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Interpersonal and Emotion‐Focused Therapy (I/EP) for Generalized Anxiety Disorder (GAD)

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Abstract

Interpersonal and emotional processing therapy (I/EP) was developed in the early 1990s as an attempt to remedy the shortcomings of cognitive‐behavioral therapy. It cohesively unifies interpersonal, emotional, and cognitive problems of the therapeutic change process and human functioning. This chapter presents an overview of the process and implementation of I/EP for the treatment of generalized anxiety disorder (GAD). Facilitating the deepening of emotional experiences for GAD patients is an integral part of I/EP. The fostering of emotional awareness is utilized as exposure to the waxing and waning of difficult and challenging emotions. Ultimately, I/EP aims to provide clients with safe corrective experiences to process, and to express emotions in the presence of another individual and overcome their fear of vulnerability with others. Effective I/EP may require GAD clients to have formal exposure to negative emotional contrasts and their related interpersonal issues.
Generalized Anxiety Disorder and Worrying: A Comprehensive Handbook for Clinicians and Researchers,
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11
Introduction
Despite being the only empirically supported treatment thus far (Chambless &
Ollendick, 2001), cognitive‐behavioral therapy (CBT) protocols present with a num-
ber of shortcomings for the treatment of generalized anxiety disorder (GAD). CBT
does not benefit some clients and demonstrates the smallest percentage of clinically
significant change for GAD relative to other anxiety disorders (Borkovec, Newman,
& Castonguay, 2003; Brown, Barlow, & Liebowitz, 1994). Interpersonal and emo-
tional processing therapy (I/EP) was developed in the early 1990s as an attempt to
remedy the shortcomings of CBT (Newman, Castonguay, Borkovec, & Molnar,
2004). At that time, CBT was viewed by some as placing too much emphasis on
intrapersonal (i.e., association between thoughts, feelings, and behaviors) as opposed
to the interpersonal (i.e., habitual patterns of relating to others) maintaining clients’
psychopathology generally (Coyne & Gotlib, 1983; Goldfried & Castonguay, 1993)
and anxiety disorders specifically (Barlow, 2002).
However, there was evidence that conflictual relationships played an instrumental
role within the context of GAD and its treatment. For example, maladaptive interper-
sonal processes are linked to the onset and maintenance of GAD. According to the
interpersonal model of GAD (Newman & Erickson, 2010), relationship difficulties
emerge from non‐optimal attachment patterns (Cassidy, Lichtenstein‐Phelps, Sibrava,
Thomas, & Borkovec, 2009), resulting in dysfunctional social cognitions (Erickson &
Newman, 2007) and persistent difficulties in maintaining harmonious relationships
with others (e.g., Przeworski etal., 2011).
Interpersonal andEmotion‐
Focused Therapy (I/EP)
forGeneralized Anxiety
Disorder(GAD)
Michelle G. Newman and Nur Hani Zainal
Department of Psychology, The Pennsylvania State University,
UniversityPark, PA, USA
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Michelle G. Newman and Nur Hani Zainal232
Variables that predicted a worse outcome of treatment of GAD include being
divorced, widowed, or remaining single (Durham, Allan, & Hackett, 1997). Pre‐
therapy relationship difficulties associated with dominant GAD clients’ predicted fail-
ure of post‐treatment maintenance of gains (Borkovec, Newman, Pincus, & Lytle,
2002) and dropouts (Sanderson, Beck, & McGinn, 1994). More recent data has
shown that antagonistic as opposed to non‐hostile criticism from partners (Zinbarg,
Lee, & Yoon, 2007) also predicted poorer treatment outcomes. In terms of psycho-
therapeutic processes, poor outcomes have been correlated with observer‐rated unsat-
isfactory therapeutic alliance (Langhoff, Baer, Zubraegel, & Linden, 2008), higher
first‐session, clinician‐rated client resistance (Westra, 2011), and in‐session negative
reactions conveyed by the therapist (e.g., frustration, power struggle, helplessness;
Westra, 2011; Westra, Aviram, Connors, Kertes, & Ahmed, 2012). GAD patients
seeking treatment within primary care settings with greater psychosocial impairments
were less likely to improve (Rodriguez etal., 2006). Taken together, cumulative evi-
dence suggests that the lack of optimal treatment progress and outcomes may be
attributable to interpersonal problems that maintain GAD symptoms.
I/EP was based in part on a model developed by Safran and Segal (1990), which
cohesively unifies interpersonal, emotional, and cognitive problems of the therapeutic
change process and human functioning. Safran (1990) posits that humans possess
“interpersonal schemata,” which are mental models of the workings of human rela-
tionships based on cumulative developmental experiences of interacting with caregiv-
ers. These mental representations generate self‐fulfilling prophecies as persons convey
and affirm these internal models in their present relationships. Furthermore, accord-
ing to Safran and Segal (1990), emotions are essential features of the interpersonal
schemata. The development of interpersonal schemas occurs in an integrative manner
through cognitive, emotional, and expressive channels. In other words, humans
emote and behave toward others based on the degree to which they validate, support,
and assuage their desires and anxieties. Emotions therefore contain vital information
about individuals’ met and unmet needs. Nonetheless, I/EP was adapted to work
with GAD clients specifically and thus does not follow exactly from the Safran and
Segal framework. Despite evidence that attests to relationship difficulties as core to
the maintenance of GAD symptoms, current CBT protocols fall short in effectively
targeting these problems (Newman etal., 2011).
Emotion‐focused (Levy Berg, Sandell, & Sandahl, 2009) and interpersonally‐
oriented psychodynamic treatments have demonstrated preliminary efficacy in
open trials for GAD patients (Crits‐Christoph, 2002). For example, brief dynamic
psychotherapy led to substantive reductions in poor interpersonal functioning
(Crits‐Christoph, Connolly, Azarian, Crits Christoph, & Shappell, 1996).
Moreover, interpersonally‐oriented psychodynamic psychotherapy demonstrated
maintenance of gains in terms of the decline in anxiety, worry, and depressive
symptoms after 12 months of follow‐up (Salzer, Winkelbach, Leweke, Leibing, &
Leichsenring, 2011). Whereas patients with GAD who tend to be overly nurturant
and non‐assertive demonstrated the largest reductions in interpersonal distress,
those who were socially avoidant benefited the least (Salzer, Pincus, Winkelbach,
Leichsenring, & Leibing, 2011). Nonetheless, CBT in a direct comparison of
interventions was superior to brief dynamic therapy on measures of trait anxiety,
worry, and depression (Leichsenring etal., 2009). Based on the foregoing reasons,
a CBT approach for GAD that integrated methods to target relationship difficulties
Generalized Anxiety Disorder and Worrying : A Comprehensive Handbook for Clinicians and Researchers, edited by Alexander Gerlach, and
Andrew Gloster, John Wiley & Sons, Incorporated, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/usf/detail.action?docID=6318882.
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233Interpersonal andEmotion‐Focused Therapy (I/EP)
and emotional processing avoidance was developed (Newman etal., 2004). Details
of the implementation of I/EP for GAD are elucidated herein.
Overview, Process, andImplementation ofInterpersonal
Therapy/Emotional Therapy
Processing therapy (I/EP)
The I/EP component for treatment of GAD was developed to specifically target rela-
tionship issues and to aid emotional processing without concurrent use of cognitive
strategies. Each I/EP session typically lasts for about 55 min following 55 min of CBT
(Newman etal., 2004). From the outset of I/EP, clinicians ask clients about the people
with whom they have established personal connections, family ties, and significant friend-
ships (Borkovec etal., 2003). Clinicians refrain from discussing developmental concerns
until they have thoroughly considered current relationship issues, particularly if such
issues are evident in the therapeutic alliance. Clinical observations have shown that clients
prefer to speak about the past to evade discussing their current feelings (Newman etal.,
2004). They easily slip into discussing at length events that occurred in their lives and
struggle with focusing on the present moment and experiencing their emotions during
the therapy session, precisely reflecting the “verbal–linguistic” function of worry
(Borkovec & Inz, 1990). As clinicians encourage deep exploration of emotions related
to an event based on their current relationship, clients will by themselves often draw a
connection between their present affective experience (with a significant other or the
clinician) and their previously occurred life event(s). Cultivating a client‐directed, rather
than a therapist‐directed, ongoing affective connection may be a potent way of gaining
insights as to why habitual ways of interacting with others may have been pragmatic and
instrumental previously, but obsolete and dysfunctional currently.
After clinicians have collected enough data about a client’s relationship issues
(approximately one to two sessions), they select another person who is a significant
other to the client and investigate more thoroughly their relationship with this
person. As clients with GAD are inclined to describe particular people rather than
their relationship and interactional styles with them, the way in which the clinician
enquires about the relationship is crucial. An instruction such as “Tell me more
about your relationship with Adam” may not suffice to obtain the needed informa-
tion from GAD clients, as they may either dismiss their relationship issues or cast
the blame on the other person. Instead of accepting the client’s rationalization that
he or she was above reproach in a specific interpersonal interaction that led to a
dispute, the clinician may instruct the client in a detailed step‐by‐step manner (i.e.,
“What did you do, then what did he/she do, then what did you do?”) (Newman
etal., 2004). The main intention is to help clients to become more aware of how
the manner in which they relate to others contributes to their relationship issues
(Hayes, Castonguay, & Goldfried, 1996). As mentioned, maladaptive behaviors
are often due to clients’ ineffectual efforts to evade their fears, although such
efforts may paradoxically engender their feared reactions from others (e.g., rejec-
tion). Once recognized and clearly defined, clients’ dysfunctional relationship
patterns, which contribute to or aggravate relationship issues and prevent the ful-
fillment of their needs, are directly targeted during therapy. Clients and clinicians
Generalized Anxiety Disorder and Worrying : A Comprehensive Handbook for Clinicians and Researchers, edited by Alexander Gerlach, and
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Michelle G. Newman and Nur Hani Zainal234
collaborate on developing adaptive ways of interacting with others, usually via role
plays, in accordance with social skills training.
Clark, a 55 year‐old professor who had undergone I/EP treatment, is a
case‐ in‐point. At the beginning of treatment, Clark was experiencing frequent argu-
ments with his former wife and felt alienated from their two children. Clark portrayed
himself as a blameless victim by trying to offer examples of how his wife and children
mistreated him. One situation involved his perception that his son and daughter paid
inadequate attention to him when he came to visit them to celebrate both Father’s
day and his daughter’s graduation. He was to attend a reception arranged by his for-
mer wife. Instead of agreeing with Clark’s viewpoint of himself as an innocent victim
of his problematic relationships with his children, the clinician skillfully probed about
a specific exchange that transpired during the visit. The clinician directed the conver-
sation by using a sequential blow‐by‐blow approach (i.e., what did you do? what
did he do? what did you do?) (see Figure11.1 for more details). The following
vignette illustrates how the clinician ascertained whether Clark’s actions (or inactions)
reduced the likelihood of satisfying his interpersonal needs.
clark: I decided that I wanted to have lunch with my son for Father’s Day, so I
called him up to find out whether he was free.
therapist: When exactly did you make this phone call?
clark: When I got into town.
therapist: So tell me exactly what you said to him when you called him.
clark: I said that I thought it would be fun if we had lunch on Saturday.
Then he said, “Mom already planned a special Father’s Day lunch with
Grandpa, so I can’t make it, but I would like to stop by before then to give
you your Father’s Day gift.”
What happened? What
Situation occured with
the other person?
What were your
initial feelings?
What did you need or
hope to get from the
other person?
What was your
actual behavior?
Did you fear anything
from the other person?
What happened next?
How did the situation
With the other person
develop?
Figure 11.1 The blow‐by‐blow approach to questioning a client’s specific interpersonal
event with a significant other based on interpersonal and emotion‐focused processing therapy.
Generalized Anxiety Disorder and Worrying : A Comprehensive Handbook for Clinicians and Researchers, edited by Alexander Gerlach, and
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235Interpersonal andEmotion‐Focused Therapy (I/EP)
therapist: And what did you say to that?
clark: I said, “Well I really wanted to have lunch, but I guess that would be
better than nothing,”
therapist: Then what happened?
clark: We said goodbye. However, I thought about what happened over and over
until he stopped by, and the more I thought about it, the angrier I got.
Imean, I’m his father, so don’t I deserve to be honored on Father’s
Day?
therapist: When was the next time you spoke with him?
clark: When he came by to give me my Father’s Day gift later that day, but by
that time I really didn’t want to see him. When he handed the gift to me,
Isaid, “Why don’t you get the hell out of here and go figure out who your
father really is!” Then I called my daughter to tell her I would not attend
her graduation reception, because I would not get to spend the kind of
time with her that I had expected.
Clark mentioned to the therapist that he felt that his status as father was under-
appreciated, given that he did not receive differential treatment as he was invited
to his daughter’s graduation reception with everyone else. Despite the fact that his
daughter told him that she was looking forward to seeing him at the reception, he
still felt dismissed and ignored. Herein, the clinician aimed to raise Clark’s level of
awareness by getting him to be cognizant of his role in these relationship disputes.
Specifically, the clinician pointed out how he waited until the last minute to ask his
son to have lunch, and how his hostile interactions led his children to distance
themselves from him. However, some efforts to evade a feared response (i.e., rejec-
tion) may ironically trigger the response itself. As Clark was afraid that his children
would not appreciate him enough, he procrastinated over making plans with his
children and failed to directly convey to them his desire to see them. His actions
played a role in his children’s unavailability, which he construed as proof that they
did not appreciate him. Following this, he estranged himself further from his chil-
dren through shouting at his son and declining to attend his daughter’s gradua-
tion. These are examples of salient interpersonal events that the clinician aims to
directly target in I/EP.
Social skills training
Social skills training targets a weakness typically observed in clients with GAD (e.g.,
Erickson & Newman, 2007). When instructed to develop alternative ways of manag-
ing their interpersonal issues, clients with GAD tend to generate “black‐and‐white,”
extreme solutions (e.g., “I could simply shut up, or shout at him/her”), probably
because of their fear of being vulnerable. As such, clients may not allow themselves to
communicate to others in a manner that would assist others to comprehend the cli-
ent’s emotions. In conducting role plays, clinicians begin by encouraging clients to be
themselves, and try to understand what and how they spoke to others. After gathering
information about clients’ actions, clinicians play clients’ roles and instruct clients to
play the role of the person with whom they are relating. Clients, in assuming others’
role, are asked to empathize and visualize as to how the interaction would affect them.
The goal is to highlight the effect that clinicians (who are assuming clients’ roles) have
on clients, instead of using the role play as a platform to exonerate themselves and
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Michelle G. Newman and Nur Hani Zainal236
elicit validation from clinicians. In so doing, clients may thus realize that they may not
be fulfilling the needs of others, despite expecting others to fulfill their needs. The
next case vignette aims to illustrate how Mindy, a college student diagnosed with
GAD, interacted in ways with her friend, Ellen, that prevented the fulfillment of her
relationship needs.
mindy: Ellen told me she thought I went home too often. When she said this I
laughed and said, “Thanks for your opinion!”
therapist: What did you feel?
mindy: Criticized.
therapist: Sounds like your friends wish they could see you more often.
mindy: I don’t feel like they are hearing me, though.
therapist: I wonder how well you are hearing them. They are saying they enjoy your
friendship, yet you feel like you are not being heard.
mindy: I’m often told I’m sensitive. But I feel condemned by them. I just feel like
ending the friendship.
therapist: Let’s do a role play where I am you and you are Ellen. Try to imagine what
she was feeling.
mindy: OK. (As Ellen) You go home too often and spend too much time with
John [Mindy’s boyfriend]. I feel like I am second best to John.
therapist: (As Mindy) Thanks for your opinion!
mindy: (as Ellen) I guess I really miss spending time with you. I am going to
graduate soon, and we won’t have as many chances to spend time together.
therapist: How did you feel as Ellen?
mindy: I don’t like being Ellen.
therapist: What does Ellen need from you?
mindy: She wants to spend more time with me. But I don’t want to spend time
with her if she is going to be critical of me and condemn me.
therapist: Do you think your response to her got you what you needed?
mindy: I guess not.
therapist: How did it feel as Ellen to hear your response?
mindy: Bad. I didn’t feel like Mindy cared about what I wanted.
therapist: Seems like your friends have needs they are not getting met, and that if you
consider their needs, maybe you will get more of what you want.
Upon recognition of dysfunctional interpersonal patterns and acquisition of healthier
ways of responding that positively affect others, clinicians assign homework to
practice new styles of responding in their daily lives. Homework is individualized
based on the client’s idiosyncratic past habits of relating to others. For instance, some
clients need to learn to better listen to others, exercise more empathy toward their
experiences, and gain a better understanding of their needs. Homework assignments
serve to reinforce more adaptive ways of behaving toward others, thereby raising the
likelihood of the fulfillment of needs of both clients and their significant others.
Use oftherapist–client interaction astreatment tool
As dysfunctional social behavior habits are often repeated during therapy, successful
therapy necessitates first needing to be “hooked” into clients’ maladaptive social
interaction patterns in order to understand their behaviors in naturalistic settings
Generalized Anxiety Disorder and Worrying : A Comprehensive Handbook for Clinicians and Researchers, edited by Alexander Gerlach, and
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237Interpersonal andEmotion‐Focused Therapy (I/EP)
(Safran & Segal, 1990). Initially, clinicians are cajoled to behave in ways that are
congruent with clients’ expectations. I/EP therapists attempt to recognize when and
how they have been partaking in clients’ interpersonal schemata. Upon recognizing
that they have been hooked, clinicians need to behave in ways that contradict clients’
expectations, thus falsifying clients’ interpersonal schemata. The purpose is to assist
clients to gain insights as to how their dysfunctional social behavior habits are instru-
mental in their relationship issues, as well as the needs that drove those behaviors
(e.g., what they hope to gain or lose from a specific interaction). Stated differently,
therapists’ behaving in ways that violate clients’ expectations facilitates corrective
emotional experiences as clients begin to perceive alternatives to rigid interpersonal
styles (Hill & Knox, 2009). Upon recognition of their needs, concrete steps may be
taken to educate clients on more adaptive ways to fulfill them.
I/EP therapists may find it difficult to realize that they have been hooked and unwit-
tingly facilitate clients’ interpersonal and emotional avoidance. Feeling that the therapy is
going nowhere, chronic frustration or helplessness in aiding the clients, as well as emo-
tional detachment from certain clients, are among the signs that the clinician has been
hooked. To manage such difficulties, clinicians document after each session ways in
which they, knowingly or unknowingly, abetted the clients’ emotional and interpersonal
avoidance. Assuming a relatively neutral, participant–observer stance is also integral to
the process (Sullivan, 1953). By practicing being a detached observer, clinicians may
recognize cues as the interaction scenario unfolds. Examples include permitting clients to
offer irrelevant background information, articulate lengthy and off‐tangent life narra-
tives, and to offer only abstract descriptions of feelings/events. Clients and clinicians may
also examine why an event occurred, why the client experienced a particular emotion, or
why another individual behaved in a certain manner. The tendency to dwell on “why”
signifies that clients are evading painful and distressing emotions at present.
Clinicians themselves may also have tendencies that impel them toward avoidance
patterns. For instance, rather than cultivating tolerance of distressing emotions, clini-
cians may attempt to make clients feel better immediately. Clinicians may also be
uncomfortable with clients’ anger being directed toward them, or may use humor
inappropriately when a client is speaking about a tough experience. Clinicians thus
need to identify and modify maladaptive styles of responding to these difficulties,
mainly by periodically checking in on their emotions to swiftly ascertain whether and
when they have been hooked, and remaining cognizant of their role as a therapist or
facilitator. Clinicians thus become more attuned to clients’ behaviors that might be
dismissed or absolved in the therapeutic context, but create longstanding problems in
clients’ daily lives. Crucially, clinicians need to remain a participant–observer in moni-
toring the ongoing interaction (Sullivan, 1953).
As clinicians become more cognizant of clients’ interactional patterns that lead
tonegative interactions during therapy, clinicians are tasked to confront these issues
in an open, frank, and non‐defensive manner. In so doing, clinicians exemplify the
communication style that clients are encouraged to adopt. A constructive approach to
provide the information may be “I feel _____ when you do ______.” (e.g., “I feel
rejected when you do not respond to me”). Following such feedback, clinicians solicit
clients’ emotional reactions to such feedback (e.g., “How did my feedback make you
feel?”). Clients’ willingness and capacity to assess their own affective reactions after
receiving such feedback (e.g., anger or disappointment), and their behavioral reac-
tions to these feelings (e.g., changing the topic), offer opportunities for clinicians to
Generalized Anxiety Disorder and Worrying : A Comprehensive Handbook for Clinicians and Researchers, edited by Alexander Gerlach, and
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Michelle G. Newman and Nur Hani Zainal238
observe clients’ receptivity to their feelings. These instances during therapy also pro-
vide invaluable information about clients’ willingness to receive and respond adap-
tively to others’ honest feedback and, correspondingly, encourages them to be
receptive and vulnerable with others (Newman etal., 2004).
Clients often respond to clinicians’ feedback by rationalizing how their reactions
assist them (e.g., “I changed the topic because discussing my feelings makes me feel
weak and vulnerable”). Clients seem to feel that justifying their actions makes their
behaviors more acceptable, although the behaviors function to avoid processing dis-
tressing emotions and do not diminish the negative effects of their behavior. When
clients do communicate their emotions, clinicians need to respond promptly by empa-
thizing with and validating their emotional experiences. Following this, clinicians
share their responses to clients’ disclosure. (“It is understandable that you wish to
avoid a subject that makes you uncomfortable. However, avoiding answering my
question also affects me and makes me feel that my question isn’t important.”)
Clinicians also attempt to facilitate raising awareness of how clients’ maladaptive
interpersonal patterns observed during therapy sessions are linked to past and present
relationship issues outside of therapy, where they spend most of their lives. However,
clinicians need to ensure that negative emotions that arise from the therapeutic rela-
tionship are addressed before attempting to draw such links. Alliance ruptures are
expected and targeted in I/EP, and should be perceived as opportunities to provide
clients with corrective experiences that disconfirm clients’ interpersonal schemata.
These corrective experiences serve to help clients develop more empirical and realistic
views about themselves and others, as well as healthier ways of relating interpersonally
(Safran, Crocker, McMain, & Murray, 1990). Clinicians are trained to detect signals
of alliance ruptures including but not limited to avoidance (e.g., non‐punctuality, not
answering questions, changing the subject, persistent confusion); antagonism (e.g.,
passive‐aggressiveness, sarcasm); disputes arising from the objectives and homework
assignments in therapy; excessively submissive behaviors; and self‐esteem‐magnifying
attempts (e.g., self‐aggrandizing, self‐justifying).
To address alliance ruptures, rather than being confrontational with the client, cli-
nicians may use the following three‐step technique derived from humanistic and
interpersonal therapies (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Piper
etal., 1999): (a) observe signs of alliance ruptures and openly discuss with the client
(e.g., “I’ve noticed that you do not seem engaged over the last few therapy sessions.
Is that how you are feeling?”); (b) reflection of client’s emotions and thoughts,
including counterproductive and invalidating instances that occurred during therapy,
until the clinician senses that the client feels understood; and (c) identify kernels of
truth in the client’s responses, however irrational it may appear (cf. “disarming tech-
nique”; Burns, 1989). The disarming technique is premised on the idea that although
a treatment barrier appears associated with clients’ struggles (e.g., bad habit of cop-
ing), therapists may have been complicit in fostering a sense of disharmony with them.
Clinicians’ acknowledgment of how they were instrumental in the interpersonal dif-
ficulty often smooths the way for both the clinician and client to disengage from a
non‐constructive process (Castonguay, 1996). Whereas treatment impediments may
arise mainly due to the client’s patterns (e.g., avoidance as a maladaptive coping strat-
egy), clinicians may have unwittingly contributed to the rupture. Acknowledging that
the clinician is not blameless in contributing to the alliance rupture and openness to
experience steers both clinician and client away from fruitless therapeutic processes
Generalized Anxiety Disorder and Worrying : A Comprehensive Handbook for Clinicians and Researchers, edited by Alexander Gerlach, and
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239Interpersonal andEmotion‐Focused Therapy (I/EP)
(Castonguay, 1996). Clinicians may approach a client’s avoidance by saying some-
thing such as, “I apologize that the stuff I’m asking may seem unimportant to you. I
realize that I haven’t been clear and upfront about my treatment rationale and
approach.” Clinicians may respond to clients who frequently change the subject in
this way: “I am afraid that I have been trying to talk with you about something that
might not be relevant to you, or that you may not be ready to speak about” (Newman
etal., 2004). Openness typically facilitates more openness (Rogers, 1961), and it fol-
lows that clinicians’ non‐defensive acknowledgment of their contributions to alliance
ruptures will be met with clients’ realization of their own actions (e.g., “Thank you
for mentioning that. I admit I did feel some pressure, but I guess I avoid talking about
these things, even though I know I should be talking about them”).
Once clinicians notice that they have been hooked in clients’ predominant interper-
sonal styles, treatment proceeds by addressing alliance ruptures with clients. Practicing
the steps outlined above is difficult because it often involves persuading a client to
speak about his or her negative emotions regarding the therapeutic process or the clini-
cian. However, preventing alliance ruptures may cause the therapist to non‐construc-
tively mimic the manner in which other people in the client’s lives respond to them.
Conversely, confronting and resolving clients’ dysfunctional interpersonal patterns
head‐on offers invaluable corrective experiences to clients (Safran & Segal, 1990).
Corrective experiences assist clients to be vulnerable and open about their feelings in
order to facilitate closer ties to others and fulfillment of their interpersonal needs.
Emotional processing aspects ofI/EP
Facilitating the deepening of emotional experiences for GAD patients is an integral
part of I/EP. The fostering of emotional awareness is utilized as exposure to the wax-
ing and waning of difficult and challenging emotions. Emotional ups and downs, after
all, provide crucial information about one’s individual and interpersonal needs
(Greenberg, Rice, & Elliott, 1996; Safran & Segal, 1990). Clinicians’ tasks are thus
to monitor the indicators of emotional shifts. For instance, clients may demonstrate
shifts in the tone and pitch of their voices, hastening or slowing of conversation pace,
and the hint of a cracking sound of tears in their voices. When these indicators become
apparent, clinicians need to persuade clients to tolerate and fully experience the
accompanying distressing emotions. Clients may also abruptly cease focusing on their
feelings, and during these moments of disengagement or disruption, clinicians redi-
rect them to attend to their present experience (e.g., “What happened? A moment
ago you were crying, why did you shift away from that experience?”). Clients with
GAD tend to “live in their heads” (Newman etal., 2004) and describe what they were
thinking. Therefore, it is imperative that clients be taught from the outset the distinc-
tion between observations/thoughts/perceptions and emotions/feelings, and to stay
with their (uncomfortable) feelings in the “here‐and‐now” (Newman etal., 2004).
Anger or frustration also presents as emotions commonly reported by clients with
GAD, probably due to the fact that such feelings prevent them from being vulnerable
to others. I/EP teaches clients that they may be experiencing other more deep‐seated
emotions beneath the superficial anger which reflects a secondary emotion.
Furthermore, in facilitating deepening of emotional experiences that were previ-
ously not processed, therapists identify humanistic therapy‐oriented indicators termed
“internal conflicts,” “problematic reactions,” and “unfinished business” (Greenberg
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Michelle G. Newman and Nur Hani Zainal240
& Newman, 1996; Greenberg & Safran, 1987). Internal conflicts may manifest as
being indecisive or “of two minds” about a present life issue (e.g., “A part of me wants
to leave my husband, but another part of me cannot imagine living life without him”).
Identifying the internal conflict is the first step before clients engage in a two‐chair
exercise that requires them to differentiate the two parts of the self (i.e., clients imagine
themselves as two distinct individuals), and assigning labels to each part may aid the
process. For example, a client with GAD named Susan may believe that she needs to
continually put up a front to others as someone who is formidable, when in truth what
she needs is social and emotional support. Her inner fears (i.e., being vulnerable) and
wishes (i.e., support) may be labeled as “inside Susan,” and outer guise may be labeled
as “outside Susan.” As the client is repeatedly instructed to switch between each role,
emotion‐focused therapy (EFT) aims to foster insight that she was suppressing her
inner fears and wishes (e.g., “inside Susan”). Crucially, she realized that her guise (e.g.,
“outside Susan”) operated on the unwillingness to confront feared situations, and
could instead lead to a more optimal balance between putting up a façade of what she
thought others expected of her and permitting her needs to be satisfied.
Clients who have “unfinished business,” wherein they still harbor unresolved feel-
ings toward another person (alive or dead), may be approached with the empty‐chair
technique (Greenberg & Foerster, 1996). This technique has clients imagine the per-
son sitting across from them in an empty chair and unequivocally and expressively
emote their feelings toward the other person. Noteworthy is the clinical observation
that unresolved emotions are not always negative and, oftentimes, clients with GAD
express regret over not conveying deep appreciation toward someone (e.g., a parent
suffering from a terminal illness; Newman etal., 2004). Therapists can acknowledge
how valuable the other person is to clients and allow them to process the significant
other completely by honestly and openly communicating their feelings to the imag-
ined person sitting in the empty chair. Several sessions may elapse before clients
become attuned to their feelings and ultimately convey them to the other person,
thereby gradually remedying their strained relationship.
Clients may react with ambivalence, surprise, or confusion toward their own reac-
tions, and such meta‐reactions are indicators of “problematic reactions.” To deal with
problematic reactions, clients are instructed to shut their eyes, and to vividly envisage
themselves in the specific situation that triggered such reactions, and to allow the
“mental movie” to unfold in slow motion in order to capture every scene. Clients are
also asked to describe in detail the events and their resulting emotions, focusing on
every internal (i.e., cognitive, visceral, emotional) cue as they repeatedly enact the
situation. Re‐experiencing their situation in a more fine‐tuned and calibrated manner,
and their consequent reactions, allows them to take ownership of the implicit emo-
tions (cf. “systematic evocative unfolding”; Greenberg etal., 1996).
Ultimately, I/EP aims to provide clients with safe corrective experiences to process,
and to express emotions in the presence of another individual (i.e., the clinician) and
overcome their fear of vulnerability with others. However, given that most of their
lives unfold outside of therapy, therapists assign homework to maximize generaliza-
tion of optimal emotional processing (i.e., tolerating distressing emotions and express-
ing them appropriately) and minimize avoidance of emotional processing. As clients
tend to approach instructions with an “all‐or‐none” cognitive bias (e.g., “Either I
express what I feel all the time or brush off all of my emotions”), the aim is to attain
an optimal balance between emotional expression and the lack/absence of expression.
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241Interpersonal andEmotion‐Focused Therapy (I/EP)
Clients are reminded that emotions form an integral facet of themselves that they
need to unconditionally accept. Thus, they need to use these emotions as they provide
vital information about their needs.
Future Directions ofI/EP
The current research evidence of the effectiveness of I/EP for GAD is promising. In
a preliminary open trial investigation, the integration of CBT and I/EP produced
encouraging outcomes, such that CBT with I/EP showed huge effect sizes during
post‐treatment (d=3.15) and one‐year follow‐up (d=2.97; Newman, Castonguay,
Borkovec, Fisher, & Nordberg, 2008). Furthermore, from baseline to 2‐year follow‐
up, combined CBT with I/EP led to large declines in anxiety severity (Cohen’s d
effect size=1.90) and three‐quarters of GAD patients who received treatment were
free of the GAD diagnosis post‐treatment (Newman etal., 2011). The RCT which
compared CBT with supportive listening versus CBT with I/EP found no statistically
significant differences between both approaches at post‐treatment and 2‐year follow‐
up (Newman etal., 2011). However, a recent secondary analysis of this data (Newman,
Castonguay, Jacobson, & Moore, 2015) showed that the effect of combining CBT
and I/EP depended on adult attachment. Specifically, persons with GAD who
reported dismissive attachment patterns with their primary caregivers demonstrated
significantly greater gains from CBT with I/EP compared to those receiving CBT
with supportive listening. Pulling all the evidence together, it appears to be the case
that CBT+ I/EP works best with individuals with certain forms of attachment
difficulties.
It is also possible, however, that I/EP could be enhanced by being informed by the
contrast avoidance model. More recent data suggests that GAD is a mental disorder of
heightened emotionality and instead of avoiding their emotions, GAD individuals use
worry to perpetually evade negative emotional contrasts (Newman, Llera, Erickson,
Przeworski, & Castonguay, 2013). Negative emotional contrasts refer to mood changes
from relatively euthymic to dysthymic or anxious/depressive states (cf. contrast
avoidance theory; Newman & Llera, 2011). Sufferers of GAD show greater emotional
reactivity than non‐anxious controls to confederates’ personal disclosures and struggle
more to regain equanimity after being confronted with events that propelled them
toward negative affective states (Erickson & Newman, 2007). Worry precludes the
opportunity to fully process one’s difficult emotions because decades of research shows
that worry produces and sustains negative affect (Newman etal., 2013). However, the
contrast avoidance model posits that GAD persons prefer to live in a heightened state
of worry in order to avoid negative emotional contrasts if feared outcomes indeed
manifest. In support of the contrast avoidance model, worry induction led to height-
ened negative emotionality in individuals with and without GAD based on subjective
reports and objective physiological indicators (Llera & Newman, 2010). Moreover,
worries are associated with greater sympathetic nervous system arousal (Llera &
Newman, 2011), which is implicated in the fight‐and‐flight response and risk of
cardiovascular diseases (Martens et al., 2010). Compared to neutral and relaxation
inductions, worry impeded sharp negative emotional shifts following negative expo-
sures (Llera & Newman, 2014). Moreover, GAD individuals reported worry to be an
effective coping strategy in response to stressors, whereas healthy controls described
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Michelle G. Newman and Nur Hani Zainal242
the opposite pattern (Llera & Newman, 2014). Thus, effective I/EP may require GAD
clients to have formal exposure to negative emotional contrasts and their related inter-
personal issues. Although past treatments have targeted worry symptoms, such treat-
ments may not have addressed the root causes that precipitated the pathological worry.
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Article
Full-text available
Introduction Generalized anxiety disorder (GAD) is common and disabling. Different versions of cognitive behavioral therapy (CBT) have been tested, but no treatment works for everyone. Therefore, researchers have attempted approaches to enhance CBT. Areas covered The current narrative review examines meta-analyses and individual trials of CBT-based treatments for GAD. We focus on CBT and its cognitive and behavioral components as well as efforts to enhance CBT and its dissemination and generalizability. Enhancement efforts included interpersonal and emotional processing therapy, mindfulness-based CBT, emotion regulation therapy, intolerance of uncertainty therapy, the unified protocol, metacognitive therapy, motivational interviewing, and contrast avoidance targeted treatment. Emerging strategies to enhance dissemination have focused on technologically based treatments. Attempts at generalizability have included examination of efficacy within diverse racial and ethnic groups. Expert opinion We conclude that CBT is efficacious, and a number of enhancement efforts have shown some promise in improving upon CBT in single trials. However, more research is needed, particularly efforts to determine which enhancements work best for which individuals and what are the mechanisms of change. Furthermore, few technological interventions have been compared to active treatments. Finally, much more attention needs to be paid to ethnic and racial diversity in randomized controlled trials.
Article
Full-text available
Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.
Article
Full-text available
Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidancemodelmay help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.
Chapter
Full-text available
Generalized anxiety disorder (GAD) is characterized by a number of symptoms that are likely to affect interpersonal relationships. The central symptom is excessive, uncontrollable anxiety and worry about a number of events or activities, occurring more days than not for at least 6 months (American Psychiatric Association, 1994). Consistent with the proposed idea of a generalized anxious temperament that belongs on Axis II (Akiskal, 1998), most people diagnosed with GAD report having always been worriers and view this as part of their personality, which may explain low treatment seeking in GAD (Bland, Newman, & Orn, 1997). Given that the primary symptoms of GAD are intrapersonal (e.g., worry, muscle tension), the fact that few theoretical models of GAD or worry explicitly address interpersonal processes is understandable. Here, we briefly review noninterpersonal theoretical models of GAD for their interpersonal implications, as well as an evolving, integrative interpersonal model of GAD.
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Psychotherapy integration has become a dominant movement (Castonguay, Reid, Halperin, & Goldfried, 2003). Convinced that "pure-form" orientations have neither provided a satisfactory understanding of psychopathology nor resulted in sufficiently effective treatments for the majority of their clients, many psychotherapists have integrated constructs and methods belonging to diverse approaches. In fact, "eclectic/integrative therapy" is the most frequent self-identified orientation among clinicians (Mahoney, 1991). This chapter begins with a description of the conceptual and empirical bases of the integrative treatment. The general structure of the treatment protocol (within the current investigation) and the therapeutic rationale provided to clients are then presented. Also described are the techniques that were added to cognitive-behavior therapy to address two specific factors involved in the etiology and/or maintenance of generalized anxiety disorder: interpersonal problems and emotional avoidance. Preliminary process and outcome data are then briefly reviewed.
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After providing background information on. the definition and nature of generalized anxiety disorder, this article describes cognitive-behavioral therapy (CBT) methods that have been empirically supported in the treatment of this disorder. Subsequent to this description, relevant outcome literature is briefly reviewed, along with evidence that the addition of other techniques beyond traditional CBT methods may be necessary to maximize clinical outcome. A description is then provided of an integrated interpersonal/emotional processing therapy that the authors have recently added to their CBT protocol. CBT with and without this integrated treatment is currently being evaluated in an experimental trial.
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This special section has a dual focus. One is on psychotherapy change research. The other is to explicate an approach to develop a program of research that builds on 2 aspects of scientific discovery: decomposition of observed phenomena and localization of specific elements that may combine to produce a complex whole. These aspects are considered within an ordered framework of 8 steps in the development and testing of a model, moving from discovery to model construction, validation, and prediction of complex outcomes. Studies on psychotherapy change processes were selected, after a masked review, to represent different levels in developing a program of research. Although it is argued that the early steps of decomposition and localization are important when developing a program of research, current editorial practices in first-tier journals, including the Journal of Consulting and Clinical Psychology, typically consider this type of study to be too preliminary for a scientific archival journal. Should this practice be revisited?
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To determine whether baseline dimensions of adult insecure attachment (avoidant and anxious) moderated outcome in a secondary analysis of a randomized controlled trial comparing cognitive-behavioral therapy (CBT) plus supportive listening (CBT + SL) versus CBT plus interpersonal and emotional processing therapy (CBT + I/EP). Eighty-three participants diagnosed with generalized anxiety disorder (GAD) were recruited from the community and assigned randomly to CBT + SL (n = 40) or to CBT + I/EP (n = 43) within a study using an additive design. PhD-level psychologists treated participants. Blind assessors evaluated participants at pretreatment, posttreatment, 6-month, 12-month, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (Penn State Worry Questionnaire, Hamilton Anxiety Rating Scale, Clinician's Severity Rating). Avoidant and anxious attachment were assessed using self-reported dismissing and angry states of mind, respectively, on the Perceptions of Adult Attachment Questionnaire. Consistent with our prediction, at all assessments higher levels of dismissing styles in those who received CBT + I/EP predicted greater change in GAD symptoms compared with those who received CBT + SL for whom dismissiveness was unrelated to the change. At postassessment, higher angry attachment was associated with less change in GAD symptoms for those receiving CBT + I/EP, compared with CBT + SL, for whom anger was unrelated to change in GAD symptoms. Pretreatment attachment-related anger failed to moderate outcome at other time points and therefore, these moderation effects were more short-lived than the ones for dismissing attachment. When compared with CBT + SL, CBT + I/EP may be better for individuals with GAD who have relatively higher dismissing styles of attachment. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
Article
The Contrast Avoidance model (Newman & Llera, 2011) proposes that individuals with generalized anxiety disorder (GAD) are hypersensitive to sharp upward shifts in negative emotion that typically accompany negative events, and use worry to maintain sustained intrapersonal negativity in an attempt to avoid these shifts. Although research shows that worry increases negative emotionality and mutes further emotional reactivity to a stressor when compared to the worry period (e.g., Llera & Newman, 2010), no study has tracked changes in negative emotionality from baseline to worry inductions followed by a range of emotional exposures. Further, no study has yet assessed participants’ subjective appraisals of prior worry on helping to cope with such exposures. The present study tested the main tenets of the Contrast Avoidance model by randomly assigning participants with GAD (n = 48) and nonanxious controls (n = 47) to experience worry, relaxation, and neutral inductions prior to sequential exposure to fearful, sad, and humorous film clips. Both physiological (nonspecific skin conductance responses [NS-SCRs]) and self-reported emotional changes were observed. Results indicated that worry boosted negative emotionality from baseline which was sustained across negative exposures, whereas low negative emotionality during relaxation and neutral inductions allowed for sharp increases in response to exposures. Interestingly, GAD participants found worry to be more helpful than other conditions in coping with exposures, whereas control participants reported the opposite pattern. Results provide preliminary support for the Contrast Avoidance model. This suggests that treatment should focus on underlying avoidance patterns before attempting to reduce worry behavior.