266 Integrative Psychotherapies for Specific Disorders and Populations expectation of catastrophe to the self is self- ries of such painful experiences. The person fears both the meanings of these painful self-endangerment. At a conscious level, self-endan- germent is characterized by a sense of losing views and the accompanying emotions such as humiliation, rage, and despair. The woundscontrol, lacking safety, and feeling powerless. When one becomes anxious, there is typi- are mostly unconscious but are nevertheless in- fluential in determining the person’s decisions,cally an automatic shift of attention to a more perceptually distant focus on the self as anxious, feelings, and actions. There are basically three nodes to an anxi-accompanied by cogitation about the implica- tions of being anxious. Cogitation typically in- ety disorder: (a) the immediate experience of the anxiety or panic; (b) cogitating about thecreases the level of anxiety. Thus, a self-endan- germent experience involves both the immediate implications of being anxious; and (c) the im- plicit meaning of the anxiety or panic attack.anxiety and cogitation about its implications. Because of this automatic shift of attention, The external and internal cues that provoke anxiety are developed through the perceptionthe individual cannot discover the implicit or preconscious meaning of the anxiety. The im- of relationships between certain life experi- ences and intense fear. That is, certain experi-plicit meaning of self-endangerment is that one anticipates a confrontation with an excru- ences are perceived as self-endangering. The cues themselves often function as abbreviatedciatingly painful view of the self. I call these unbeara bl y painful se lf-perce pt ion s self-wounds. shorthand for the painful memory that exists beyond the individual’s conscious awareness.I use the metaphor of wounds because of the pain that is experienced when they are ex- The feared catastrophes that are signaled by the sense of self-endangerment relate to bothposed. For persons suffering from an anxiety disorder, wounds to the self generate a chronic physical and psychological survival. Physical fears include the fear of dying, paralysis, orstruggle with their own subjective experience. In other words, their immediate experience physical breakdown. Psychological fears in- clude the fear of being unlovable, unworthy,feels dangerous. Figure 12.1 provides a sche- matic model of anxiety disorders. unacceptable, inadequate, abandoned, isolated, rejected, weak, pathetic, humiliated, domi-Self-wounds are basically organized struc- tures of painful self-related experience—or nated, or controlled. In addition, there is dread associated with the pending loss or destructiongeneralizations of such painful experience— that are stored in memory. These wounds may of one’s meaning in life. The content of the unconscious conflicts in-be known directly as a damaged sense of self or known conceptually as beliefs and propositions volve the wounded self struggling with the “on- tological givens” in life; that is, the unavoid-about the self. These painful self-views may be specific memories that a person has experi- able human realities we all must face. These conflicts frequently concern how much free-enced with a significant other or may represent a generalized self-view constructed out of a se- dom versus how much security one wants to Automatic shift of attention to Increases anxiety symptoms Implicit meaning of anxiety symptoms ReinforcesGenerates Cogitation Anxiety symptoms FIGURE 12.1 Schematic Model of Anxiety Disorder Integrative Psychotherapy of the Anxiety Disorders 267 have in one’s life; acceptance versus denial of underlying maladaptive self-beliefs. Psycholog- ical defenses in this model serve as self-defeat-one’s mortality; how much to trust people in one’s life; acceptance of personal responsibility ing efforts to protect one’s self-image. for one’s thoughts, feelings, and actions; and acceptance of the inevitability of the loss—of Maintenance of an loved ones, relationships, careers, and physical Anxiety Disorder capabilities. All of these views suggest a perception of A number of cognitive and emotional pro- cesses automatically spring into action to pro-self as one who cannot cope with—and there- fore needs protection from—the rigors and re- tect the self-wound from exposure. Instead of confronting the self-wound head-on, anxietyalities of everyday living. Because these realities are unavoidable, the anxious individual must patients typically engage in strategies designed to keep them hidden from one’s self and fromcreate indirect strategies for coping with these realities that protect them from intolerable emo- others. There are three categories of strategies that anxiety patients typically employ: (a) cogi-tions while at the same time keep them from facing these realities head on. Such strategies tation, (b) avoidance, and (c) negative cycles of interpersonal behavior. These strategies orrange from behavioral avoidance to cognitive ritual to emotional constriction; they usually psychological defenses us ually produce untended interpersonal consequences that have the para-produce unintended interpersonal consequences that have the paradoxical effect of reinforcing doxical effect of reinforcing the patient’s pain- ful core beliefs about the self (i.e., self-wounds).the patient’s core beliefs about the self. When we observe the consequences of these self-image protective strategies, we see that the Development of an wound analogy breaks down, because these Anxiety Disorder protective processes do not allow the self- wound to heal, but rather guarantee that theyAlthough this model acknowledges that certain patients may have a genetically transmitted will not heal. Unhealed self-wounds are the primary reason for the maintenance or contin-predisposition for developing an anxiety disor- der, the bulk of the causative weight is placed uation of an anxiety disorder. on the patients’ damaging life experiences, the self-wounds that those experiences generate, Integrative Model Applied and the ineffective “protective strategies” that to Specific Anxiety Disorders are employed to prevent the exposure of those wounds. These damaging experiences stem This integrative etiological model is applicable to all anxiety disorders. The details, however,from a variety of sources, including traumatic experiences, shaming or toxic ideas, betrayals shift slightly from disorder to disorder. Space limitations allow only a brief description of theby significant others, emotional miseducation, and ineffectual responses to the realities of or- model for two separate anxiety disorders: social phobia and panic disorder.dinary living. In our field’s drift toward a more biomedical view of mental illnesses, the extent Social phobias develop in a matrix of de- structive hypercriticism from primary caregiv-of damaging life experiences and their role in the generation of emotional disorders have ers. When individuals are severely criticized for revealing a vulnerability or weakness, theybeen seriously underestimated. In response to the initial anxiety, patients are likely to internalize toxic opinions of the self. Typically, these opinions suggest that indi-typically engage in cogitating about being anx- ious (i.e., self-preoccupation), avoiding the viduals are defective or inferior. These opin- ions produce self-wounds, which are character-fear-inducing objects and situations, and/or en- gaging in negative interpersonal cycles. These ized by feared self-appraisals that they are socially inadequate, unlovable, or unworthy. Asstrategies result in the temporary reduction of anxiety and the reinforcement of the patient’s a result, social situations and public-speaking 268 Integrative Psychotherapies for Specific Disorders and Populations opportunities produce the experience of self- the panic attacks, the individual, associating the location of a panic attack with its cause,endangerment. The associated anxiety protects the individual from painful feelings of inade- begins to avoid the panic locations. This pro- cess can become so extensive that the personquacy. The extreme humiliation is unbearable and is thus avoided by experiencing the panic/ may become housebound. Panic disorder is maintained by agorapho-anxiety instead. The anxiety or panic leads to an automatic shift of attention to a preoccupa- bic avoidance, the continuation of the un- healed self-wounds, and the inability to experi-tion with one’s social limitations and with the imagined rejection from a hostile or disdaining ence the implicit meanings of the panic attack. As with other anxiety disorders, panic patientsaud ience. This self-preoccupation de grades social performance, and the vicious circle is then com- cannot tolerate the experience of certain pain- ful emotions. In my experience, the emotionspleted w he n the d egr ad ed social performanc e reinforces the feared negative self-appraisals. that panic patients seek to avoid at all costs in- clude anger/rage and humiliation/shame.The disord er i s basi ca lly maintained by three separat e processes: (1) the self-diminish in g opin- ions (i.e., self-wounds), (2) avoidance of social occasions or public speaking engagements, and INTEGRATIVE TREATMENT MODEL (3) impression management, which involves be- having in ways that patients believe will bring Since the publication of this chapter in the ear- lier edition of the Handbook, my treatmentthem approbation from others. The difficulty with impression management strategies is that model has moved closer to a more seamless integration. The treatment attempts to synthe-the behavior feels inauthentic. Typically, social phobics fear several interre- size elements of psychodynamic, behavioral, cognitive-behavioral, and experiential thera-lated catastrophes, including being exposed as a fraud or imposter, being unacceptable or in- pies. The model defines ultimate and interme- diary treatment goals. The core intermediaryferior, being rejected, and losing status. Social phobics also fear the associated emotions of goal is the reduction or resolution of the symp- toms of an anxiety disorder. The achievementshame and humiliation. Panic disorder with or without agoraphobia of this goal is a necessary prelude to the ulti- mate goal of healing the self-wounds that pre-is rooted in an unconscious self-wound. Pa- tients suffering with panic disorder and agora- sumably generate the anxiety symptoms. There are a number of subsidiary goals associatedphobia learn early on that it is dangerous to live autonomously in an unsafe world. They with this healing process, including (1) en- hancing the individua l’s sense of agency or s e lf-secretly believe that they cannot cope with life’s unavoidable realities. Although the feared efficacy, (2) increasing the individual’s toler- ance for emotional experience, particularlycatastrophes vary from person to person, they generally concern the inability to accept such negative affects, (3) identifying and modifying the various cognitive and affective defensesontological givens as death, loss, increased re- sponsibilities, intense negative emotions, au- erected against emotional experience, (4) re- structuring toxic views of the self, and (5) in-tonomy, and interdependence. Past self-endan- germent experiences, however, have been creasing the patient’s ability to engage in au- thentic relationships.“zipped” and are now unconscious except for a somatic trace of the original experience. These The reduction of anxiety symptoms neces- sarily involves an increasing ability to toleratesomatic traces (i.e., bodily sensations of anxi- ety) lead to an automatic shift of attention to painful affects. This is achieved through a painstaking focus on the individual’s direct, in-cogitating about the implications of these sen- sations, which, in turn, produces more anxiety. the-moment experience. Once the patient has achieved a sense of control over the anxietyThis process may spiral upward until the pa- tient has a panic attack. In an effort to control symptoms, he or she is invited to explore the Integrative Psychotherapy of the Anxiety Disorders 269 underlying determinants of the anxiety symp- tant fears of disappointment, the patient may find it difficult to acknowledge and accept thetoms. therapist’s care and concern. Part of the alli- ance-building phase of therapy will identify the Phase I: Establishing various strategies by which the patient inter- the Therapeutic Alliance rupts his or her immediate experience of the therapist’s trustworthiness. As these defensesThis integrative treatment conceptualizes the treatment process in terms of four phases (Wolfe are identified and found to be inapplicable in the current context, the patient may begin to& Sigl, 1998). Phase I involves establishing the therapeutic alliance. Therapy with anxious pa- experience and “take in” the therapist’s trust- worthiness. The resurrection of immediate ex-tients is often characterized by a difficult be- ginning because of their self-protecting inter- periencing will begin to lead to a corrective emotional experience regarding the depend-personal style. The life histories of anxiety disorder patients are replete with experiences ability of a significant other. The direct experiencing of the therapist’sof betrayal, empathic failures, mistreatment, and difficulties with attachment. Thus, the ne- trustworthiness indirectly contributes to the re- building of the patient’s sense of self-efficacy.gotiation of trust is typically the first task of therapy. From the first session onward, the With the therapist as ally, the patient feels more confident of his or her ability to face thetherapist will typically encounter fears of trust- ing, humiliation, and of being known. The anxiety-inducing objects or situations and to endure the automatically occurring anxiety.process of repairing the wounded self begins here by attempting to enhance the client’s abil- The provision of a safe relationship that is em- pathic, genuine, and nonjudgmental serves asity to trust both the therapist and him or her- self, and with desensitizing the client’s fear of a therapeutic bulwark against which the pa- tient leans as he or she negotiates the specificbeing known. A frequently occurring phobogenic conflict therapy tasks (Rogers, 1957). in agoraphobic patients, for example, involves the bipolar dimension of freedom versus secu- Phase II: Treating the Symptoms rity. Each pole possesses both a positive and a of an Anxiety Disorder negative valence. Freedom connotes autonomy and isolation; security connotes being cared for By the third or fourth session—although there are many instances where it may take longer—and being controlled. With such patients, ther- apists will be called upon to pass specific tests most clients suffering with an anxiety disorder are ready to begin phase II, which focuses onof trustworthiness (Friedman, 1985; Weiss & Sampson, 1986). Can therapists care for with- the symptom layer of the disorder, including the bodily symptoms of anxiety and the obses-out controlling agoraphobic patients? By the same token, can therapists allow patients to sive catastrophic cogitating about the symp- toms. The primary focus of this phase is to helpfunction autonomously without abandoning them? Unless therapists pass such tests, agora- the patient achieve some measure of control over the symptoms of an anxiety disorder. Cog-phobic patients cannot make use of any of the therapeutic techniques and tasks, including nitive-behavior interventions are in the ascen- dancy during this phase. Relaxation strategies,imaginal or in vivo exposure. The first thera- peutic task, then, is for therapists to establish exposure to fear stimuli, and the cognitive re- structuring of conscious catastrophic thoughtstheir trustworthiness, and for patients to receive this trustworthiness. surrounding the fear stimuli are the primary interventions during this phase of treatment.To the extent that the therapist is being trustworthy, he or she is providing the patient It is extremely important to monitor the state of the therapeutic alliance as the patientwith important information to be assimilated. But because of past disillusionments and resul- begins to carry out the phase II interventions. 270 Integrative Psychotherapies for Specific Disorders and Populations The introduction and implementation of these patient is subsequently instructed to focus all of his or her attention on the anxiety-inducingtherapy techniques possess meaning for the pa- tient in terms of his or her feelings toward the cue and simply to notice whatever thoughts, feelings, or images appear. In the case of pho-therapist. If they are presented in an authoritar- ian manner, for example, the patient may rebel bias, the patient is asked to imagine the phobic object or situation. In the case of panic disor-either directly or implicitly and may refuse to carry out the treatment or terminate it prema- der, the patient is asked to identify the most prominent bodily sites of anxiety or fearfulturely. The patient may resist the treatment be- cause its nature or manner of presentation acti- bodily sensations and to maintain a strict atten- tional focus on these sites. For OCD patients,vates unconscious conflicts regarding authori ty. Sometimes the conflict may be conscious. I the strict attentional focus is on the obsessive thought that is causing anxiety. Typically,once treated a patient suffering with obsessive- compulsive disorder (OCD) by presenting him within one or two sessions, this procedure re- sults in the appearance of several thematicallywith a self-initiated program of exposure plus response prevention. Two weeks in a row he related and emotionally laden images. It usu- ally takes longer with panic-disorder patientsreturned to therapy without having started the program. When I asked him why he had not because they have great difficulty contacting emotion-laden imagery. Despite this, however,been able to carry out the potentially helpful therapy, his reply was as follows: “I cannot the procedure is almost uniformly successful in eliciting the catastrophic imagery reflecting astand to be told what to do by a male authority figure.” This revelation not only uncovered a specific self-wound. The imagery is imbued with themes of con-potential rupture in the therapeutic alliance but also led to a temporary shift in therapeutic flict and catastrophe that the patient is helpless to prevent or terminate. These memories offocus to the exploration of his painful relation- ship with his caustically critical father. self-endangerment reflect specific self-wounds. For example, memories of parental betrayal may shape a painful view of oneself as un- Phase III: Eliciting the Tacit wanted, unlovable, or unworthy, which in turn Self-Wounds produces fears of abandonment. These memo- ries are usually accompanied by powerful andOnce an anxiety patient achieves some mea- sure of control over his or her anxiety symp- painful emotions, which also become fear stimuli.toms, the therapy is at a decision-point. For some patients, the therapy is complete. They This technique often segues into a guided- imagery procedure that allows us to explore thehave received what they came for and are ready to terminate the therapy. Many other pa- network of interconnected ideas, feelings, and associations that constitute the implicit mean-tients, however, wish to explore the roots of their anxiety and are willing to undergo a shift ing of anxiety. One interesting feature of applying this pro-in therapeutic focus and technique. The thera- peutic goal of phase III is to elicit the tacit self- cedure with panic disorder patients is that where- as, consciously, their fears are often about physi-wounds and the feared catastrophes and emo- tions associated with them. The major technique cal destruction, the tacit catastrophic imagery is most often about psychological destruction.employed during phase III is Wolfe’s Focusing Technique, a form of imaginal exposure (Wolfe The goals of the modified imaginal exposure depart somewhat from the original behavioral& Sigl, 1998). The patient is first told to relax and to en- version. The experience of anxiety is not only for the purpose of learning that the feared di-gage in the previously taught diaphragmatic breathing for about 2 minutes. During this in- saster will not take place or that the anxiety will habituate but also for the patient to uncoverduction process, the patient is primed to allow him or her to be open to whatever thoughts the underlying self-wound and its associated felt catastrophes.or feelings may arise during the exercise. The Integrative Psychotherapy of the Anxiety Disorders 271 Though Wolfe’s focusing and guided imag- The enhancement of the patient’s self-effi- cacy actually begins with phase II, the symp-ery are the major techniques for eliciting self- wounds, they also may be elicited on occasion tomatic treatment phase. By achieving some control over their anxiety symptoms, patientsthrough interpretive insight-oriented techniques. Socratic questioning has also being successful, begin to feel more confident and hopeful not only about “beating their disorder” but alsoon occasion, in pursuing a fear to its ultimate catastrophic end, which will reveal the specific about solving the basic difficulties of their lives. That sel f-efficacy in cr eas es as t he y be gin to allowself-wound in question. Whether one initially employs imagery, interpretation, or question- themselves to experience and accept their tacit fears and disavowed emotions.ing depends on what is determined to be the most acceptable or congenial access point for Often, the imagery work will uncover tacit catastrophic conflicts to be resolved. Conflictthe patient. Some patients are most comfort- able beginning with behavioral techniques; resolution essentially involves the creation of a synthes is between incompat ibl e aims. The stepsothers prefer more cognitive interventions to start with; still others prefer insight-oriented involved in resolving conflict include (a) iden- tifying the poles of the conflict, (b) employinginitial work. In rare instances, patients begin with experiential or imagery-based interven- the two-chair technique in order to heighten the experience of each pole, (c) beginning ations. dialogue between the two poles in an effort to create a synthesis, and (d) making a provisional Phase IV: Healing the Self-Wounds decision to take specified steps toward change. Once a decision has been made regarding spe-The healing of the activated self-wounds in- volves a variety of interventions, focused on a cific behavioral changes, the next step is to take action and allow one’s immediate experiencenumber of separate but interrelated goals. For self-wounds to heal, a number of processes to inform the patients of the results of the change steps taken. Successful outcomes frommust be set in motion, including (a) identify- ing and modifying the patient’s defensive inter- these self-fashioned choices increase the likeli- hood of a change in dysfunctional self-repre-ruption of his or her organismic experiencing, (b) enhancing the patient’s self-efficacy (Band- sentations. As the patients try to change, they will encounter the specific ways in which or-ura, 1977) or sense of agency, (c) resolving dis- crepancies between self-beliefs and immediate ganismic experience is defensively interrupted, and additional work will be necessary to limitself-experiencing, (d) in creas ing tolerance for— and ownership of—negative affects, (e) resolu- the impact of these defenses and increase the patients’ ability to accept their immediate-in-tion of conflicts that prevent the patient from a complete commitment to a particular self- the-moment emotions. focus, (f) the emotional processing of painful realities, and (g) increasing the patient’s will- ingness to engage in authentic relationships. ASSESSMENT AND CASE FORMULATIONOften, this phase of therapy begins with the identification of the patient’s defenses against emotional and visceral experience. This is of- A clinical interview is the primary means of assessing anxiety disorders. On occasion, thisten done in conjunction with the application of Wolfe’s Focusing Technique. Occasionally, might be supplemented with a standardized in- strument, such as the Anxiety Disorders Inter-patients are unable to carry out this technique, and the immediate therapeutic task is to under- view Schedule (ADIS-R; DiNardo et al., 1985), which may be useful in the differential diagno-stand why. Typically, one finds variations of the same theme, an intense fear of feelings. sis of an anxiety disorder as opposed to another Axis I disorder. However, a clinical interviewThese fears are desensitized gradually, which then allows the patient to engage in the imag- not only can produce a clear symptom pic- ture, but it can also supply some clues regard-ery techniques previously described. 272 Integrative Psychotherapies for Specific Disorders and Populations ing the underlying determinants of an anxiety dressed the self-care and attachment issues in a more exploratory approach.disorder. The major diagnostic tool for uncovering the implicit meaning of anxiety symptoms is Wolfe’s Focusing Technique. It involves a APPLICABILITY AND STRUCTURE strict attentional focus on the anxiety-inducing cue. For panic patients, the attentional focus is As the title of the chapter suggests, this integra- tive treatment is most relevant for patients suf-on the frightening bodily sensation. For OCD patients, it is the disturbing obsessional thought. fering from an anxiety disorder. My clinical ex- perience, however, suggests that many aspectsFor the specific phobic, it is the feared object or situation that is imagined. This approach to of this approach are relevant for patients suffer- ing from mood disorders, somatoform disor-diagnosi s and case formulation results, I believe, in a more comprehensive description of a pa- ders, and milder forms of personality disorders. It may be less useful for severe forms of border-tient’s anxiety disorder by delineating the spe- cific symptom cluster associ ated with a g iven li ne and narci ss ist ic perso nal it y disorders, which might best ben efit from other approache s (Koer-anx iety disord er and the underlying self-wounds that presumably generate the symptoms. ner & Linehan, 1992). In general, this ap- proach is most relevant with those disorders forThe assessment of anxiety disorders focuses on six key elements: (1) the nature of anxiety which the inhibition of emotional processing and organismic experiencing play a centralsymptoms, (2) the intensity of the anxiety, (3) the extent of interference in the patient’s life, role. For the most part, psychotherapy is con-(4) the underlying catastrophic events and con- flicts (if any) and the self-wounds they reflect, ducted once per week for 45–50 minutes. Dur- ing the symptom-focus phase, the therapy ses-(5) other physical and psychological problems, and (6) the degree of connection between the sions tend to be more structured. Homework is typically assigned and then reviewed duringauxiliary problems and the anxiety symptoms. The anxiety symptoms become the first targets the early part of the session. The in-session work then will typically focus on specific symp-of treatment. Once patients feel that they have some control over the symptoms, they will be toms. When therapy progresses to a focus on the roots of the disorder, the therapy is moreasked if they would like to explore the possible underlying issues governing their anxiety symp- exploratory and experiential and therefore less structured. In-session markers serve as cues fortoms. At their option, we would then proceed with the focusing work in an effort to uncover specific experiential techniques. If the patient is struggling with a particular issue, therapythese presumed underlying issues. Focusing typically will uncover the substan- may involve exploration and interpretations. On occasion, the exploratory work may un-tial network of ideas, images, and feelings con- nected to specific self-wounds. For example, cover or activate an underlying self-wound for which specific cognitive techniques may beone driving-phobic patient remembered an early panic attack while driving with his wife employed. At this juncture, the therapy re- sumes a more structured cast. The alternationwhen she announced that their marriage was over. This attack was associatively connected to between periods of more and less structure is particularly characteristic of this integrative ap-a panic attack that he had when he was only 9 years old. He had been left alone and in charge proach. of two siblings while his alcoholic parents went out drinking. Self-wounds around attachment and self-care apparently began to develop here. PROCESSES OF CHANGE Exposure therapy was helpful in that it allowed him to drive up to 8 miles from his home. Psychotherapy researchers by and large have concluded that the debate about whether in-Here, he stymied in his progress, and we ad- Integrative Psychotherapy of the Anxiety Disorders 273 sight or behavior change is the fundamental feared situation. There is therefore a dialectical tension between one’s immediate experiencemechanism of therapeutic change is a sterile one. Insight without behavior change often re- of the world and the ideas that we have already stored in memory. The tension that permeatessults in a new way of talking about one’s prob- lems, but behavior change without a change problematic moments and the painful memo- ries that seem ineluctably associated with themin the person’s “central processing unit” (i.e., cognitions, emotional processing, attitude, or are at the heart of the therapeutic modification of anxiety disorders.perspec ti ve) is not li kel y to endure. Each mech- anism, however, seems to point to a particular In this model, direct experience is the medi- ator of all change. It is a necessary ingredienttruth about change. Behavior change implies a proactive engagement with the world in which in the modification of behavior, cognitions, af- fects, and underlying self-beliefs. Different pa-one makes a decision to act, implements that decision, and experiences the consequences of tients, however, possess different access points for the process of change. For a variety of rea-that decision. Whatever else is included in a concept of therapeutic change, the element of sons, patients differ in their comfort level in the initial focus of therapeutic work. Behaviorbehavior change as proactiv e engagement seems to be a necessary one (Wachtel & McKinney, change is the initial access point for many pa- tients. For some patients, cognitive change is1992). The concept of insight, however, points to the initial point of access. For a very few pa- tients, therapeutic work may begin with a focusthe necessity of change in the way we perceive, think, and feel about the world and ourselves. on bringing about corrective emotional experi- ences (Alexander & French, 1946). ResearchThus, insight implies some kind of cognitive- emotional change in the way we construe self data and clinical experience both confirm that behavior change is the simplest and easiest lo-and world. What has been sundered by the po- lemics between psychoanalysts and behavior cus of change; cognitive change tends to be more difficult; and changes in the core self aretherapists needs to be (re)integrated. An inte- grative concept of change must, on the one the most difficult to effect and require treat- ment of the longest duration (Howard, Kopta,hand, involve behavior, cognition, and affect, and, on the other, encompass both behavior Krause, & Orlinsky, 1986). Changing core self beliefs and healing internal wounds requirechange and “deep structure” change. With re- spect to anxiety disorders, this translates into corrective emotional experiences and the emo- tional processing of painful as well as positivesymptom reduction, on the one hand, and the healing of the underlying self-wounds, on the meanings. One can view an anxiety disorder as a two-other. Change in this model is construed as an os- tiered disorder. Tier 1 includes the anxiety symptoms and the patient’s catastrophic cogita-cillating process between engagement with the world and the articulation of emotional experi- tions about the symptoms. Tier 2 includes the implicit roots of an anxiety disorder that gener-ence resulting from that engagement. Change results from the emotional processing of experi- ate the bodily symptoms of anxiety. Change can also be thought of as a two-tiered processential contact with the world. The anxiety pa- tients who can remain anxious when confront- (a) the reduction of anxiety symptoms and the patient’s cogitating about them and (b) chang-ing the feared situation will eventually begin to experience the disavowed emotions connected ing the underlying determinants of an anxiety disorder (i.e., healing the self-wounds).to past catastrophic situations. When patients can do this, they come to see that they are ac- The treatment of Tier 1 anxiety symptoms tends to be cognitive-behavioral in nature. Thetually not being threatened in the present. Once the discrimination can be made between cognitive-behavioral treatment of anxiety dis- orders attempts to reconnect patients to theirpast catastrophe and present reality, anxiety pa- tients eventually gain a sense of safety in the direct experience of the world while simultane- 274 Integrative Psychotherapies for Specific Disorders and Populations ously trying to change their threat-laden inter- tion on their immediate self-experience. And it is organismic self-experiencing and its symbol-pretations of that experience (i.e., cogitation). Once patients achieve some control over their ization that provide the necessary information for human change. For anxious patients, resis-symptoms, they may be willing to explore, and attempt to modify, the underlying determi- tance to change is manifested by avoidance of situations and feelings that appear to threatennants of their anxiety disorder. Change at the level of the implicit roots of the viability of self-experience. Whenever pa- tients try to enter a particular context of fear,anxiety (Tier 2) is achieved by having the pa- tients confront, process, and ultimately revise they experience the growing presentiment of self-annihilation. Therapist empathy and pa-the extremely painful self-views they morbidly fear. The healing of self-wounds proceeds by tient acceptance of this experience are prereq- uisites of change.first analyzing and gently confronting patients’ defenses against their immediate, organismic experience. Once patients’ recognize and are willing to modify their defensive strategies, the THERAPY RELATIONSHIP way is opened to experiential work that allows them to emotionally process their feared self- All therapeutic change is predicated on the de- velopment of a strong, supportive non-judg-views. The emotional processing may also in- volve Socratic questioning designed to help pa- mental therapeutic alliance. As mentioned above, the safety of the therapeutic alliancetients experience their feared emotions around the self (i.e., self-wounds). This work will also allows the patient to tolerate the intimate and sometimes painful exploration and expressioninclude behavioral experiments designed to help patients enact a new sense of self. of his or her most tender thoughts and feelings. The therapeutic relationship is now viewed byThe process of therapeutic change rarely runs as smoothly as may be implied by the all therapy orientations as a critical element of the change process; it is an integrative com-above description. The dynamics of change ap- pear to be characterized by oscillations be- mon factor of all psychotherapies (Horvath & Greenberg, 1994).tween ol d a nd n ew patterns of functioning (M a- honey, 1991). Any change will be experienced When one explores the details involved in the establishment and maintenance of a strongby the patient initially as dissonance relative to the individual’s current level of self-organiza- therapeutic alliance, one finds that many of the issues emphasized by the psychodynamiction. Accordingly, change tends to be resisted, not because of pathology, but rather because perspective are involved. In this integrative model, it is critically important for the therapistof, as Mahoney puts it, “individuals’ healthy caution about embarking upon or embracing to stay in touch with transference and counter- transference as well as the characteristic inter-experiences that challenge their integrity, co- herence, or (felt) viability as a living system” personal defenses revealed by the patient dur- ing the therapy session. The monitoring of the(p. 329). Resistance to change, therefore, is viewed as therapeutic alliance is particularly important when a therapist attempts to implement a spe-a precondition to change. The therapist at- tempts to work toward identifying the sources cific therapeutic task (e.g., exposure therapy). The therapist needs to remain cognizant ofof resistance and endeavors to help patients un- derstand its necessary functions. The patients what the task means (explicitly and implicitly) to the patient particularly with respect to hisneed to accept that they will resist change as much as they need to accept other aspects of or her feelings about the therapist. How the therapist relates to the patient may activate thetheir current functioning (i.e., painful emo- tions and self-views). The acceptance of “who patient’s in-session defenses, which can im- pede or even undermine his or her ability tothey are” at the moment is an enabling condi- tion of change (Beisser, 1970). In-the-moment carry out any of the therapeutic tasks, includ- ing the initial symptom-reduction strategies.self-acceptance allows people to focus atten- [...]... bridge from basic research to clinical practice Journal of Psychotherapy Integration, 13, 83– 91 Wolfe, B E., & Sigl, P (1998) Experiential psychotherapy of the anxiety disorders In L S Greenberg, J C Watson, & G Lietaer (Eds.), Handbook of experiential psychotherapy (pp 272–294) New York: Guilford 13 Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for Chronic Depression JAMES P MCCULLOUGH,... al., 2000) showed that the average number of sessions received among 2 16 responding psychotherapy- alone patients and 2 26 responding patients who received combination treatment was 16. 0 (±4.7) and 16. 2 (±4.8) sessions, Cognitive Behavioral Analysis System of Psychotherapy for Chronic Depression respectively However, a better indicator of the typical number of required sessions for a positive treatment... comparisons of DSM-IV subtypes of chronic depression: Validity of the distinctions Part 2 Journal of Abnormal Psychology, 112, 61 4 62 2 McCullough, J P., Klein, D N., Keller, M B., Holzer, C E., Davis, S M., Kornstein, S G., et al (2000) Comparison of DSM-III-R chronic major depression and major depression superimposed on dysthymia (double depression): Validity of the distinction Journal of Abnormal... Levis, D J (1 967 ) Essentials of implosive therapy Journal of Abnormal Psychology, 72, 4 96 503 Wachtel, P L., & McKinney, M K (1992) Cyclical psychodynamics and integrative psychodynamic therapy In J C Norcross & M R Goldfried (Eds.), Handbook of psychotherapy integration (pp 335–370) New York: Basic Books Weiss, J., & Sampson, H (19 86) The psychoanalytic process New York: Guilford Weitzman, B (1 967 ) Behavior... Weitzman, B (1 967 ) Behavior therapy and psychotherapy Psychological Review, 74, 300–317 Wolfe, B E (1992) Self-experiencing and the inte- grative treatment of the anxiety disorders Journal of Psychotherapy Integration, 2, 29–43 Wolfe, B E (2001) The integrative experience of psychotherapy integration In M R Goldfried (Ed.), How therapists change: Personal and professional reflections (pp 289–312) Washington,... retardation is the result of a developmental history of maltreatment where “surviving the hell of the family,” not growth, was the major goal (Cicchetti, Ackerman, & Izard, 1995; McCullough, 2000; Piaget, 1981/1954; Spitz, 19 46) Recent data from the Keller et al (2000) study (Nemeroff et al., 2003) revealed that one-third of the outpatient sample reported abuse Thirty-four percent of 68 1 outpatients reported... of “Full Response Subjects” (Ss) at the End of the Acute and Continuation Phases in the 3 Treatment Groups End Acute Phase Combination group Percentage full responders Medication-only Percentage full responders CBASP-only Percentage full responders End Continuation Phase 48% (109/226Ss) 62 % (92/148Ss) 29% (62 /220Ss) 62 % (59/90Ss) 33% (72/226Ss) 63 % (54/86Ss) Ss = Subjects in the study Spielman, Scarvalone,... American Journal of Psychiatry, 140, 68 0 69 4 Keller, M B., Lavori, P W., Rice, J., Coryell, W & Hirschfeld, R M A (19 86) The persistent risk of chronicity in recurrent episodes of nonbipolar major depressive disorder: A prospective follow-up American Journal of Psychiatry, 143, 24–28 Keller, M B., McCullough, J P., Klein, D N., Ar- Cognitive Behavioral Analysis System of Psychotherapy for Chronic Depression... Gelenberg, A J., et al (2000) A comparison of nefazodone, the Cognitive Behavioral Analysis System of Psychotherapy, and their combination for the treatment of chronic depression New England Journal of Medicine, 342, 1 462 –1470 Keller, M B., & Shapiro, R W (1982) “Double depression”: Superimposition of acute depressive episodes on chronic depressive disorders American Journal of Psychiatry, 139, 438–442 Keller,... System of Psychotherapy Journal of Clinical Psychology: In Session, 59, 833–8 46 McCullough, J P., & Carr, K F (1987) Stage process design: A predictive confirmation structure for the single case Psychotherapy: Theory, Research, and Practice, 24, 759– 768 McCullough, J P., Kasnetz, M D., Braith, J A., Carr, K F., Cones, J H., Fielo, J., et al (1988) A longitudinal study of an untreated sample of predominantly . grative treatment of the anxiety disorders. Jour- nal of Psychotherapy Integration, 2, 29–43.and Research, 14, 111–112. Stampfl, T. G., & Levis, D. J. (1 967 ). Essentials of Wolfe, B. E. (2001) J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy bridge from basic research to clinical practice. Journal of Psychotherapy Integration, 13, 83–integration (pp. 335–370) showed that the average num-2003). A second level of DV illustrates how treat- ber of sessions received among 2 16 responding psychotherapy- alone patients and 2 26 respond-ment influences the generalized