Cogn itive-Behavioral Assimilative Integration · 2019-08-28 · cises and cognitive therapy with...

In J.e. Norcross & M.R. Goldfried (~) (2005)Handbook of pSYchotherapy integration (2nQ edition).New York: Oxford University Press

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Cogn itive-BehavioralAssimilative Integration

LOUIS G. CASTONGUAY, MICHELLE G. NEWMAN,THOMAS D. BORKOVEC, MARTIN GROSSE HOL TFORTH,AND GLORIA G. MARAMBA

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The educational and cultural backgrounds ofthe authors vary considerably. How frequentlyis a chapter written by a French Canadian, aJewish woman from New Jersey, an ex-semi-narian from the Midwest, a German-born liv-ing in Switzerland, and an Asian Americanborn and raised in the Philippines? Nonethe-less, each of us defines himself or herself, withmore or less conviction, as a cognitive behaviortherapist. Operationally, this means that we be-lieve that distressing behaviors, cognitions, andemotions should be primary targets of our in-terventions. Severe social anxiety, frequentpanic attacks, and chronic insomnia, to name afew specific impairments, deserve our clinicalattention. We also agree that both situational(e.g., external contingencies) and intrapersonal(e.g., inaccurate cognitions) factors are in-volved in the etiology and/or maintenance of

, our clients' impairments. As cognitive behavior, therapists, we also believe that a fruitful strat-egy to identify the determinants of clients' dif-

~ficulties is to conduct comprehensive func-~~

~..I

tional analyses that are grounded in knownempirical knowledge.

Although we believe that psychotherapy canreduce clients' impairments, we are convincedthat cure is not a possibility. Even after success-ful therapy, the difficulties of life will likelycontinue to trigger vulnerabilities that are linkedto years of complex learning, implicit meaningstructures, biological processes, and geneticpredispositions. In our opinion, the ultimategoal of therapy is to facilitate the acquisition ofcoping skills (emotional, cognitive, and behav-ioral) that will help clients cope with life'sstressful demands.

Along with the theoretical writings of lead-ing figures in cognitive-behavioral therapy(CBT), however, our clinical experience hassuggested that traditional cognitive-behavioraltherapy techniques are not always sufficient totreat clients' distress and to help them developbetter ways of dealing with life's difficulties.On more than one occasion, we have found ithelpful to let clients talk extensively about

242 Integrative Psychotherapy Models

early relationships with their parents, to en-courage them to experience and "stay with"painful feelings, or to draw links between whatis taking place in the therapy relationship andwhat has occurred in their interpersonal rela-tionships outside of therapy.

The beneficial use of what many wouldconsider non-cognitive-behavioral therapy (non-CBT) methods has raised the question of howbest to incorporate methods derived from (orconsistent with) humanistic, psychodynamic,interpersonal, or systemic approaches into ourCBT practice. The integrative approach de-scribed in this chapter represents our effort toimprove the efficacy of CBT via a systematicand theoretically cohesive assimilation of treat-ment procedures typically associated with otherpsychotherapy orientations.

EXPANDING COGNITIVE·BEHAVIORAL THERAPY

Our integrative approach is based on the as-sumption that clinical improvement is due inpart to principles of change that cut across dif-ferent forms of therapy (Castonguay, 2000). Asdescribed by Coldfried (1980; Goldfried & Pa-dawer, 1982), we believe that several tech·niques associated with particular orientationsare idiosyncratic manifestations of commonprinciples. These principles include the acqui-sition of a new perspective of self, the establish-ment of a therapeutic alliance, the facilitationof new or corrective experiences, and general-ization of therapeutic change to the client'sdaily life. Thus, from a clinical standpoint, ourapproach is based on the premise that the rep-ertoire of interventions of a particular orienta-tion (e.g., CST) can be increased by addingtechniques that reflect general principles of in-tervention while allowing this specific approachto address more directly or adequately certaindimensions of human functioning. Based onresearch findings, as well as on conceptual cri-tiques and modifications of CBT, we con-cluded that the most fruitful way to improveCBTs efficacy was to add techniques aimed at

facilitating interpersonal functioning and elTl~tional deepening.

Interpersonal Focus

Several authors have criticized CBT (and espe-cially cognitive therapy) for not paying suffi-cient attention to interpersonal factors involvedin psychopathology (Coyne & Gotlib, 1983.Coldfried & Castonguay, 1993; Robins &Hayes, 1993). As demonstrated by Blagys andHilsenroth (2000), there is convincing evi-dence that cognitive-behavioral therapists focusless on interpersonal experience than psycho-dynamic-interpersonal (PI) therapists. In addi-tion, while one preliminary study found thatCBT therapists tended to focus more on inter-personal issues than intra personal issues (Kerr,Goldfried, Hayes, Castonguay, & Coldsamt,1992), the reverse was found in two later stud-ies (Castonguay, Hayes, Goldfried, & De-Rubeis, 1995; Castonguay, Hayes, Coldfried,Drozd, Schut, & Shapiro, 1998). More impor-tantly, interpersonal focus in CBT has beenfound to be unrelated to client's improvementin two studies (Castonguay et al., 1998; Kerr etaI., 1992). Moreover, one study found that thetherapist focus on interpersonal cognitions neg-atively related to outcome in cognitive therapy(Hayes, Castonguay, & Gold&ied, 1996). Bycontrast, evidence suggests that when psycho-dynamic-interpersonal therapists focus on in-terpersonal issues, such focus is positivelylinked with outcome (Castonguay et aI., 1998;Kerr et aI., 1992).

Furthermore, process studies also suggestthat clients do improve when cognitive behav-ior therapists focus on the kinds of interper-sonal issues typically emphasized in psycho-dynamic treatment For instance, Hayes et al.(1996) found a positive relationship betweenthe therapist's focus on early attachment pat-terns and client's improvement in CBT. Otherstudies (Ablon & Jones, 1998; Jones & Pulos,1993) also found that the therapist's connec-tions between the therapeutic relationship andother relationships were among a set of psycho-dynamic techniques positively related to thera-peutic change in CBT. Taken together, these

Cognitive-Behavioral Assimilative Integration1findings suggest that adding techniques fromthe psychodynamic and interpersonal tradi--lionsto address client's maladaptive relationshippatterns might increase the therapeutic impactofCBT.

Qualitative findings have also suggested thatcertain ways of dealing with problems in thetherapeutic relationship observed in CBT mayimpede its efficacy. Castonguay, Goldfried,Wiser, Raue, & Hayes (1996) find that whenconfronted with alliance ruptures, cognitivetherapists frequently increased their focus oncognitivetherapy rationale or techniques. Ratherthan resolving the alliance difficulties, how-ever, such interventions seemed to exacerbatethem. These findings suggest that integratingnew strategies to address alliance difficulties,such as the ones proposed by Bums (1989) andSafran and Segal (1990), might also improvethe efficacy of CBT.

Emotional Deepening

Prominent authors in the field have criticizedCBT for approaching emotions as phenomenato be controlled rather than being experienced(e.g., Mahoney, 1980). One study (Wiser &Goldfried, 1993) provided evidence to suggestthat cognitive-behavior therapists see the re-duction of emotional experiencing as a sig-nificant event during the session. Summarizingthe empirical literature, Blagys and- Hilsenroth(2000) concluded that "recent studies lendvel}'strong support for the notion that PI fo-cuses more than CBT therapy on the expres-sion of patients emotions" (p. 172). They alsoadded that current findings

support the notion that PI therapy attempts toevokethe expressionof patients' emotion whileCB therapy attempts to control or reduce pa-tiena' feelings.The propensityof PI therapy tofocuson affectnot onlyconveysa greaterempha-sison cathartic expression,but also a greater fo-cus on emotional insight and a greater encour-agement to identify, stay with and/or acceptemotions.

Interestingly. a number of studies havefound that the client's emotional experience in

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CBT is positively linked with outcome (Cas-tonguay et a!., 1996; Castonguay, Pincus,Agras, & Hines, 1998). Processes and tech-niques related to emotional exploration werecomponents of different sets of therapeutic fac-tors found to be positively linked with outcomeeither in CBT (Ablon & Jones, 1998; Jones &Pulos, 1993) or across CBT and interpersonaltherapy (Ablon & Jones, 1999; Coombs, Col-ema, & Jones, 2002). Although not all studieshave found emotional experience to be predic-tive of outcome (Hayes & Strauss, 1998), as awhole, research suggest that adding techniquesthat facilitate client experience and expressionof emotions may also improve the effectivenessofCBT.

Our decision to emphasize interpersonaland emotional issues when attempting to im-prove CBT has also been influenced by Sa-fran's expansion of cognitive therapy (Safran1998; Safran & Segal, 1990). Although endors-ing the concept of schema, Safran has arguedthat such mental representation of self is intrin-sically interpersonal. Relationships with others,according to Safran, are embedded in our un-derstanding of who we are. In addition, coreschema are not purely cognitive. Rather, theyare cognitive-affective structures, or "hot" cog-nitions. The interpersonal and emotional na-ture of our core schema reflect the fact thatour views of self are deeply shaped by our rela-tionships with significant others. The ways weperceive and treat ourselves are based on theway important others (past and current) haveviewed and treated us. Within this context, anemotionally immediate exploration of the cli-ents' problematic relationships with importantothers (parents, spouse, therapist himlherself)provides a unique opportunity to better under-stand their interpersonal needs and fears, aswell as to correct their maladaptive schema ofself and others and their behavioral relation-ship patterns. In sum, Safran's model providedus with a conceptual framework accounting forand addressing interpersonal and emotional di-mensions of human functioning when, as cog-nitive therapists, we attempt to provide a newperspective of self, to facilitate positive experi-ence, foster more adaptive ways of dealing with


reality, and to enhance or repair our therapeu-tic alliances.

Having described the empirical and theoret-ical bases of our integrative approach, we nowtum to a more pragmatic question: How do weactually combine traditional CBT techniqueswith interpersonally and emotionally focusedinterventions that are derived from (or cons is·tent with) interpersonal, psychodynamic, andhumanistic orientations?

APPLICABILITY AND STRUaURE

Our efforts to increase the effectiveness of CBThas evolved via the development and empiricaltesting of treatments for depression (Caston-guay et aI., 2004) and generalized anxiety dis-orders (CAD) (Newman, Castonguay, Borko-vec, & Molnar, 2004). Because it is the mostcomprehensive of the two, the GAD treatmentwill be the main focus of this chapter.

CBT includes multiple techniques that di-rectly address situational and intra personal fac-tors involved in the etiology or maintenance ofCAD. Previous studies have demonstrated thatthis treatment leads to statistically and clini-cally significant change in the short· and long-term and has an impact on both CAD specificsymptoms and comorbid conditions. CBT hasbeen found to be superior to no-treatment,nondirective therapy, psychodynamic therapy,and pharmacotherapy (Borkovec & Ruscio,2001). A recent review of outcome studies onGAD concluded that "the most successful psy-chosocial treatments combine relaxation exer-cises and cognitive therapy with the goal ofbringing the worry process itself under the pa-tient's control" (Barlow, Raffa, & Cohen, 2002,p. 326). In fact, CBT -<lriented treatment cur-rently stands as the only form of psychotherapymeeting criteria for empirically supportedtreatment for GAD (DeRubies & Crits-Chirs-toph, 1998).

The evolution of our integrative therapy forGAD and its incorporation of interpersonaland experiential techniques had its origins inempirical results that were emerging duringthe third author's conduct of basic and therapy

outcome research on GAD from 1984 to 1995(Borkovec, 1996). The fact that many clientsin these earlier therapy tria)s were not retumedto normal levels of anxiety by the end of treat-ment (Borkovec & Whisman, 1996) suggestedthat a therapeutic focus soley on intra personalprocesses may be insufficient. On the otherhand, considerable evidence indicated that in-terpersonal processes were likely involved inthe origins and maintenance of GAD. Forinstance, worry was most closely associatedwith social-evaluative fears (Borkovec, Robin-son, Pruzinsky, & DePree, 1983) and interper-sonal topics (Roemer, Molina, & Borkovec,1997). GAD clients also reported elevated lev-els of role-reversed relationships with their pri-mary \:aregivers in childhood (Cassidy, 1995;Schut et aI., 1997), suggesting an understand-able etiological basis for their world view as adangerous place for both themselves and theirparents. Moreover, a majority of GAD clientsfall into an overly nurturing and intrusive inter-personal style that caused difficulties for themin their current relationships, possibly based ontheir childhood history of taking care of others(Pincus & Borkovec, 1994). Dimensions of in-terpersonal problems also significantly pre-dicted posttherapy and follow-up clinical im-provement (Borkovec, Newman, Pincus, &Lytle, 2002).

On the basis of this accumulating evidence,Borkovec decided that the next therapy investi-gation needed to test whether adding tech-niques that targeted interpersonal functioningcould increase improvement rates generated byCBT. With the arrival of the first and secondauthors at Penn State and due to their expertisein interpersonal methods, he invited them tojoin future therapy projects and to make sug-gestions on how best to develop the envisionedinterpersonal therapy element. The therapy el-ement that was eventually added to CBT wascreated by the second author. Based in part onSafran and Segal's (1990) work, this elementcombines techniques derived from both inter-personal and experiential therapies.

Despite the incorporation of techniquesfrom different theoretical orientations, the thirdauthor was comfortable with the fact that exist-

Cognitive-Behavioral Assimilative Integration 245

ing empirical knowledge allowed such tech-niqueS to be used from within a cognitive-behavioral perspective. Interpersonal therapycan be viewed from within CBT as an ap-proach that exa~ines, and then att~mpts tomodify by emohonally focused and mterper-sonally focused methods, the cause-and-effectlinks that exist among (a) environmental events,(b) the client's cognitive, affective, behavioral,and interpersonal processes, and (c) the conse-quences of the client's interpersonal behaviors.Moreover, the use of the therapeutic relation-ship to provide feedback to the client about hisor her interpersonal effect on the therapist isfully in line with CBT principles of change(Kohlenberg & Tsai, 1991).

Finally, the use of emotional deepeningtechniques (prescribed in both experientialand interpersonal therapies) turned out to fitthe behavioral learning view quite well, oncerecent discoveries were made concerning CADand emotional process in general. Specifically,evidence now suggests that CAD clients largelyignore their emotions and indeed may be fear-ful of many of them, including positive ones.These findings suggest that worry, the cardinalsymptom of CAD, may actually serve the roleof cognitive avoidance of affect (Borkovec, Al-caine, Behar, 2004). From a CBT perspective,therefore, emotional deepening techniquescan be used as exposure methods for the sakeof full emotional processing of fear (Foa & Ko-zak, 1986).

The structure of the CAD treatment isunique. Rather than involving a simultaneousblend of theoretically diverse intervention, itinvolves a sequential application of two "pure"form of therapy. Specifically, our therapists aretrained to conduct a 50-minute segment ofCBT, which is immediately followed by a 50-minute segment of InterpersonallEmotionaJ Pro-cessing (IIEP) therapy (Newman et aI., 2004).

This Structure of our integrative therapy hasbeen dictated by a specific scientific purpose.If this treatment combination (CBT +IIEP) canbe shown to be superior to the combination ofCBT and a supportive listening (SL) condition(CBT+SL), then our research would not onlyprovide evidence that CBT can be improved

but also that such incremental improvement iscausally attributable to the added interven-tions. Such an additive design is one of the fewdesigns that caD adequately address a majorquestion that drives science: Causality (Borko-vec & Castonguay, 1998).

Our concern with internal validity, how-ever, comes at a price of external validity. Ourintegrative tre.atment, the way it is currentlystructured, is not easily transportable to theclinical setting. Effectiveness research willhopefully be conducted to assess the feasibilityand impact of a treatment structure more insync with the way psychotherapy is typicallyconducted (e.g., I-hour session involving amore permeable implementation of the twotreatments). We should mention, however, thatwith the exception of scheduling a 2-hour ap-pointment every week, our therapists and cli-ents have not found it onerous to work withina particular orientation for 50 minutes andthen shift to a different treatment approach foranother 50 minutes. In fact, our therapist haveFrequently mentioned that the sequential struc-ture has helped them to focus on the tasksspecific to each segment and has on many oc-casions prevented them from prematurely shift-ing to an Uoff-task" intervention.

though we have developed the integrativeapproach specifically for CAD, we believe thatit could be applied to other clinical problems.We would predict that many CBT protocolsmay be improved by adopting parts of our treat-ment when targeting any problems for whichthe etiology and maintenance involve interper-sonal difficulties or the avoidance of painfulemotions.

ASSESSMENT AND FORMULATION

Because our CAD treatment has been devel-oped and used in the context of clinical trials,the clients treated by our therapists have beenassessed by two independent administrations ofa semistructured interview-the Albany Anxi-ety Disorder Interview Schedule-IV (ADIS;Brown, DiNardo, & Barlow, 1994). The ADISallows us to determine whether an individual


suffers from the clinical disorder targeted byour treatment and identifies the specific con-tent of the client's worries. Moreover, it allowsus to systematically assess comorbid conditionsthat are likely to influence case formulation.For instance, knowing that a client also strug-gles with social phobia helps us to determineour intervention targets (e.g., social skills) whenaddressing interpersonal issues.

Our assessment also involves a number ofquestionnaires and self-monitoring instru-ments. For example, the therapists use the Dys-functional Attitude Scale (DAS; Beck, Brown,Steer, & Weissman, 1991) to identify the nega-tive cognitions that may reflect and contributeto the client's worry and anxiety. Therapistsalso review the client's scores, obtained at pre-treatment, on the Inventory of InterpersonalProblem-Circomplex (IIP-C; Alden, Wiggins,& Pincus, 1990), the Inventory of Adult At-tachment (IIA; Lichtenstein & Cassidy, 1991),and the Structured Clinical Interview forDSM-N Axis II (SCID-II; First, Spitzer, Gib-bon, Williams, & Benjamin, 1994). Along withthe gathering of interpersonal history informa-tion during sessions, as well as the observationof the client's behavior toward them, therapistsuse these pretreatment scores to understandthe client's relationship patterns. The dailymonitoring of clients' anxiety, as well as thesystematic monitoring of their relationships,also help therapists conduct functional analy-ses of clients' problematic reactions.

The information derived by such an exten-sive assessment is use to construct case formu-lation, which in turns guides an ideographicapplication of the CBT and IIEP techniques.In CBT, therapists built their case formulationsaround the following questions: What are theearly cues (situational and internal) of the cli-ent's anxiety reaction? What are the maladap-tive elements (cognitive, imaginal, physiologi-cal) if such reaction that could be replaced bymore adaptive responses? In IIEP, the case for-mulations are centered around the followingquestions: What are the clients' most centralinterpersonal schema (Le., core views of self inrelation with others)? What do clients wantand fear from others? What do they do to gettheir needs met? What is the impact they have

on others? Are their specific emotions that theyare avoiding and that might tell them whatthey want from others?

PROCESSES OF CHANGE

We assume that a substantial part of the pro-cess of change can be attributed to generalprinciples that cut across different forms of psy_chotherapy and, needless to say, operate inboth segments (CBT and llEP) of our integra.tive approach. In line with Goldfried's model(1980; Goldfried & Padawer, 1982), however,the ways by which these principles were imple-mented vary from one segment to another.

Early in therapy, therapists work toward cre-ating positive expectations for the clients. Thisis accomplished by providing a rationale ex-plaining factors that might have contributed totheir difficulties, as well as a description oftechniques that will be used to address thesefactors. In CBT, the rationale focuses on situa-tional and intra personal issues. Specifically,clients are informed that their experiences ofuncontrollable worry and anxiety are leamedresponses to threat cues, which involve mal·adaptive and habitual interactions among cog-nitive, behavioral, and physiological systems.For example, GAD patients frequently have apreattentive bias to indications of danger,which can trigger images of negative events.These, in tum, lead to defensive somatic reac-tions. As one component in the spiraling inten-sification of anxiety, such somatic responsescan result in greater attention to physiologicalactivity, which can interfere with a client's at-tention to (and realistic appraisal of) extema]reality and further increase hislher internal re-sponse of worry and rumination. The goal ofCBT is to identify early cues that indicate thatan anxiety spiral is beginning and to help theclient replace these maladaptive reactions withadaptive coping responses.

In the llEP segment, the rationale focuseson both interpersonal and emotional issues.We inform clients that chronically anxious in-dividuals frequently develop interpersonalstyles that contribute to their anxiety. Thera-pists tell their clients that when they interact


with others, anxious people tend to focus moreon avoiding what they fear rather than tryingto get what they need. Unfortunately, attemptsto avoid what one feaTSsometimes lead to spe-cific-and anxiety provoking-reactions fromothers that one tried to avoid (e.g., being extra-attentive to another's need in order to not beignored can lead the other to move away fromthe relationship because he or she is feelingintruded upon). The attention to what theyfear has become such an automatic focus forchronically anxious persons that they are fre-quently unaware of many of their interpersonalneeds. Clients are informed that one way tobecome aware of what they need from othersis to explore their emotions. Accordingly, thegoal of llEP is to help clients become awareof, and then change, the maladaptive ways theyinteract with others, including the therapist. Byexploring and owning emotions that are trig-gered by their relationship difficulties, clientswill increase their abilities to get what theywant and better deal with what they fear fromothers.

Another principle of change underlying eachsegment of our integrative treabnent is the pro-vision of a new perspective. By offering an ex-planation of the etiology and maintenance ofGAD symptoms, the rationales described aboveintrinsically serve this principle. As describedin the next section, each segment of the proto-col includes additional procedures to foster anew understanding such as (a) helping the cli-ent challenge inaccurate thoughts, cognitiveerrors, and maladaptive attitudes, (b) experi-encing and expressing previously implicit emo-tions and meanings, and (c) exploring wishesand fears about others, interpersonal schemas,and maladaptive relationship patterns. Thoughserving the same general principle of change,these interventions focus on different dimen-sions of human functioning (Le., cognitive,emotional, interpersonal). Our clinical obser-vations suggest that clients are able to recog-nize multiple types of determinants involved intheir difficulties, as well as to establish mean-ingful connections among them. For example,they realize that some of their ways of thinking,at times, parallel their ways of relating withothers or that being more open about their

emotions will help them to become less rigidabout their appraisal of themselves.

Several of the techniques described later inthis chapter directly serve the principles of cor-rective experience and continued test with real-ity. For example, relaxation and self-control de-sensitization techniques are used during CBTsegments and between sessions to help the cli-ent to learn and rehearse new, more adaptivecoping responses to anxiety-provoking cues.Similarly, attempts at fostering new and moremeaningful ways of relating with others aredone by paying attention to interaction withthe therapist during llEP segments, as well asbetween the client and others in his or herdaily life.

Interestingly, though different techniquesare used to foster these two principles of change,some of the techniques are based on the sameleaming processes. For instance, exposure inCBT is designed to help the client gain controlover his or her anxiety. In IIEP, it is aimed athelping the client to stay with and own his orher painful emotions. In both situations, themastery of previously intolerable situations isexperienced as a positive corrective event.Modeling and problem-solving skills are alsoinvolved in the techniques used in each spe-cific segment to correct maladaptive responses,learn more adaptive reactions, and implementthem in situations outside the sessions. For ex-ample, such learning processes are at play whentherapists help clients to react more adaptivelyto anxiety provoking cues or when therapistshelp clients to find better ways to get what theywant from others.

Finally, as in all forms of psychotherapy, theuse of the therapeutic relationship reflects acore principle of change in our integrative treat-ment. The ways in which therapists attend tothe working alliance in each of the segmentare described in the next section.

THERAPY RELATIONSHIP

[n both segments of our protocol, therapistspay careful attention to the development andmaintenance of a positive therapeutic alliance.There is, of course, a good reason for this. The

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quality of the therapeutic alliance currentlystands as one of the most robust predictors ofchange in psychotherapy (Constantino, Caston-guay, & Schut, 200 I). Thus, during the wholecourse of the treatment, therapists make all pos-sible efforts to be empathic, warm, and support-ive toward their clients and to foster mutualagreement on the goals and tasks of therapy.

However, there is an important differenceabout the role of the relationship in the processof change in the two segments of our integra-tive therapy. In the CBT segment, the relation-ship is primarily viewed as a precondition forchange. Therapists, in other words, adopt asupportive attitude mainly to build the client'strust in the treatment rationale and procedures,as well as to foster the client's willingness to dowhat he or she needs to do to develop bettercoping skills. It is assumed that if a good thera-peutic bond (based on mutual respect and af-fection for each other) is created, that if thetherapist genuinely understands the client'ssubjective experience, if he or she is flexibleand tactful in the use of the prescribed tech-nique, and if he or she encourages and rein-forces the client's engagement in the treatmenttask, that it is then likely that the client willface what he or she had avoided in the pastand will implement, during and between ses-sions, new ways of reacting to anxiety cues.

The same assumption is held in IIEP. Agood relationship is viewed as a necessary con-dition for the client's engagement in the de-manding and anxiety-provoking tasks prescribedin this therapy segment. In this segment, how-ever, the therapeutic relationship is also usedas a direct mechanism of change. Therapistsuse what takes place during the session to helpclient's gain awareness of, and change, theirmaladaptive patterns of interpersonal interac-tion. Therapists, in other words, not only at-tempt to built a positive relationship in llEPbut also to work with the relationship to iden-tify and deepen authentic primary emotionand to modify interpersonal habits that havecontributed to clients' anxiety.

In addition, specific techniques are in-cluded in llEP to deal with alliance ruptures.Although therapists are asked to pay attentionto markers of alliance ruptures in both the

CBT and IIEP segments, these markers are ad-dressed only during the IIEP portion of therapy,

METHODS AND TECHNIQUES

Although some principles of change cut acrossthe two segments of our integrative treatmentfor CAD, the techniques used to implementthese principles differ. Before describing thesetechniques, however, it is important to indicatethat the stance of the therapist in both seg-ments is fairly directive. SpecificaJly, therapistsmust remain actively involved in making surethat the focus of the session is in line with therespective goals of each segment. While focus-ing on different dimensions of functioning ineach segment, therapists help clients to bemore cognizant of what they perceive as dan-gers (e.g., specific external events, internal im-ages, negative emotions, interpersonal issues)and to replace their earlier coping responses(e.g., catastrophizing, scanning physiologicalreactions, avoidance of emotion, engaging infear-reducing interpersonal behaviors). Help-ing clients to develop new skills to deal withanxiety requires that the therapist be task-oriented and directive, irrespective of the stim-uli feared and the skills to be taught.

CBT

The CBT segment is primarily aimed at modi-fying and reducing internal responses to spe-cific threats, Following is a brief overview ofstandard methods employed in the CST seg-ment to achieve this therapeutic task (Borkovec& Sharpless, 2004; Newman, 2002)

Self-Monitoring and EarlyCue Detection

Clients are taught to identify their earliest reac-tions to perceived threats, their reactions tothese early reactions, as well as the spiralingchain of internal events (attention, thoughts,images, bodily sensations, emotions, and be-haviors) that then occur. Clients can begin todiscover early components of anxious respond-ing by describing typical worry and anxiety ex-


periences and/or imagining situations involv-ing different components of their anxietyresponses. Therapists can also help clients de-tect early cues of anxiety by asking them to in-tentionally worry about a personal concern.Therapists are also asked to pay great attentionto noticeable shifts in the clients' affectivestates as they occur during the therapy session.Immediately pointing out such a shift cansharpen the client's own early cue detection.In addition to these in-session experiences,the client is asked to self-monitor his or herworrying and anxiety responses on a daily ba-sis. As sessions progress, clients are increas-ingly asked to pay attention to and process allimmediately available experiences, both inthe environment and internally. The goal isto help clients to shift attention to present-moment reality and away from the illusions ofthe future and of the past that their worryingand rumination create.

Stimulus Control Methods

Once clients have learned to detect early cuesfor anxiety, a stimulus control method is usedto reduce the amount of time spent worryingand to decrease the habit strength of worrying.Specifically, clients are instructed to postponeany early-detected worrying during the day toa fixed period of worrying- 30 minutes at thesame time and in the same place every day,during which they can engage in problem solv-ing about the worry or apply cognitive restruc-turing skills to it. Such a deliberate postpone-ment of worry enables clients to refocusattention to the present environment and thetask at hand.

Relaxation Methods

As part of the natural response to perceivedthreats ("fight or Right"), anxiety reactions areclosely associated with the activation of thesympathetic nervous system (SNC). One wayto attenuate the SNC at the early detection ofanxious responding is by activating the para-sympathetic system through learning and re-peatedly using applied relaxation methods(Bernstein, Borkovec, & Hazlett-Stevens, 2000).

Multiple relaxation methods are taught inorder to encourage flexibility in the use of cop-ing resources and to find those that are mosthelpful for clients in different situations or inresponse to different internal cues. Slowed,paced, diaphragmatic breathing is an idealstarting point to provide the client with an im-mediate, noticeable, and positive effect of treat-ment and to teach him or her ways to reach arapid relaxation response that is easy to learnand readily applicable in daily living. The cli-ent is instructed to slow-down breathing and toshift it from the chest to the stomach by lettingthe diaphragm rise and fall without expandingthe chest. Progressive muscle relaxation (PMR)is aimed at reducing muscle tension and sym-pathetic activation via systematic tensing andreleasing various muscle groups. Meditationaltechniques can be combined with PMR to fa-cilitate the client's ability to shift away fromanxiety-provoking cues and toward pleasant, in-ternal stimuli. At the end of each PMR prac-tice session, the client can be instructed to fo-cus on a meaningful, pleasant internalstimulus (an image, a word, etc.) that is associ-ated with safety, comfort, security, love, and/ortranquility. A related technique, guided imag-ery, can be used to further deepen the relax-ation by leading the patient through a sequenceof tranquil and pleasant images. The use of ap-plied relaxation allows the clients to cultivate amore relaxed lifestyle and to cope adaptivelywith perceived threats as they occur in day-to-day living. It is applied on a moment-to-moment basis whenever clients recognize earlycues of anxiety (and, eventually, any time cli-ents are aware of the absence of a calm or tran-quil state) and is intended to shift attentionaway from tension/anxiety toward relaxation.Therapist help clients to acquire and practicethis coping skill during the session by fre-quently asking them to apply the relaxation re-sponse whenever therapists or clients observesigns of increased anxiety.

Self-Control Desensitization

Self-control desensitization (SCD) involves therehearsal of relaxation responses (and, later in

250 IntegrativePsychotherapyModels

therapy, cognitive perspective shifts) while imag-ining frequently occurring anxiety-provoking sit-uations (both environmental cues and internalcues). First, the client is asked to imagine him-self or herself in a situation in which he or shedetects anxiety cues. The therapist then repeat-edly guides the client through imagining him-self or herself successfully applying relaxationtechniques in that situation. In the course oftherapy, SCD is practiced with several sets ofanxiety cues in order to generalize this adaptivecoping response to various situations. Clientsare also asked to include SCD at the end oftheir daily relaxation practice. Finally, in thecourse of cognitive therapy (described next),images of the most likely outcomes for worri-some topics are created, and these are to beimagined vividly as soon a worry is detected.

Cognitive Therapy

From a CBT perspective, clients' inaccurateperceptions are important components of theirworry and anxious experiences. As such, nu-merous cognitive techniques are used to helpthem develop cognitions that more closely cor-respond with the available environmental in-formation. Clients are first instructed to ob-serve their environment, as well as to monitorthe content of their anxious thoughts on a dailybasis. Clients' inaccurate perceptions and/orinterpretations are then challenged by diversemethods, such the search for evidence to sup-port and reject clients' cognitions, the genera-tion of alternative perspectives, and the identi-fication of core beliefs (or nonadaptive attitudes)underlying many of their specific inaccuratethoughts and negative images. Because worryfrequently involves an exaggeration of the neg-ative implications of specific events, the cogni-tive technique of decatastrophizing (Le., a step-by-step analysis of what it is that the client fearsmight happen, including the probability ofeach of these steps and the client's coping re-sources to deal with them) is particularly usefulfor CAD clients. Perhaps differing From someCBT approaches, we place special emphasison the creation of multiple perspectives for any

given situation in order to maximize flexibilityin thinking.

Clients also complete a Worry OutcomeDiary, wherein they write down (a) their wor-ries when detected, (b) what they fear will hap-pen, and (c) the actual outcome once it oc-CUTS. The purpose of this information is to helpclients to build a new history of evidence of theway things actually are and to facilitate theirprocessing of all available information fromtheir environments, not just the negative bi-ased information.

Behavioral experiments are also used to testunrealistic cognitions, as well as to provide ad·ditional exposure to feared situations and op-portunities to practice applied relaxation andperspective shifts. On the basis of the data col-lected in these analytic and behavioral exer-cises, the clients learn to treat their perceptionsas hypotheses and revise inaccurate predictionsor assumptions involved in the spiraling inten-sification of their anxiety. By learning to payless attention to negative environmental cuesand by focusing less on the past or the future,the clients also learn to be fully immersed intheir present reality, to process environmentalinformation as needed, and to be confidentthat they will be able to deal with smaller orbigger challenges to come. Indeed, the even-tual goal in therapy is to move from inaccurateexpectations about the future, to relativelymore accurate expectations, and ultimately tono expectations at all. Such expectancy-freeliving is our cognitive therapy method for con·tributing to the goal of living in the presentmoment, wherein there can be no anxiety ordepression.

Finally, clients are encouraged increasinglyto make use of intrinsically motivated behav-iors for approaching worrisome or anxiety-provoking situations and for taking an activeapproach to daily living in general in order toma:<imize joy in life. Thus, drawing from thevalues that clients hold neaT and dear to theirhearts, the therapist helps them to create emo-tional and cognitive sets reflective of those val-ues and facilitative of a true, wholeoQrganismapproach to each life situation that they areabout to enter.


a general understanding of clients' perceptionsof their interpersonal needs and fears, as wellas their typical attempts to deal with them. Asearly as in the second or third session, however,the primary focus of treatment shifts away froma description of these past and/or current rela-tionships to an exploration, in an emotionallyimmediate way, of the therapeutic relationship.

Cuided by Safran and Segal's (1990) inte-gration of interpersonal therapy constructs(e.g., Sullivan, [953), we assume that clients'maladaptive patterns of relating are likely to berepeated in the therapeutic relationship. Assuch, an important task of therapists is to iden-tify when and how they have been participat-ing in clients' interpersonal schemata. Safranand Segal (1990) have suggested that therapistsactually need to be uhooked" into clients' mal-adaptive ways of relating 10 others-to bepulled by clients into behaving consistentlywith clients' expectations-in order to helpthem change the way they interact with others.Adopting an attitude of a participant-observer(Sullivan, 1953), therapists pay constant atten-tion to signs of having been hooked, such as afeeling of being emotionally detached from theclient, or the realization of having frequentlylet the client tell long tangential stories. An-other indicator of therapists being hooked iswhen they andlor their clients are trying to 6ndout why clients are reacting (or not reacting)in a particular way, instead of helping the cli-ent 10 become aware, own, or deepen theiremotional experience.

Once hooked, the therapist stops acting inways that are consistent with the client's expec-tations. lnstead, he or she i.s asked to explorewhat is taking place in the relationship in orderto help the client gain awareness of his or hermaladaptive ways of relating. as well as therigid construal of interpersonal relationshipsthat underlies these pattems. Such exploration6rst requires the therapist to disclose, in anopen and nondefensive manner, his or her re-action to what transpired in the relationship,such as saying U[ feel pushed away, when youdon't answer my questions." [n some cases, thetherapist self-disclosure immediately leads cIi-ents to being open to their own emotional ex-

Exploring and ChangingInterpersonal Functioning

Early in the [IEP segment, the task of the ther-apist is to get a sense of the clients' interper-sonal history. Open-ended questions about r~)ationships with past and current significantothers are aimed at providing the therapist with

liE?

[/EP has been added to CBT so that therapistscan address the clients' problematic relation-ships and facilitate emotional deepening. Brieflyput, the goals pursued in this segment are tofacilitate clients' identification of interpersonalneeds, fears, and schemas and to help themdevelop behaviors that will better satisfy theirpersonal needs. Though the focus of interven-tions and the techniques used differ fromCBT, the general goal is the same. Essentially,therapists attempt to help clients to live in thepresent-to focus on their immediate experi-ence with others. Rather than paying attentionto the past or the future (the bad things thathappened and/or could happen), clients learnto focus on what they currently want from oth-ers, as well as on what others want from them.A greater awareness of their contributions tomaladaptive patterns of relating and the acqui-sition of new social skills will also help clientsto reduce their negative impact on others.

As in the CBT segment, [IEP directly tar-gets the CAD clients' tendency to avoid. Cli-ents are encouraged to expose themselves tofeared emotions, feared critical feedback abouttheir impact on others, and their fear of beingvulnerable to other people by showing whothey really are. By trying things that may helpthem confront their immediate fear, clients be-come aware of how their avoidance of negativeemotions in the short term comes at a greatcost in terms of a restricted lifestyle in whichtheir needs are not mel in the long term. Thetherapist also helps clients to shift their atten-tiona! focus away from danger anticipation andtoward openness, spontaneity, and vulnerabil-ity with others as weU as toward a greater em-pathic attention to the needs of others.


perience. With our CAD clients, however, wehave rarely observed such an ability or willing-ness to be vulnerable with another person.What is typically required is gentle but re-peated invitations for the client to identify, ex-perience, and express emotions triggered bythe therapist's self-disclosure and/or the eventthat preceded it. The therapists' role is then toempathize with and validate the affective expe-riences expressed by the client, as well as toshare his or her own reactions to the client'sself-disclosures, such as saying "Of course, youwould want to avoid a topic that made you un-comfortable. However, not answering my ques-tion also has an impact on me and makes mefeel as though what I am asking for isn't impor-tant." Therapists are also encouraged to ob-serve and communicate whether clients' re-sponses to their openness help them feelunderstood by clients.

When used with warmth and support, theseinterventions can help the client becomeaware of his or her impact on another person.In addition, such an exploration of the thera-peutic relationship allows the therapist tomodel an open communication style. By dis-confirming the validity of the client cognitive-interpersonal schema (i.e., "It is dangerous toopenly communicate with others), this way ofworking with the therapeutic relationship-ofmetacommunicating (Kiesler, 1996) -can pro-vide the client with a unique corrective experi-ence (Alexander & French, 1946; Coldfried,1(80).

Similar techniques of metacomffiunicationare also used in IIEP to repair alliance rup-tures. In fact, the enactment of client interper-sonal schema during sessions, as when the cli-ent walls off the therapist or pulls for his or herhostility, will at times create alliance ruptures.This, however, in no way suggests that clientsare always responsible for alliance problems.Such alliance tears can be caused or exacer-bated by the therapist's less than adequate levelof engagement, attention, empathy, warmth,tact, or attunement to the client needs. Thetherapist may frustrate the client's desire to behelped by not using the most appropriate tech-nique, by failing to use competently a perfectlyadequate intervention, or by being blinded by

his or her own interpersonal schema (avoidingcore therapeutic issues because of his or herown fears of hurting the client or being hurtby outbursts of anger). From a cognitive-inter_personal perspective (Safran & Segal, 1990),alliance ruptures are events that can be ex-pected when two individuals are involved in acomplex, demanding, and emotionally mean-ingful relationship such as therapy.

Accordingly, our therapists are trained torecognize markers of alliance ruptures, such ascI ients' overt expressions of dissatisfaction, indi-rect expressions of hostility, disagreements aboutthe goals or tasks of therapy, overly compliantbehavior, evasive behavior, and self-esteem-boosting maneuvers (Safran, Crocker, McMain,& Murray, 1990). Therapists are asked to at-tend to markers of alliance ruptures duringboth the CBT and UEP segments, but thesemarkers can only be addressed during the llEPsegment because, for our additive design study,the protocols could not allow therapeutic workon interpersonal behaviors during CBT seg-ments.

Based on the contributions of Bums (1989)and Safran (Safran & Segal, 1(90), attemptsare made to repair the alliance by followingthree steps. First, therapists invite clients to talkabout their negative reactions (e.g., UI have asense that you aren't as engaged as you havebeen in other sessions. Is that how you are feel-ing?"). Second, the therapist empathizes withthe client's perception and emotions and in-vites him or her to express additional emotionsand thoughts about what was unhelpful or in-validating in the treatment. When the therapisthas the sense that the client feels understood,the therapist should then recognize and com·ment on his or her own contribution to theirrelationship difficulty. This last step, elegantlycaptured by Bums (1989) as a "disarming"technique, requires the therapist to find sometruth in the client's reaction, even when thereaction may seem unreasonable. The use ofthis technique is based on the assumption thatthe therapist has invariably contributed insome way to the lack of synchrony between cli-ent and therapist. It is also based on the as-sumption that the therapist's openness to his orher experiences can lead to the client's open-

J


ness to his or her experience, which may intum help them to exit an unproductive cul-de-sac in their relationship (Castonguay, 1996).

Contrary to the client's expectation, he orshe learns that being emotionally vulnerablecan lead to stronger and safer relationships.The client also learns that when "living in themoment" (such as when experiencing and ex-ploring in an emotionally immediate way whatis taking place in a relationship), he or sheceases to pay attention to the past and the fu-ture. Worries and ruminations dissipate as onebecomes real and present with others.

In addition to paying attention to the thera-peutic relationship, therapists also help clientsto draw links between interaction pattems ob-served in the session and patterns in clients'past or current relationships with significantothers. Therapists, however, are reminded thatsuch connections are sometimes drawn (by theclient or themselves) as a way to avoid process-ing negative events taking place in the thera-peutic relationship. Such defensive maneuversmay prevent the client From fully experiencinghis or her emotions and further reinforce long-standing avoidance strategies (e.g., intellectual-izing or "staying in his or her head" as opposedto being open and vulnerable with another per-son). When part of an emotionally immediateexploration of the client's experience, however,such connections with outside interpersonalevents frequently helps clients gain a deeperawareness of their rigid constructions of rela-tionships and maladaptive ways of relating withothers.

Therapists also ask clients to monitor andrecord events taking place between sessionswith significant others. Specifically, clients areasked to describe specific interactions and totake note of the emotions they felt during theseinteractions, what they wanted and feared Fromthe other person, what they did, and what hap-pened next. Such functional analyses of intra-personal and interpersonal factors Frequentlyhelps clients to identify what they need andwhat they actually get from others (McCul-lough, 2005). In particular, these analyses re-veal the negative impacts that some of the cli-ent's behaviors have on others. When indicated,behavioral strategies (e.g., social skills training)

are then used to teach clients better ways tosatisfy their interpersonal needs.

Facilitating Emotional Deepening

In the IIEP segment, helping the client to ex-perience, deepen, and express his or her emo-tion is aimed in part at extinguishing fear andavoidance (including worry as a cognitive avoid-ance response) of emotion. As mentioned above,basic research has suggested that when individ-uals with CAD worry, they do so in part toavoid painful events (future bad outcomes ordistressing emotions). As such, worry is main-tained, at least in part, by its negative reinforce-ment quality (e.g., suppression of somatic as-pects of anxiety or the eventual nonoccurrenceoflow-probability, but feared, negative events).By exposing the client to his or her emotionalexperience, he or she leams that althoughsome emotions can be painful, they are notdangerous (e.g., sadness and anger over anoth-er's betrayal). As such, the safety of the thera-peutic relationship provides clients with yetanother unique opportunity for corrective ex-periences. Indeed, if the experience with andexploration of feeling repeatedly fails to be in-tolerable, they learn that there is nothing tofear From their emotional experience. Andwhen there is nothing to fear, there is no rea-son to avoid. Worry, as a consequence, loses itsreinforcing impact, and clients begin to gainaccess to primary affects that can motivate anddirect adaptive behaviors, as described below.

Emotions are an important source of infor-mation for what we need in life. As such, emo-tional deepening is also used in lIEF to helpclients better understand what they need fromothers. Guided by the work of Greenberg andhis colleagues (Greenberg, Rice, & Elliott, 1996;Greenberg & Safran, 1987), therapists aretrained to track markers of emotionality in or-der to decide when to use techniques aimed atdeepening feelings. Examples of such markersare changes in voice quality, the sound of tearsin the voice, and a slowing or quickening ofconversational pace. When such markers arenoted, clients are encouraged to stay with theiremotions and to allow themselves to fully expe-rience them. Therapists also pay attention to

254 Integrative Psychothprapy Models

moments of emotional disruption or disengage-ment. When clients stop emoting and/or beingattentive to their affective experience, thera-pists invite them to focus on their immediateexperience. For example. "What just hap-pened? You were allowing yourself to cry, andyou quickly moved away from your feeling."

When markers of a sel{4Naluative split-internal conflict experienced by clients-areobserved, clients are invited to take part in atwo-chair exercise. In the exercise, clientsdistinguish the two parts of themselves-asthough they were two separate people-andthen embody each one separately and repeat-edly as one part speaks to the other until clientshave gained greater insight into their feelingsand their own needs in the internal conflict.

In contrast, markers of unfinished busi-ness-unresolved feelings toward another per-son-are dealt within an empty-chair exercise.Here, the client expresses his or her feelingswhile imagining another person sitting acrossin an empty chair.

The technique of "systematic evocative un-folding" (Greenberg et aI., 1996) is also usedto address markers of problematic reactions-when clients experience surprise or confusionabout one of their own reactions. Clients areasked to close their eyes and imagine them-selves back in the situation that evoked the reoaction and play the scene in slow motion intheir imagination. They are asked to vividly re-member every aspect of the scene, describe indetail the events and their feelings during thesituation, and to pay attention to every internalcue as they repeatedly describe the situation.By reexperiencing fine-grained details andtheir reactions to them, clients can better ex-press and own the emotions that first surprisedthem, as well as gain access to previously im-plicit emotions.

Therapists also encourage clients to focuson and own their emotions as they go on intheir day-to-<lay lives. It is indeed important tohelp clients generalize the corrective experi-ences of expressing feelings in the safe environ-ment of the therapy session to interpersonalrelationships outside of therapy. Continued at-tention to clients' experience and behavior inthe real world may well be crucial to help

them overcome their fear of vulnerability andachieve a lasting change in their habitualavoidance of emotion.

CASE EXAMPLE

The following case was chosen because it illus-trates the major thrust of our integrative treat-ment. It demonstrates how the addition of spe-cific techniques to CBT allows therapists to workwith material not directly or adequately addressedin traditional CBT. As such, the case descriptionwill mostly focus on the IIEP segment of thetherapy.

Wendy was a White undergraduate seenwithin the context of a National Institute of Men-Ial Health (NIMH)-funded study aimed at provid-ing preliminary evidence for the feasibility andimpact of our integrative CBT+I/EPtreatment forGAD (this study is presented in more detail in thenext section). Although Wendy's primary diagno-sis was GAD, she was also diagnosed with co-morbid social phobia, obsessive compulsive dis-order, and a specific phobia. She reported thatshe had previously sought psychotherapy for aninterpersonal problem and that this therapy lasted2 months. She was not currently taking any medi-cations nor had she taken any psychiatric medi-cations in the past. In terms of her GAD symp-toms, she reported that the current bout of GADhad been chronically ongoing for 7 years. She re-ported that she was not aware of any formal diag-noses of mental health problems in her immedi-ate family but that she would characterize hermother as a worrier.

Wendy was treated by a White male psychol-ogist, who was primarily trained in CBT. In addi-tion to his full-time private practice, the therapisthad served as a protocol therapist in several pre-vious CBT studies.

Wendy felt very comfortable during the CBTsegment. She took the therapist's directives toheart and actively complied with the therapeutictasks prescribed during and between sessions. Onthe other hand, the IIEPsegment was much moredifficult for her, at least initially, She was reluc-tant to reveal herself, expressing minimal emotionand. when she did, only in response to the thera-

Cognitive-Behavioral Assimilative Integration 25S

pist's persistent requests. Although she wanted toplease the therapist, he felt discounted by herlack of authentic interpersonal and emotional be-havior toward him, probably due to her fear ofbeing vulnerable. Though she tried hard to under-stand and follow the therapist's instructions (asthe perfect client that she wanted to be-and feltthat she could be in CaD, the therapist did notfeel that she wanted to connect with him or allowherself to be emotionally close during the I/EPsegment.

What was happening during therapy paral-leled what had been taking place in Wendy's in-terpersonal relationships. Early on in IIEP, she re-ported that she felt that she had to be perfect withothers. Her view of relationships was that she feltobligated to take care of others' happiness. Notsurprisingly, she felt burdened by what she per-ceived to be the expectations of others, becameangry when friends asked her to socialize be-cause it was taking time away from her studies,and frequently avoided being with them.

As therapy progressed, it became clear thatshe had a hard time being empathic to others. Inpart, because her attention was on her own be-havior (her attempt to please others), she did notfully listen to others. She was so focused on herfear of failure in meeting their needs that she hadlittle energy left to listen to the needs they actu-ally expressed. She thus found herself trapped inan unfortunate paradox: She spent so much timetrying to do everything for others that she feetburdened by others and thus discarded them.

At the same time she was surprised to learnthat she did not meet their needs. For example,when she asked the therapist after several ses-sions whether he liked her, she was quite sur-prised by his reply that he did not know whetherhe liked her or not, because he had not yet reallymet the real her. She thought that she was doingeverything he wanted her to do, including self-disclosing.

Shewas also expecting important others in herlife, including her boyfriend, to have a similarview of relationships. Specifically, she expectedothers to be vigilant and attentive to her needs.She expressed considerable frustration at the factthat her boyfriend was not always anticipatingwhat she wanted from him. As therapy helped herto focus on her interpersonal needs, she became

aware that she had difficulty being spontaneouswith others. One of her first realizations was thatshe felt angry at others. This led her to be moreassertive with her boyfriend, but it also made itmore difficult for her to be vulnerable, as well asto be attentive to his needs.

Her interactions with her boyfriend led thetherapist to focus on her impact on others, includ-ing on the therapist himself, which in turn led herto become more emotionally expressive. The ther-apist then used emotional deepening techniquesto explore the origins of her fear of being vulnera-ble with others. Specifically, the therapist used asystematic evocation technique and allowed herto reexperience her feeling of being betrayed byanother person when she was in high school. Thisincident appeared to play an important role in herfear of trusting others, of letting her guard down,of being herself, of not worrying about (and there-fore being burden by) others. The use of an emptychair (where she expressed her feeling of beingbetrayed and hurt) in the same session allowedher to become aware that the price paid for notbeing herself was social isolation, loneliness, andsadness. She realized that she had missed her pre-vious connection with others.

At the same time, she was genUinely surprisedby the therapist's acceptance of her tears and sad-ness (of her vulnerability) expressed during theevocation of these memories; Nyou like me whenI'm like this, reallyl This is what you were lookingforI" Because the therapist's reaction to her firstauthentic emotional reaction in therapy was op-posite to what she expected, it led to a significantcorrective emotional experience.

In the following sessions, the client becamemore emotionally present, displayed a wider rangeof and more intense emotions, and began makingnumerous and adaptive changes in the way shewas relating to others outside of therapy.

Wendy has now been followed up 2 yearsafter therapy was completed. At pretherapy, herassessor severity level was 6 and by follow-up itwas 1. Also, the client demonstrated clinicallysignificant change and high endstate functioning(Le., her score was within the range of a normativesample) on 6 of the 6 measures of GAD-associatedsymptoms (e.g., self-reported worry, self-reportedtrait anxiety, self-reported relaxation-induced anxi-ety, assessor-rated severity of GAD, observer-rated


anxiety symptoms, and self-reported diary mea-sure of worry), demonstrating that she showed atleast 20% change and was within the range of anormative sample on all measures.

EMPIRICAL RESEARCH

Our integrative treatment for GAD has beenthe object of two NIMH-funded clinical trials.The first was a preliminary study aimed at de-termining whether it could be implementedand if it outcome would suggest possible im-provement over traditional CBT for GAD.

Eighteen adults meeting DSM-N criteriafor CAD received the CBT +IIEP describedabove. The treatment was delivered by threeexperienced therapists (one originally trainedin CBT and two primarily !rained as psychody-namic therapists). Numerous process findingsand adherence checks suggested that what tookplace during each segment of therapy was con-sistent with the treatment manuals. An observer-rated measure of the therapist interventions, forexample, showed that although therapists fo-cused more on interpersonal issues (e.g., inter-personal pattern, general interactions with oth-ers) in llEP than in CBT, they focused moreon intrapersonal issues (e.g_, the link betweendifferent aspect of functioning such as the im-pact of thoughts on feelings) in CBT than inlIE? (Castonguay et aI., 2002). Also as pre-dicted, both clients and therapists reportedtalking more about interpersonal matters suchas the client's family and significant relation-ships in UEP than in CBT, whereas talkingmore about matters related to work and anxietytriggers in CBT than in llEP (Castonguay,Schut, Newman, & Borkovec, 1999). In addi-tion, both self-report (client and therapist) and·observe-measures showed that, as predicted,higher levels of negative emotions (e.g., sad-ness) were found in llEP. For a number of pos-itive emotions (e.g_, confidence, joy), however,higher levels of intensity were found in CBT(Castonguay, Schut, Newman, & Borkoveck,1999; Castonguay et aI., 2001), which is consis-tent with its focus on building skills and in-creasing self-efficacy.

Although tentative, the outcome findingsobtained in this open trial were promising. Theeffect sizes (reflecting differences between pre-treatment and post-treatment outcome mea-sures) indeed appeared to be superior to thoseobtained by previous studies conducted withtraditional CBT. In fact, whereas the averagewithin participant effect size from previousCBT studies was 2.44, our pilot study obtaineda 3.5 effect size (Newman, Castonguay & Bor-kovec, 2002).

Based on these preliminary findings, wehave embarked on a randomized clinical trial.When completed, more than 70 GAD clientswill have been assigned to either CBT +IIEP orCBT +SL. The use of such an additive designwill permit us to determine specificallywhether the addition of specific components(interpersonal focus and emotional deepeningtechniques) will lead to an improved outcomeover traditional CBT package. Our early resultssuggest that lIE? does show some added bene-fit at 2-year follow-up with a significantly greaterpercentage of participants receiving the inte-grative therapy demonstrating high endstatefunctioning when compared to the CBTISLcondition (Newman, Castonguay, & Borkovec,2002).

We have also conducted a preliminary out-come study on an integrative treatment for de-pression which we called integrative cognitivetherapy (lCT; Castonguay et aI., 2004). Here,only one of the components of the llEP pack-age was added to a traditional form of CBT.Specifically, alliance ruptures were addressedin cognitive therapy (CT) by using techniquesdescribed by Bums (1989) and Safran & Segal(1990). Although the integrative treatment wasconducted by inexperienced therapists (gradu-ate students), the findings showed that it wassuperior to a waiting-list condition. As a whole,the findings also compared favorably withfindings of previous results obtained with tradi-tional CT. The effect size obtained for theBeck Depressive Inventory (Beck, Ward, Men-delson, Mock, & Erbaugh, 1961), for example,was more than twice that estimated in a meta-analysis of control studies comparing CT andwait-list or placebo condition (Gloaguen, Cot-traux, Cucherat, & Blackburn, 1998). Because


of its small N and the absence of a direct com-parison with a traditional CT, however, thesefindings should be considered very cautiously.

FUTURE DIRECTIONS

We hope to expand our research program in anumber of scientifically and clinically impor-tant directions. Based on preliminary analysesconducted on the current CAD trial, we havesubmitted a research proposal for a study in-vestigating the impact of our integrative treat-ment at different sites and with more diverseethnic clients. It is indeed important to deter-mine whether potential improvement of theefficacy of CBT for GAD can be generalized10 different treatment environments and di-verse clinical populations. We also hope toeventually conduct investigations in more nat-uralistic settings in order to investigate the ef-fectiveness of our protocol. Directly relevant toeffectiveness is the question of whether itwould be possible and advantageous to com-bine the techniques involved in the integrativetreatment within the same sessions-as opposedto dividing them into different segments· oftherapy sessions.

We are also interested in determiningwhether the treatment developed for GAD canbe applied successfully to other clinical prob-lems. Depression, for instance, is likely to bean appropriate target, as many of the processfindings and theoretical arguments that guidedour selection of the techniques to be added totraditional CBT emerged from the depressionliterature.

Much more research should be done on theless comprehensive protocol that we have be-gun to test on depression. Several other stud-ies-with large sample sizes, conducted at dif-ferent sites, and involving direct comparisonsbetween ICT and CT -are required before itcan be confidentially asserted that adding tech-niques to repair alliance ruptures improves theefficacy of cognitive therapy for depression. Aswith the protocol for GAD, future researchshould not be restricted to efficacy studies.Funding is currently being pursued by mem-bers of our team to determine if training thera-

pists to use alliance repair techniques in theirday-to-day practice (irrespective of their theo-retical orientation and across a variety of clini-cal populations) can improve their effectiveness.

Finally, we hope to continue using our clin-ical experience, the progress made in the theo-retical and empirical literature, as well as theresults of our current and future research tocontinue to develop and test treatment meth-ods that might improve CBT, as well as to pro-vide heuristics for the potential improvementof other treatment approaches.

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