could pave the
way to healing. Alexander is considered one of the founders of psychosomatic
medicine (Alexander, 1962). Alexander’s work was a continuation and realization of
ideas first proposed by Ferenczi and Rank (1925). Ferenczi opposed to the touch taboo
and was not comfortable with the distant and neutral position of the psychoanalyst. He
wished for a more genuine relationship and included bodily techniques to reach a
deeper level of contact with the client. He believed that through physical contact he was
addressing early developmental needs in his clients (Eiden, 2002).
Winnicott, emphasized the relational aspect in therapeutic work. He regarded
the ‘holding environment’ as essential for the emotional development of the child
(Winnicott, 1960). The needs of the emotional body self were taken more into account.
Sensual and tactile needs were no longer seen as sexual needs; instead it was
considered as vital for the individual to have joy in bodily activity and tactile
experiences. These were seen as necessary to build an embodied sense of self – the
body as a container of the self. Winnicott (1962) stated that: “the ego is based on a
body-ego but it is only when all goes well that the person of the baby starts to be linked
with the body and the body functions, with the skin as the limiting membrane“ (p 59).
It is through the sensations from the skin that we can reach the twofold
experience of both having a body and being a body (Anzieu, 1989). Anzieu argues that
the functions of the skin serve as a rudimentary model for the primitive ego, what he
calls the skin ego. Aron (1998) proposes that the term skin ego may be better termed
2
1.1 MIND-BODY RELATIONSHIP IN PSYCHOTHERAPY
Freud stated in the Ego and the Id (1927) that the ego is “first and foremost a body-ego
(p 26)”…”the ego is ultimately derived from bodily sensations, chiefly from those
springing from the surface of the body” (p 27). Freud fought throughout his earlier
career with the integration or lack of integration between body and mind. As Freud’s
psychoanalytic theory and technique developed it became more trapped in the mind-
body dualism prevalent in European culture of the time. One of Freud’s associates,
Wilhelm Reich, has contributed to our understanding of the body’s role in
psychotherapy. He developed a theory of muscular armour, which sought to understand
the ways in which we inhibit our “libidinal flow” by means of muscular defences
mostly seen in the thorax. Reich’s (1948) work is the basis for many approaches to
body psychotherapy that exist today, and it has influenced the ABP. Reich used touch
to accompany the talking cure, taking an active role in sessions, feeling his patients'
chests to check their breathing, repositioning their bodies and sometimes requiring
them to remove their clothes, so that men were treated wearing shorts and women in
bra and panties.
Another of Freud’s associates was Franz Alexander, a Hungarian psychoanalyst
and physician, who investigated the dynamic interrelation between mind and body.
Alexander observed that patients with certain illnesses had corresponding personality
styles. He concluded that addressing the personal style of the patient could pave the
way to healing. Alexander is considered one of the founders of psychosomatic
medicine (Alexander, 1962). Alexander’s work was a continuation and realization of
ideas first proposed by Ferenczi and Rank (1925). Ferenczi opposed to the touch taboo
and was not comfortable with the distant and neutral position of the psychoanalyst. He
wished for a more genuine relationship and included bodily techniques to reach a
deeper level of contact with the client. He believed that through physical contact he was
addressing early developmental needs in his clients (Eiden, 2002).
Winnicott, emphasized the relational aspect in therapeutic work. He regarded
the ‘holding environment’ as essential for the emotional development of the child
(Winnicott, 1960). The needs of the emotional body self were taken more into account.
Sensual and tactile needs were no longer seen as sexual needs; instead it was
considered as vital for the individual to have joy in bodily activity and tactile
experiences. These were seen as necessary to build an embodied sense of self – the
body as a container of the self. Winnicott (1962) stated that: “the ego is based on a
body-ego but it is only when all goes well that the person of the baby starts to be linked
with the body and the body functions, with the skin as the limiting membrane“ (p 59).
It is through the sensations from the skin that we can reach the twofold
experience of both having a body and being a body (Anzieu, 1989). Anzieu argues that
the functions of the skin serve as a rudimentary model for the primitive ego, what he
calls the skin ego. Aron (1998) proposes that the term skin ego may be better termed
3
the skin self and may then be viewed as one aspect of what Stern (1985) calls the “core
self”. Aron (1998) states: “Our bodies, our sensations, particularly the sensations of
our skin surface are critical in shaping our images of our selves. In infancy , our bodily
sensations are greatly affected by the qualities of the “holding” and “handling” that
we receive from caretakers, and so it is not much of an extension to suggest that our
self is foremost a body-as experiences-being-handled-and–held-by-other-self, in other
words, our self is foremost a body-in-relation-self (p.20).
Both Lowen (1958) and Reich (1948) suggested that there was a close
connection between the inhibition of breath and inhibition of feelings. Lowen (1976)
has developed bioenergetics based on Reich’s structure model, a theoretical system
and a practical approach concerned with raising consciousness about how we use our
‘life energy’. In bioenergetics focus is directed towards facilitating breathing and body
exercise to facilitate emotional expression. Keleman (1992) developed another system
of body structures based on anatomical structures with focus on parts where ‘energy’ is
constricted or suppressed. He would emphasize the body work and requested his
patients to listen to what the body could tell (Eiden, 2002).
During Reich’s stay in Norway in the 1930s he came to influence the
psychotherapy of the time. The Norwegian physician and psychoanalyst Braatøy was
greatly influenced by the work of Reich. Braatøy (1947/1965) discovered the interplay
between tense muscles, respiration and nervousness as he worked closely together with
the physiotherapist Bülow Hansen. Their joint work laid the foundation to the now
widely recognized Norwegian psychomotor physiotherapy, developed by Thornquist
and Bunkan (1990). This is considered the first cornerstone of the Affect-focused body
psychotherapy (ABP).
1.2 PSYCHOMOTOR PHYSIOTHERAPY
In Psychomotor Physiotherapy (Bunkan, Thornquist & Radøy, 1982) the body is seen
as a functional unit. This signifies that local symptoms are viewed in the context of the
whole person as a social, psychological and physiological being. In Psychomotor
Physiotherapy the aim is not to break the defence mechanism but to offer a possibility
for new experiences and facilitate the ability to get in touch with earlier experiences.
The treatment in psychomotor physiotherapy is partly based on findings from the
physical examination, performed following the Resource Oriented Body Examination
(ROBE) developed by Bunkan (1996). This type of body examination represents a
qualitatively different approach than the objective, biomedical oriented body
examination. In the ROBE communication, subjective experiences and the relation
between the patient and the therapist are crucial elements. The body examination gives
important information concerning the patient’s way of relating towards himself as well
as his resources. (Bunkan, 1996; Bunkan, Ljunggren, Opjordsmoen, Moen, & Friis,
2001; Bunkan, Opjordsmoen, Moen, Ljunggren, & Friis, 1999; Friis, Bunkan,
3
the skin self and may then be viewed as one aspect of what Stern (1985) calls the “core
self”. Aron (1998) states: “Our bodies, our sensations, particularly the sensations of
our skin surface are critical in shaping our images of our selves. In infancy , our bodily
sensations are greatly affected by the qualities of the “holding” and “handling” that
we receive from caretakers, and so it is not much of an extension to suggest that our
self is foremost a body-as experiences-being-handled-and–held-by-other-self, in other
words, our self is foremost a body-in-relation-self (p.20).
Both Lowen (1958) and Reich (1948) suggested that there was a close
connection between the inhibition of breath and inhibition of feelings. Lowen (1976)
has developed bioenergetics based on Reich’s structure model, a theoretical system
and a practical approach concerned with raising consciousness about how we use our
‘life energy’. In bioenergetics focus is directed towards facilitating breathing and body
exercise to facilitate emotional expression. Keleman (1992) developed another system
of body structures based on anatomical structures with focus on parts where ‘energy’ is
constricted or suppressed. He would emphasize the body work and requested his
patients to listen to what the body could tell (Eiden, 2002).
During Reich’s stay in Norway in the 1930s he came to influence the
psychotherapy of the time. The Norwegian physician and psychoanalyst Braatøy was
greatly influenced by the work of Reich. Braatøy (1947/1965) discovered the interplay
between tense muscles, respiration and nervousness as he worked closely together with
the physiotherapist Bülow Hansen. Their joint work laid the foundation to the now
widely recognized Norwegian psychomotor physiotherapy, developed by Thornquist
and Bunkan (1990). This is considered the first cornerstone of the Affect-focused body
psychotherapy (ABP).
1.2 PSYCHOMOTOR PHYSIOTHERAPY
In Psychomotor Physiotherapy (Bunkan, Thornquist & Radøy, 1982) the body is seen
as a functional unit. This signifies that local symptoms are viewed in the context of the
whole person as a social, psychological and physiological being. In Psychomotor
Physiotherapy the aim is not to break the defence mechanism but to offer a possibility
for new experiences and facilitate the ability to get in touch with earlier experiences.
The treatment in psychomotor physiotherapy is partly based on findings from the
physical examination, performed following the Resource Oriented Body Examination
(ROBE) developed by Bunkan (1996). This type of body examination represents a
qualitatively different approach than the objective, biomedical oriented body
examination. In the ROBE communication, subjective experiences and the relation
between the patient and the therapist are crucial elements. The body examination gives
important information concerning the patient’s way of relating towards himself as well
as his resources. (Bunkan, 1996; Bunkan, Ljunggren, Opjordsmoen, Moen, & Friis,
2001; Bunkan, Opjordsmoen, Moen, Ljunggren, & Friis, 1999; Friis, Bunkan,
4
Ljunggren, Moen, & Opjordsmoen, 1998). The body examination comprises four
distinct parts: observation of the patient’s body posture, reactions to passive
movements, palpatory examination of skeletal muscles, and observation of respiration.
The patients overall reactions, during and after the physical examination, also helps the
physiotherapist understand the patient’s specific needs and resources.
1.3 BODY AWARENESS
There are many techniques that aim at improving body awareness. One of the first in
Europe might have been Gindler. From her personal experience of recovering from
tuberculosis, she helped establish an entire school of bodywork. Her efforts in this field
have later led to the Esalen institute. At the same time Feldenkrais and Frederick
Matthias Alexander established techniques named by their family names. They have
different backgrounds; Feldenkrais from engineering and Alexander (1932) from being
an actor. Both created different ways of altering bodily difficulties and (re)learning new
ways of acting and relating to ones body. The Feldenkrais method (Feldenkrais, 1977)
has been evaluated in patients with shoulder pain (Lundblad, Elert, Gerdle, 1999) and
along with Basic body awareness therapy in patients with chronic pain (Malmgren-
Olsson, Armelius, & Armelius, 2001) and as a means to reduce anxiety (Kolt, &
McConville, 2000).
Amongst Swedish physiotherapists the far most known bodily intervention is
the Basic Body Awareness Therapy introduced by Roxendal (1985) with great
influence from the French movement teacher Dropsy (1975, 1988, 1999). He
combined Eastern meditation with western influences. The Body Awareness Therapy
has been evaluated in patients with psychiatric disorders with good results (Friis,
Skatteboe, Kvamsdal Hope, & Vaglum, 1989; Gyllensten, Hansson, & Ekdahl, 2003;
Mattsson, 1998; Roxendal, 1985) and in patients with experiences of childhood
sexual abuse (Mattsson, Wikman, Dahlgren, Mattsson, & Armelius, 1998) as well as
in patients with irritable bowel syndrome (Eriksson, Nordwall, Kurlberg, Rydholm, &
Eriksson, 2002).
1.4 AFFECT-FOCUSED BODY PSYCHOTHERAPY
The ABP stems from the combination of bodily intervention developed in the
Psychomotor Physiotherapy and the focus on affect exploration. The treatment model is
named Psychodynamic Body Therapy by Monsen (1989). In order to emphasize the
focus on affects, rather than transference issues, the method is referred to in this thesis
as Affect-Focused Body Psychotherapy (ABP). It is essentially the same method as
PBT. In ABP the focus is on understanding the information latent in affects and to
increase the tolerance for affects in general and anxiety in particular (Monsen &
Monsen, 2000).
4
Ljunggren, Moen, & Opjordsmoen, 1998). The body examination comprises four
distinct parts: observation of the patient’s body posture, reactions to passive
movements, palpatory examination of skeletal muscles, and observation of respiration.
The patients overall reactions, during and after the physical examination, also helps the
physiotherapist understand the patient’s specific needs and resources.
1.3 BODY AWARENESS
There are many techniques that aim at improving body awareness. One of the first in
Europe might have been Gindler. From her personal experience of recovering from
tuberculosis, she helped establish an entire school of bodywork. Her efforts in this field
have later led to the Esalen institute. At the same time Feldenkrais and Frederick
Matthias Alexander established techniques named by their family names. They have
different backgrounds; Feldenkrais from engineering and Alexander (1932) from being
an actor. Both created different ways of altering bodily difficulties and (re)learning new
ways of acting and relating to ones body. The Feldenkrais method (Feldenkrais, 1977)
has been evaluated in patients with shoulder pain (Lundblad, Elert, Gerdle, 1999) and
along with Basic body awareness therapy in patients with chronic pain (Malmgren-
Olsson, Armelius, & Armelius, 2001) and as a means to reduce anxiety (Kolt, &
McConville, 2000).
Amongst Swedish physiotherapists the far most known bodily intervention is
the Basic Body Awareness Therapy introduced by Roxendal (1985) with great
influence from the French movement teacher Dropsy (1975, 1988, 1999). He
combined Eastern meditation with western influences. The Body Awareness Therapy
has been evaluated in patients with psychiatric disorders with good results (Friis,
Skatteboe, Kvamsdal Hope, & Vaglum, 1989; Gyllensten, Hansson, & Ekdahl, 2003;
Mattsson, 1998; Roxendal, 1985) and in patients with experiences of childhood
sexual abuse (Mattsson, Wikman, Dahlgren, Mattsson, & Armelius, 1998) as well as
in patients with irritable bowel syndrome (Eriksson, Nordwall, Kurlberg, Rydholm, &
Eriksson, 2002).
1.4 AFFECT-FOCUSED BODY PSYCHOTHERAPY
The ABP stems from the combination of bodily intervention developed in the
Psychomotor Physiotherapy and the focus on affect exploration. The treatment model is
named Psychodynamic Body Therapy by Monsen (1989). In order to emphasize the
focus on affects, rather than transference issues, the method is referred to in this thesis
as Affect-Focused Body Psychotherapy (ABP). It is essentially the same method as
PBT. In ABP the focus is on understanding the information latent in affects and to
increase the tolerance for affects in general and anxiety in particular (Monsen &
Monsen, 2000).
5
The Psychodynamic Body Therapy has been tried out in two controlled
outcome studies. In the first one, 28 patients with fibromyalgia received PBT treatment
or ordinary physiotherapy (Monsen, et al., 1994). The therapy was conducted by eight
therapists with three years of learning this specific approach. The PBT group changed
significantly more on subjective experience of pain, somatisation and general
symptoms (MMPI and SCL-90) than did the control group (Monsen, et al., 1994). The
second study included 40 patients with long lasting pain; half of the patients were
treated with PBT for 33 sessions, and the other half received treatment as usual (TAU)
or no treatment. At the end of therapy the pain was significantly reduced in the PBT
group compared to the controls, and 50% of the PBT patients reported no pain. The
findings further showed a significant and substantial change in somatisation,
depression, anxiety, denial, assertiveness, social withdrawal and increased affect
consciousness. The results remained stable at one year follow up, and the PBT patients
even continued their improvement concerning depression, anxiety and assertiveness
during follow up (Monsen & Monsen, 2000).
1.4.1 ABP according to Wampold’s levels of abstraction of
psychotherapy
Treatments can be described from different view points. Wampold (2001) has depicted
four levels of abstraction of psychotherapy: theoretical approach, technique, strategies,
and meta-theory. This model of analysis will be used to further describe ABP.
In the following text the therapist will be addressed as “she” and the patient as “he”.
1.4.1.1 Theoretical approach
The ABP has several roots; stemming from existentialism, self psychology and affect
theory as well as Psychomotor Physiotherapy.
The existentialist part can be traced back to Buber and his I-Thou relationship.
It has also been outlined by Rogers (1942) in his client–centred therapy: The focus is
on the interaction; the therapist does not only function as an alter ego but also as an
independent pole of interaction. At times the therapist expresses, to the client, her own
feelings about the situation. On account of this transparency, the process becomes more
a dialogue, an I-thou encounter (Buber, 1923/1958). In the I-Thou dialogue the
therapist attempts to be fully present in the moment, attending to the patient’s inner
experience, regularly checking her understanding with him, letting the patient know
that she understands how he feels on the inside, and attempting to focus his attention on
what is merely becoming conscious. This has more recently been described by
Greenberg (2002). The therapist might not be aware of the patients affect experience
through what he is communicating verbally but rather in the way he is saying it, his
vocal tone, and her bodily experience. The therapist’s role is to contribute to making
these experiences verbally explicit (Greenberg, 2002). This is also in line with other
5
The Psychodynamic Body Therapy has been tried out in two controlled
outcome studies. In the first one, 28 patients with fibromyalgia received PBT treatment
or ordinary physiotherapy (Monsen, et al., 1994). The therapy was conducted by eight
therapists with three years of learning this specific approach. The PBT group changed
significantly more on subjective experience of pain, somatisation and general
symptoms (MMPI and SCL-90) than did the control group (Monsen, et al., 1994). The
second study included 40 patients with long lasting pain; half of the patients were
treated with PBT for 33 sessions, and the other half received treatment as usual (TAU)
or no treatment. At the end of therapy the pain was significantly reduced in the PBT
group compared to the controls, and 50% of the PBT patients reported no pain. The
findings further showed a significant and substantial change in somatisation,
depression, anxiety, denial, assertiveness, social withdrawal and increased affect
consciousness. The results remained stable at one year follow up, and the PBT patients
even continued their improvement concerning depression, anxiety and assertiveness
during follow up (Monsen & Monsen, 2000).
1.4.1 ABP according to Wampold’s levels of abstraction of
psychotherapy
Treatments can be described from different view points. Wampold (2001) has depicted
four levels of abstraction of psychotherapy: theoretical approach, technique, strategies,
and meta-theory. This model of analysis will be used to further describe ABP.
In the following text the therapist will be addressed as “she” and the patient as “he”.
1.4.1.1 Theoretical approach
The ABP has several roots; stemming from existentialism, self psychology and affect
theory as well as Psychomotor Physiotherapy.
The existentialist part can be traced back to Buber and his I-Thou relationship.
It has also been outlined by Rogers (1942) in his client–centred therapy: The focus is
on the interaction; the therapist does not only function as an alter ego but also as an
independent pole of interaction. At times the therapist expresses, to the client, her own
feelings about the situation. On account of this transparency, the process becomes more
a dialogue, an I-thou encounter (Buber, 1923/1958). In the I-Thou dialogue the
therapist attempts to be fully present in the moment, attending to the patient’s inner
experience, regularly checking her understanding with him, letting the patient know
that she understands how he feels on the inside, and attempting to focus his attention on
what is merely becoming conscious. This has more recently been described by
Greenberg (2002). The therapist might not be aware of the patients affect experience
through what he is communicating verbally but rather in the way he is saying it, his
vocal tone, and her bodily experience. The therapist’s role is to contribute to making
these experiences verbally explicit (Greenberg, 2002). This is also in line with other
6
therapists working with affect awareness such as Fosha (2005) and Mc Cullough &
Andrews (2001).
Both Rogers and later on self psychologists such as Kohut stressed that the cure
comes along with the therapist’s way of being empathic. Kohut (1977) described it as a
“consistent empathetic stance” and his followers as “sustained empathic inquiry”
(Stolorow, Brandshaft & Atwood, 1987).
The Affect Consciousness Treatment model developed by Monsen & Monsen
(1999) is the second cornerstone in ABP. Affects, feelings and emotions are concepts
that are not easily defined and they have different connotations depending on the
researcher. Many researchers (Basch, 1976; Damasio, 2002; Nathanson, 1992)
distinguish between affect, emotion and feeling, where affect refers to the biological
activation- and signal system, and feeling corresponds to the mental experience of the
affect, whereas emotion corresponds to the cognitive evaluation of the affect i.e.
including previous experiences attached to the affect. Nathanson (1992, p. 50)
concisely summarises the relations among these three concepts:”Affect is biology,
feeling is psychology and emotion is biography”. However, the literature on affect
consciousness seldom makes this distinction. When we talk about affects we usually
talk about them in relation to a specific situation, and from that point of view it is not
really possible to separate affects from emotions and feelings.
Darwin (1872) was the first to describe different patterns of behaviour in
differing situations of danger, victory, or defeat delineating patterns of emotional
reactions with motor and somatic components. He treated them as components of
successful or unsuccessful ways to adapt to certain demands of the surroundings.
Fundamental in ABP is the view, launched by Tomkins (1962), that affects, and not our
drives, are the primary motivators of behaviour.
Each affect has a biologically inherited program controlling facial muscle
responses, blood flow-, respiratory-, and vocal responses (Tomkins, 1963). Affects are
obviously bodily experiences, although interpreted and named by the mind (Damasio,
2002). Ekman (1992) has demonstrated that each affect is characterized by a discrete
pattern of skeletal muscle contraction visible on the face and in body posture. Each
affect also feels different on the inside of the body, however the ability to observe these
bodily sensations vary between individuals. This is one, of four, aspect of the ability
that has been called affect consciousness (AC; Monsen, Ødegård & Melgård, 1989).
The four aspects of affect consciousness are; awareness, tolerance, emotional
expression, and conceptual expression. A basic belief in ABP is that a general low
degree of affect consciousness is likely to hinder the adaptive functions of affect in the
organisation of personality functioning. It can be expected to influence the capacity to
form mutual relationships, and if severely inhibited, it can also contribute to a loss of
contact with a basic sense of self (Stern, 1985). It has been demonstrated that a low
6
therapists working with affect awareness such as Fosha (2005) and Mc Cullough &
Andrews (2001).
Both Rogers and later on self psychologists such as Kohut stressed that the cure
comes along with the therapist’s way of being empathic. Kohut (1977) described it as a
“consistent empathetic stance” and his followers as “sustained empathic inquiry”
(Stolorow, Brandshaft & Atwood, 1987).
The Affect Consciousness Treatment model developed by Monsen & Monsen
(1999) is the second cornerstone in ABP. Affects, feelings and emotions are concepts
that are not easily defined and they have different connotations depending on the
researcher. Many researchers (Basch, 1976; Damasio, 2002; Nathanson, 1992)
distinguish between affect, emotion and feeling, where affect refers to the biological
activation- and signal system, and feeling corresponds to the mental experience of the
affect, whereas emotion corresponds to the cognitive evaluation of the affect i.e.
including previous experiences attached to the affect. Nathanson (1992, p. 50)
concisely summarises the relations among these three concepts:”Affect is biology,
feeling is psychology and emotion is biography”. However, the literature on affect
consciousness seldom makes this distinction. When we talk about affects we usually
talk about them in relation to a specific situation, and from that point of view it is not
really possible to separate affects from emotions and feelings.
Darwin (1872) was the first to describe different patterns of behaviour in
differing situations of danger, victory, or defeat delineating patterns of emotional
reactions with motor and somatic components. He treated them as components of
successful or unsuccessful ways to adapt to certain demands of the surroundings.
Fundamental in ABP is the view, launched by Tomkins (1962), that affects, and not our
drives, are the primary motivators of behaviour.
Each affect has a biologically inherited program controlling facial muscle
responses, blood flow-, respiratory-, and vocal responses (Tomkins, 1963). Affects are
obviously bodily experiences, although interpreted and named by the mind (Damasio,
2002). Ekman (1992) has demonstrated that each affect is characterized by a discrete
pattern of skeletal muscle contraction visible on the face and in body posture. Each
affect also feels different on the inside of the body, however the ability to observe these
bodily sensations vary between individuals. This is one, of four, aspect of the ability
that has been called affect consciousness (AC; Monsen, Ødegård & Melgård, 1989).
The four aspects of affect consciousness are; awareness, tolerance, emotional
expression, and conceptual expression. A basic belief in ABP is that a general low
degree of affect consciousness is likely to hinder the adaptive functions of affect in the
organisation of personality functioning. It can be expected to influence the capacity to
form mutual relationships, and if severely inhibited, it can also contribute to a loss of
contact with a basic sense of self (Stern, 1985). It has been demonstrated that a low
7
degree of AC is significantly correlated to high distress in a psychiatric population
(Monsen, Ødegård
& Melgård, 1989; Monsen, Eilertsen, Melgård, & Ødegård,1996;
Monsen, Odland, Faugli, Dae, & Eilertsen, 1995).
Reich’s theory concerning the body armour, supported by Lowen’s hypothesis
that there is a close connection between the inhibition of breath and inhibition of
feelings, has also influenced ABP.
1.4.1.2 Technique
Awareness of body and affect is at the core of ABP. The bodily part of the therapy will
focus on helping the patient to gain a better stability through exercises and massage
grips that will enhance the patient’s contact with his legs, thus emphasizing the
importance of having a firm base. Bodily techniques such as massage grips and specific
exercises are performed in different ways, depending on the patient's resources as they
appear during the inquiry of anamnesis and physical examination (Monsen & Monsen,
2000). It is necessary that the patient gains the feeling of stability and control before the
therapy is furthered. The use of massage and touch will generally have an anxiety-
reducing effect and pave the way for self-reflection and mentalization processes.
Special massage grips are used to loosen the stiff muscles around the thorax, aiming at
a less controlled and deeper respiration. It is believed that loosening of muscular
stiffness and/or restricted respiratory patterns may allow the patient to be emotionally
moved and let affects have an impact on him. The bodily interventions may also help
the patient to become more aware of affect signals and habitual ways of responding to
them. Exercises can be used to stimulate new ways of acting; for instance, instead of
withdrawal and silence when experiencing pain, the patient can discover ways of
expressing pain and demonstrating rejection of the pain-provoking stimuli (Monsen,
2002).
Affect awareness is fundamentally a bodily experience. The therapist tries to
understand the patients’ affect information; may it be verbal or nonverbal (breathing,
body posture and body reactions) and also by being observant of her own reactions
using them as a way of sensing what the patient may be feeling. The affect exploration
is focused on how the affects are organised concerning the four self-functions:
awareness, tolerance, emotional expression and conceptual expression. The inter-
ventions are aimed at helping the patient to become more aware of the affect signal, to
tolerate and let the affect influence him, which is necessary if the affect is to become a
meaningful signal and not a mere anxiety provoking state. And finally to evolve the
ability to express the affect emotionally and conceptually in a way that is appropriate
and meaningful (Monsen & Monsen, 1999, 2000). This procedure is repeated while
working directly with the body – with massage grips or movements – or while in the
therapeutic dialogue focusing on bodily and verbal processes. The affect exploration
focuses on how affects are experienced and expressed in the treatment room as well as
in relation to other people - thereby identifying maladaptive organizing patterns
7
degree of AC is significantly correlated to high distress in a psychiatric population
(Monsen, Ødegård
& Melgård, 1989; Monsen, Eilertsen, Melgård, & Ødegård,1996;
Monsen, Odland, Faugli, Dae, & Eilertsen, 1995).
Reich’s theory concerning the body armour, supported by Lowen’s hypothesis
that there is a close connection between the inhibition of breath and inhibition of
feelings, has also influenced ABP.
1.4.1.2 Technique
Awareness of body and affect is at the core of ABP. The bodily part of the therapy will
focus on helping the patient to gain a better stability through exercises and massage
grips that will enhance the patient’s contact with his legs, thus emphasizing the
importance of having a firm base. Bodily techniques such as massage grips and specific
exercises are performed in different ways, depending on the patient's resources as they
appear during the inquiry of anamnesis and physical examination (Monsen & Monsen,
2000). It is necessary that the patient gains the feeling of stability and control before the
therapy is furthered. The use of massage and touch will generally have an anxiety-
reducing effect and pave the way for self-reflection and mentalization processes.
Special massage grips are used to loosen the stiff muscles around the thorax, aiming at
a less controlled and deeper respiration. It is believed that loosening of muscular
stiffness and/or restricted respiratory patterns may allow the patient to be emotionally
moved and let affects have an impact on him. The bodily interventions may also help
the patient to become more aware of affect signals and habitual ways of responding to
them. Exercises can be used to stimulate new ways of acting; for instance, instead of
withdrawal and silence when experiencing pain, the patient can discover ways of
expressing pain and demonstrating rejection of the pain-provoking stimuli (Monsen,
2002).
Affect awareness is fundamentally a bodily experience. The therapist tries to
understand the patients’ affect information; may it be verbal or nonverbal (breathing,
body posture and body reactions) and also by being observant of her own reactions
using them as a way of sensing what the patient may be feeling. The affect exploration
is focused on how the affects are organised concerning the four self-functions:
awareness, tolerance, emotional expression and conceptual expression. The inter-
ventions are aimed at helping the patient to become more aware of the affect signal, to
tolerate and let the affect influence him, which is necessary if the affect is to become a
meaningful signal and not a mere anxiety provoking state. And finally to evolve the
ability to express the affect emotionally and conceptually in a way that is appropriate
and meaningful (Monsen & Monsen, 1999, 2000). This procedure is repeated while
working directly with the body – with massage grips or movements – or while in the
therapeutic dialogue focusing on bodily and verbal processes. The affect exploration
focuses on how affects are experienced and expressed in the treatment room as well as
in relation to other people - thereby identifying maladaptive organizing patterns
8
(Monsen & Monsen, 1999). By repeating this process, the patient may be able to
reorganize his view of emotionally important other persons as well as his self-image.
ABP can be viewed as a learning process, starting with stimulating the patient’s interest
and curiosity about exploring their affects and aiming at the patient adopting the affect
exploration process and being able to continue it on his own (Johansson, Levy Berg,
Biguet & Clinton, 2002; Monsen & Monsen, 1999). This way, the patients will learn to
perceive affects as meaningful self-signals (Monsen & Monsen, 1999).
1.4.1.3 Strategies - the therapist’s role
In ABP the focus is on external relationships and scenes from daily life that may
activate maladaptive ways of functioning. There is no focus on the transference
process; (i.e. the repetition in the present of a relationship that was important in a
person's childhood) which is the core of psychodynamic psychotherapy. In this sense it
differs quite substantially from the body-therapy by Downing (1994) who stresses the
importance of working with the transference. In ABP there is a fundamental belief that
the therapist and the patient mutually affect one another. The curative part of the
treatment is considered to be the therapist’s way of catching and identifying the
patients’ emotional experience. The therapists affect attunement and deep
understanding of the patients experience is crucial in ABP. The patients’ curiosity
about the therapist plays a subordinated role. The therapist’s role is to be empathic; to
see, recognize, acknowledge and validate the patient’s emotional state.
The therapist’s role is active and supportive, encouraging and assisting the patient to
explore his own feelings and to tolerate and express them adequately and directly
(Johansson, Levy Berg, Biguet & Clinton, 2002; Monsen & Monsen, 1999; Monsen &
Monsen, 2000).
1.4.1.4 Meta-theory
Wampold (2001) describes two different meta-theories in psychotherapy research; the
contextual and the medical. In the contextual model it is emphasized that common
factors are of fundamental importance, and it is argued that there is no evidence for
specific intervention effects. Adherence to a specific technique is supposed to be of less
importance but on the other hand coherence and the role of the therapist is underscored.
In the medical model, common factors are regarded of less interest for research,
according to Wampold. Instead the variation in efficacy between different
psychotherapy techniques and the adherence to them are stressed.
The medical model in psychotherapy differs from the medical model in
medicine in the following ways “(a) disorders, problems, or complaints are held to
have psychological rather than physiochemical etiology; (b) explanations for disorders,
problems, or complaints and rationale for change are psychological rather than
medical”(Wampold, 2001, pp16). Considering these facts, the point of departure when
initiating this study was to study ABP from the medical perspective. In the following
section I will describe how ABP could be viewed that way:
8
(Monsen & Monsen, 1999). By repeating this process, the patient may be able to
reorganize his view of emotionally important other persons as well as his self-image.
ABP can be viewed as a learning process, starting with stimulating the patient’s interest
and curiosity about exploring their affects and aiming at the patient adopting the affect
exploration process and being able to continue it on his own (Johansson, Levy Berg,
Biguet & Clinton, 2002; Monsen & Monsen, 1999). This way, the patients will learn to
perceive affects as meaningful self-signals (Monsen & Monsen, 1999).
1.4.1.3 Strategies - the therapist’s role
In ABP the focus is on external relationships and scenes from daily life that may
activate maladaptive ways of functioning. There is no focus on the transference
process; (i.e. the repetition in the present of a relationship that was important in a
person's childhood) which is the core of psychodynamic psychotherapy. In this sense it
differs quite substantially from the body-therapy by Downing (1994) who stresses the
importance of working with the transference. In ABP there is a fundamental belief that
the therapist and the patient mutually affect one another. The curative part of the
treatment is considered to be the therapist’s way of catching and identifying the
patients’ emotional experience. The therapists affect attunement and deep
understanding of the patients experience is crucial in ABP. The patients’ curiosity
about the therapist plays a subordinated role. The therapist’s role is to be empathic; to
see, recognize, acknowledge and validate the patient’s emotional state.
The therapist’s role is active and supportive, encouraging and assisting the patient to
explore his own feelings and to tolerate and express them adequately and directly
(Johansson, Levy Berg, Biguet & Clinton, 2002; Monsen & Monsen, 1999; Monsen &
Monsen, 2000).
1.4.1.4 Meta-theory
Wampold (2001) describes two different meta-theories in psychotherapy research; the
contextual and the medical. In the contextual model it is emphasized that common
factors are of fundamental importance, and it is argued that there is no evidence for
specific intervention effects. Adherence to a specific technique is supposed to be of less
importance but on the other hand coherence and the role of the therapist is underscored.
In the medical model, common factors are regarded of less interest for research,
according to Wampold. Instead the variation in efficacy between different
psychotherapy techniques and the adherence to them are stressed.
The medical model in psychotherapy differs from the medical model in
medicine in the following ways “(a) disorders, problems, or complaints are held to
have psychological rather than physiochemical etiology; (b) explanations for disorders,
problems, or complaints and rationale for change are psychological rather than
medical”(Wampold, 2001, pp16). Considering these facts, the point of departure when
initiating this study was to study ABP from the medical perspective. In the following
section I will describe how ABP could be viewed that way:
9
Following Wampold, the medical model has five components:
Client disorder
In the present material we have been treating patients with the GAD diagnosis
following the DSM-IV manual (APA, 1994). Thus attributing an importance to the
medical diagnosis.
Psychological explanation for the disorder
In ABP it is a basic belief that the patients’ difficulties can be related to a deficiency in
affect awareness, tolerance and expressivity. Our presumptions are that the patients
care givers not have been able to create a safe enough environment thus impeding a
proper affect development in line with suggestions from other researchers (Crits-
Christoph, Connoly, Azarian, Crits-Christoph, & Shappell, 1996) who state: The
emerging research literature on GAD and worry suggests that GAD is linked to both
insecure/conflicted attachment in childhood and to a history of past traumas (pp 421).
Abel (1991) has shown that GAD patients report difficulties identifying what
they feel and describing their affects, therefore it has been suggested that GAD patients
may avoid emotional experiences in general and not just anxious feelings (Borkovec,
Newman, & Castonguay, 2003). In ABP it is suggested that affects that are not being
accepted are being withheld presumably by tightening muscles especially around the
thorax thus impeding the free breathing (Bunkan, 1996; Bunkan, Ljunggren,
Opjordsmoen, Moen, & Friis, 2001; Bunkan, Opjordsmoen, Moen, Ljunggren, &
Friis,1999; Friis, Bunkan, Ljunggren, Moen, & Opjordsmoen, 1998; Havik et al.,
1991; Lowen, 1958; Meurle-Hallberg, Armelius, & von Koch, 2004; Reich, 1948). In
that way the muscular armour is supposed to defend the individual against unwanted or
unacceptable feelings. Affects can also be held back by lack of muscular tonus similar
to the acting dead described by Rothschild (2000).
The mechanisms of change offered in ABP are increased affect consciousness and
improved bodily awareness
Specific therapeutic ingredients are the focus on the body and the affects as they are
experienced within the body. ABP, as all body psychotherapies, addresses the meaning
of bodily expressions and in doing so works against the fundamental split between the
mind and the body (Eiden, 2002) that is prevalent in patients suffering from GAD.
Specificity
Special intervention methods in ABP are the therapists acknowledging and accepting
attitude, the interest that the therapist shows towards the patient, his body and bodily
reactions, and the therapist’s way of actually letting herself be moved by the patients
affects, thus helping the patient to get access to his affect states. In ABP there is a belief
that the specific therapeutic ingredients, such as the affect exploration process and
9
Following Wampold, the medical model has five components:
Client disorder
In the present material we have been treating patients with the GAD diagnosis
following the DSM-IV manual (APA, 1994). Thus attributing an importance to the
medical diagnosis.
Psychological explanation for the disorder
In ABP it is a basic belief that the patients’ difficulties can be related to a deficiency in
affect awareness, tolerance and expressivity. Our presumptions are that the patients
care givers not have been able to create a safe enough environment thus impeding a
proper affect development in line with suggestions from other researchers (Crits-
Christoph, Connoly, Azarian, Crits-Christoph, & Shappell, 1996) who state: The
emerging research literature on GAD and worry suggests that GAD is linked to both
insecure/conflicted attachment in childhood and to a history of past traumas (pp 421).
Abel (1991) has shown that GAD patients report difficulties identifying what
they feel and describing their affects, therefore it has been suggested that GAD patients
may avoid emotional experiences in general and not just anxious feelings (Borkovec,
Newman, & Castonguay, 2003). In ABP it is suggested that affects that are not being
accepted are being withheld presumably by tightening muscles especially around the
thorax thus impeding the free breathing (Bunkan, 1996; Bunkan, Ljunggren,
Opjordsmoen, Moen, & Friis, 2001; Bunkan, Opjordsmoen, Moen, Ljunggren, &
Friis,1999; Friis, Bunkan, Ljunggren, Moen, & Opjordsmoen, 1998; Havik et al.,
1991; Lowen, 1958; Meurle-Hallberg, Armelius, & von Koch, 2004; Reich, 1948). In
that way the muscular armour is supposed to defend the individual against unwanted or
unacceptable feelings. Affects can also be held back by lack of muscular tonus similar
to the acting dead described by Rothschild (2000).
The mechanisms of change offered in ABP are increased affect consciousness and
improved bodily awareness
Specific therapeutic ingredients are the focus on the body and the affects as they are
experienced within the body. ABP, as all body psychotherapies, addresses the meaning
of bodily expressions and in doing so works against the fundamental split between the
mind and the body (Eiden, 2002) that is prevalent in patients suffering from GAD.
Specificity
Special intervention methods in ABP are the therapists acknowledging and accepting
attitude, the interest that the therapist shows towards the patient, his body and bodily
reactions, and the therapist’s way of actually letting herself be moved by the patients
affects, thus helping the patient to get access to his affect states. In ABP there is a belief
that the specific therapeutic ingredients, such as the affect exploration process and
10
bodily focus, are remedial, and that the specific ingredients are assumed to be
responsible for client change or progress toward therapeutic goals. Specificity implies
that specific effects will be overwhelmingly larger than general effects (Wampold,
2001).
1.5 GENERALISED ANXIETY DISORDER
GAD in the DSM-IV nosology is defined by the key features of excessive,
uncontrollable worry of at least 6 months‘ duration about a number of life events or
activities, accompanied by at least 3 of 6 associated symptoms of negative affect or
tension such as restlessness or feeling keyed up or on edge, being easily fatigued,
difficulty concentrating or mind going blank, irritability, muscle tension and sleep
disturbance (Appendix 1; APA, 1994).
A person with GAD thus experiences anxiety most of the time, with a
cognitive dysfunction that is prospective rather than retrospective as in depression.
The worry content deals with prospective themes concerning safety and harm issues
for oneself and the immediate family. In general, people with anxiety, have a low
tolerance for experiencing their anxiety and do whatever possible to oppress it and try
to hide it from others. They are actually afraid of their anxiety and are thus caught in
a negative spiral where they become anxious of fear from getting into a situation
where they believe that they will feel anxious (Wells, 1995). The more the person
tries to solve the problem by avoiding it, the more it persists and even gets stronger
(Malan, 1999; McCullough, 1998). People with GAD frequently have been hindered
in their working life and in their spare time due to their reluctance of taking risks and
their vulnerability to stress.
1.5.1 Prevalence and incidence
Generalized Anxiety Disorder (GAD) is the most prevalent anxiety disorder in the
general population and in primary care, with lifetime prevalence rates of about 6 per
cent, mostly presenting in middle age (Hoyer, Beesdo, Becker & Wittchen, 2003). In a
population sample drawn from the Swedish Twin registry, women were diagnosed with
GAD twice as often as men (3.95 % versus 1.74 %; Mackintosh, Gatz, Loebach
Wetherell, & Pedersen, 2006).
In a screening of 14000 patients seeking primary health care in Belgium and
Luxemburg, 8.3 % were given a GAD diagnosis (Ansseau, Fischler, Dierick, Mignon
& Leyman, 2005). In a Scandinavian study, the prevalence of GAD in patients
consulting their general practitioner was studied (Munk-Jørgensen et al., 2006). Among
the Swedish 1300 patients in that study, 5% were diagnosed with pure GAD and an
additional 1.5 % of the males, and 3% of the women had comorbid GAD and major
depression.
10
bodily focus, are remedial, and that the specific ingredients are assumed to be
responsible for client change or progress toward therapeutic goals. Specificity implies
that specific effects will be overwhelmingly larger than general effects (Wampold,
2001).
1.5 GENERALISED ANXIETY DISORDER
GAD in the DSM-IV nosology is defined by the key features of excessive,
uncontrollable worry of at least 6 months‘ duration about a number of life events or
activities, accompanied by at least 3 of 6 associated symptoms of negative affect or
tension such as restlessness or feeling keyed up or on edge, being easily fatigued,
difficulty concentrating or mind going blank, irritability, muscle tension and sleep
disturbance (Appendix 1; APA, 1994).
A person with GAD thus experiences anxiety most of the time, with a
cognitive dysfunction that is prospective rather than retrospective as in depression.
The worry content deals with prospective themes concerning safety and harm issues
for oneself and the immediate family. In general, people with anxiety, have a low
tolerance for experiencing their anxiety and do whatever possible to oppress it and try
to hide it from others. They are actually afraid of their anxiety and are thus caught in
a negative spiral where they become anxious of fear from getting into a situation
where they believe that they will feel anxious (Wells, 1995). The more the person
tries to solve the problem by avoiding it, the more it persists and even gets stronger
(Malan, 1999; McCullough, 1998). People with GAD frequently have been hindered
in their working life and in their spare time due to their reluctance of taking risks and
their vulnerability to stress.
1.5.1 Prevalence and incidence
Generalized Anxiety Disorder (GAD) is the most prevalent anxiety disorder in the
general population and in primary care, with lifetime prevalence rates of about 6 per
cent, mostly presenting in middle age (Hoyer, Beesdo, Becker & Wittchen, 2003). In a
population sample drawn from the Swedish Twin registry, women were diagnosed with
GAD twice as often as men (3.95 % versus 1.74 %; Mackintosh, Gatz, Loebach
Wetherell, & Pedersen, 2006).
In a screening of 14000 patients seeking primary health care in Belgium and
Luxemburg, 8.3 % were given a GAD diagnosis (Ansseau, Fischler, Dierick, Mignon
& Leyman, 2005). In a Scandinavian study, the prevalence of GAD in patients
consulting their general practitioner was studied (Munk-Jørgensen et al., 2006). Among
the Swedish 1300 patients in that study, 5% were diagnosed with pure GAD and an
additional 1.5 % of the males, and 3% of the women had comorbid GAD and major
depression.
11
GAD is associated with a wide spectrum of somatic disorders, such as
pulmonary and heart disease (Kubzansky et al., 1997) as well as depression
(Allgulander, 1994; Andersson, Noyes & Crowe, 1984; Wittchen, Zhao, Kessler &
Eaton, 1994). Researchers conclude that comorbidity between anxiety and depressive
disorders may represent the rule rather than the exception, especially within clinical
samples (Belzer, & Schneier, 2004). Researchers have also found high rates of PD
diagnoses (Dyck et al., 2001; Sanderson & Barlow, 1990; Sanderson, Wetzler, Beck &
Betz, 1994 a). Once diagnosed, patients tend to describe their cognitive dysfunction and
worrying style for having persisted for as long as they can remember, while the social
consequences tend to become apparent in their middle ages, thus analogous with a
personality disorder rather than an axis I disorder (Allgulander, personal
communication).
1.5.2 Etiology
The underlying causes of generalized anxiety disorder are unknown. This might be due
to the difficulty to delineate GAD from other co-occurring disorders such as
depression, panic attacks and social phobia, and a shared genetic substrate shown in
women (Allgulander, 1998). It thus involves a combination of hereditary and
predisposing childhood experiences (Angst & Vollrath, 1991).
1.5.2.1 Genetic explications
Some researchers have through twin studies found evidence for a heritability of
psychological traits, thus supporting the genetic risk contribution for developing GAD
(Bouchard. 2004; Woodman, 1993). Kendler’s study of female twins provides support
for the concept that in women, major depression and GAD are based on a shared
vulnerability. Environmental risk factors then determine whether a woman will develop
GAD or major depression (Kendler, 1996). In the Swedish twin registry cited above,
10,566 same-sexed twins aged 55-74 were interviewed to determine the genetic
contribution to GAD. It was estimated at 27%, while individual environmental factors
were 72% and shared environmental risk factors 1% or less (Mackintosh et al., 2006).
1.5.2.2 Childhood experiences
GAD is a persisting, perhaps life-long disorder with many studies indicating an age of
onset as far back as an individual can remember (Barlow, Blanchard, Vermilyea,
Vermilyea, & DiNardo, 1986; Rapee, 1987). Some researchers have retrospectively
examined childhood factors in GAD and compared them with patients suffering from
panic attacks (Raskin, Pecke, Dickman, & Pinsker, 1982). Raskin el al. (1982) found
that the GAD patients reported a less “grossly disturbed childhood environment” than
did the panic patients. Angst and Vollrath (1991) showed that distressing conditions in
the family, such as conflict between parents or with parents, lack of attention, or sexual
trauma, were more prevalent among subjects with anxiety disorders than among
controls.
11
GAD is associated with a wide spectrum of somatic disorders, such as
pulmonary and heart disease (Kubzansky et al., 1997) as well as depression
(Allgulander, 1994; Andersson, Noyes & Crowe, 1984; Wittchen, Zhao, Kessler &
Eaton, 1994). Researchers conclude that comorbidity between anxiety and depressive
disorders may represent the rule rather than the exception, especially within clinical
samples (Belzer, & Schneier, 2004). Researchers have also found high rates of PD
diagnoses (Dyck et al., 2001; Sanderson & Barlow, 1990; Sanderson, Wetzler, Beck &
Betz, 1994 a). Once diagnosed, patients tend to describe their cognitive dysfunction and
worrying style for having persisted for as long as they can remember, while the social
consequences tend to become apparent in their middle ages, thus analogous with a
personality disorder rather than an axis I disorder (Allgulander, personal
communication).
1.5.2 Etiology
The underlying causes of generalized anxiety disorder are unknown. This might be due
to the difficulty to delineate GAD from other co-occurring disorders such as
depression, panic attacks and social phobia, and a shared genetic substrate shown in
women (Allgulander, 1998). It thus involves a combination of hereditary and
predisposing childhood experiences (Angst & Vollrath, 1991).
1.5.2.1 Genetic explications
Some researchers have through twin studies found evidence for a heritability of
psychological traits, thus supporting the genetic risk contribution for developing GAD
(Bouchard. 2004; Woodman, 1993). Kendler’s study of female twins provides support
for the concept that in women, major depression and GAD are based on a shared
vulnerability. Environmental risk factors then determine whether a woman will develop
GAD or major depression (Kendler, 1996). In the Swedish twin registry cited above,
10,566 same-sexed twins aged 55-74 were interviewed to determine the genetic
contribution to GAD. It was estimated at 27%, while individual environmental factors
were 72% and shared environmental risk factors 1% or less (Mackintosh et al., 2006).
1.5.2.2 Childhood experiences
GAD is a persisting, perhaps life-long disorder with many studies indicating an age of
onset as far back as an individual can remember (Barlow, Blanchard, Vermilyea,
Vermilyea, & DiNardo, 1986; Rapee, 1987). Some researchers have retrospectively
examined childhood factors in GAD and compared them with patients suffering from
panic attacks (Raskin, Pecke, Dickman, & Pinsker, 1982). Raskin el al. (1982) found
that the GAD patients reported a less “grossly disturbed childhood environment” than
did the panic patients. Angst and Vollrath (1991) showed that distressing conditions in
the family, such as conflict between parents or with parents, lack of attention, or sexual
trauma, were more prevalent among subjects with anxiety disorders than among
controls.
12
Wolfe (2005) has proposed a psychodynamic theory of the etiology of GAD. He
suggests there are three processes involved in the acquisition of GAD: 1) A failure to
learn specific social and life–care skills; 2) Internalization of toxic opinions of
significant others regarding one’s basic worth; and 3) The development of unconscious
conflicts centering on the expression of one’s feelings (pp. 146-147)
1.5.3 Understanding the worry in GAD
Deficient regulation of affect is often seen in patients with psychiatric and/or
psychosomatic disorders and is a main feature in Generalized Anxiety Disorder (GAD).
Significant in GAD worry is that the focus of worry seems to change over time, only
the worry persists. Worry in GAD can be viewed as a defensive manoeuvre. Wolfe
(2005) suggests that patients with GAD are fearful of their emotional reactions, and
worry in GAD can be viewed as a form of avoidance (Borkovec, Alcaine & Behar,
2004). Studies have also revealed that GAD worry is characterized by meta- worry, i.e.
worry about worry (Wells & Carter, 2001). There are at least two possible ways to
understand the worry as avoidance:
Considering that worry might reduce the probability of a future negative incident
and thereby reducing the sense of uncertainty (Craske & Hazlett-Stevens, 2002;
Freeston, Rhéaume, Letarte, Dugas, & Ladouceur, 1994; Dugas, Gagnon. Ladouceu, &
Freeston, 1998).
Worrying about trivial matters may reduce thoughts and feelings about one’s sense
of worthlessness (i.e. shame) or other unpleasant internal experiences (Roemer &
Orsillo, 2002). Eventually worry itself becomes an unwanted internal experience,
which triggers attempts to avoid it, which may increase its frequency (Wells, 1995;
Roemer & Borkovec, 1994).
The hypothesis that worry serves as an avoidance of internal distress is
supported by findings that GAD is associated with chronic tension, as well as vigilance
and scanning symptoms rather than the increased sympathetic activation seen with all
the other anxiety disorders (Brown, Barlow, & Liebowitz, 1994; Marten et al., 1993).
1.5.4 Therapeutic treatment
Cognitive-behavioural therapy has been shown in controlled studies to be effective in
reducing symptoms of GAD (Ballenger et al., 2001; Borkovec & Costello, 1993;
Butler, Fennel, Robson & Gelder, 1991; Durham, Murphy, Allan, & Rickard, 1994;
Falsetti & Davis, 2001). Cognitive therapy and cognitive-behavioural therapy and
applied relaxation have been compared (Arntz, 2003; Borkovec, Newman, Pincus, &
Lytle, 2002; Öst & Breitholtz, 2000) and all methods were found equally effective, with
recovery rates about 50-60%. Some authors conclude that it may be necessary to also
develop methods that address the interpersonal problems that patients with GAD often
present (Borkovec et al., 2002). Thus it seems to be essential to integrate methods of
12
Wolfe (2005) has proposed a psychodynamic theory of the etiology of GAD. He
suggests there are three processes involved in the acquisition of GAD: 1) A failure to
learn specific social and life–care skills; 2) Internalization of toxic opinions of
significant others regarding one’s basic worth; and 3) The development of unconscious
conflicts centering on the expression of one’s feelings (pp. 146-147)
1.5.3 Understanding the worry in GAD
Deficient regulation of affect is often seen in patients with psychiatric and/or
psychosomatic disorders and is a main feature in Generalized Anxiety Disorder (GAD).
Significant in GAD worry is that the focus of worry seems to change over time, only
the worry persists. Worry in GAD can be viewed as a defensive manoeuvre. Wolfe
(2005) suggests that patients with GAD are fearful of their emotional reactions, and
worry in GAD can be viewed as a form of avoidance (Borkovec, Alcaine & Behar,
2004). Studies have also revealed that GAD worry is characterized by meta- worry, i.e.
worry about worry (Wells & Carter, 2001). There are at least two possible ways to
understand the worry as avoidance:
Considering that worry might reduce the probability of a future negative incident
and thereby reducing the sense of uncertainty (Craske & Hazlett-Stevens, 2002;
Freeston, Rhéaume, Letarte, Dugas, & Ladouceur, 1994; Dugas, Gagnon. Ladouceu, &
Freeston, 1998).
Worrying about trivial matters may reduce thoughts and feelings about one’s sense
of worthlessness (i.e. shame) or other unpleasant internal experiences (Roemer &
Orsillo, 2002). Eventually worry itself becomes an unwanted internal experience,
which triggers attempts to avoid it, which may increase its frequency (Wells, 1995;
Roemer & Borkovec, 1994).
The hypothesis that worry serves as an avoidance of internal distress is
supported by findings that GAD is associated with chronic tension, as well as vigilance
and scanning symptoms rather than the increased sympathetic activation seen with all
the other anxiety disorders (Brown, Barlow, & Liebowitz, 1994; Marten et al., 1993).
1.5.4 Therapeutic treatment
Cognitive-behavioural therapy has been shown in controlled studies to be effective in
reducing symptoms of GAD (Ballenger et al., 2001; Borkovec & Costello, 1993;
Butler, Fennel, Robson & Gelder, 1991; Durham, Murphy, Allan, & Rickard, 1994;
Falsetti & Davis, 2001). Cognitive therapy and cognitive-behavioural therapy and
applied relaxation have been compared (Arntz, 2003; Borkovec, Newman, Pincus, &
Lytle, 2002; Öst & Breitholtz, 2000) and all methods were found equally effective, with
recovery rates about 50-60%. Some authors conclude that it may be necessary to also
develop methods that address the interpersonal problems that patients with GAD often
present (Borkovec et al., 2002). Thus it seems to be essential to integrate methods of
13
different kinds to meet the multifaceted needs of patients with GAD. Several attempts
to apply theoretical integration (Stricker & Gold, 1996) in the treatment of patients with
GAD have been presented. Crits-Christoph (2002) suggested a treatment package that
integrates cognitive, behavioural, psychodynamic/inter-personal and acceptance-based
models for patients with GAD (Crits-Christoph, Connoly, Azarian, Crits-Christoph, &
Shappell,1996; Crits-Christoph, Connoly Gibbons, Narducci, Schamberger, & Gallop,
2005). Likewise, Roemer and Orsillo (2002) have described a model for treating GAD
integrating mindfulness/acceptance-based approaches with existing CBT models.
Wolfe has developed an integrative psychotherapy especially suited for patients
with anxiety disorders that incorporates psychodynamic, behavioural, cognitive-
behavioural, humanistic-experiential, and biomedical perspectives on anxiety disorders.
He also emphasizes the need to treat both the symptoms and the associated underlying
issues and thus has developed a four-stage treatment; first establishing the therapeutic
alliance, then ameliorating the anxiety symptoms, uncovering the deficiencies in
immediate self-experiencing, and finally repairing underlying self pathology (Wolfe,
1989, 1992, 1995, 2005; Wolfe & Sigl, 1998). His model is consistent with the “three-
tier” model of personality structure and change, developed by Gold & Stricker (1993).
Tier one refers to overt behaviour, tier two to conscious cognition, affect, perception
and sensation and tier three to unconscious mental processes, motives, conflicts,
images, and representations of significant others. Gold and Stricker (1993) have
developed an integrative method that addresses pathology on all three tiers.
1.6 PATIENT’S PREFERENCES AND EXPERIENCES RELATED TO
OUTCOME
The medical model predicts that differences among therapies are obscured by various
patient characteristics and that it might be necessary to match therapies to fit the
patient’s specific characteristics such as psychiatric diagnosis, illness etiology or
treatment preferences. Various terms have been associated with designs that test for
differential interactions between patients’ characteristics and therapy content, such as:
matching studies, aptitude x treatment interactions, and moderating variables
(Wampold, 2001).
Thus, patient’s preferences for particular treatment strategies could be a
possibly important mediating factor in the treatment of GAD. It has been demonstrated
that beliefs or attitudes that patients bring to therapy have an important influence on the
process and outcome of treatment (Frank, 1959; Joyce & Piper, 1998). It has also been
shown that initial treatment preferences were significantly related to treatment
satisfaction at follow-up in patients with eating disorders (Clinton, Björck, Sohlberg &
Norring, 2004). Several researchers have demonstrated that the congruence between a
patient’s treatment assignment and his/her preference for a particular form of treatment
was significantly related to whether the patient remained in treatment (Clinton, 1996;
13
different kinds to meet the multifaceted needs of patients with GAD. Several attempts
to apply theoretical integration (Stricker & Gold, 1996) in the treatment of patients with
GAD have been presented. Crits-Christoph (2002) suggested a treatment package that
integrates cognitive, behavioural, psychodynamic/inter-personal and acceptance-based
models for patients with GAD (Crits-Christoph, Connoly, Azarian, Crits-Christoph, &
Shappell,1996; Crits-Christoph, Connoly Gibbons, Narducci, Schamberger, & Gallop,
2005). Likewise, Roemer and Orsillo (2002) have described a model for treating GAD
integrating mindfulness/acceptance-based approaches with existing CBT models.
Wolfe has developed an integrative psychotherapy especially suited for patients
with anxiety disorders that incorporates psychodynamic, behavioural, cognitive-
behavioural, humanistic-experiential, and biomedical perspectives on anxiety disorders.
He also emphasizes the need to treat both the symptoms and the associated underlying
issues and thus has developed a four-stage treatment; first establishing the therapeutic
alliance, then ameliorating the anxiety symptoms, uncovering the deficiencies in
immediate self-experiencing, and finally repairing underlying self pathology (Wolfe,
1989, 1992, 1995, 2005; Wolfe & Sigl, 1998). His model is consistent with the “three-
tier” model of personality structure and change, developed by Gold & Stricker (1993).
Tier one refers to overt behaviour, tier two to conscious cognition, affect, perception
and sensation and tier three to unconscious mental processes, motives, conflicts,
images, and representations of significant others. Gold and Stricker (1993) have
developed an integrative method that addresses pathology on all three tiers.
1.6 PATIENT’S PREFERENCES AND EXPERIENCES RELATED TO
OUTCOME
The medical model predicts that differences among therapies are obscured by various
patient characteristics and that it might be necessary to match therapies to fit the
patient’s specific characteristics such as psychiatric diagnosis, illness etiology or
treatment preferences. Various terms have been associated with designs that test for
differential interactions between patients’ characteristics and therapy content, such as:
matching studies, aptitude x treatment interactions, and moderating variables
(Wampold, 2001).
Thus, patient’s preferences for particular treatment strategies could be a
possibly important mediating factor in the treatment of GAD. It has been demonstrated
that beliefs or attitudes that patients bring to therapy have an important influence on the
process and outcome of treatment (Frank, 1959; Joyce & Piper, 1998). It has also been
shown that initial treatment preferences were significantly related to treatment
satisfaction at follow-up in patients with eating disorders (Clinton, Björck, Sohlberg &
Norring, 2004). Several researchers have demonstrated that the congruence between a
patient’s treatment assignment and his/her preference for a particular form of treatment
was significantly related to whether the patient remained in treatment (Clinton, 1996;
14
Elkin et al., 1999). Preferences of treatment may be related to patients’ coping styles,
since patients may tend to prefer and expect to be helped by interventions that reflect
their own characteristic coping styles. Some authors suggest that coping style may
interact with treatment form as an important predictor of treatment response (Dance &
Neufeld, 1988; Blatt & Felsen, 1993). Some coping styles may be particularly
important, such as: a) active and independent versus passive and dependent, b)
introspective versus focused on external solutions, and c) confrontative versus avoidant.
In the case of GAD, greater knowledge of patients’ preferences and experiences of
treatment may help to improve treatment efficacy and outcome by contributing to
improved treatment planning, since patients may initially be motivated for treatment
that is compatible with their own preferences, yet unmotivated for methods that conflict
with their preferences. Better knowledge of preferences of treatment interventions in
GAD may also help therapists to engage patients in treatment. By alerting therapists to
sources of potential conflict when preferences are discrepant or inappropriate, it may be
possible to reduce the risk of dropout and improve screening procedures for better
matching of patient to treatment, as well as facilitating the working alliance (Clinton,
2001).
1.7 LOCATING MYSELF
In my view there are many ways of knowing and no single truth, thus I adhere to
epistemological relativism. This signifies that there are multiple realities and that they
are socially constructed (Lincoln, & Guba, 1989). Furthermore realities are experienced
differently depending on the person experiencing and judging them (Öhman, 2005).
Therefore it is valuable to use different perspectives to try and capture various aspects
of the problem in focus. Restricting oneself to a single way of knowing can result in a
limitation to the depth of knowledge that can be applied to a given problem situation
(Shepard, Jensen, Schmoll, Hack, & Gwyer, 1993).
Therefore I will describe my own role and preconceptions with regard to the
research area. I have had a twofold role; being one of the four clinicians in this study as
well as the researcher. When starting this study, my colleagues and I were all working
in psychiatry. We had just finished the training in the ABP method, named
Psychodynamic Body Therapy (PBT). We were trained and examined in PBT by Kirsti
Monsen, who had created the method (Monsen, K., 1989, Monsen & Monsen, 1999).
Another of our teachers was Berit Bunkan (1996), who together with Thornquist and
Radøy had established the psychomotor physiotherapy method, one of the cornerstones
in PBT. We were also trained in affect theory and affect interviewing by Jon Monsen
(Monsen, Melgård, & Ødegård, 1986).
Since the start of this thesis in 1998, I have completed psychodynamic
psychotherapy training. In my work as a body psychotherapist, in psychiatry and
psychosomatics, I am constantly engaged in how to integrate different techniques to
14
Elkin et al., 1999). Preferences of treatment may be related to patients’ coping styles,
since patients may tend to prefer and expect to be helped by interventions that reflect
their own characteristic coping styles. Some authors suggest that coping style may
interact with treatment form as an important predictor of treatment response (Dance &
Neufeld, 1988; Blatt & Felsen, 1993). Some coping styles may be particularly
important, such as: a) active and independent versus passive and dependent, b)
introspective versus focused on external solutions, and c) confrontative versus avoidant.
In the case of GAD, greater knowledge of patients’ preferences and experiences of
treatment may help to improve treatment efficacy and outcome by contributing to
improved treatment planning, since patients may initially be motivated for treatment
that is compatible with their own preferences, yet unmotivated for methods that conflict
with their preferences. Better knowledge of preferences of treatment interventions in
GAD may also help therapists to engage patients in treatment. By alerting therapists to
sources of potential conflict when preferences are discrepant or inappropriate, it may be
possible to reduce the risk of dropout and improve screening procedures for better
matching of patient to treatment, as well as facilitating the working alliance (Clinton,
2001).
1.7 LOCATING MYSELF
In my view there are many ways of knowing and no single truth, thus I adhere to
epistemological relativism. This signifies that there are multiple realities and that they
are socially constructed (Lincoln, & Guba, 1989). Furthermore realities are experienced
differently depending on the person experiencing and judging them (Öhman, 2005).
Therefore it is valuable to use different perspectives to try and capture various aspects
of the problem in focus. Restricting oneself to a single way of knowing can result in a
limitation to the depth of knowledge that can be applied to a given problem situation
(Shepard, Jensen, Schmoll, Hack, & Gwyer, 1993).
Therefore I will describe my own role and preconceptions with regard to the
research area. I have had a twofold role; being one of the four clinicians in this study as
well as the researcher. When starting this study, my colleagues and I were all working
in psychiatry. We had just finished the training in the ABP method, named
Psychodynamic Body Therapy (PBT). We were trained and examined in PBT by Kirsti
Monsen, who had created the method (Monsen, K., 1989, Monsen & Monsen, 1999).
Another of our teachers was Berit Bunkan (1996), who together with Thornquist and
Radøy had established the psychomotor physiotherapy method, one of the cornerstones
in PBT. We were also trained in affect theory and affect interviewing by Jon Monsen
(Monsen, Melgård, & Ødegård, 1986).
Since the start of this thesis in 1998, I have completed psychodynamic
psychotherapy training. In my work as a body psychotherapist, in psychiatry and
psychosomatics, I am constantly engaged in how to integrate different techniques to
15
enhance the patient’s ability to experience the mind-body unity. I am inspired by
experiential psychotherapy such as Fosha (2001) and McCullough (1998), the relational
perspective (Aron & Anderson, 1998) as well as trauma treatment (Rothshild, 2000).
My knowledge in the ABP method gave me the possibility to pose questions to
the patients who had been in treatment and it helped me understand their descriptions
and experiences. This could be viewed as a clear advantage. However, there is always
a danger in this procedure that the researcher will “go native”, as it is described in
action research. This signifies that the researcher is far to involved to see clearly and
thus loses the necessary distance to critically examine data. Others say that it is
necessary to “go native” to be able to: “pick it to pieces, deconstruct, reconstruct and
transform it with its tensions, tacit assumptions and practical preconditions exposed”
(Eikland, 2001, pp. 154). My intention was to strive in that direction in order to explore
and articulate some of the ingredients in the ABP method for patients with GAD.
My understanding of worry in GAD corresponds to the view presented by
Wolfe (2005); worrying is a cognitive process that protects the person from
experiencing painful emotions. It can be viewed as an escape from one’s direct, in-the-
moment experiencing. This study is based on the view that the worrying behaviour can
function as a defence blocking more adaptive forms of responding. The conflicted
feelings can be any of the full range of feelings that the person is not capable of
accepting (McCullough, 1998).
1.8 RATIONALE
GAD is an incapacitating illness and the impairment from GAD can be compared to
that seen in depression (Hoffman, Dukes, & Wittchen, 2008). Although CBT for GAD
has been listed as an empirically-supported treatment by the Task Force for the
Dissemination and Promotion of Empirically Supported treatments (Chambless, &
Ollendick, 2001) some methods of assessing clinically significant change suggest that
only about 50% of GAD patients receiving CBT return to normal levels of anxiety
(Borkovec, & Whisman,1996). The focus on affect-exploration and bodily
interventions are expected to help the patient to get in touch with his/her feelings,
thoughts and behaviour in the physically felt, bodily experience. The wish to develop
an alternative and integrative treatment for patients suffering from GAD has been the
impetus to the present study.
15
enhance the patient’s ability to experience the mind-body unity. I am inspired by
experiential psychotherapy such as Fosha (2001) and McCullough (1998), the relational
perspective (Aron & Anderson, 1998) as well as trauma treatment (Rothshild, 2000).
My knowledge in the ABP method gave me the possibility to pose questions to
the patients who had been in treatment and it helped me understand their descriptions
and experiences. This could be viewed as a clear advantage. However, there is always
a danger in this procedure that the researcher will “go native”, as it is described in
action research. This signifies that the researcher is far to involved to see clearly and
thus loses the necessary distance to critically examine data. Others say that it is
necessary to “go native” to be able to: “pick it to pieces, deconstruct, reconstruct and
transform it with its tensions, tacit assumptions and practical preconditions exposed”
(Eikland, 2001, pp. 154). My intention was to strive in that direction in order to explore
and articulate some of the ingredients in the ABP method for patients with GAD.
My understanding of worry in GAD corresponds to the view presented by
Wolfe (2005); worrying is a cognitive process that protects the person from
experiencing painful emotions. It can be viewed as an escape from one’s direct, in-the-
moment experiencing. This study is based on the view that the worrying behaviour can
function as a defence blocking more adaptive forms of responding. The conflicted
feelings can be any of the full range of feelings that the person is not capable of
accepting (McCullough, 1998).
1.8 RATIONALE
GAD is an incapacitating illness and the impairment from GAD can be compared to
that seen in depression (Hoffman, Dukes, & Wittchen, 2008). Although CBT for GAD
has been listed as an empirically-supported treatment by the Task Force for the
Dissemination and Promotion of Empirically Supported treatments (Chambless, &
Ollendick, 2001) some methods of assessing clinically significant change suggest that
only about 50% of GAD patients receiving CBT return to normal levels of anxiety
(Borkovec, & Whisman,1996). The focus on affect-exploration and bodily
interventions are expected to help the patient to get in touch with his/her feelings,
thoughts and behaviour in the physically felt, bodily experience. The wish to develop
an alternative and integrative treatment for patients suffering from GAD has been the
impetus to the present study.
16
1.9 AIM OF THE THESIS
The overall aim of this thesis was to evaluate and explore the Affect-focused body
psychotherapy for patients with Generalised anxiety disorder
The specific aims were:
I. To study the long-term effects of Affect-focused body psychotherapy in
comparison with psychiatric treatment as usual.
II. To investigate if affect consciousness is influenced by Affect-focused
body psychotherapy. To explore if there is a relationship between affect
consciousness and psychiatric distress, and if so, to describe the
relationship between affect consciousness and distress.
III. To explore preferences for particular sorts of treatment interventions,
(i.e. support, inward reflection, concrete and directive problem solving,
and affective expression), how patients experience such interventions,
and the relationship between treatment preferences and experiences to
outcome.
IV. To gain knowledge in how patients experience the ABP and if/how the
treatment enhances the patients’ capacity to redefine their anxiety
symptoms.
16
1.9 AIM OF THE THESIS
The overall aim of this thesis was to evaluate and explore the Affect-focused body
psychotherapy for patients with Generalised anxiety disorder
The specific aims were:
I. To study the long-term effects of Affect-focused body psychotherapy in
comparison with psychiatric treatment as usual.
II. To investigate if affect consciousness is influenced by Affect-focused
body psychotherapy. To explore if there is a relationship between affect
consciousness and psychiatric distress, and if so, to describe the
relationship between affect consciousness and distress.
III. To explore preferences for particular sorts of treatment interventions,
(i.e. support, inward reflection, concrete and directive problem solving,
and affective expression), how patients experience such interventions,
and the relationship between treatment preferences and experiences to
outcome.
IV. To gain knowledge in how patients experience the ABP and if/how the
treatment enhances the patients’ capacity to redefine their anxiety
symptoms.
17
2 METHOD
2.1 RESEARCH DESIGN
The research design in study I-III corresponds to the medical model, described above
(1.4.1.4 Meta- theory). The four levels of abstraction served as a guide to the research
design utilized.
In study I the specific approach in ABP was investigated. The corresponding
research question was if ABP was as effective as another treatment intervention. Thus a
randomized clinical trial was chosen.
In study II the specific technique with affect exploration was investigated. The
research questions concerned if the method actually could influence the affect
consciousness and if there was a link between affect consciousness and outcome. The
research design that I used to answer these questions was a clinical trial without control
group.
In study III the focus was to investigate if the patients’ treatment preferences
were related to outcome and how their experiences were related to initial preferences
and outcome and if it differed between the treatment modalities. The research design
that I used to answer these questions was a clinical trial with a control group.
The research design in study IV is rooted in the life-world perspective. The
research question was still concerned with the ABP treatment but the focus was on
what participation in ABP meant to the patients, their life-world perspective was
central. The life-world perspective was initially formulated by Edmund Husserl (1970).
He stated that we in phenomenology are interested in the persons’ lived experiences
rather than objectivistic descriptions. The basic methodological question for Husserl
was how to study subjectivity (Husserl, 1970). The life-world is thus the world as we
perceive it, and it is constituted of our memories, our experiences of the everyday world
and expectations about the future. A hermeneutic approach has been used to interpret
the interviews, with the aim of acquiring a valid understanding of the meaning that the
patients attributed to participating in ABP. In this thesis the purpose of the qualitative
work was to extend the understanding of the ABP process from the patients’
perspective. Therefore it was natural to have the qualitative part at the end of the thesis.
However, the different approaches have the same importance.
There is no unbiased interpretation of a text, because the interpreter cannot
leave the tradition of understanding the reality he or she lives in (Kvale, 1996). I would
like to add that there is no unbiased interpretation of numbers/statistics either.
17
2 METHOD
2.1 RESEARCH DESIGN
The research design in study I-III corresponds to the medical model, described above
(1.4.1.4 Meta- theory). The four levels of abstraction served as a guide to the research
design utilized.
In study I the specific approach in ABP was investigated. The corresponding
research question was if ABP was as effective as another treatment intervention. Thus a
randomized clinical trial was chosen.
In study II the specific technique with affect exploration was investigated. The
research questions concerned if the method actually could influence the affect
consciousness and if there was a link between affect consciousness and outcome. The
research design that I used to answer these questions was a clinical trial without control
group.
In study III the focus was to investigate if the patients’ treatment preferences
were related to outcome and how their experiences were related to initial preferences
and outcome and if it differed between the treatment modalities. The research design
that I used to answer these questions was a clinical trial with a control group.
The research design in study IV is rooted in the life-world perspective. The
research question was still concerned with the ABP treatment but the focus was on
what participation in ABP meant to the patients, their life-world perspective was
central. The life-world perspective was initially formulated by Edmund Husserl (1970).
He stated that we in phenomenology are interested in the persons’ lived experiences
rather than objectivistic descriptions. The basic methodological question for Husserl
was how to study subjectivity (Husserl, 1970). The life-world is thus the world as we
perceive it, and it is constituted of our memories, our experiences of the everyday world
and expectations about the future. A hermeneutic approach has been used to interpret
the interviews, with the aim of acquiring a valid understanding of the meaning that the
patients attributed to participating in ABP. In this thesis the purpose of the qualitative
work was to extend the understanding of the ABP process from the patients’
perspective. Therefore it was natural to have the qualitative part at the end of the thesis.
However, the different approaches have the same importance.
There is no unbiased interpretation of a text, because the interpreter cannot
leave the tradition of understanding the reality he or she lives in (Kvale, 1996). I would
like to add that there is no unbiased interpretation of numbers/statistics either.
18
2.2 PATIENTS
The patients were recruited consecutively through six first-line psychiatric out-patient
clinics south of Stockholm. They were examined by a medical doctor or a team
member. The following inclusion criteria were applied: GAD according to DSM-IV
(APA, 1994); age 18-55 years; ability to understand and speak Swedish well enough to
be able to answer the questionnaires. Exclusion criteria were: Major Depressive
Disorder and Bipolar Disorder according to DSM-IV, with or without severe suicidal
risk; organic brain damage; psychotic syndrome; ongoing drug or alcohol abuse and
current pregnancy.
Table 1.
Patients characteristics Treatment groups
ABP n=33 TAU n=28
Age
Age mean (range) 38 (25-55) 37 (21-53)
Sex
Female/male 24 / 9 18 /10
Martial status
Married or cohabiting 24 17
Single/divorced 4 / 5 5 / 6
Working capacity
Working full time 8 13
Working part time 9 2
Sick leave/pension 10/1 6 / 3
Unemployed 3 1
Parental leave/studying 1/1 1 / 2
Education
a
High 5 (15%) 7 (25 %)
Medium 22 (67%) 14 (50%)
Low 6 (18%) 7 (25%)
Medication
b
24 (73%) 20 (71%)
Personality disorders
No personality disorder 6 (18%) 6 (21%)
1-3 diagnoses 17 (52%) 14 (50%)
4-8 diagnoses 10 (30%) 8 (29%)
a
High: > 12 years. Medium: 10-12 years. Low: 9 years or less
b
Anxiolytcis and/or antidepressants and/or sleeping pills
18
2.2 PATIENTS
The patients were recruited consecutively through six first-line psychiatric out-patient
clinics south of Stockholm. They were examined by a medical doctor or a team
member. The following inclusion criteria were applied: GAD according to DSM-IV
(APA, 1994); age 18-55 years; ability to understand and speak Swedish well enough to
be able to answer the questionnaires. Exclusion criteria were: Major Depressive
Disorder and Bipolar Disorder according to DSM-IV, with or without severe suicidal
risk; organic brain damage; psychotic syndrome; ongoing drug or alcohol abuse and
current pregnancy.
Table 1.
Patients characteristics Treatment groups
ABP n=33 TAU n=28
Age
Age mean (range) 38 (25-55) 37 (21-53)
Sex
Female/male 24 / 9 18 /10
Martial status
Married or cohabiting 24 17
Single/divorced 4 / 5 5 / 6
Working capacity
Working full time 8 13
Working part time 9 2
Sick leave/pension 10/1 6 / 3
Unemployed 3 1
Parental leave/studying 1/1 1 / 2
Education
a
High 5 (15%) 7 (25 %)
Medium 22 (67%) 14 (50%)
Low 6 (18%) 7 (25%)
Medication
b
24 (73%) 20 (71%)
Personality disorders
No personality disorder 6 (18%) 6 (21%)
1-3 diagnoses 17 (52%) 14 (50%)
4-8 diagnoses 10 (30%) 8 (29%)
a
High: > 12 years. Medium: 10-12 years. Low: 9 years or less
b
Anxiolytcis and/or antidepressants and/or sleeping pills
19
The total patient group consisted of 61 individuals. There were 42 women and 19 men;
the mean age was 37 years (range 21-55); 70 % were married or living with a partner;
more than half of the group were working at least part time. About 60 % had 10-12
years in school, 20 % had less and 20 % had some form of higher education (see Table
1).
According to a self-report instrument, SCID screen (Ekselius, Lindström, von
Knorring, Bodlund & Kullgren, 1994), 49 (80 %) patients met the DSM-IV Axis II
criteria for at least one personality disorder (PD). This is an important observation in its
own right. However, we did not use PD as an exclusion criterion. More than half of the
group had 1-3 self-reported PDs and one fourth had 4-8 (see Table 1). Slightly more
than 70 % of the patients were on medication (anxiolytics and/or antidepressants and/or
sleeping pills). More than 50 % of the patients had had their first contact with
psychiatry more than three years prior to the study.
2.3 PROCEDURES
Prospective participants diagnosed with GAD were given both written and verbal
information about the trial, and written consent was obtained from all participants. The
study was approved by relevant professional ethics committees.
A flow chart of the study is presented in Figure 1. The patients were recruited
from six different psychiatric clinics. All participating patients had a doctor in charge at
the psychiatric clinic, and if needed the patients received medication. Consenting
patients were then referred to physiotherapists who administered assessment measures
prior to randomisation and treatment (T0). Patients were subsequently assessed one and
two years after initial assessment (T1 and T2).
Sixty-four patients met the GAD criteria in the screening. However, three of the
patients fulfilled exclusion criteria, and were therefore not included in the study. Of the
61 patients 33 were randomized to ABP and 28 to TAU, using a random number table.
Twenty-seven patients completed the one-year ABP, and six patients dropped out.
During the second year 18 patients in the ABP group (including three from the drop-out
group) had no further treatment in psychiatry, but 15 continued with some other kind of
treatment. One patient had a few booster sessions of ABP and another patient had
counselling due to a traumatic event, two had a few sessions of family therapy and
three from the dropouts continued in therapy other than ABP. Eight patients had regular
but scarce medical contact (see Figure 1).
19
The total patient group consisted of 61 individuals. There were 42 women and 19 men;
the mean age was 37 years (range 21-55); 70 % were married or living with a partner;
more than half of the group were working at least part time. About 60 % had 10-12
years in school, 20 % had less and 20 % had some form of higher education (see Table
1).
According to a self-report instrument, SCID screen (Ekselius, Lindström, von
Knorring, Bodlund & Kullgren, 1994), 49 (80 %) patients met the DSM-IV Axis II
criteria for at least one personality disorder (PD). This is an important observation in its
own right. However, we did not use PD as an exclusion criterion. More than half of the
group had 1-3 self-reported PDs and one fourth had 4-8 (see Table 1). Slightly more
than 70 % of the patients were on medication (anxiolytics and/or antidepressants and/or
sleeping pills). More than 50 % of the patients had had their first contact with
psychiatry more than three years prior to the study.
2.3 PROCEDURES
Prospective participants diagnosed with GAD were given both written and verbal
information about the trial, and written consent was obtained from all participants. The
study was approved by relevant professional ethics committees.
A flow chart of the study is presented in Figure 1. The patients were recruited
from six different psychiatric clinics. All participating patients had a doctor in charge at
the psychiatric clinic, and if needed the patients received medication. Consenting
patients were then referred to physiotherapists who administered assessment measures
prior to randomisation and treatment (T0). Patients were subsequently assessed one and
two years after initial assessment (T1 and T2).
Sixty-four patients met the GAD criteria in the screening. However, three of the
patients fulfilled exclusion criteria, and were therefore not included in the study. Of the
61 patients 33 were randomized to ABP and 28 to TAU, using a random number table.
Twenty-seven patients completed the one-year ABP, and six patients dropped out.
During the second year 18 patients in the ABP group (including three from the drop-out
group) had no further treatment in psychiatry, but 15 continued with some other kind of
treatment. One patient had a few booster sessions of ABP and another patient had
counselling due to a traumatic event, two had a few sessions of family therapy and
three from the dropouts continued in therapy other than ABP. Eight patients had regular
but scarce medical contact (see Figure 1).
20
Randomization, n=61
ABP, n=33
TAU, n=28
Drop-outs
n=6
ABP
n=27
Regular, scarce
contact n=12
Psychotherapy
n=11
Unsystematic
treatm n=5
No further treatment, n=18
Continued treatment, n=7
Scarce contact, n=8
No further treatment, n=12
Continued psychotherapy, n=6
Scarce contact, n=10
T
0
T
1
T
2
First line psychiatric department
Screening for GAD, n=64
Figure 1. Flow chart of the study
2.4 INSTRUMENTS AND MEASURES
Various quantitative and qualitative instruments were used in the studies in this
dissertation (Table 2).
2.4.1 Self-rated instruments
2.4.1.1 Socio-demographic data
Background and Treatment Inventory; a questionnaire constructed, by the author and
co-workers regarding different socio-demographic data and previous illness and
treatment history.
2.4.1.2 Severity of psychiatric symptoms
The Symptom Check List (SCL-90; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi,
1974) was used to measure patients’ subjective experience of psychiatric symptoms.
The degree of distress was rated on a 5-point scale ranging from 0 (not at all) to 4
(extremely) for each item. Besides 10 subscales, the Global Severity Index (GSI) is
constituted by the mean across all 90 items. In a Swedish standardization the mean GSI
for psychiatric patients was 1.02 (SD= .69) for men and 1.21 (SD= .73) for women
(Fridell, 2002).
20
Randomization, n=61
ABP, n=33
TAU, n=28
Drop-outs
n=6
ABP
n=27
Regular, scarce
contact n=12
Psychotherapy
n=11
Unsystematic
treatm n=5
No further treatment, n=18
Continued treatment, n=7
Scarce contact, n=8
No further treatment, n=12
Continued psychotherapy, n=6
Scarce contact, n=10
T
0
T
1
T
2
First line psychiatric department
Screening for GAD, n=64
Figure 1. Flow chart of the study
2.4 INSTRUMENTS AND MEASURES
Various quantitative and qualitative instruments were used in the studies in this
dissertation (Table 2).
2.4.1 Self-rated instruments
2.4.1.1 Socio-demographic data
Background and Treatment Inventory; a questionnaire constructed, by the author and
co-workers regarding different socio-demographic data and previous illness and
treatment history.
2.4.1.2 Severity of psychiatric symptoms
The Symptom Check List (SCL-90; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi,
1974) was used to measure patients’ subjective experience of psychiatric symptoms.
The degree of distress was rated on a 5-point scale ranging from 0 (not at all) to 4
(extremely) for each item. Besides 10 subscales, the Global Severity Index (GSI) is
constituted by the mean across all 90 items. In a Swedish standardization the mean GSI
for psychiatric patients was 1.02 (SD= .69) for men and 1.21 (SD= .73) for women
(Fridell, 2002).
21
In paper I and III we separated changes in anxiety from changes in distress in other
respects, hence we calculated two separate scores:
Anxiety as the mean across the 10 anxiety items (named Anx in paper I and
SCLAnx in paper III).
Global Severity minus Anxiety as the mean across the remaining 80 items
(named GSI–Anx in paper I and GSI_anx in paper III).
In paper II we used the Global Severity Index (GSI), constituted by the mean across all
90 items, to measure general distress. The GSI has high internal consistency and high
test-retest reliability in a Swedish translation (Fridell, 1998). In our material Cronbach’s
alpha was .96 on the GSI, .98 on the GSI without the anxiety scale, and .91 on the
Anxiety scale.
2.4.1.3 Severity of anxiety symptoms
Beck’s Anxiety Inventory (BAI; Beck, Epstein Brown & Steer, 1988; Beck & Steer,
1993) is a 21-item self-report scale that assesses common features of anxiety, with a
focus on body symptoms and cognitions on a 4-point severity scale. It has been widely
used in studies of psychological treatments for anxiety. The BAI has high internal
consistency and test-retest reliability over one week and it can discriminate anxiety
disorders from non-anxiety disorders. In our sample Cronbach’s alpha was .91.
Table 2. Review of instruments and methods used in the dissertation
Variable Instrument Presentation
Baseline data
Self rated personality
disorder
Background data concerning
socio-demographic facts and
previous illness and
treatment history
SCID screen
Background and Treatment
Inventory
Paper I, II, III
Paper I, II, III, IV
Outcome
Psychiatric symptoms
Anxiety symptoms
Well being
Patients treatment
preferences and experiences
Symptom Checklist -90 (SCL-90)
Beck’s anxiety inventory (BAI)
WHO’s well being index
Treatment preferences and
experiences scale (TPEX)
Paper I, II, III
Paper I, II, III
Paper I, II
Paper III
Affect-consciousness
Affect-consciousness interview,
semi-structured
Paper II
Patients experiences of
participating in ABP
Interviews directly after treatment
and one year later, semi-structured
Paper IV
21
In paper I and III we separated changes in anxiety from changes in distress in other
respects, hence we calculated two separate scores:
Anxiety as the mean across the 10 anxiety items (named Anx in paper I and
SCLAnx in paper III).
Global Severity minus Anxiety as the mean across the remaining 80 items
(named GSI–Anx in paper I and GSI_anx in paper III).
In paper II we used the Global Severity Index (GSI), constituted by the mean across all
90 items, to measure general distress. The GSI has high internal consistency and high
test-retest reliability in a Swedish translation (Fridell, 1998). In our material Cronbach’s
alpha was .96 on the GSI, .98 on the GSI without the anxiety scale, and .91 on the
Anxiety scale.
2.4.1.3 Severity of anxiety symptoms
Beck’s Anxiety Inventory (BAI; Beck, Epstein Brown & Steer, 1988; Beck & Steer,
1993) is a 21-item self-report scale that assesses common features of anxiety, with a
focus on body symptoms and cognitions on a 4-point severity scale. It has been widely
used in studies of psychological treatments for anxiety. The BAI has high internal
consistency and test-retest reliability over one week and it can discriminate anxiety
disorders from non-anxiety disorders. In our sample Cronbach’s alpha was .91.
Table 2. Review of instruments and methods used in the dissertation
Variable Instrument Presentation
Baseline data
Self rated personality
disorder
Background data concerning
socio-demographic facts and
previous illness and
treatment history
SCID screen
Background and Treatment
Inventory
Paper I, II, III
Paper I, II, III, IV
Outcome
Psychiatric symptoms
Anxiety symptoms
Well being
Patients treatment
preferences and experiences
Symptom Checklist -90 (SCL-90)
Beck’s anxiety inventory (BAI)
WHO’s well being index
Treatment preferences and
experiences scale (TPEX)
Paper I, II, III
Paper I, II, III
Paper I, II
Paper III
Affect-consciousness
Affect-consciousness interview,
semi-structured
Paper II
Patients experiences of
participating in ABP
Interviews directly after treatment
and one year later, semi-structured
Paper IV
22
2.4.1.4 Well being
The WHO (Ten) Well Being Index (WWBI; Bech, Gudex & Staehr Johansen, 1996)
includes negative and positive aspects of well-being in a single scale. The 10-item scale
has been found to constitute a valid index of well-being, being derived from the 28-
item WHO Well-Being Questionnaire. After reversing one item the scale measures
positive well-being. In our material Cronbach’s alpha was .95.
2.4.1.5 SCID II screen
This is a self-report instrument including questions for all items in the DSM-IV axis II.
(Ekselius, Lindström, von Knorring, Bodlund & Kullgren, 1994). The 97 items can be
answered by a ‘yes’ or a ‘no’. Compared to the SCID interview the SCID screen is
over-inclusive. Ekselius has therefore suggested raising the cut-off point so that one
more criterion has to be fulfilled for each of the PDs. It has been demonstrated that the
SCID screen questionnaire with raised cut-off levels can be used to give a rough
estimate of the frequency of PD in a population. The overall kappa for the agreement
between the SCID interviews and the SCID screen questionnaire with adjusted cut-off
has been found as high as .78 (Ekselius et al., 1994). We have used the number of PD’s
as a rough indication of the severity of the patients’ personality problems.
2.4.1.6 Treatment preferences and experiences
Assessment of initial preferences and subsequent experiences of treatment interventions
was made using the Treatment Preferences and Experiences Questionnaire (TPEX;
Clinton, & Sandell, 2007), a 29-item questionnaire being developed in an on-going
project looking at the relationship of treatment preferences and experiences to outcome
in different forms of psychotherapy. The TPEX has two forms, one for assessing
preferences and the other for assessing experiences. Prior to treatment subjects were
asked to rate the extent to which they believed they would be helped by specific
interventions and therapist characteristics; at follow-up patients were asked to rate the
extent to which they believed they been helped by these interventions. TPEX uses a
six-point Likert scale, with items grouped according to four subscales: Outward
Orientation (interventions focusing on concrete and directive problem solving), Inward
Orientation (interventions focusing on reflection and inner mental processes such as
fantasies, memories and dreams), Catharsis (focusing on expressive interventions and
affect) and Support (focusing on active advice, encouragement and sympathy from the
therapist).
Psychometric properties of the TPEX subscales were satisfactory. Internal consistency
using Cronbach’s α in the present combined sample (ABP and TAU) ranged between
α .77 and .95. Coefficients for individual subscales were: Catharsis α .82 (preferences),
α .87 (experiences); Inward Orientation α .77 (preferences), α .89 (experiences);
Outward Orientation α .78 (preferences); α .90 (experiences); Support α .81
(preferences); α .93 (experiences).
22
2.4.1.4 Well being
The WHO (Ten) Well Being Index (WWBI; Bech, Gudex & Staehr Johansen, 1996)
includes negative and positive aspects of well-being in a single scale. The 10-item scale
has been found to constitute a valid index of well-being, being derived from the 28-
item WHO Well-Being Questionnaire. After reversing one item the scale measures
positive well-being. In our material Cronbach’s alpha was .95.
2.4.1.5 SCID II screen
This is a self-report instrument including questions for all items in the DSM-IV axis II.
(Ekselius, Lindström, von Knorring, Bodlund & Kullgren, 1994). The 97 items can be
answered by a ‘yes’ or a ‘no’. Compared to the SCID interview the SCID screen is
over-inclusive. Ekselius has therefore suggested raising the cut-off point so that one
more criterion has to be fulfilled for each of the PDs. It has been demonstrated that the
SCID screen questionnaire with raised cut-off levels can be used to give a rough
estimate of the frequency of PD in a population. The overall kappa for the agreement
between the SCID interviews and the SCID screen questionnaire with adjusted cut-off
has been found as high as .78 (Ekselius et al., 1994). We have used the number of PD’s
as a rough indication of the severity of the patients’ personality problems.
2.4.1.6 Treatment preferences and experiences
Assessment of initial preferences and subsequent experiences of treatment interventions
was made using the Treatment Preferences and Experiences Questionnaire (TPEX;
Clinton, & Sandell, 2007), a 29-item questionnaire being developed in an on-going
project looking at the relationship of treatment preferences and experiences to outcome
in different forms of psychotherapy. The TPEX has two forms, one for assessing
preferences and the other for assessing experiences. Prior to treatment subjects were
asked to rate the extent to which they believed they would be helped by specific
interventions and therapist characteristics; at follow-up patients were asked to rate the
extent to which they believed they been helped by these interventions. TPEX uses a
six-point Likert scale, with items grouped according to four subscales: Outward
Orientation (interventions focusing on concrete and directive problem solving), Inward
Orientation (interventions focusing on reflection and inner mental processes such as
fantasies, memories and dreams), Catharsis (focusing on expressive interventions and
affect) and Support (focusing on active advice, encouragement and sympathy from the
therapist).
Psychometric properties of the TPEX subscales were satisfactory. Internal consistency
using Cronbach’s α in the present combined sample (ABP and TAU) ranged between
α .77 and .95. Coefficients for individual subscales were: Catharsis α .82 (preferences),
α .87 (experiences); Inward Orientation α .77 (preferences), α .89 (experiences);
Outward Orientation α .78 (preferences); α .90 (experiences); Support α .81
(preferences); α .93 (experiences).
23
2.4.2 Interviews
2.4.2.1 Affect Consciousness interview
The Affect Consciousness Interview (ACI; Monsen et al., 1996), used in study II, is a
semi-structured interview designed to assess a person’s capacity to cope with his or her
feelings, across nine basic affect categories; Interest-Excitement, Enjoyment-Joy, Fear-
Terror, Anger-Rage, Shame-Humiliation, Sadness-Despair, Envy-Jealousy, Guilt-
Remorse and Tenderness-Devotion (Monsen et al., 1996). For each of these affects the
interviewer attempts to assess and rate the interviewee’s capacity to (a) be aware of, (b)
tolerate, and express, (c) emotionally and (d) conceptually, inner emotional states. The
assessment is based on the interviewee’s free accounts of affect-laden life experiences.
Monsen et al. (1996) have shown that ratings have satisfactory inter-rater reliability and
high levels of internal consistency.
In this study five affects were assessed in the affect consciousness interview:
Enjoyment-Joy, Fear-Terror, Anger-Rage, Shame-Humiliation and Sadness-Despair.
These five affects are the ones that both Tomkins (1963) and Monsen et al. (1996)
suggest as the primary affects, besides Interest-Excitement. However, pilot tests
revealed that Interest-Excitement could not be scored with sufficient reliability, so it
was not further covered in the analysis.
For each affect the following four aspects of affect consciousness were explored
according to Monsen et al. (1996, pp 242).
Awareness: The ability to feel, sense, become aware of, recognize or notice when
experiencing a particular affect.
Tolerance: The ability to be influenced by the affect; physically and mentally
without acting out or becoming overwhelmed.
Emotional expression: The ability to express the affect nonverbally in different
kinds of object relations in a clear and appropriate way according to the
circumstances.
Conceptual expression: The ability to articulate the affect experiences in different
interpersonal settings in a clear and appropriate way according to the
circumstances.
The interviews were performed by physiotherapists, who were trained, by J. and K.
Monsen to perform the interviews and apply the scoring method. Pre-treatment
interviews were made by the physiotherapist who was going to treat the patient; post-
treatment interviews by another physiotherapist previously unfamiliar to the patient.
The interviews lasted for 90-120 minutes and were video- and tape recorded.
Subsequently, the interviews were analysed according to Monsen et al. (1986)
using a 5-point scale, where 5 stands for the highest possible degree of affect
23
2.4.2 Interviews
2.4.2.1 Affect Consciousness interview
The Affect Consciousness Interview (ACI; Monsen et al., 1996), used in study II, is a
semi-structured interview designed to assess a person’s capacity to cope with his or her
feelings, across nine basic affect categories; Interest-Excitement, Enjoyment-Joy, Fear-
Terror, Anger-Rage, Shame-Humiliation, Sadness-Despair, Envy-Jealousy, Guilt-
Remorse and Tenderness-Devotion (Monsen et al., 1996). For each of these affects the
interviewer attempts to assess and rate the interviewee’s capacity to (a) be aware of, (b)
tolerate, and express, (c) emotionally and (d) conceptually, inner emotional states. The
assessment is based on the interviewee’s free accounts of affect-laden life experiences.
Monsen et al. (1996) have shown that ratings have satisfactory inter-rater reliability and
high levels of internal consistency.
In this study five affects were assessed in the affect consciousness interview:
Enjoyment-Joy, Fear-Terror, Anger-Rage, Shame-Humiliation and Sadness-Despair.
These five affects are the ones that both Tomkins (1963) and Monsen et al. (1996)
suggest as the primary affects, besides Interest-Excitement. However, pilot tests
revealed that Interest-Excitement could not be scored with sufficient reliability, so it
was not further covered in the analysis.
For each affect the following four aspects of affect consciousness were explored
according to Monsen et al. (1996, pp 242).
Awareness: The ability to feel, sense, become aware of, recognize or notice when
experiencing a particular affect.
Tolerance: The ability to be influenced by the affect; physically and mentally
without acting out or becoming overwhelmed.
Emotional expression: The ability to express the affect nonverbally in different
kinds of object relations in a clear and appropriate way according to the
circumstances.
Conceptual expression: The ability to articulate the affect experiences in different
interpersonal settings in a clear and appropriate way according to the
circumstances.
The interviews were performed by physiotherapists, who were trained, by J. and K.
Monsen to perform the interviews and apply the scoring method. Pre-treatment
interviews were made by the physiotherapist who was going to treat the patient; post-
treatment interviews by another physiotherapist previously unfamiliar to the patient.
The interviews lasted for 90-120 minutes and were video- and tape recorded.
Subsequently, the interviews were analysed according to Monsen et al. (1986)
using a 5-point scale, where 5 stands for the highest possible degree of affect
consciousness. A scoring manual developed by Monsen et al. (1986) was used and
further developed by the author and co-workers in 2004 (unpublished, can be sent on
request to the author).
The following ten scores were computed for each interview: The mean score for
each affect across the four aspects of affect consciousness; the mean score of each
aspect across all affects; and a global score as the mean of all the 20 ratings. Following
Monsen et al. (1996) we have analysed the scores parametrically.
Additional analysis
In order to give a description of how changes in affect consciousness could be
manifested, I also conducted a minor qualitative study concerning the patients who
showed reliable change in affect consciousness regarding the specific affects.
1.1.1.1 Qualitative interviews
In study IV, a qualitative, semi-structured interview was undertaken directly after
treatment termination and once again after a year. The interviews aimed at addressing
all relevant aspects of the ABP interventions and the patients’ life situation before and
after therapy. Specifically, the interview entails a collaborative process between patient
and interviewer, by which the patient is engaged in reflecting on the experiences of
therapy and the interviewer extracts information relevant to specific research questions
regarding the therapy process.
The interview directly after treatment termination focused on the patients’
situation before therapy start, their initial attitude towards being offered the ABP
treatment, their understanding of the treatment and the treatment impact on symptoms,
relations and self image. The patients’ relationship towards the therapist and memories
of turning points in therapy were also elucidated.
The interview at one year follow up focused mainly on the patients’ present
situation in comparison to before therapy. The main themes were, the present
trouble/pains/symptoms and how it was understood by the patient, the social situation,
the patients view of themselves and experience of and attribution to change
The interviews lasted for between 45 minutes to 90 minutes and were audio
taped and transcribed verbatim. The patients could choose place for the interview, either
at their home or at the clinic were they were treated. The interviews were conducted by
a physiotherapist previously unknown to the patient.
1.2 TREATMENT AND THERAPISTS
Four female physiotherapists, the author being one of them, administered the ABP once
weekly during one year. Their professional experience in psychosomatics or psychiatry
24
consciousness. A scoring manual developed by Monsen et al. (1986) was used and
further developed by the author and co-workers in 2004 (unpublished, can be sent on
request to the author).
The following ten scores were computed for each interview: The mean score for
each affect across the four aspects of affect consciousness; the mean score of each
aspect across all affects; and a global score as the mean of all the 20 ratings. Following
Monsen et al. (1996) we have analysed the scores parametrically.
Additional analysis
In order to give a description of how changes in affect consciousness could be
manifested, I also conducted a minor qualitative study concerning the patients who
showed reliable change in affect consciousness regarding the specific affects.
1.1.1.1 Qualitative interviews
In study IV, a qualitative, semi-structured interview was undertaken directly after
treatment termination and once again after a year. The interviews aimed at addressing
all relevant aspects of the ABP interventions and the patients’ life situation before and
after therapy. Specifically, the interview entails a collaborative process between patient
and interviewer, by which the patient is engaged in reflecting on the experiences of
therapy and the interviewer extracts information relevant to specific research questions
regarding the therapy process.
The interview directly after treatment termination focused on the patients’
situation before therapy start, their initial attitude towards being offered the ABP
treatment, their understanding of the treatment and the treatment impact on symptoms,
relations and self image. The patients’ relationship towards the therapist and memories
of turning points in therapy were also elucidated.
The interview at one year follow up focused mainly on the patients’ present
situation in comparison to before therapy. The main themes were, the present
trouble/pains/symptoms and how it was understood by the patient, the social situation,
the patients view of themselves and experience of and attribution to change
The interviews lasted for between 45 minutes to 90 minutes and were audio
taped and transcribed verbatim. The patients could choose place for the interview, either
at their home or at the clinic were they were treated. The interviews were conducted by
a physiotherapist previously unknown to the patient.
1.2 TREATMENT AND THERAPISTS
Four female physiotherapists, the author being one of them, administered the ABP once
weekly during one year. Their professional experience in psychosomatics or psychiatry
24
25
varied from ten to twenty years. The treatment was guided by a manual (Monsen,
1989). Before the study, the physiotherapists were trained and examined in the ABP
method by its author. During the treatment period all therapists had supervision twice
monthly by another ABP teacher to ensure the quality of the ABP treatment and
adherence to the manual.
2.6 PATIENTS AND METHODS OF ANALYSIS
The various methods of analyses that have been used are displayed in table 3. Data
analysis was conducted by means of the Statistical package for Social Sciences (SPSS,
16.0)
2.6.1 Paper I-III
In paper I, data is presented on the entire intent-to-treat sample (ABP, n = 33; TAU, n
= 28), with the last observation carried forward for all persons with incomplete data.
The intent-to-treat approach is a conservative way to evaluate treatment effects for
those patients for whom the treatment was intended, regardless of whether they
completed treatment or not. Six patients (18%) dropped-out from ABP. The number of
patients that did not return outcome data in the ABP group was two at T1 (6%) and
three at T2 (9%). In the TAU group there were seven non-responders at T1 (28%) and
three at T2 (10%).
Statistical analysis, paper I
Repeated measures multivariate analysis of covariance (MANCOVA) was performed
on the SCL-90, BAI and WWBI. Effect sizes, d, on the raw scores on each outcome
variable were also calculated. The raw score differences between the first measurement
(baseline) and each of the two follow-up measurements for each scale in each group
were divided by the standard deviation at baseline (Cohen, 1988; Leichsenring &
Leibing, 2003). Between-groups effect sizes, , were calculated using Becker’s (1988)
method, that is, computing the difference between the within-group d’s.
In paper II, a sub sample consisting of 22 patients from the first study was used. For
inclusion in this study patients were required to have completed the one year ABP
treatment and to have participated in the affect-consciousness interview before
treatment start and after treatment termination. Sixteen women and six men were
included in this study. Mean age was 41 years (range: 26-55 years).
Statistical analysis, paper II
The scoring of all interviews was performed by the author. In order to estimate the
reliability of the ratings another physiotherapist scored nine randomly chosen
interviews. Intraclass correlations (ICC) ranged between .65 (for shame) and .95 (for
awareness) with a median of .88.
25
varied from ten to twenty years. The treatment was guided by a manual (Monsen,
1989). Before the study, the physiotherapists were trained and examined in the ABP
method by its author. During the treatment period all therapists had supervision twice
monthly by another ABP teacher to ensure the quality of the ABP treatment and
adherence to the manual.
2.6 PATIENTS AND METHODS OF ANALYSIS
The various methods of analyses that have been used are displayed in table 3. Data
analysis was conducted by means of the Statistical package for Social Sciences (SPSS,
16.0)
2.6.1 Paper I-III
In paper I, data is presented on the entire intent-to-treat sample (ABP, n = 33; TAU, n
= 28), with the last observation carried forward for all persons with incomplete data.
The intent-to-treat approach is a conservative way to evaluate treatment effects for
those patients for whom the treatment was intended, regardless of whether they
completed treatment or not. Six patients (18%) dropped-out from ABP. The number of
patients that did not return outcome data in the ABP group was two at T1 (6%) and
three at T2 (9%). In the TAU group there were seven non-responders at T1 (28%) and
three at T2 (10%).
Statistical analysis, paper I
Repeated measures multivariate analysis of covariance (MANCOVA) was performed
on the SCL-90, BAI and WWBI. Effect sizes, d, on the raw scores on each outcome
variable were also calculated. The raw score differences between the first measurement
(baseline) and each of the two follow-up measurements for each scale in each group
were divided by the standard deviation at baseline (Cohen, 1988; Leichsenring &
Leibing, 2003). Between-groups effect sizes, , were calculated using Becker’s (1988)
method, that is, computing the difference between the within-group d’s.
In paper II, a sub sample consisting of 22 patients from the first study was used. For
inclusion in this study patients were required to have completed the one year ABP
treatment and to have participated in the affect-consciousness interview before
treatment start and after treatment termination. Sixteen women and six men were
included in this study. Mean age was 41 years (range: 26-55 years).
Statistical analysis, paper II
The scoring of all interviews was performed by the author. In order to estimate the
reliability of the ratings another physiotherapist scored nine randomly chosen
interviews. Intraclass correlations (ICC) ranged between .65 (for shame) and .95 (for
awareness) with a median of .88.
26
Multivariate analysis of variance (MANOVA) was used to evaluate the affect
scores. Furthermore, within-group effect sizes, d (Cohen, 1988) and the Reliable
Change Index (RCI) according to Evans, Margison and Barkham (1998) were
calculated.
Reliable Change (RC) is about whether patients changed sufficiently that the
change is unlikely to be due to simple measurement unreliability. The formula for
criterion level, based on change that would happen less than 5% of the time by
unreliability of measurement alone, is: 1.96*SD
1
*2* (1-reliability).
In order to analyse the interaction between AC and outcome measures over time we ran
a descriptive path analysis on an autoregressive cross-lagged model with standardized
variables, using the LISREL 8.80 software. It is in the nature of this kind of model that
each path is estimated with all other independent variables constant, making the
dependent variables correspond to a standardized residual.
Qualitative analysis, paper II. Interviews that showed a positive reliable change were
analysed qualitatively using the method of content analysis (Krippendorff, 2004). The
number of interviews varied between 3 (shame and fear) and 13 (sadness). The
software ATLAS.ti was used as an aid to the analysis (Graneheim, & Lundman, 2003).
Before a statement was coded, it was first considered in its context to avoid using the
patient’s statement in a way that the patient might not have intended. Based on the aims
of this study, the specific question put to the material was: How did the patient
experience, tolerate and express the affect before and after therapy?
In paper III, a sub sample consisting of 43 patients from the first study was used. For
inclusion in the study patients were required to have: a) either completed treatment in
the ABP group or adhered to treatment in the control group; and b) completed all
relevant measures at initial assessment (T0) and follow-up after one and two years (T1
and T2). In the ABP group T1 corresponded to the end of treatment. Twenty-six
patients in ABP and seventeen in TAU fulfilled criteria. Mean age in both groups was
38 years (range: 21-55 years).
Statistical analysis, paper III
Independent-sample t-tests were used to compare ABP and controls on initial TPEX
Preferences. In order to control for initial treatment preferences, univariate ANOVA
was used, to examine between-group differences on TPEX Experiences. Paired-sample
t-tests were used to compare scores on TPEX Preferences with scores on TPEX
Experiences within each treatment group separately. In order to more fully explore
patterns of treatment preferences and experiences we conducted a cluster analysis
(Everitt, Landau & Leese, 2001). Cluster analysis is conceptually similar to factor
analysis; however, while factor analysis reveals patterns among variables, cluster
analysis focuses on groupings of individuals.
26
Multivariate analysis of variance (MANOVA) was used to evaluate the affect
scores. Furthermore, within-group effect sizes, d (Cohen, 1988) and the Reliable
Change Index (RCI) according to Evans, Margison and Barkham (1998) were
calculated.
Reliable Change (RC) is about whether patients changed sufficiently that the
change is unlikely to be due to simple measurement unreliability. The formula for
criterion level, based on change that would happen less than 5% of the time by
unreliability of measurement alone, is: 1.96*SD
1
*2* (1-reliability).
In order to analyse the interaction between AC and outcome measures over time we ran
a descriptive path analysis on an autoregressive cross-lagged model with standardized
variables, using the LISREL 8.80 software. It is in the nature of this kind of model that
each path is estimated with all other independent variables constant, making the
dependent variables correspond to a standardized residual.
Qualitative analysis, paper II. Interviews that showed a positive reliable change were
analysed qualitatively using the method of content analysis (Krippendorff, 2004). The
number of interviews varied between 3 (shame and fear) and 13 (sadness). The
software ATLAS.ti was used as an aid to the analysis (Graneheim, & Lundman, 2003).
Before a statement was coded, it was first considered in its context to avoid using the
patient’s statement in a way that the patient might not have intended. Based on the aims
of this study, the specific question put to the material was: How did the patient
experience, tolerate and express the affect before and after therapy?
In paper III, a sub sample consisting of 43 patients from the first study was used. For
inclusion in the study patients were required to have: a) either completed treatment in
the ABP group or adhered to treatment in the control group; and b) completed all
relevant measures at initial assessment (T0) and follow-up after one and two years (T1
and T2). In the ABP group T1 corresponded to the end of treatment. Twenty-six
patients in ABP and seventeen in TAU fulfilled criteria. Mean age in both groups was
38 years (range: 21-55 years).
Statistical analysis, paper III
Independent-sample t-tests were used to compare ABP and controls on initial TPEX
Preferences. In order to control for initial treatment preferences, univariate ANOVA
was used, to examine between-group differences on TPEX Experiences. Paired-sample
t-tests were used to compare scores on TPEX Preferences with scores on TPEX
Experiences within each treatment group separately. In order to more fully explore
patterns of treatment preferences and experiences we conducted a cluster analysis
(Everitt, Landau & Leese, 2001). Cluster analysis is conceptually similar to factor
analysis; however, while factor analysis reveals patterns among variables, cluster
analysis focuses on groupings of individuals.
27
---------------------------------------------------Insert table 3 here----------------
Table 3. Number of included patients, instruments, and methods of analysis in the four
studies. Obs! Denna skall vändas för att få plats sida nr 27!
Study
Treatment
groups
ABP TAU
n n
Data collection
method
Analyses
S
econda
r
analyses
sub
g
rou
p
patients
I
33
28
SCL-90 (GSI–Anx, Anx)
BAI
WWBI
MANCOVA
Within-group effect sizes, d,
Between group effect size, d
Number
of PD’s:
0
1-3
4-8
II
22
(From
Study I)
ACI
SCL-90
BAI
WWBI
MANOVA
Within-group effect sizes, d
Reliable Change Index (RCI)
Descriptive path analysis
Reliable
change s
c
III
26
(From
study I)
17
(From
study I)
TPEX
SCL-90 (GSI_anx, SCL anx)
BAI
Independent sample t-test
Univariate ANOVA
Paired sample t-test
Hierarchical cluster analysis
Relative
treatmen
t
experien
c
Positive
Negative
IV
30
(From
study I)
Follow up interviews
Hermeneutic approach
1
Additional analysis only in the frame of this thesis
Table 3. Number of included patients, instruments, and methods of analysis in the four studies.
Study
Treatment
groups
ABP TAU
n n
Data collection
method
Analyses
Secondary
analyses of
subgroups of
patients
Analyses
I
33
28
SCL-90 (GSI–Anx, Anx)
BAI
WWBI
MANCOVA
Within-group effect sizes, d,
Between group effect size, d
Number
of PD’s:
0 n= 12
1-3 n = 31
4-8 n= 18
MANCOVA
II
22
(From
study I)
ACI
SCL-90
BAI
WWBI
MANOVA
Within-group effect sizes, d
Reliable Change Index
(RCI)
Descriptive path analysis
Reliable change
scores
1
Content
analysis
III
26 (From
study I)
17
(From
study I)
TPEX
SCL-90 (GSI_anx, SCL
anx) BAI
Independent sample t-test
ANOVA univariat
Paired sample t-test
Hierarchical cluster analysis
Relative treatment
experience
Positive n=29
Negative n=14
MANCOVA
Simultaneous
multiple
regression
IV
30 (From
study I)
Follow up interviews
Hermeneutic approach
1
Additional analysis only in the frame of this thesis
27
---------------------------------------------------Insert table 3 here----------------
Table 3. Number of included patients, instruments, and methods of analysis in the four
studies. Obs! Denna skall vändas för att få plats sida nr 27!
Study
Treatment
groups
ABP TAU
n n
Data collection
method
Analyses
S
econda
r
analyses
sub
g
rou
p
patients
I
33
28
SCL-90 (GSI–Anx, Anx)
BAI
WWBI
MANCOVA
Within-group effect sizes, d,
Between group effect size, d
Number
of PD’s:
0
1-3
4-8
II
22
(From
Study I)
ACI
SCL-90
BAI
WWBI
MANOVA
Within-group effect sizes, d
Reliable Change Index (RCI)
Descriptive path analysis
Reliable
change s
c
III
26
(From
study I)
17
(From
study I)
TPEX
SCL-90 (GSI_anx, SCL anx)
BAI
Independent sample t-test
Univariate ANOVA
Paired sample t-test
Hierarchical cluster analysis
Relative
treatmen
t
experien
c
Positive
Negative
IV
30