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Emotion-focused psychotherapy for GAD: individual case comparison of a good and poor outcome case

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Abstract

Emotion-focused psychotherapy proposes that maladaptive emotional processing and a vulnerable sense of self is core to generalized anxiety disorder (GAD). This paper examined changes in clients’ maladaptive emotions and negative treatment of self in a good and a poor outcome case in emotion-focused psychotherapy. Transcribed sessions were coded using a measure of emotion derived from Plutchik’s wheel of emotion and a measure of negative treatment of self based on subscales of the Measure of Client Productive Processing. The changes observed across therapy for each client on each dimension were compared and contrasted and the trajectory of change plotted and described. The findings provide a preliminary model of change in GAD to inform future investigations of the change process in GAD and the development of a task analytic model of resolution for clients with GAD.

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... Klienti si nejvíce cenili podpůrného terapeutického vztahu a experienciálních technik. Účinnost EFT při léčbě GAD byla ověřována rovněž v případových studiích (Timuľák & McElvaney, 2016;Watson et al., 2017 Dosud nejnovější studii účinnosti EFT při léčbě sociální úzkosti realizovali Shahar et al. (2017). Využili při tom zajímavého výzkumného designu (tzv. ...
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This article sets forth a new model for knowledge generation in applied and professional psychology -- the pragmatic case study (PCS) method. Drawing from both psychology's traditional/quantitative and alternative/qualitative approaches, the PCS method involves the creation of systematic, peer-reviewed case studies in psychotherapy (and in all other areas of applied psychology) that follow D. Peterson's "disciplined inquiry" epistemological model. The studies are designed to be organized into "journal-databases," like Pragmatic Case Studies in Psychotherapy (PCSP), which combine (a) individual studies; (b) articles that address epistemological, theoretical, methodological, logistical, economic, political and ethical issues in the PCS method; and (c) substantive cross-case analyses of groups of individual cases already published in the database. To lay out the model's arguments, the article is divided into four major sections that consider, respectively: (1) a discussion of the relevant historical and philosophical context from which the PCS model emerges; (2) a proposal for an initial set of methodological guidelines for ensuring rigorous quality in each case study; (3) an illustrative application of the model to cognitive-behavioral efficacy research; and (4) an exploration of the implications of the model. Throughout, the emphasis is upon creating an integrative, pragmatic alternative for gaining new useful knowledge in our discipline.
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A reliability generalization study for Spielberger’s State-Trait Anxiety Inventory (STAI) was conducted. A total of 816 research articles utilizing the STAI between 1990 and 2000 were reviewed and classified as having (a) ignored reliability (73%), (b) mentioned reliability or reported reliability coefficients from another source (21%), or (c) computed reliability for the data at hand (6%). Articles in medically oriented journals were shorter and somewhat less likely to mention or compute reliability than nonmedically oriented articles, perhaps due to paradigm differences. Average reliability coefficients were acceptable for both internal consistency and test-retest, but variation was present among the estimates. State test-retest coefficients were lower than internal consistency coefficients. Score variability was predictive of internal consistency reliability for scores on both scales. Other predictors were the age of research participants, the form of the STAI, and the type of research design.
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Unlabelled: Although associations with outcome have been inconsistent, therapist adherence and competence continues to garner attention, particularly within the context of increasing interest in the dissemination, implementation, and sustainability of evidence-based treatments. To date, research on therapist adherence and competence has focused on average levels across therapists. With a few exceptions, research has failed to address multiple sources of variability in adherence and competence, identify important factors that might account for variability, or take these sources of variability into account when examining associations with symptom change. Objective: (a) statistically demonstrate between- and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and (b) examine the relationship between adherence/competence and symptom change. Method: Randomly selected audiotaped sessions from a randomized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence. Patients completed a self-report measure of panic symptom severity prior to each session and the Inventory of Interpersonal Problems-Personality Disorder Scale prior to the start of treatment. Results: Significant between- and within-therapist variability in adherence and competence were observed. Adherence and competence deteriorated significantly over the course of treatment. Higher patient interpersonal aggression was associated with decrements in both adherence and competence. Neither adherence nor competence predicted subsequent panic severity. Conclusions: Variability and "drift" in adherence and competence can be observed in controlled trials. Training and implementation efforts should involve continued consultation over multiple cases in order to account for relevant patient factors and promote sustainability across sessions and patients.
The authors of this volume offer a behind-closed-doors look at brief emotion-focused therapy (EFT) in the treatment of depression, capturing the state of the art of this important and widely used therapy. Six in-depth case studies--three that result in a good outcome and three in a poor outcome--exemplify the principles of EFT and show how treatment progresses. The clients vary widely in their backgrounds, personalities, and beliefs about the roots of their depression, vividly demonstrating the utility of EFT across a range of circumstances. Meticulous session-by-session descriptions of the therapy process include extensive dialogue and postsession evaluations using a variety of objective process measures. These measures illuminate clients' moment-to-moment cognitive-affective processing and their perspectives on self and others. The focus on therapists' strategic choices deepens readers' understanding of the interaction between client and therapist as therapy unfolds. Client characteristics that influence outcome are compared and discussed to help therapists identify who may or may not benefit from brief EFT. Finally, the authors provide suggestions that will help readers more quickly identify when clients may be having difficulty in brief EFT and present a set of therapeutic strategies for working with these clients. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Posted May 3, 2000. The power struggle between the efficacy and effectiveness models in psychotherapy research has reached an impasse, and the time is ripe for fundamentally new ideas. This article contends that one way of transcending the impasse is to adopt a new, case-based "pragmatic psychology" paradigm that, while deeply and inherently different, (1) draws elements from both the efficacy and effectiveness approaches in an integrative manner and (2) can be viewed as complementing rather than competing with these approaches. Centered within philosophical pragmatism and following K. I. Howard's "patient-focused" research approach, the new pragmatic psychology paradigm calls for the development of databases of systematic, rigorous, solution-focused case studies of human service programs of all types, including psychotherapy. This article proposes that an ideal way of pilot-testing the pragmatic psychology paradigm is for the American Psychological Association (APA) to sponsor a new, electronic "Journal of Pragmatic Case Studies" that would begin by focusing on psychotherapy. The nature, structure, and scholarly and practical uses of such a journal are set forth. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Presents a view of empathy as an active ingredient of change that facilitates clients' meta-cognitive processes and emotional self-regulation. The author reviews the research on empathy and argues that it reveals that empathy is an essential component of successful therapy in every therapeutic modality. The author also discusses how empathy informs humanistic and experiential therapists' practice and provides a theoretical model of empathy's role in promoting change in psychotherapy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Background: The 7-item Generalized Anxiety Disorder Scale (GAD-7) is a practical self-report anxiety questionnaire that proved valid in primary care. However, the GAD-7 was not yet validated in the general population and thus far, normative data are not available. Objectives: To investigate reliability, construct validity, and factorial validity of the GAD-7 in the general population and to generate normative data. Research Design: Nationally representative face-to-face household survey conducted in Germany between May 5 and June 8, 2006. Subjects: Five thousand thirty subjects (53.6% female) with a mean age (SD) of 48.4 (18.0) years. Measures: The survey questionnaire included the GAD-7, the 2-item depression module from the Patient Health Questionnaire (PHQ-2), the Rosenberg Self-Esteem Scale, and demographic characteristics. Results: Confirmatory factor analyses substantiated the 1-dimensional structure of the GAD-7 and its factorial invariance for gender and age. Internal consistency was identical across all subgroups (α = 0.89). Intercorrelations with the PHQ-2 and the Rosenberg Self-Esteem Scale were r = 0.64 (P < 0.001) and r = -0.43 (P < 0.001), respectively. As expected, women had significantly higher mean (SD) GAD-7 anxiety scores compared with men [3.2 (3.5) vs. 2.7 (3.2); P < 0.001]. Normative data for the GAD-7 were generated for both genders and different age levels. Approximately 5% of subjects had GAD-7 scores of 10 or greater, and 1% had GAD-7 scores of 15 or greater. Conclusions: Evidence supports reliability and validity of the GAD-7 as a measure of anxiety in the general population. The normative data provided in this study can be used to compare a subject's GAD-7 score with those determined from a general population reference group.
Article
The effects of smoking cigarettes with differing FTC nicotine deliveries on anxiety and EEG activity were evaluated in 40 smokers who were compared with 40 non-smokers, matched for age and gender. Following smoking (sham-smoking in the case of the non-smokers), the participants viewed a stress-inducing movie. Smoking higher-nicotine delivery cigarettes during the movie, as compared to smoking low-nicotine control cigarettes, was associated with reductions in anxiety and right hemisphere activation, increased heart rate, and enhancement of the ratio of left-hemisphere parietal EEG activation to right-hemisphere activation. These results are interpreted as indicating that the anxiolytic effects of nicotine may be mediated by the right hemisphere. The EEG activity and emotional responses of non-smokers were more like those of smokers who smoked the lower-nicotine cigarettes than those of smokers of the higher-nicotine cigarettes.
Article
To date, few studies have been published on the dose-response relationship, but there is general consensus that between 13 and 18 sessions of therapy are required for 50% of patients to improve. Reviewing the clinical trials literature reveals that in carefully controlled and implemented treatments, between 57.6% and 67.2% of patients improve within an average of 12.7 sessions. Using naturalistic data, however, revealed that the average number of sessions received in a national database of over 6,000 patients was less than five. The rate of improvement in this sample was only about 20%. These results suggest that patients, on average, do not get adequate exposure to psychotherapy, nor do they recover from illness at rates observed in clinical trials research.
Article
The development of a 21-item self-report inventory for measuring the severity of anxiety in psychiatric populations is described. The initial item pool of 86 items was drawn from three preexisting scales: the Anxiety Checklist, the Physician’s Desk Reference Checklist, and the Situational Anxiety Checklist. A series of analyses was used to reduce the item pool. The resulting Beck Anxiety Inventory (BAI) is a 21-item scale that showed high internal consistency (α = .92) and test—retest reliability over 1 week, r (81) = .75. The BAI discriminated anxious diagnostic groups (panic disorder, generalized anxiety disorder, etc.) from nonanxious diagnostic groups (major depression, dysthymic disorder, etc). In addition, the BAI was moderately correlated with the revised Hamilton Anxiety Rating Scale, r (150) = .51, and was only mildly correlated with the revised Hamilton Depression Rating Scale, r (153) = .25.
Article
Even though generalized anxiety disorder (GAD) is one of the most common of the anxiety disorders, relatively little is known about its precursors. Bowlby's attachment theory provides a framework within which these precursors can be considered. According to Bowlby, adult anxiety may be rooted in childhood experiences that leave a child uncertain of the availability of a protective figure in times of trouble.Furthermore, adult "current state of mind with respect to attachment" is thought to relate to adult anxiety. Both attachment-related components were assessed with 8 subscales of the Perceptions of Adult Attachment Questionnaire(PAAQ). Clinically severe GAD clients who were about to begin therapy reported experiencing less maternal love in childhood, greater maternal rejection/neglect, and more maternal role-reversal/enmeshment than did control participants.In keeping with a cumulative risk model, risk for GAD increased as indices of poor childhood attachment experience increased. GAD clients, in contrast to controls,also reported greater current vulnerability in relation to their mothers as well as more difficulty accessing childhood memories. Logistic regression analyses revealed that elevations on PAAQ subscales could significantly predict GAD vs.non-GAD status. Results and the implications for advancing the theory and treatment of GAD are discussed.
Article
The purpose of this study was to examine further the factor structure, reliability, and validity of the Beck Anxiety Inventory (BAI) in samples of adolescents, ages 14 to 18 years. The BAI is a 21-item self-report measure of anxiety severity. The BAI total score differentiated between the inpatient and high-school adolescents. In the psychiatric inpatient sample, girls obtained higher anxiety-severity scores than boys; no gender differences were obtained for the BAI total score in the high-school sample. Confirmatory factor analyses did not provide adequate fit for the two- factor oblique BAI models to the separate male and female psychiatric inpatient data. Principal axes with varimax and promax rotations initially identified a four-factor solution in the separate male and female inpatient participants. However, second-order analyses of the primary factors provided stronger support for a single-factor structure in each sample. Estimates of reliability for the BAI were adequate in samples of psychiatric inpatient and high-school adolescents. Evidence for convergent and discriminant validity of the BAI was investigated separately in the male and female inpatient samples. Overall, the BAI showed acceptable psychometric properties in these populations.
Article
The objective of this paper is to provide a review on available data to date on the epidemiology of GAD in Europe, and to highlight areas for future research. MEDLINE searches were performed and supplemented by consultations with experts across Europe to identify non-published reports. Despite variations in the design of studies, available data suggest that (a) about 2% of the adult population in the community is affected (12-month prevalence), (b) GAD is one of the most frequent (up to 10%) of all mental disorders seen in primary care, (c) GAD is a highly impairing condition often comorbid with other mental disorders, (d) GAD patients are high utilizers of healthcare resources, and (e) despite the high prevalence of GAD in primary care, its recognition in general practice is relatively low. Marked data deficits are: lack of data from eastern European countries, lack of information about the natural course of GAD in unselected samples, the vulnerability and risk factors involved in the aetiology of GAD and lack of data about adequate and inappropriate treatments in GAD patients as well as the associated and societal costs of GAD.
Article
Three studies provide preliminary support for an emotion dysregulation model of generalized anxiety disorder (GAD). In study 1, students with GAD reported heightened intensity of emotions, poorer understanding of emotions, greater negative reactivity to emotional experience, and less ability to self-soothe after negative emotions than controls. A composite emotion regulation score significantly predicted the presence of GAD, after controlling for worry, anxiety, and depressive symptoms. In study 2, these findings were largely replicated with a clinical sample. In study 3, students with GAD, but not controls, displayed greater increases in self-reported physiological symptoms after listening to emotion-inducing music than after neutral mood induction. Further, GAD participants had more difficulty managing their emotional reactions. Implications for GAD and psychopathology in general are discussed.
Article
Generalized anxiety disorder (GAD) responds only modestly to existing cognitive-behavioural treatments. This study investigated a new treatment based on an empirically supported metacognitive model [Wells, (1995). Metacognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301-320; Wells, (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester, UK: Wiley]. Ten consecutive patients fulfilling DSM-IV criteria for GAD were assessed before and after metacognitive therapy, and at 6, and 12-month follow-up. Patients were significantly improved at post-treatment, with large improvements in worry, anxiety, and depression (ESs ranging from 1.04-2.78). In all but one case these were lasting changes. Recovery rates were 87.5% at post treatment and 75% at 6 and 12 months. The treatment appears promising and controlled evaluation is clearly indicated.
Article
To determine diagnostic overlap of depression, anxiety and somatization as well as their unique and overlapping contribution to functional impairment. Two thousand ninety-one consecutive primary care clinic patients participated in a multicenter cross-sectional survey in 15 primary care clinics in the United States (participation rate, 92%). Depression, anxiety, somatization and functional impairment were assessed using validated scales from the Patient Health Questionnaire (PHQ) (PHQ-8, eight-item depression module; GAD-7, seven-item Generalized Anxiety Disorder Scale; and PHQ-15, 15-item somatic symptom scale) and the Short-Form General Health Survey (SF-20). Multiple linear regression analyses were used to investigate unique and overlapping associations of depression, anxiety and somatization with functional impairment. In over 50% of cases, comorbidities existed between depression, anxiety and somatization. The contribution of the commonalities of depression, anxiety and somatization to functional impairment substantially exceeded the contribution of their independent parts. Nevertheless, depression, anxiety and somatization did have important and individual effects (i.e., separate from their overlap effect) on certain areas of functional impairment. Given the large syndrome overlap, a potential consideration for future diagnostic classification would be to describe basic diagnostic criteria for a single overarching disorder and to optionally code additional diagnostic features that allow a more detailed classification into specific depressive, anxiety and somatoform subtypes.
Improving outcomes and preventing relapse in cognitive therapy
  • M M Antony
  • D Roth Ledley
  • Heimberg
Antony, M. M., Roth Ledley, D., & Heimberg, R. G. (Eds.). (2005). Improving outcomes and preventing relapse in cognitive therapy. New York: Guilford Press.