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(p. 299) More Than a Feeling?: Application of Principles of Change to Treatment of Anxiety 

(p. 299) More Than a Feeling?: Application of Principles of Change to Treatment of Anxiety
Chapter:
(p. 299) More Than a Feeling?: Application of Principles of Change to Treatment of Anxiety
Author(s):

Igor Weinberg

DOI:
10.1093/med-psych/9780199324729.003.0011
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date: 19 August 2019

The goal of this chapter is to describe how I, as a practicing clinician, might implement a variety of principles of change that have received empirical support. Before doing so, however, it is important for me to present fundamental elements of my understanding and treatment approach to anxiety disorders that provide a conceptual and clinical context to the implementation of these principles.

Writing the chapter brought up a few reactions. I was excited to describe the anticipated course of treatment of the cases and elucidate my own thinking regarding parameters that are likely to make these treatments effective. My own clinical work is guided by a number of principles—some intuitive and some are more explicit. Therefore, the task of thinking about the empirically validated principles described in this book made me want to explicate my own clinical thinking about the treatment of anxiety disorders. I will describe them in the following discussion.

Using treatment principles, rather than session-by-session protocols to guide treatment allows for a flexible approach that is both adherent to these treatment principles and compatible with complex clinical situations. In fact many of the empirically supported therapies for complicated clinical cases, such as dialectical behavior therapy (DBT), are principle-based.

In my discussion of the cases, I will describe a few principles of assessment and treatment that I find helpful in the treatment of anxiety disorders. In these cases, similar to many others in my clinical practice, anxiety does not appear alone. Commonly, it appears as an unwelcome concomitant of other difficulties, and many times it is the ultimate reason that the patient presents to treatment. In other words, anxiety adds an element of unbearable anguish to the patient’s (p. 300) suffering that leads the patient to finally seek treatment—sometimes after years of help rejection and denial. Acute personal distress and pervasive avoidance that progressively reinforce each other and trap the patient in an intolerable state are the Phobos and Deimos of anxiety disorders. Like the two moons of Mars, they are present wherever anxiety disorder is. Not only, then, is anxiety a target of treatment, but it is also a motivating factor for change. Productively using anxiety can help engage the patient in collaborative work on the reasons that led to anxiety.

Yet another aspect of treatment of anxiety disorders helps to guide my thinking. That is, their dynamics, meaning, and treatment change depending on characteristics of the patient, such as demographic factors, co-morbid conditions, personality, and cognitive style. Although anxiety is easily identified by the patient as the reason for treatment, it requires thorough assessment of these contextual factors and careful consideration of interventions and priorities. Fortunately, as the following discussion illustrates, some of the contextual factors are addressed by a particular cluster of principles of change (i.e., client prognostic principles). In some cases, anxiety might have to be conceptualized in the context of other aspects of pathology that receive higher priority in treatment. Risks of iatrogenic effects of treatment on anxiety also need to be taken into account. Iatrogenesis can result from styles of interventions (i.e., hyperfocusing on discussion of anxiety), inadequate interventions (i.e., not challenging the cognitions that maintain anxiety), or misguided conceptualization of the problem (i.e., treating anxiety as a primary problem and ignoring the actual cause of it). Finally, another principle that guides my clinical work is that I usually start treatment with assessment and then use my assessment to put together all clinically important information in a concise formulation that helps me decide regarding the recommended treatment as well as anticipate various treatment responses.

Let’s turn to the clinical material and see how the treatment and assessment exemplifies important clinical principles described in this book.

Case 1

Case Formulation and Treatment Plan

I usually find it helpful to start treatment by setting a frame. In the case of Philip, I would start with carefully listening to what he wants to accomplish and what he expects from treatment. Growing up in an immigrant family, he (p. 301) is likely to have adopted a style of deferring to the person in the position of authority. Instead, a successful treatment will be sensitive to his experiences and wishes and will encourage his own sense of agency—becoming an authority over his anxiety. Anticipating Philip’s sensitivity to power differential in life and, therefore in therapy, it is helpful to adopt an egalitarian collaborative stance. This can be accomplished by taking a genuine interest in Philip’s life story and experiences, disclosing personal reactions to his life history and inquiring about his experiences in therapy—requesting feedback and making adjustments if appropriate. From this perspective, coming up with a case formulation and accurate diagnostic assessment is critical to “not missing” what is unique about Philip.

Let’s start with the diagnostic case formulation. A number of features make Philip’s social anxiety diagnosis presentation quite typical. Clinically, Philip presents with discomfort around others, anxiety around meetings, fear of negative evaluations, and avoidance of personal interactions with most others outside of his family and close friends. History of overprotection in childhood is typical as well, though the history of assignment of a caregiver role is more unique to Philip’s past. His somewhat dependent attitude toward others is also a typical characteristic of people with social anxiety disorder. Interestingly, once he became a caregiver as an adult—once his son was born—he became depressed and agoraphobic, as if he could not tolerate being cast in this role again. In contrast to being a caregiver, his functioning at work is plagued by lack of assertiveness and ambition. Whereas lack of assertiveness is typical of someone diagnosed with social anxiety disorder, it is also likely to carry additional meanings. Philip has already been “promoted” once as a child into a caregiver and learned to resent that role. So—not again! Unfortunately, inhibition of ambition comes with a price of remaining in a submissive, inferior role. In this way, he remains dependent on others, which satisfies his need for dependence. A goal of my treatment with Philip would be to help him recognize how his upbringing predisposed him to avoid ambition, fear promotion, and resent caregiving roles, which led to inhibitions, as well as agoraphobia and depression as a way to avoid the experience and expression of anger.

However, it is not possible to fully understand this case without taking into account cultural aspects—coming from an immigrant family. This part of his life will still have strong implications for treatment even if the therapist shares his background. The unspoken part of his history stems from him growing up in an immigrant family and, possibly, having experienced typical hardships related to financial, cultural, and value differences with the “dominant culture.” One possible outcome is developing an internal conflict between the family orientation of his family of origin and the push toward self-reliance by the US (p. 302) culture. We do not know what his fantasies or expectations were regarding finding his own place within both cultures. Was he experiencing one culture as inferior, and another as superior? One “dominant” culture and another “passive?” One culture that prioritizes ambition, and another one, family? One culture that prioritizes individual needs, and another, the needs of others? While growing up, not only did Philip have to deal with all of the struggles of an immigrant family and had to take care of his siblings, but also he had to reconcile these questions and dilemmas.

These dilemmas are possible reasons to become socially anxious, to feel different, to actually be different, and to worry about acceptance of and evaluation by others. Philip’s life story makes me wonder if being responsible and doing “the right thing” is a central value for him. This creates an important conflict between being responsible, on one hand, and following his heart, on the other. In addition, conflicts between his wishes and family wishes, as well as his needs and family needs, are apparent. Growing up he learned to prioritize family over personal and career needs. However, both “society” and his wife expect him to make his career and ambition a higher priority. This must be confusing, to say the least! Is social anxiety, then, an adaptive response of a person from a subdominant culture to the dominant culture? Is it also an adaptive way to survive in culture with different value systems? In other words, anxiety allowed him to maintain vigilance about differences between him and the society in terms of values, priorities, and needs and in such a way not make assumptions about others based on his own experiences. These considerations are helpful in guiding the treatment and in validating meanings of the social anxiety in Philip’s life. Another aspect of the case is a significant family/couple component that might actually require separate intervention. Both Philip and Christina share a cultural background though the acculturation process may have affected them differently.

In my opinion, it is critically important to structure this treatment around a treatment relationship that is sensitive to Philip’s upbringing and to his current issues. Such a relationship will offer him an opportunity to explore his relationship with the dominant culture and authority figures. It will also offer him a new type of a relationship where repetitions of old patterns can be acknowledged and new patterns can be learned and “rehearsed.” Acknowledging inherent power differences, cultural differences, and limits to mutual understanding of these experiences is important. This is likely to run counter to Philip’s prior experiences where differences were not discussed and negotiated but unconditionally and silently accepted, and his subjectivity was suppressed in service of family survival. Once a trusting, genuine, and collaborative relationship is established, I might decide to incorporate behavioral assignments, such exposure exercises or assertiveness training. Framing these interventions (p. 303) as an opportunity, not a requirement, is yet another way in which the therapist will account for the inherent power differential in a treatment like this one.

Implementation of Principles of Change

Let’s go back to the principles discussed in the book and see what they have to say about the prognosis. The first cluster of empirically based principles relate to prognostic considerations. What is a likely outcome of therapy for Philip? The following characteristics increase the chances of a good outcome: an only moderate level of baseline impairment (Principle 1), high therapy outcome expectation (Principle 4), high intrinsic motivation (Principle 5), high readiness for change (Principle 6), and middle-class status (Principle 7). These are some of the strengths that Philip brings into therapy. These strengths allow treatment to take a change-oriented direction and become the foundation for the previously outlined treatment goals: exploration of important relationships in his life, development of a new relationship with others, and successful engagement in behavioral assignments.

However, other factors decrease his chances for improvement: insecure attachment (Principle 3), difficult childhood (Principle 8), and high level of negative self-attributions (Principle 9). How can these obstacles be addressed? In my opinion, and as I demonstrate in the following discussion, these difficulties are best understood in terms of development of his self and attachment in the context of immigration and acculturation stress. Changes in these factors are usually slow and likely to follow the development of a trusting and positive relationship with the therapist. In my opinion, building the foundation for such a positive relationship and fostering its development with the therapist both have a high priority in any effective treatment for Philip. Such treatment is likely to take some time before the problems related to self and attachment can be addressed. Thus, in line with Principle 16, Philip may well derive benefits from long-term treatment, even if he shows a relatively low level of baseline impairment. Furthermore, whereas most intrinsically motivated clients who are ready for change are likely to benefit from a more directive and change-oriented approach (Principles 11 and 12), in case of Philip, it is important to understand the effect of acculturation stress in his development. Considering his internalizing coping style and his moderate level of problem assimilation, he is likely to benefit from interventions aimed at fostering self-awareness and understanding (Principles 18 and 10). Therefore, in line with the principle of flexibility (Principle 33), it will be critical to find balance between nondirective and person-centered interventions (Principles 11 and 12) aimed at fostering (p. 304) positive genuine attachment on the one hand and using exposure-based change-oriented interventions on the other.

As previously mentioned, establishing genuine connection is critical for this treatment (Principle 23). A strong alliance will indeed be necessary for Philip to become actively engaged in the exploratory and action-oriented processes as previously mentioned, which, in turn, may foster his improvement (Principle 21). Therapy, however, runs a risk of becoming a “false” treatment if Philip perceives it as yet another acculturation experience where he has to sacrifice his needs in the service of treatment or treatment protocols. Such risk is inherent in the history of Philip and the power differential between him and the therapist. Put in terms of Principles 21 and 22, how can the therapist maximize the likelihood of Philip’s active participation in therapy and minimize the risk of triggering resistance/reactance to it? Treatment has to start with the recognition that the power differential inherent in the treatment relationship, including possible differences in cultural backgrounds between the therapist and patient, are likely to play a role in therapy and could perpetuate the type of dynamics that caused Philip’s social anxiety. Moreover, a willingness to consider how such differences are enacted and elaborated by both the therapist and Philip is important (Principle 35). Understanding what are (almost) expected enactments is critical for determining how both Philip and I will contribute to them, how he could understand and change such contribution into other relationships in his life and address possible contribution of others to the perpetuation of his repeated roles from the past. A number of features of treatment might invite “false” engagement and/or create alliance ruptures (Principle 27). First, treatment that prioritizes protocol-based sequences of interventions is likely to invite the perception that this treatment is not designed for Philip but yet another demand with which he must comply. Using general language, devoid of references to personal or subjective aspects of Philip’s history, is likely to convey a similar message that his experiences do not matter—contradicting relationship-based principles (working alliance, positive regard, empathy, congruence) and possibly running counter to preference principles (Principles 13 and 14). Using language that introduces treatment interventions as “the truth,” or treatment assignments as requirements, is likely to repeat his experience of giving up his authority in service of his external needs. Such processes can be subtle enough that they “trigger” old patterns outside of Philip’s awareness. Therefore, the therapist is facing a formidable task of offering treatment that is participatory, genuine, and collaborative (Principles 21 and 22, as well as Principles 23–26, are all relevant to this aim).

During such treatment, it would likely be beneficial to inquire about Philip’s experiences, including those related to the therapy and the therapist (Principle 32), as well as to invite him to become more aware of and to embrace his own (p. 305) sense of authority and ownership of his therapy, his past, and the present—thereby fostering his self-understanding and emotional deepening (Principles 35 and 36). During this process, incorporating Philip’s language and metaphors and avoiding a formulaic approach is critical. Philp’s agency can also be a target of exploration. For example, exploring his childhood can be supplemented with validation of how he preserved (agency) his family values by prioritizing his family over his needs (Principle 26). Identifying how his sense of agency is growing and manifesting itself inside and outside therapy session is another avenue for validation. For example, at some point the therapist might say, “I am noticing that you are pointing out today ways in which I misunderstood you—what’s that like?” In line with Principle 27, such intervention aimed at an alliance rupture could be beneficial Philip, above and beyond the repair of the relationship breach.

I usually do not use structured outcome measures to track progress in therapy (Principle 31). In my opinion, while routine measurements generate shared knowledge of progress or lack thereof, it also runs a risk of inviting false compliance in a case like Philip’s. My preference would be to track progress through open discussion and through noticing spontaneous examples of progress in therapy. In these cases I would be inclined to share my observations with Philip and ask about his perspective.

Based on Principle 15, the use of transference interpretation is not likely to be detrimental to someone with Philip’s level of interpersonal functioning. However, if the therapist decides to offer interpretations (transferential or not), they need to be offered as possibilities, not as ultimate “truths.” This is to avoid the risk of “erasing” Philip’s personal experience through inaccurate interpretation. Interpretations are better offered as hypotheses, alternative perspectives, or summary statements that restate what Philip has started understanding about himself on his own (Principles 29 and 30). The interpersonal dynamic of offering interpretations is important. It is better to offer interpretations that validate what the patient is already becoming aware of during close collaborative exploration. Offering interpretations from an interpersonal distance or about material that has not been explored enough is running the risk of repeating his childhood drama of blind compliance.

Another important consideration in conducting such treatment is offering protocol-based treatments for social anxiety, agoraphobia, or depression. Among the primary focus of these treatments are interventions aimed at fostering adaptive interpersonal and behavioral changes (Principles 34 and 38). Those can be helpful, though they run the risk of perpetuating the same problem that is central to Philip’s life—sacrificing one’s self to the dominant discourse of culture, family needs, and now treatment protocol. This could run the risk of iatrogenically reinforcing maladaptive solutions. Again, guided by (p. 306) a principle of flexibility (Principle 33), I would rather recommend a treatment approach that capitalizes on helping Philip develop a personalized narrative of his past and present. Such a narrative will help with development of his sense of agency that is so critical in this treatment. Whereas, theoretically speaking, one might expect that in itself such a process will be sufficient for the resolution of his symptoms, I would be cautious in expecting that a single intervention will be sufficient to accomplish such a change. Therefore, in addition to using nondirective, self-understanding, and emotional-deepening interventions (Principles 35–37), I would be prepared to introduce others, including exposure and/or assertiveness training.

At times, such narrative includes an intergenerational past, for which he is a likely “container.” In many immigrant families, children become such containers once parents feel that they have immigrated “for the sake of their children.” Helping Philip develop his own narrative can help him create some separation between himself and his family of origin, as well as his own family, and to think about various aspects of his acculturation and identity—a process reflecting both an increase of self-understanding and adaptive interpersonal functioning (Principles 35 and 36). Such a process is likely not only to require genuineness, nonjudgment, empathic listening, validation (as captured by Principles 23–26), and appropriately disclosing personal reactions to his life history (Principle 28) but also an openness to learning about cultural aspects of Philip’s experiences (which is consistent with Principle 13). However, it is also likely to encounter predictable challenges related to the perception of the cultural affiliation of the therapist. This is likely to lead to re-experiencing feelings of fear and inadequacy on the one hand and anger and desire to emulate the dominant culture on the other hand. At some stage in treatment, a different side of Philip might start to surface. Comparison with the therapist, feelings of jealousy, or contempt are likely signs that he is preparing to explore his own motivation that was suppressed during the acculturation process. It is important to find room for these feelings and to help Philip articulate his own narrative of his life. The hope is that this process will “undo” the suppression of various parts of himself that were cast away as a result of the acculturation process, recognize conflicts related to different values, and put into perspective his struggles growing up in his family of origin. Reflected in this complex therapeutic process are different facets of principles of engagement (Principles 21 and 22) and self-exploration (Principles 35–37).

Such a process is also likely to rely on multiple cycles of repairs of expected ruptures in the therapeutic relationship (Principles 23 and 27). One of the challenges for this therapy is noticing signs of alliance ruptures: missed sessions, distancing in therapy, avoiding feelings, avoiding discussion of vulnerability, and using the therapist’s language for personal experience—a parallel (p. 307) to his experiences of eschewing his subjectivity in service of his family. Ability to tactfully bring up these experiences and explore their possible relevance to Philip’s perception of misalignment in therapy is critical for therapy progress—not only to repair alliance ruptures but also as an opportunity for increased self-understanding. It should be noted, however, that such misalignment is likely to stem from power differential, subtle demonstration of power, and cultural differences of the therapist. Similarly, misunderstanding of the patient by the therapist or misunderstanding of the therapist by the patient can equally bring about such misalignment. In my experience, it is important to discuss real contributions of both the therapist and the patient to these developments. Such discussions can be facilitated by a skillful use of relational, nondirective strategies, self-disclosure, and interpretative interventions (a complex integration of Principles 23–26 and 28–30). In this context, however, interpretations can be perceived as false attempts of the therapist to avoid responsibility, not genuine validation of the real experiences of Philip. It is better to reserve interpretations for a “summary statement” of what the therapist and Philip understand together about these misattunements.

Another possibility for intervention is couples therapy that can be conducted adjunctively. This intervention takes into account the importance of the family values, and it destigmatizes Philip as the “identified patient.” Such treatment will need to be conducted within the same frame as the individual therapy, with full recognition of cultural and power differences. As a means to foster adaptive interpersonal functioning (Principle 34), it will also have the advantage of helping the couple co-create a narrative that integrates their personal narratives within a larger narrative of them as a family.

Case 2

Case Formulation and Treatment Plan

Robert presents both diagnostic and treatment challenges. Although at first glance he meets criteria for both social anxiety disorder and alcohol use disorder, moderate to severe, one has to wonder if this is the only way to look at his palpable difficulties. First, he meets criteria for alcohol use disorder because of excessive and regular drinking, unsuccessful attempts to stop drinking, some signs of withdrawal, and clear negative consequences in vocational, social, and romantic relationship realms. The diagnosis of social anxiety is more complicated. At first glance, signs of social anxiety disorder can be easily found in his current clinical presentation, including fear of being judged by others, (p. 308) hypervigilance, avoidance of public activities, and physical signs of anxiety. We are also learning that he gets suicidal due to his social isolation, suggesting the possibility of a co-occurring affective disorder. However, the complexity of this case comes from difficulty ascertaining his diagnoses.

From his history, we know that Robert had social difficulties prior to actual onset of either social anxiety or problematic drinking. Does it mean that social anxiety developed secondary to drinking, social consequences of drinking, and pre-existing social difficulties? In this case, is Robert anxious because he is actually realistically aware that social interactions are not his strengths and, thus, when intoxicated he tends to embarrass himself? Is it, then, a realistic assessment of the consequences of his drinking or, alternatively, his pre-existing personality? Robert is likely to be profoundly embarrassed about his drinking and its disastrous and tragic effects on his life. Socially isolated, he is likely to experience an intense sense of failure and shame around the demise of his romantic life, as well as being on verge of a vocational crisis. These feelings are likely to fuel anxiety in interactions with others, fears of judgment, and further avoidance of interpersonal closeness. His externalizing cognitive style and tendency to externalize responsibility or assign blame to others are not just an impediment to engaging Robert in self-exploration but also in him taking responsibility over his behaviors. When coupled with an intense sense of shame, an externalizing cognitive style leads not only to a tendency to assign blame to others but also to expect shaming responses from others. This is likely to promote hypervigilance and an anxious presentation. Instead of dealing with his own self-shaming process, he expects it to come from outside. Consequently, he describes social anxiety signs, though in the context of his externalizing cognitive style, it is more a sign of projected shame.

The role of alcohol use disorder is hard to overestimate. The first issue to consider is that the co-morbid affective component is not just a result of isolation but also a result of heavy drinking. Pharmacologically speaking, alcohol is a sedative. It produces signs of depression, typically after the initial intoxication or elation stage. This is especially likely in Robert’s case, given that he reports a violent transformation of his character during intoxication. Having more pronounced mood changes in response to alcohol, whether depressive or angry in nature, is a sign of progression of alcoholism, suggesting that his addiction has to be taken seriously. Another issue to consider is that given his shame around drinking, Robert is likely to downplay the centrality of his difficulties with alcohol and overly emphasize another problem/disorder. For that reason, the extent to which he actually has social anxiety needs to be ascertained using behavioral and longitudinal observations, as well as collateral information.

The treatment will start with a diagnostic assessment. Once these diagnostic dilemmas are identified, a few considerations will guide the next steps. The (p. 309) first treatment recommendation, in line with Principle 38, is to stop drinking to diagnose and address other difficulties. This recommendation will likely require psychoeducation as to reasons why the clinician strongly believes that treatment will not address social difficulties or “depression/suicidal thinking” without establishing a baseline of sobriety. Robert might need little convincing to agree that alcohol is a problem. However, he might have significant ambivalence in actually quitting the behavior.

The possibility of co-occurring posttraumatic stress disorder (PTSD) needs to be assessed. A history of adversity in childhood, specifically a physically abusive father, suggests that Robert might be using alcohol to medicate PTSD. In this case, asking him to give up alcohol is like asking him to face memories of childhood abuse without any numbing mechanism. It is like facing his abusive father without the protection of his mother—experiences that he had too many times in the past to make room for once again. The possibility of PTSD will require additional careful assessment. If present, a number of treatment options can be offered. PTSD and alcohol use disorder can be addressed concurrently using such procedures as the COPE (Back et al., 2014) protocol or using the Seeking Safety (Najavits, 2001) protocol. COPE incorporates working on traumatic memories (including prolonged exposure to traumatic memories) and on beliefs formed because of trauma. I would recommend this intervention if Robert is capable of tolerating such an intensive treatment focus. Seeking Safety would invite Robert to learn behavioral coping skills to manage the effects of trauma and PTSD symptoms without discussing the traumatic memories directly. It is advised for patients who are not able or willing to work on traumatic memories but still want to learn skills to manage the PTSD symptoms.

Implementation of Principles of Change

As I did in the case of Philip, let’s first review factors related to the prognostic principles and derive guidelines to address them in treatment. The following factors decrease his chances for improvement: a significant level of baseline impairment (Principle 1), low therapy outcome expectation (Principle 4), lack of intrinsic motivation (Principle 5), low readiness for change (Principle 6), insecure attachment (Principle 3), difficult childhood (Principle 8), high level of negative self-attributions (Principle 9), and low socio-economic status (Principle 7). Robert’s ambivalence about sobriety, minimization of drinking, and externalizing style are main roadblocks to successful treatment. This indicates that his prognosis is poor, making his expected treatment outcome less favorable than Philip’s prognosis.

(p. 310) How can these obstacles be addressed? Robert’s treatment needs to prioritize alcohol dependence over other treatment targets. Further, given the fragility of his self-esteem, his treatment will require a lot of tactful, well-timed interventions that, over time, have the promise of helping him embrace sobriety. Considering the severity of his alcohol and self-esteem problems and his fairly high level of functional impairment, long-term treatment is indicated (Principle 16). Also, considering his levels of resistance and motivation, Robert is likely to benefit from therapy that is, at least initially, geared toward validation of Robert’s experiences, rather than encouraging change (Principle 12), especially if such therapy is nondirective (Principle 11). Especially early in treatment, the use of nondirective and client centered intervention would also be attuned to his relatively low level of problem assimilation (Principle 10). Higher order interventions, such as confrontations, interpretations, or analysis of the treatment relationship need to be avoided—at least initially (Principle 15). Due to his externalizing coping style, therapy is more likely to be successful if it is behaviorally focused (e.g., discussing the effects of drinking) rather than insight-oriented (e.g., discussing personal motives; Principle 17). Similarly, addressing interpersonal functioning seems important given social difficulties that Robert experiences (Principle 19). Consistent with Principle 20, the successful implementation of these diverse principles of change, as well as Robert’s treatment in general, is not contingent on whether or not the therapist has a personal history of substance use problems.

As treatment progresses from assessment to therapy, establishing a nonjudgmental, collaborative relationship is central to effectiveness. Relying on the principles inherent to such a relationship (Principles 23–26), motivational interviewing (Miller & Rollnick, 2002) was established as a set of empirically based, interviewing techniques that help many patients with addictions develop motivation to stop using substances. This is a treatment that also meets the definition of a therapy that is likely to benefit Robert at least at earlier stages of treatment (see previous discussion). Motivational interviewing in his case will start with validation of his experiences and decisions related to drinking. Validation does not mean agreement—the therapist will walk a fine line of expressing understanding of Robert’s drinking without condoning it. One way to accomplish that is to validate the personal function of drinking: “I understand that you are drinking—it helps you make the depression go away.” The goal of validation and reflection is establishing a positive relationship and conveying, in a genuine way, that the clinician understands him. Like most patients with alcohol dependence, Robert displays signs of avoidant attachment, marked by social anxiety, fear of interacting with others, avoidance of others, and negative self-image (Brown & Elliott, 2016). Avoidant attachment suggests that Robert tends to withdraw from others as a strategy to regulate emotional distress. This makes (p. 311) alliance with the therapist more tenuous. For Robert, similar to other patients with substance use disorder, attachment to alcohol feels more powerful than anything else, including attachment to the therapist. Since his motivation to stop drinking is low, attachment to alcohol is high, and attachment to the therapist is low, it becomes important to use the type of interventions that strengthen the treatment relationship and avoid provoking anxiety that will propel the patient out of treatment. These interventions are not only fully in line with Principles 23 to 26, they are also consistent with engagement principles (Principles 21 and 22): Robert’s high level of resistance/reactance makes him at risk of dropping out, and the therapist must act tactfully to help him to participate and possibly benefit from therapy.

I would use descriptive, nonjudgmental language to convey my understanding of his difficulties (Principles 24 and 26). I would start with validating Robert’s difficulties with alcohol, mood, and social interactions. I would express clear concern that his current drinking is not only a significant problem with regard to personal, social, vocational, medical, and possibly legal consequences (note his violent temper!) but also in precluding more diagnostic clarity. Given the recurrent suicidal thinking, I would express concern that drinking is likely to be contributing to this type of thinking and frame drinking as a possibly life-threatening condition. I would do this not only to communicate my empathy and build our alliance (Principles 23 and 26) but also to enhance Robert’s expectation, motivation, willingness to change, and active participation in treatment (Principles 4–6 and 21).

It is our intention that the validation of Robert and empathy toward the inherent ambivalence about drinking, conveyed using motivational interviewing techniques, will create sufficient curiosity in Robert to notice the effects of his drinking and to stimulate an intrinsic desire to stop drinking. Taking a directive approach is likely to externalize the internal ambivalence that Robert has about drinking, thereby triggering or reinforcing his already high level of resistance to therapy (Principle 22). In that case, the therapist starts representing the idea of sobriety, and the patient embraces the drinking position. However, if the therapist avoids taking a directive approach (Principle 37), Robert will “discover” his own ambivalence. Motivational interviewing takes one step further, however. It incorporates paradoxical interventions by “siding” with the patient’s desire to drink. If “siding” with a position of sobriety is reinforcing the patient’s position of drinking, then “siding” with the position of drinking might push the pendulum in the opposite direction and elicit the patient’s desire to be sober.

With this rationale in mind, motivational interviewing offers interventions that range from reflection (Principle 26) to strategic amplification of the patient’s arguments (Principle 38) in service of tilting ambivalence toward a decision to stop drinking (Principles 17 and 38). For example, the therapist might (p. 312) indicate, using a matter-of-fact tone, that “it seems that drinking is working” for Robert. Such a statement is likely to elicit a disclosure from Robert about how drinking is actually detrimental for him. However, for such a statement to have a good impact (in terms of self-understanding and emotional experience [Principles 35 and 36]), process wise, its timing has to be optimal (Principle 21). Such a statement is likely to be effective when the therapist has already spent some time validating reasons for drinking and Robert seems ready to push the discussion to the next level.

Robert might be underplaying his readiness and/or his ability to quit. This issue will require assessment and an open and empathic discussion. Is he afraid of withdrawal? Is he afraid to lose alcohol, which became for him his best defense mechanism? Is he afraid to find out who he actually is without alcohol? What if not all of his difficulties go away once he is sober? Will he be able to face and take ownership over his problems? This is not an easy dilemma for someone who relies on externalization as a central coping mechanism. Given the paucity of connections in his family, drinking might be the only way to identify with his otherwise absent father. Thus, giving up drinking would mean giving up a part of his connection to his father.

Treatment using motivational interviewing principles is likely to help Robert explore reasons why giving up alcohol is so challenging. This is when Robert will be invited to express his ambivalence about drinking versus staying sober. The therapist is likely to tactfully challenge some myths related to drinking and “social anxiety”—thereby fostering both his self-understanding and adaptive interpersonal change (Principles 34 and 35). Whereas drinking decreases the anxiety, it also diminishes the “performance”—many times drinking leads to acting inappropriately. Drinking also interferes with taking ownership over social success—“Is it me or is it the alcohol?” Drinking also creates an undesirable reputation for the person. In the case of Robert, using motivational interviewing will hopefully help him develop stronger motivation to take necessary steps to stop drinking (Principle 38), such as participating in medically supervised detoxification (if advised), residential, or partial treatment that is likely to be followed by outpatient treatment. When motivational interviewing is working, the therapist will see a clear shift in Robert’s statements in therapy (“I think I want to stop drinking”), affect (e.g., displaying anxiety, shame, or helplessness around drinking), and indication of a desire to take steps to stop drinking (e.g., asking for help in identifying next steps, seeking guidance in starting a medical detoxification; Principles 35, 36, and 38). Once that milestone is reached, Robert and the therapist need to develop an action plan for how to become sober (Principle 38).

The motivational interviewing approach will need to take into account both his history (of childhood adversity and abuse, and repeated “failures” in (p. 313) relational and possibly vocational realms), as well his defensive style, which suggests that shame, negative self-evaluation, and fragility of self-esteem are likely inner experiences from which he is running away. The treatment approach will require special sensitivity on the part of the clinician to provide both validation and empathy, that is, an ability to see things from the patient’s perspective (Principles 24 and 26). The therapist will need to be patient and to resist the countertransferential need to push the patient to give up alcohol. The therapist also needs to be prepared for a few relapses along the way and help prepare Robert for their possibility. Sometimes I use the metaphor of running a marathon: I might have 100% motivation to run the marathon, but if I still lack the capacity, I will not get to the finish line. Treatment is about gaining both motivation to change and developing the capacity (e.g., skills) to stay sober. Each relapse is an opportunity to learn about both motivation and capacity.

Provision of feedback about Robert’s progress is critical (Principle 32), given his tendency to externalize responsibility and minimize the effects of alcohol. Incorporating regular discussion about how he thinks he is progressing can help him develop a bird’s-eye view of his treatment trajectory and confront externalization, avoidance, and minimization.

If Robert succeeds in establishing significant sobriety, the therapist will have the opportunity to assess the presence of other co-morbid disorders, including social anxiety disorder, major depressive disorder, and PTSD. Treatment of these disorders in a sober patient is important as a form of relapse prevention, as the possibility of future relapses decreases when other psychiatric disorders are being addressed (Kelly, Daley, & Douaihy, 2012). The use of treatment of these conditions should be guided by flexibility (Principle 33), depending on the preferences of the patient (Principle 13) and the therapist, as well as what will transpire diagnostically, once Robert is no longer drinking. For example, if the diagnosis of social anxiety gets confirmed, exposure-based treatment for social anxiety (Heimberg, Heimberg & Turk, 2004) is a likely recommendation for treatment. If he displays clear effects of trauma and maybe PTSD, then treatment approaches such as Seeking Safety or COPE can be suggested. In all of these treatments, it will be important to maintain a dual focus—helping Robert with the co-morbid disorders (social anxiety, PTSD), while carefully monitoring risk and craving for alcohol (Principles 35 and 38). Usually, developing a relapse prevention plan (Principle 38)—an action plan as to what steps to take to avoid drinking (e.g., call a friend, engage in hobbies, go for a walk)—helps in decreasing risks of a relapse. Robert is likely to have a higher risk of relapse during intensive work on anxiety. Therefore, and again in line with Principles 35 and 38, it will be beneficial to anticipate increased risk by discussing it with the patient, developing a coping plan (including a relapse prevention plan) and carefully monitoring whether Robert can tolerate these interventions. In fact, (p. 314) if he is not able to tolerate exposure work without relapses, such interventions need to be postponed until further stages in treatment (Principle 33).

As a part of exposure tasks, Robert might be asked to talk in front of a crowd, such as at an AA meeting, or join an amateur stand-up comedy club. In such a way he can start engaging in activities that provoke his social anxiety and even push these activities beyond his usual social engagements (simultaneously fostering change highlighted in Principles 34 and 38). This is likely to help in eliminating most of his social anxiety. If the PTSD diagnosis gets confirmed, he might be asked to develop a detailed narrative of his childhood experiences of being physically and emotional abused by his father and then go over that narrative numerous times with his therapist until his distress subsides (Principles 35, 36, and 38).

Once again reflecting principles of preference (Principle13) and flexibility (Principle 33), this treatment can also be based on more traditional psychodynamic therapy to help Robert with emotional suppression, including inhibition of his anger, coming to terms with childhood adversity, and his fragile self-esteem. Such treatment will ask Robert to describe his childhood experiences and explore their effects on his sense of self, perception of others, and his experience in the world (Principle 35). It is possible that he internalized both the feeling of being insignificant and bad and deserving of his father’s violent abuse, as well as a sense of responsibility for his father’s temper, along with a fear of his own anger grounded in his unconscious identification with his father. Consequently, his social anxiety is yet another way to shield himself against his own anger and fear of becoming savagely violent like his father. Exploring and re-experiencing these feelings in therapy—very much in line with emotional exposure—is likely to help him develop a better self-esteem and a more integrated perception of his own anger, as well as better self-awareness (Principles 35, 36, and 38). Through judicious use of interpretations (as describe by Principles 29 and 30), Robert could start coming to terms with projection of self-shaming and self-criticism as well as with projection of his own feared anger. These will help with decreasing his externalization as well as his tendency to cast others into critical roles—yet another component of social anxiety. Re-experiencing his childhood relationships is likely to color his relationship with the therapist. He might develop an apprehension that the therapist will get angry at him or that he might get angry at his therapist. From that fearful stance, he might project perception of his angry father on the therapist or enact his own identification with his father. The alliance ruptures that are likely to result from such emergence of anger will then need to be attended to and repaired (Principle 27). With skillful and empathic (Principle 26) use of interpretations (Principles 29 and 30) and self-disclosure (Principle 28), the therapist can help Robert identify these patterns, experience them, and put (p. 315) them in the perspective, which, in turn, could free him up from the stifling grip of his past (Principles 34–36). In such a way, psychodynamic therapy is likely to help Robert address his difficulties that made him want to drink. In line with dual-focus treatments for substance use disorder patients with other co-morbid disorders, Robert’s treatment will not only have to keep an eye on possible relapses to help Robert have a better handle of his sobriety but also to help him understand that alcohol use, social anxiety, depression, and possible PTSD are different reflections of his general vulnerability that came from a combination of genetic predisposition and childhood adversity. Helping him create new and meaningful directions in life, somewhat in line with Hayes’s acceptance and commitment therapy is another potential area of intervention.

Case 3

Case Formulation and Treatment Plan

In my opinion, this is a great case to demonstrate the importance of identifying personality pathology in patients with anxiety disorders. Accurately identifying personality disorders helps in guiding the treatment and identifying treatment priorities. Alternatively, and very much in line with a need for therapeutic flexibility (Principle 33), missing personality pathology is likely to lead to stalemates in treatment. What are the signs of personality pathology, most likely borderline personality disorder (BPD)? The patient describes symptoms of emotional instability, relational instability, an unstable sense of self, and suicidality. A number of features associated with the clinical presentation of this patient’s history signal that this is not “just an anxiety disorder.” The patient describes difficulty with intimacy and sustaining relationships over time, as well as brief affairs and risky choice of partners. These are features that are inconsistent with the avoidance of risks and fear of embarrassment characteristic of typical patients with social anxiety.

Using the language of object relations, these features represent opposite, unintegrated sides of self and object representation and, thus, suggest lack of internal integration. Thus, fear of embarrassment is not the main reason behind the clinical picture of what the patient is describing as “social anxiety.” In this formulation, lack of inner integration results in a fragile sense of self. This fragile self appears dependent on a positive relationship with a positively viewed other, which results in anxiety when these positive reactions are absent.

Another issue is the tendency to project negative, aggressive intent on others—a feature of BPD that results from splitting off of unintegrated (p. 316) aggression. This will lead to the coloring of interpersonal relations with sensitivity to criticism. The patient’s history suggests difficulty functioning following separations, such as after starting college. This is another pattern that is typical of patients with BPD (Masterson, 1978)

The importance of such assessment is twofold: (1) It allows the clinician to choose effective treatment, and (b) it permits the provision of psychoeducation regarding these difficulties to the patient and explain anxiety as part of BPD pathology. In fact, in my experience, social anxiety in cases such as Marie’s is rarely a separate disorder but rather is a manifestation of core BPD issues: rejection sensitivity, projection of aggression, and a nonconsolidated fragile self. Marie is likely to find such explanation validating and it will give her new hope that by treating BPD, the signs of social anxiety will improve as well (see the following discussion of diagnostic disclosure).

In this case, accurate diagnosis of the co-morbid BPD indicates that treatment of social anxiety needs to be conducted in the context of treatment of BPD. However, treatment of BPD should not ignore social anxiety. In fact, it will be helpful to convey that the therapist understands how painful and limiting social anxiety can be for Marie and explain how targeting BPD will also help with her social anxiety (Principle 24 and 26). Studies show that in BPD patients the co-morbid social anxiety improves following improvement of BPD (Keuroghlian et al., 2015). However, if BPD does not improve, social anxiety does not improve either (Keuroghlian et al., 2015). Thus, if BPD is ignored, the social anxiety treatment is not likely to be effective.

Again referring to the principle of flexibility (Principle 33), what will this diagnostic assessment imply in terms of treatment? Treatment will be structured around addressing BPD. A number of treatments were validated to treat BPD (Gunderson, Weinberg, & Choi-Kain, 2013; Stoffers et al., 2012; Weinberg, Ronningstam, Goldblatt, Schechter, & Maltsberger, 2011). Primarily, DBT (Linehan, 1993) was validated in numerous randomized controlled trials. Other treatments such as mentalization-based treatment (MBT; Bateman & Fonagy 2004), transference-focused psychotherapy (TFP; Clarkin et al., 2015), and general psychiatric management (GPM; Gunderson 2008) have shown comparable efficacy as DBT in reducing many symptoms of BPD patients, including their anxiety (Stoffers et al., 2012).

Which one of these treatments is the most appropriate for Marie? In many ways, Marie’s presentation is very typically of BPD patients, and therefore, in my opinion, any of the specialized treatments for BPD will be likely to help her. In her case, the nonspecialized treatments are not likely to be as effective as a specialized one. Specialized treatments for BPD are uniquely equipped to reduce suicidality in these patients (Gunderson et al., 2013). Her unique features, (p. 317) however, stem from demoralization and ambivalence, and I will subsequently discuss how these challenging characteristics can be addressed.

Implementation of Principles of Change

Based on the first cluster of principles of change, what can we say about the likely prognosis for Marie? The following characteristics increase chances of a good outcome: only moderate level of baseline impairment (Principle 1), intrinsic motivation (Principle 5), moderate readiness for change (Principle 6), and middle-social class status (Principle 7). However, other factors decrease her chances for improvement: co-morbid personality disorder (Principle 2), insecure attachment (Principle 3), low therapy outcome expectation (Principle 4), and difficult childhood (Principle 8).

In my experience of cases like this one, structuring treatment around BPD is the most effective way to accomplish change, including change in social anxiety. Most of the factors that reduce her prognosis can be seen through the lens of the co-morbid BPD. Reviewing the prognosis for BPD, however, shows that one can be cautiously optimistic regarding her prospects. She is young, has no known history of childhood abuse, no known history of substance use in her family, has a part-time job, takes classes at school, and has no signs of a co-morbid Cluster C personality disorder (Gunderson et al., 2006; Zanarini et al., 2006). Interestingly, she presents with some irritability during the interview. This is a positive prognostic sign: She can access her emotions and is willing to express them. In patients like Marie, anger is predictive of a better treatment alliance (Colson, Eyman, & Coyne, 1994). Therefore, I would feel somewhat optimistic that offering Marie any of the evidence-based treatments for BPD is likely to help her address her personality functioning, which is likely to be accompanied by improvement in signs of social anxiety. That said, her ambivalence is a main roadblock to effective treatment.

After the initial assessment, Marie can benefit from a psychoeducational discussion of her diagnosis, including suggested understanding of the social anxiety symptoms, as well as the recommended treatments. From the perspective of prognosis, it is critical to explain the following points. First, the therapist might explain that BPD is a “good prognosis diagnosis,” to use an apt expression coined by Mary Zanarini. With treatment, patients with BPD can get better across most domains (Gunderson et al., 2011; Zanarini et al., 2003). Second, I would add a brief explanation about the nature of BPD, explaining how emotional instability, relational difficulty, impulsivity, and problems with sense of self develop in the context of difficult early attachments. Third, improvement (p. 318) of co-morbid disorders, including social anxiety, often follows improvement in BPD symptoms, not the other way around (Keuroghlian et al., 2015; Zanarini et al., 2003). This means that addressing BPD is a sine qua non of resolution of other disorders, such as anxiety or depression (Gunderson, 2008). When BPD improves symptomatically, relapses of symptoms are not common (Zanarini et al., 2010), though they are certainly possible in time of stress, loss, and exceptional life challenges (McGlashan et al., 1986). Patients can, however, be prepared for such instances. Finally, I would add that treatments are available today to address these difficulties and that I believe I can help her, if she agrees to participate. This explanation is usually well received, so in Marie’s case, I would expect her to feel more validated and more hopeful following this explanation. Considering the impairment level associated with personality disorder, however, she would have to accept that her treatment would likely be longer-term (Principle 16) and would have to address her unfulfilled social needs (Principle 19).

An important challenge in Marie’s treatment is how to engage her in therapy (Principle 21). Many patients with BPD feel demoralized because they have a history of not being helped in prior therapies. In my experience, many of them start feeling more hopeful once they start specialized treatment for BPD. Such increase in motivation comes from a number of directions, many of them converging along the quality of a good working alliance, including the formation of a bond, and a mutual agreement about the goals and tasks of therapy (Principle 23). First, they receive an explanation about their diagnosis that they experience as validating (Gunderson & Links, 2014). Sometimes, this is the first time that they have received an explanation of all their difficulties that actually makes sense. Second, they participate in treatment with a therapist that understands their psychopathology and the treatment itself and uses interventions that effectively address their problems. Whereas these interventions could potentially work, it is possible that Marie still feels reluctant to embark on therapy. This is understandable given her childhood history. A cold mother, a distant father, lack of close connection with siblings, and an abusive brother are not only suggestive of an invalidating environment but also suggest insecure attachment—a likely reason she continued to feel disconnected from others and lonely in her adult life.

Possibly, Marie internalized the view of others as being abusive (like her brother), distant and cold (like her parents and siblings), or nonprotective (like her whole family who did not protect her from her brother). In line with Principles 11 (resistance) and 12 (motivation), I would be inclined to validate that her ambivalence is an honest self-disclosure that is very understandable, given her history (Principles 26 and 37). This is likely to pave the way to an exploration of how this general attitude of distancing helped her survive as she (p. 319) was growing up (Principle 24–26 and 35). I would be inclined to discuss many of her behaviors, such as distancing, distracting the therapist, cutting, drug use, and reliance on relationships for comfort in terms of efforts to survive in the chaotic, invalidating environment of her childhood. This can take a preliminary stage in treatment that will help Marie feel understood and trusting of the therapist as well as consolidate hope for treatment engagement. At that stage, and hopefully in line with her own preference (Principle 13), Marie might consider engaging in any of the suggested specialized treatments with an explanation offered by the therapist that these treatments are likely to help her accomplish the kind of the changes she is seeking—developing a meaningful life (“life worth living”; DBT), stable relationships, and self-esteem as well as decreasing anxiety and self-destructive behaviors.

What would these treatments look like if delivered to Marie? In DBT, for example, the therapist is likely to rely on a hierarchy of treatment targets, which will prioritize Marie’s suicidality (a Stage I target) overavoidance, anxiety, and emotional dysregulation (Stage II or quality-of-life targets). Treatment will expect Marie to attend individual therapy and a DBT skills group, monitor target behaviors, and use skills. In this approach, reduction of BPD symptoms and improvement of social anxiety is attributed to the increased use of skills that are consistent with Principles 34 to 38: emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness. In DBT, these skills are fostered by the therapist’s maintenance of a dialectic balance between acceptance (client-centered, nondirective) and change (directive, behavioral change-oriented) techniques. The responsive use of these various types of interventions is likely to be beneficial considering Marie’s relatively low level of problem assimilation (Principle 10), relatively high level of reactance level (Principle 11), and her presentation of both internalizing and externalizing coping styles (Principles 17 and 18). The acceptance techniques, as well as the use of self-disclosure (Principle 28), are particularly emphasized in the repair of alliance ruptures (Principle 27), which are frequent in the treatment of BPD.

In TFP, the risk of suicidality will also be taken up with the patient. Improvement in social anxiety will likely to happen once Marie develops a better integrated and thus less fragile identity and starts recognizing instances of projection of her anger. In TFP, the therapist is likely to explore how her sensitivity recurs in the treatment relationship and help her develop insight into projected anger (Principles 26, 27, 29, 34–36). In GPM, the therapist and Marie will collaborate on pragmatic goals, such as getting and keeping a job, and maintaining functional relationships (Principle 34, 38). Social anxiety becomes understood in the context of “rejection sensitivity,” which is a temperamental difficulty of many BPD patients. Accepting and recognizing this difficulty in the context of temperamental factors will hopefully help Marie (p. 320) anticipate it and learn various coping skills to manage it (Principles 38). MBT will help Marie with social anxiety by helping her develop a broader perspective on other people’s states of mind (Principle 34, 35). This is usually done by “mentalizing”—thinking through—different possible states of mind of others.

These psychodynamic approaches differ as to what they recommend regarding various principles. Principle 30 applies to TFP treatments but is less likely to play a role in MBT or GPM that, consistent with Principle 15, discourage a transference focus, especially early on in treatment. Use of self-disclosure (Principle 28) is strongly discouraged in TFP but very much present and used strategically in both MBT and GPM.

Although coming from different perspectives, these treatments are likely to look very much alike when delivered. They are all likely to emphasize the emotional focus of therapy, attention to the treatment relationship, a pragmatic focus on treatment goals, respective collaboration, expectations, and keeping Marie in a proactive role (Weinberg et al., 2011). Such similarities in therapeutic focus emphasized by so many of the principles of change identified in this book allow for, if not intrinsically encourage, flexible use of the most appropriate interventions to particular clients (Principle 33). The following vignette illustrates a likely development in any effective treatment of Marie.

After a few months of therapy, Marie comes for a regular appointment; she enters the therapist’s office, sits down, and proceeds silently looking at the floor.

therapist: I am noticing you are silent today. Could you share what’s on your mind?

marie: (shaking her head) I thought . . . I want to stop therapy . . . stop coming here.”

therapist: Can you say more about what made you think about stopping therapy?

marie: I don’t think it is a good fit; I don’t feel I am connecting with you.

therapist: I am not sure I understand yet—can you help me understand the way you experience it?

marie: I guess . . . I was feeling that for a while . . . for the last few weeks . . . after that time you called and canceled the appointment. I guess, you said you were feeling sick and offered to reschedule, but. . . . After that I started feeling it was not going to work.

therapist: What was on your mind when I called, do you remember?

marie: It was just over for me. . . . I thought you are like everyone else, it is like a job for you. And here I am, stupid me, wanting you to care.

therapist: Seems like you are saying that I don’t care.

marie: No, you don’t. (p. 321)

therapist: That must have felt terrible—here we go again, here is another person who does not care.

marie: (starting to tear up) Yep, you nailed it. Yet another person.

therapist: What is behind your tears, Marie?

marie: I don’t know. . . . I feel stupid that I was hoping that maybe it can be different this time, was hoping you could be different. First, my parents, then all these boyfriends I had and then Marc. And now—you.

therapist: I hear you. How would you know that anyone cares?

marie: (looking at the therapist now and is sounding angry) They are there for me; they are helping me. And you were not there that day. That means you don’t.

therapist: You sound angry now—could you say more?

marie: More? What more do you want? You are the one who messed up, you cancelled! And you want ME to talk?

therapist: Ok, now I think I see it. You were really looking forward to seeing me and thought I cared; then I canceled the appointment and your whole world collapsed—you felt that I don’t care anymore.

marie: I know, it does not make sense. You were sick, you sounded really sick that day. I just never know what to trust. I always have worries that people will betray me, so I don’t get close to them. I feel such a terrible person—I yelled at you now.

therapist: No offense taken. But maybe it tells you something about your relationships with other people?

marie: That I worry so much that they will leave me that once they disappoint me I say, “That’s it, done with you, I am leaving?” (looking at the therapist with a half-smile)

therapist: Well said. I would suggest remembering this thought the next time you feel that people don’t care. And I am also noticing you are not looking away anymore?

marie: I think I feel better now. I get it—sometimes I go with my worries and feel alone.

In this example the therapist and Marie collaborate closely around their relationship with a clear affective focus. Given her heightened emotional state, the interventions are mostly empathic validation. The therapist is working hard on staying connected with her emotional experience. This helps them work things out between them, repair the alliance, and help Marie develop a new important understanding of herself that is also relevant to her social anxiety and relationships with others (Principles 26, 27, 35, 37).

If specialized treatment for BPD is not effective in reducing the social anxiety, the therapist should include additional focus on social anxiety. In fact, in (p. 322) some cases, DBT requires the addition of a separate attentional focus on using exposure-based interventions (Harned, Korslund, & Linehan, 2014), whereas GPM is “friendly” to the incorporation of additional anxiety focus, if such focus is clinically justified (Principle 38).

Reflection on the Writing Process

In my clinical work I see patients with complex clinical pictures. That means that most of my patients present with multiple disorders, and almost all of them would be excluded from clinical trials that test evidence-based interventions that became a gold standard of clinical care. Treating such a patient population is a likely common practice and possibly not that unique to the clinical settings in which my colleagues and I are working hard on translating effective treatment approaches into effective care for each individual patient with their unique circumstances.

Coming from that perspective, writing my reactions to the three cases was very educational. I found the approach helpful in developing treatment plans for how to extrapolate existing treatments outside the areas of their usual application. For example, how does one apply treatment for social anxiety, commonly treated by exposure-based interventions, to a person with a different cultural background, or a patient with alcohol use disorder, or a patient with BPD? Having explicit treatment principles helps with generalizing treatment interventions in a meaningful way while taking into account the subjective characteristics and circumstances of an individual patient. While some of the of the principles were known to me either based on the literature or clinical experiences, others were not and that was a welcome learning opportunity.

Writing this chapter deepened my thinking about anxiety disorders. In all three cases anxiety does not appear alone but rather in the context of other clinical characteristics that critically affect treatment. In the case of Philip, acculturation stress and its effect on the development of his identity and relationships highlighted the need for altering treatment targets (identity, relationships) and treatment style (genuine connection, awareness of power differential). In the case of Robert, recognition of co-morbid alcohol use emphasized the complexity of a diagnosis of social anxiety in the presence of active drinking as well as difficulty treating social anxiety in the absence of treatment for alcohol use. In the case of Marie, accurate diagnosis of BPD highlighted the importance of addressing BPD and understanding social anxiety in the context of BPD psychopathology. In all of these cases, cultural background or co-morbid disorders (p. 323) (alcohol use, BPD) interact with individual characteristics of the patients, but all of these factors have separate effects on social anxiety symptoms.

Writing this chapter also prompted me to think about explicit or implicit principles I use in my own clinical practice (e.g., using dual-focus treatments in patients with substance use and co-morbid disorders, prioritizing treatment of personality disorders in patients with these conditions, understanding the psychopathology of the patient helps in understanding and validating the patient, anticipating the future course/prognosis, and in developing treatment goals). Thinking in terms of such principles helps not only in translating the literature into practice but also in subjecting my own thinking to more explicit scrutiny and identifying what works, what does not and what, potentially, harms the patient.

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