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http://ccs.sagepub.com/content/7/6/538The online version of this article can be found at:

DOI: 10.1177/1534650108321307

2008 7: 538 originally published online 23 July 2008Clinical Case StudiesPeter J. Norton and Debra A. Hope

Behavioral Therapy for Anxiety DisordersTransdiagnostic Group CognitiveThe ''Anxiety Treatment Protocol'' : A Group Case Study Demonstration of a

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538

The Anxiety Treatment Protocol

A Group Case Study Demonstration of aTransdiagnostic Group CognitiveBehavioral

Therapy for Anxiety Disorders

Peter J. NortonUniversity of Houston

Debra A. HopeUniversity of NebraskaLincoln

This article describes a group study of clients partaking in the Anxiety Treatment Protocol

(ATP), a 12-week transdiagnostic group cognitivebehavioral therapy (CBT) for individuals

with any anxiety disorder. The treatment rationale is briefly described, along with a discussion

of the accessibility, dissemination, and therapeutic advantages of delivering transdiagnostic

anxiety group treatment. The session-by-session protocol is described in detail, and a quanti-

tative case study of one recent groupand two clients in particularis presented.

Keywords: anxiety; transdiagnostic; CBT

1 Theoretical and Research Basis

In recent years, a shift in the conceptualization of anxiety disorder has begun to emerge,

with a growing emphasis on the commonalities among the different DSM-IV(Diagnostic

and Statistical Manual of Mental Disorders, 4th edn; American Psychiatric Association

[APA], 1994) diagnoses. Such conceptualizations hold that the distinctions between the

DSM-IVanxiety disorder diagnoses are somewhat artificial or unnecessary, whereas the

common aspects are of greater clinical importance. Indeed, some (e.g., Barlow, Allen, &

Choate, 2004) have suggested that from this conceptualization, anxiety and depressive dis-

orders could be subsumed under a single negative affect syndrome label.Along with this conceptualization, several groups have begun to explore the so-called

transdiagnostic group treatments for anxiety that incorporate individuals with differing

DSM-IVanxiety disorder diagnoses within the same treatment groups. The purpose of this

article is to describe one such transdiagnostic group treatment protocol that has yielded

Clinical Case Studies

Volume 7 Number 6

December 2008 538-554

2008 Sage Publications

10.1177/1534650108321307

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hosted at

http://online.sagepub.com

Authors Note: Correspondence concerning this article should be addressed to Peter J. Norton, PhD,

Department of Psychology, University of Houston, 126 Heyne Bldg, University of Houston, Houston, TX

77204-5022; e-mail: [email protected]. The writing of this manuscript, and portions of the research described

herein, have been supported by NIMH Grant 1K01MH073920 and a UH Grant to Enhance and Advance

Research, both awarded to the first author.

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Norton, Hope / Anxiety Treatment Protocol 539

intriguing efficacy evidence across controlled and uncontrolled outcome trials. We begin

with a brief overview of the treatment model and the rationale for why a transdiagnostic

treatment approach for anxiety disorders is viewed as feasible and appropriate. Second, the

Anxiety Treatment Protocol (ATP), a 12-session manualized group protocol is described indetail, followed by a summary of the available efficacy evidence. Finally, the article con-

cludes with a quantitative case study of a recent treatment group and a discussion of future

directions for study and treatment application.

Background and Theoretical Underpinnings

Although a complete review of the theoretical model underlying transdiagnostic anxiety

treatments is beyond the scope of this article, a brief review is presented (for comprehen-

sive reviews, see Barlow, 2000; Barlow et al., 2004; Norton, 2006, in press a). Several dis-

tinct lines of investigation appear to support the hypothesis that the DSM-IV anxietydisorders may represent a single core pathology that may be elicited by different stimuli

and manifested in distinct ways. First, considerable research indicates that negative affec-

tivity, a temperamental personality trait characterized by sensitivity to negative emotions

because of a low sense of control underlies the manifestations of clinical anxiety (Clark &

Watson, 1991; Eysenck, 1957; Gray, 1982; Spielberger, 1985). Second, observed rates of

comorbidity within theDSM-IVanxiety disorders greatly exceed that which would be pre-

dicted if anxiety disorders were independent disorders (Andrews, Stewart, Allen, &

Henderson, 1990; Brown & Barlow, 1992; Sanderson, Di Nardo, Rapee, & Barlow, 1990).

One explanation for the high comorbidity is that the comorbid disorders are not indepen-dent disorders, but rather multiple manifestations of the same negative affect pathology. It

is also possible that the high rates of comorbidity could be the result of other mechanisms,

such as a common risk factor for two or more independent disorders. However, this alter-

native explanation appears less tenable in light of the third line of evidence: treatment out-

come data. Highly similar cognitivebehavioral therapy (CBT) and pharmacological

treatments are efficacious across the anxiety disorders (Norton & Price, 2007), suggesting

that these treatments may be impacting on a core pathology underlying each of these diag-

nostic groups. This evidence is strengthened by findings that nontargeted comorbid anxiety

and depressive diagnoses frequently remit after treatment for a principal anxiety diagnosis

(Blanchard et al., 2003; Borkovec, Abel, & Newman, 1995; Brown, Antony, & Barlow,1995; Norton, Hayes, & Hope, 2004). Thus, though there may be some utility in consider-

ing each of the anxiety disorders as distinct entities, the evidence here suggests greater

similarity than difference.

Empirical Support

To date, three empirical studies have directly examined the efficacy of the ATP with

diagnostically mixed groups of participants with anxiety disorder diagnoses. First, Norton

and Hope (2005) conducted a trial of their treatment and found that, compared to clients in

a waitlist control condition, clients receiving treatment improved significantly. Roughly

67% of those receiving treatment, as compared to none of the waitlist controls, showed a

reduction in diagnostic severity to subclinical levels, and significant improvement was also



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noted on some, albeit not all, indices of anxiety. Unfortunately, the limited sample size of

this study (n = 23) precluded analyses of outcome by diagnosis. As a follow-up analysis of

the Norton and Hope (2005) data, Norton et al. (2004) reported significant decreases in

depressive symptoms and in the diagnostic severity of depressive disorders among thosereceiving treatment, despite depression not being targeted in treatment, whereas no change

in depression was noted for waitlist controls. Finally, using a separate sample recruited dur-

ing an open uncontrolled trial, Norton (in press b) applied mixed-effect regression modeling

to data from 52 participants with an anxiety disorder diagnosis. Analyses revealed a signif-

icant overall session slope, indicating that participants tended to improve over treatment.

Comparative analyses found no evidence of diagnosis by session interactions, suggesting

no differential outcome for any diagnostic groups.

Corroborating these data are the results of several other transdiagnostic anxiety treat-

ment trials using similar, but independently developed, mixed-diagnosis anxiety treatments.

Erickson (2003) reported the results of an uncontrolled trial of a transdiagnostic CBT pro-gram for 70 individuals with an anxiety disorder diagnosis. His results suggested signifi-

cant decreases in self-reported anxiety and depression among clients completing the

11-week treatment. Furthermore, 6-month follow-up data from 16 participants suggested

maintenance of treatment gains. Lumpkin, Silverman, Weems, Markham, and Kurtines

(2002) reported similar treatment effects following a 12-week transdiagnostic treatment

with anxious youths. Multiple baseline results suggested notable reductions on measures of

anxiety occurring during treatment, but no change during the baseline periods. As well,

treatment gains were maintained at 6 and 12 months. McEvoy and Nathan (2007) reported

that participants attending their 10-week group treatment program showed improvementsthat were comparable to those observed in several randomized controlled trials that were

used as benchmarks. Finally, Allen, Ehrenreich, and Barlow (2005) presented a case study

of six individually treated clients with different anxiety and depressive diagnoses using a

unified treatment protocol, and noted that five of the six clients showed decreases in the

severity of their primary diagnoses to subclinical levels. Data from self-report question-

naires generally supported these findings.

Overall, multiple studies are providing converging evidence supporting the efficacy of

transdiagnostic anxiety treatments in general, and the ATP in particular. Despite this, fur-

ther analyses of efficacy are clearly warranted, particularly using comparison conditions of

increasing sophistication.

2 Case Presentation

This case study presents information and data regarding a single treatment group that

began with eight clients. For the purposes of description of session content, the experiences

of two clients, Ricardo and Kay,1 are presented in detail. The remainder of the group clients

are simply referred to as Clients A through F.

Ricardo is a 27-year-old married Hispanic man. He is currently attending college while

working full time in a hospital setting. Ricardo and his wife have no children. He has lived

in the United States his entire life. Kay is a 33-year-old Caucasian woman who is married

and finishing up coursework required for licensure in her profession. Her family is currently

540 Clinical Case Studies



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only supported through her husbands employment. She was raised in Europe, but immi-

grated to the United States in 2005 with her then-fianc/current husband. Kay and her hus-

band have no children.

3 Presenting Complaints

Kay presented to the clinic for assistance for anxiety and panic attacks in social situa-

tions. During her telephone intake, Kay reported a longstanding history of social anxiety

and situationally bound panic attacks that had begun around 2002. She reported that the

attacks occur when she is meeting new people, interviewing, and during public speaking.

She reported worries that her symptoms had become more difficult to hide, but up until that

point, they had not prevented her from interacting with others.

Ricardo presented to the clinic because of panic attacks that typically arise when he iseating, alone, or has time to think. During the telephone intake, Ricardo began by report-

ing that he believes that he has generalized anxiety disorder (GAD). When asked to

describe his symptoms, he stated that he feels dizzy and light-headed throughout the day.

He reports that he has a number of physical symptoms and then he begins having irrational

thoughts. These irrational thoughts include I am going to go crazy, I am having a heart

attack, and I am never going to get better. He stated that he has had these problems all

his life, but 3 years ago the symptoms increased in severity.

4 History

Ricardo reported that his anxiety and panic attacks began several years before he got

married. He presented at that time to emergency rooms three times; during each visit he

received Lorazapam. Subsequently, after an involuntary 72-hr hold because of a severe

panic attack, he voluntarily admitted himself to a small psychiatric hospital where he

received medication and unspecified psychotherapy. His current panic attacks resumed a

month-and-a-half before he presented for the current services. Ricardo reported a moder-

ate family history of anxiety and depression.

Kay indicated that she started experiencing panic attacks in social situations approxi-mately 4 years prior to presenting to the clinic. At that time she was still living in Europe

and received hypnotherapy for her anxietywhich she indicated was not helpful. During

the past year, including during her move to the United States, she felt her anxiety was grad-

ually increasing to the point where she felt it was interfering with her life. She reported no

history of anxiety or depression in her family, although she did indicate that one of her

parents had a history of problems with alcohol.

5 AssessmentAll clients were assessed using the Anxiety Disorder Interview Schedule for DSM-IV

(ADIS-IV; Brown, Di Nardo, & Barlow, 1994) and associated Clinician Severity Ratings




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(CSR) at pretreatment, and all completers were reassessed using the ADIS-IV within 2

weeks of the final session. During each session, attendees completed the State-Trait

Anxiety InventoryState Version (STAI; Spielberger, 1983) immediately prior to the begin-

ning of each session, and the Working Alliance InventoryShort Form (WAI: Tracey &Kokotovic, 1989) or Gross Cohesion Scale (GCS: Stokes, 1983) on alternating sessions.

WAI (measuring alliance with the therapists) and GCS (measuring alliance with the group)

were completed privately at the end of the session and deposited in a lock box to ensure

that the therapists and other group members would not see their responses. Table 1 presents

a summary of these eight clients initially enrolled in the treatment group.

As noted in Table 1, most of the participants in this group had anxiety diagnoses of panic

disorder with agoraphobia (PDA) or panic disorder without agoraphobia (PD) or social

anxiety disorder (SAD). One client was assigned coprimary diagnoses of GAD and SAD,

whereas another had a comorbid diagnosis of GAD. Although not representing a broad

range of anxiety diagnoses, the group composition was not uncharacteristic of the typicalgroup demographic seen at our clinics. Despite the number of socially anxious individuals

in the group, the therapists documented in their case notes that the group were all highly

interactive with the therapists and with each other. The treatment group was seen for 12 ses-

sions during 2006 and was conducted by two senior graduate student therapists who were

experienced in the delivery of the treatment protocol.

Kay was diagnosed with SAD (CSR = 5). Her social anxiety held some panic-like fea-

tures in that she feared specific symptoms (shaking) that were exacerbated when she

became anxious, but she did not meet criteria for PD as the focus of her concerns was on

others negative reactions to her symptoms. She further reported some other fears, includ-ing driving on freeways and punctuality, but did not meet criteria for other Axis I diagnoses.

Ricardo was diagnosed with PD (CSR = 6), but because he denied any situational avoid-

ance, he did not meet criteria for agoraphobia. With the exception of choking sensations,

he endorsed experiencing all of the prototypical symptoms of panic at a very severe inten-

sity. Ricardo did not meet criteria for any other Axis I disorder.

6 Case Conceptualization

Consistent with transdiagnostic cognitivebehavioral models of anxiety, the cases wereconceptualized an excessive or irrational fear of X. Differences between clients regarding

specific fear-eliciting Xs are seen as less important than the common features of biased

beliefs about the dangerousness or likelihood of negative consequences occurring, and

attempts to control the fear through maladaptive avoidant-coping attempts such as avoid-

ance, escape, or compulsive rituals. Attempts at avoiding then reinforce prior biased beliefs

and maintain the fears.

7 Course of Treatment and Assessment of ProgressThe ATP utilizes 12 weekly group sessions, each lasting 2 hr. Group sizes are typically

capped at 6-8 clients and 2 therapists. With the exception of the first session, sessions are




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active, with skills and treatment components being practiced within the session. Practice of

treatment skills outside of session (i.e., homework) is strongly encouraged, and home-

work noncompliance is addressed in the session as a barrier to recovery. The interventions

in ATP draw heavily on standard cognitivebehavioral practice such as Becks cognitivetherapy (e.g., Beck & Emery, 1985), Heimbergs treatment for SAD (Heimberg & Becker,

2002; Hope, Heimberg, Juster, & Turk, 2000; Hope, Heimberg, & Turk, 2006), and Barlow

and Craskes (2000) treatment for PD.

The ATP is divided into two phases of treatment. The first phase emphasizes traditional

CBT techniques for addressing the principal feared stimuli. The second phase shifts away

from the fears and focuses on developing skills to address the general neurotic style that

may still promote new acquisition of emotional problems or return of fear. An overarching

philosophy that permeates the treatment is that clients are seen as having an excessive or

irrational fear of X, as opposed to having diagnoses of PD, obsessivecompulsive disorder

(OCD), and the like. Our experience is that use of such diagnostic labels create perceptionsof differences among group members and may cause therapists to conceptualize multiple

diagnoses hierarchically as opposed to deriving a single case conceptualization. In essence,

all participants were encouraged to examine the commonalities among their fears as

opposed to the differences in their diagnoses, in much the same way that a heterogeneous

group of individuals in a group OCD treatment are encouraged to see the commonalities in

their presentations rather than differences among their intrusions, appraisals, and rituals.

In the following description of the group, we have presented a group as it actually

unfolded. Not everything went perfectlysometimes participants missed sessions and

dropped out. Occasionally events did not go as planned. Despite this, the participants whostayed with the group made substantial clinical gains. We are continuing to refine our pro-

cedures and training but we hope this case description will offer some sense of how such a

transdiagnostic group could be conducted (see Table 2).

Table 1

Participant Summary at Group Initiation

Client Sex Age Diagnoses and CSR Session 1 STAI Session 1 WAI

Ricardo M 27 PDA-6 56 46

Kay F 33 SAD-5 53 80

Client A F 23 PD-6 41 56

Client B M 22 PD-4 32 84

Client C M 30 SAD-6 48 59

Client D M 35 SAD-5 46 72

Client E M 35 SAD-6

(GAD-5) 51 72

Client F F 30 GAD-5

SAD-5 61 81

Note: Client initials altered to ensure confidentiality. Diagnoses in parentheses are comorbid/nonprimary. CSR,Clinician Severity Ratings; GAD, generalized anxiety disorder; PD, panic disorder without agoraphobia; PDA,

panic disorder with agoraphobia; SAD, social anxiety disorder; STAI, State-Trait Anxiety Inventory (State

Version); WAI, Working Alliance Inventory.



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Phase 1

The general purpose of the first phase of the ATP protocol is to reduce or eliminate the

presenting fears using psychoeducation, cognitive restructuring, and intensive graduated

exposure.

Session 1Education and group socialization. The initial session and part of the second

session are primarily educational; they are designed to provide an understanding of anxi-

ety, anxiety disorders, and the cognitivebehavioral model, to thoroughly describe the com-

ponents of treatment and their purpose, and to facilitate group cohesion. During the first

session, the concept of a fear-avoidance hierarchy is discussed, and each client develops a

hierarchy with assistance from the therapists.

In the illustration group, the session was largely didactic and all group members

appeared to understand the psychoeducational material. With the exception of Client B,

STAI scores,M =

48.50, sd =

9.06, were at or above clinical norms for individuals with ananxiety disorder diagnosis (see Antony, Orsillo, & Roemer, 2001). Working alliance was more

variable, with scores ranging from the scale maximum to the midpoint,M= 68.75, sd= 13.66.

Ricardo was a very active participant in the first session, openly discussing his fears,

Table 2

Session-by-Session Quantitative Summary

Ricardo Kay

ADIS severity at posttreatment

Session PDA-6 SAD-5

Pre STAI WAI GCS STAI WAI GCS

1 56 46 53 80

2 45 37 a

3 63 64 47 84

4 51 44 54 58

5 50 66 41 84

6 40 54 45 667 42 58 49 84

8 a a 34 84

9 a a a a

10 54 46 47 68

11 45 59 36 84

12 37 41 42 68

ADIS severity at posttreatment

Post PDA-4 SAD-2

Note: Client names altered to ensure confidentiality. ADIS, Anxiety Disorder Interview Schedule; GCS, Group

Cohesion Scale on sessions 2, 4, 6, 8, 10, and 12; PDA, panic disorder with agoraphobia; SAD, social anxietydisorder; STAI, State-Trait Anxiety Inventory (State Version); WAI, Working Alliance Inventory on sessions 1,

3, 5, 7, 9, and 11.

a. Client did not attend or complete measure for this session.



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triggers, and family history of psychopathology. He also discussed his past treatment history,

particularly the medications he has previously taken. Kay, despite her social fears, also openly

participated in session and was engaged in the group process. She appeared to have a good

understanding of the nature of anxiety as well as the three component model of anxiety.

Session 2Education, treatment rationale, and cognitive restructuring. In the second

session, the treatment rationale is further discussed, followed by a discussion of automatic

thoughts. Cognitive restructuring is introduced with a thorough discussion of the impor-

tance of automatic thoughts or appraisals in provoking anxious states. Clients are asked to

monitor automatic thoughts during the week as homework.The group members all appeared to understand the role of automatic thoughts in pro-

voking episodes of anxiety. Because of a discussion of intrusive obsessional thoughts

regarding self-harm by another client, Ricardo described a belief that psychologists want

you to say that you want to kill yourself so that they can hospitalize the client. In the sub-

sequent discussion, it became clear that Ricardo greatly feared hospitalization and was

once involuntary committed under a 72-hr hold. This discussion upset several other group

members as it exacerbated fears of losing cognitive and emotional control and of being

institutionalized. The therapists processed these concerns with the group and the session

continued according to protocol. Subsequently, the other group members were also able toclearly identify automatic thoughts underlying recent anxious episodes, and these thoughts

were all highly typical of their fears (e.g., assuming bodily sensations signaled a medical

catastrophe, anticipating that others were forming negative social impressions of them,

0

10

20

30

40

50

60

70

80

STAI WAI GCS

Figure 1

Mean State Anxiety, Working Alliance, and Croup Cohesion scores across sessions.

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etc.). STAI scores were generally lower than before session 1,M = 39.86, sd = 9.42, which

may simply reflect increasing comfort with the treatment group. Group cohesion, however,

tended toward the midpoint of the scale,M = 44.83, sd = 10.78, suggesting that the group

bond was somewhat tentative. Kay did not attend the second session for unknown reasons.

Session 3Cognitive restructuring. During the third session, thought monitoring home-

work is reviewed, the concept of thinking errors is discussed, and clients are encouraged to

identify errors in their monitored thoughts. The process of asking and answering disputing

questions is then covered and practiced with the monitored thoughts, initially with thera-

pist assistance. Finally, rational responses are developed based on thought challenging.

All of the group clients attended the third session where, according to protocol, the art of

identifying thinking errors in automatic thoughts, challenging the errors, and developing

rational responses was introduced and practiced using the automatic thoughts that were

recorded for homework. STAI scores continued to decrease,M= 38.25, sd= 14.51, althoughRicardo showed a notable increase in anxiety. He indicated that the previous sessions dis-

cussion of involuntary institutionalization had upset him and that he spent much of the week

ruminating about his previous experience and worrying about possibly being committed

again. Because of her absence in Session 2, Kay actively listened to other group members

describe their automatic thoughts but was a reluctant participant. She did eventually describe

some recent automatic thoughts regarding an upcoming social event. She appeared to

quickly grasp the rationale and technique of identifying and challenging automatic thoughts,

and generating rational responses. Therapist alliance continued to improve,M = 73.13, sd =

10.15, with those initially scoring in the midrange showing much improved alliance.

Sessions 4 through 9Exposure and response prevention. Sessions 4 through 9 are dedi-

cated to in-session graduated exposure and response prevention. At the start of each session,

exposure exercises are introduced, negotiated, and planned. Where possible, exposures are

devised where multiple group members will draw benefit from participating, such as having

two clients with socioevaluative concerns engage in a political debate. All exposures are pre-

ceded by cognitive restructuring of likely automatic thoughts. In previous groups, 50-75% of

the group clients engage in an exposure in each session. Those not engaging in an in-session

exposure are assigned self-exposure homework and engage in an in-session exposure during

the following session. Clients report their anxiety during exposures using subjective units ofdiscomfort scale (SUDS) that goes from 0 to 100, with 100 being high anxiety. As discussed

later, the scale is occasionally abbreviated to 1-5 to facilitate nonverbal reports.

Immediately before the groups fourth session, Client C cancelled his attendance citing

a conflict with a work meeting. In his message, he specifically stated that it was not related

to the upcoming exposure exercises and noted that he would attend the following week.

Unfortunately, he did not respond to further attempts to contact him, and he dropped out of

the treatment group. Two other clients also missed this session for unknown reasons, but

both attended the subsequent week. With five clients in attendance, exposure exercises were

specifically practiced for four clients (interoceptive hyperventilation, role-played con-frontation with an employee, role-played small talk conversation at a party), including both

Ricardo and Kay. During the exposures, all of the participating clients showed expected

habituation curves (average peak SUDS = 62.5, average ending SUDS = 25.0). Not




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surprisingly for the first exposure session, STAI scores were elevated from the previous

week for most attending clients,M = 44.60, sd = 13.20, but group cohesion increased sub-

stantially,M = 58.80, sd = 9.65.

Kays exposure involved a role-played small-talk conversation at a party, with one of thetherapists portraying someone that Kay did not know at the party. Kays automatic thoughts

were Theyll see that Im nervous and They wont want to talk to me. She challenged

her thoughts and developed a rational response of Even if they notice [her perceived shak-

ing] Im still capable of having a conversation. During the role-played exposure, her

SUDS began at 60-70 (out of 100) but declined to 40 after 3 min of a light and natural con-

versation. Furthermore, despite her concerns about shaking, the other group members indi-

cated that they saw no visible shaking or trembling. Kay appeared surprised by this but

appeared to accept their feedback.

An interoceptive exercise of hyperventilating was selected for Ricardos first exposure.

Prior to the exposure he reported automatic thoughts of Ill lose control, Ill go crazy,and Ill hear things. Cognitive restructuring was somewhat difficult for Ricardo, but he

developed a rational response of chances are slim that Ill hear things. After a demon-

stration, Ricardo began the exposure by hyperventilating very strenuously, such that his

SUDS ratings increased from one (out of five, made using a show of fingers during the

hyperventilation) to a four before beginning to subside. In the following session, Ricardo

sought out one of the therapists to clarify his fears. He indicated that his panic attacks arise

not because of physical sensations but rather when he experiences sensory or cognitive

events that he fears might mean he is going psychotic. For example, he indicated that when

he sees movement out of the corner of his eye, he fears that it might have been a halluci-nation. Careful screening did not reveal the presence of any hallucinatory, delusional, or

other psychotic symptoms, only a fear of such symptoms that developed when he was

briefly institutionalized and when he observed psychotic inpatients.

Subsequent exposure sessions involved gradually moving up through the triggers on their

fear and avoidance hierarchies. Ricardo experienced difficulty in preparing for, and com-

pleting, his exposures during session. Attempts to develop a worry script for imaginal expo-

sures of losing psychological control were delayed because of low homework compliance.

He then missed two exposure sessions because of self-described health reasons and tired-

ness, but did complete an exposure to video clips of individuals going crazy and being

forcibly committed (peak SUDS = 80; ending SUDS = 50). During these sessions, however,Ricardo admitted to some ongoing suicidal ideation and increasing depression and was seen

individually by a therapist to assess and manage the ideation and depressive feelings.

Interestingly, though Ricardo had difficulty with exposures, depression, and suicidal

thoughts, he continued to show a downward trend in his STAI scores from 51 during the first

exposure to 42 at his last exposure session. His therapist alliance and group cohesion scores

tended to be lower that those of the others in the group during this time, however.

Kays exposures included a role-played exposure to making small talk at a party while hold-

ing a full glass of water (fears of shaking visibly; peak SUDS = 70; ending SUDS = 30).

Despite being nearly full, no water spilled from the glass during the exposure. Kay felt this was

a very strong piece of evidence against her belief that she shakes visibly and uncontrollably. In

vivo exposures to initiating a conversation with random groups of students on campus were



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conducted (peak SUDS = 70; ending SUDS = 30), as was an exposure of giving a presentation

to the group (peak SUDS = 80; ending SUDS = 40) and multiple homework exposures such

as initiating conversations with strangers and attending social events.

Other group members also proceeded up their fear-avoidance hierarchies throughouttreatment. Client A did not attend the initial exposure session and had little arousal evoked

by the exposure in Session 5 (straw breathing; peak SUDS = 40; ending SUDS = 40). She

missed Session 6 because of a bad panic attack earlier in the day, but a chair-spinning

exposure in Session 7 elicited an expected response (peak SUDS = 100; ending SUDS =

50). Client A then missed Session 8 because of allergies, but reported that she used cogni-

tive restructuring effectively when she became fearful of her symptoms. Unfortunately, she

did not attend any further sessions and did not make any further contact with the clinic.

Client Bs in-session exposures included a variety of interoceptive exercises, such as straw

breathing (peak SUDS = 80; ending SUDS = 20) as well as avoiding physical activities

(playing basketball: peak SUDS = 90; ending SUDS = 30; playing basketball against ahighly talented athlete: peak SUDS = 50; ending SUDS = 20). Client D conducted several

in-session exposures, including an in vivo exposure of speaking with an authority figure

(actually a confederate; peak SUDS = 80; ending SUDS = 30) and giving an impromptu

unrehearsed speech (peak SUDS = 90; ending SUDS = 60). Homework exposures included

confronting coworkers, speaking with authority figures, and interacting with strangers.

Because of time constraints, Client E did not participate in an exposure during Session 4. In

Session 5, he helped devise an exposure wherein he had to learn a new skill while the other

group members watched (peak SUDS = 50; ending SUDS = 50). Subsequent exposures

included joining a conversation being held by strangers (peak SUDS=

80; ending SUDS=

0), asking a stranger for change (peak SUDS = 50; ending SUDS = 30), and interacting with

opposite sex strangers (peak SUDS = 80; ending SUDS = 40). Finally, Client F completed a

role-played social exposure of small talk with a stranger (peak SUDS = 70; ending SUDS =

50), but several days later she contacted the therapists and stated that she was no longer inter-

ested in services because the sessions conflicted with her work schedule.

Phase 2

During the second phase of treatment, the protocol shifts from emphasizing the present-

ing fears to deeper schema-level beliefs that are seen as underlying each clients variousanxiety manifestations. Maladaptive beliefs are highlighted, and cognitive restructuring

techniques are employed to begin to challenge their validity and appropriateness. The intent

of this work is to help shift negative schemas that might leave the client susceptible to

return-of-fear or new fear acquisition.

Session 10Advanced cognitive restructuring. In Session 10, the focus returns to cog-

nitive restructuring but the emphasis is shifted from presenting fear to more global experi-

ences of negative affect. This and the following session are designed to promote rationally

examining thoughts in general, as opposed to only those related to specific fears, in aneffort to reduce general susceptibility to negative affect and potentially minimize the future

development of similar or new fears. For Session 10, the concept of core underlying beliefs



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is presented and examples are given of how core beliefs can not only influence moods and

behaviors in general, but also ones fears in particular. Finally, the clients and therapists

begin identifying possible core beliefs.

Given the past experience with cognitive restructuring during sessions 2 and 3, and thepreexposure cognitive restructuring during each exposure session, the clients were very

amenable to this part of treatment. Core themes identified included I am a failure (three

clients, including Kay and Ricardo, identified this belief) and I am a fraud and people will

find out. Ricardo provided an example of how his core belief of being a failure impacted

day-to-day life, in that he has difficulty celebrating any of his wifes successes or achieve-

ments because this belief causes him to feel angry at his perceived failures. As a result he

tends to withdraw, which has caused some marital distress. Session 10 STAI scores were

stable, although Ricardo and Client E showed some elevation over previous sessions.

Group cohesion and therapist alliance were generally strong, although Ricardos scores

indicated some continued cohesion and alliance difficulties in these later sessions.

Session 11Advanced cognitive restructuring. In Session 11, the focus continues with

the cognitive restructuring of more global experiences of negative affect. Although Session

10 emphasized identifying and challenging events that promoted excessive negative affect,

Session 11 focuses on identifying common themes in these periods of negative affect in an

effort to predict and minimize the emotional consequences of future events. Kay actively

worked on disputing her belief that I am a failure by generating considerable evidence to

the contrary. She indicated that it felt odd that she would focus on one or two negative expe-

riences among many positivesa tendency the other clients also describedand a discus-sion of negative thinking styles ensued. Ricardo participated in the discussion and exercises

and, although he did go through the process of disputing his beliefs, he maintained a con-

sistently negative perspective even when directly challenged on that perspective by other

members of the group.

Session 12Termination and relapse prevention. The final session is devoted to termi-

nation issues, identifying successes made in treatment and developing relapse prevention

action plans. This session typically has a celebratory flavor to it, but unresolved issues or

items needing clarification are often discussed. During this session, Kay specifically cited

cognitive restructuring and exposure to the parts of treatment she found most beneficial.She also remarked that though she was apprehensive initially about joining a group, she

now felt it was beneficial to see other people coping with similar problems. Finally, Kay

also stated that she had success during the past week in identifying and reframing instances

of her core beliefs influencing her emotions and behavior. Ricardo indicated that he felt that

he was over the hump in terms of his anxiety, and that his depression had also remitted

significantly. Indeed, he later indicated that these have been the best two weeks I have had

since Ive been in the program. When asked about the most beneficial aspects of treatment,

he specifically commented on the helpfulness of the group process. All attending clients

identified signs that might suggest a lapse in their treatment gains and developed action

plans to help combat lapse and prevent relapse.




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8 Complicating Factors

Although group-based treatments have many advantages, there are also some disadvan-

tages. The group format offers less treatment time for any particular client. As can be seen inthe outcome data for this group, some clients would have benefited from additional therapy.

This can be handled by additional individual sessions, or perhaps our current format of 12

weeks is too short. We are investigating this in our current research. Another disadvantage of

group treatment is that clients can provoke a negative reaction in one another. A skilled ther-

apist can usually manage this situation in the group and turn it into an opportunity to promote

growth and change, especially if it occurs because something has evoked someones core

fears. However, not all clients are appropriate for group and screening out group members

who are especially vulnerable or provocative can prevent problems from occurring.

9 Managed Care Considerations

In a changing health care environment, a variety of evidence-based treatment options

will be in demand. We hope that practitioners in settings with sufficient number of indi-

viduals with anxiety disorders will consider moving beyond diagnosis-specific individual

treatment to a contemporary group treatment that emphasizes the commonalities among

anxiety disorders.

10 Follow-Up

Posttreatment. At posttreatment assessments, treatment gains were apparent in all com-

pleters. Kay continued to have minor socioevaluative concerns (CSR = 2), but these were

rated as of subclinical severity. She reported only moderate nervousness about parties,

meetings, or classes, but no avoidance of such activities. Public speaking remained moder-

ately distressing because of continued concerns that she will shake, but she indicated

greatly reduced avoidance of public speaking. Despite the mild social fears, she indicated

to the assessor that she felt that she no longer needed services. In addition, she noted that

she had been offered and had accepted a job for which she had interviewed 2 weeks earlier.She anticipated that her job would give her numerous opportunities for exposure to anxi-

ety-provoking situations to maintain the gains that she had made.

Ricardo showed improvements in his PD (CSR = 4) although the posttreatment asses-

sors rated these as still being of clinical severity. Although he still reported apprehension

about possible panic attacks, particularly because of concerns that he will go crazy or psy-

chotic because of the attacks, he stated that he had not experienced any panic attacks in the

past 2 weeks. His most recent panic attacks occurred when he was reportedly hungry and

stressed about meeting deadlines for school. Furthermore, these panic attacks were very

brief, peaking within 5 s and lasting at peak intensity for roughly 2 s. Additional individualcognitivebehavioral therapy was recommended but, to date, Ricardo has not followed

through with arranging more sessions.



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Client B continued to have some remaining subclinical apprehension about panic attacks

(CSR = 3). Client D showed improvement in his socioevaluative concerns, although they

were still of clinical severity at posttreatment (CSR = 4). Even so, Client D declined fur-

ther services. Client E no longer reported any symptoms of GAD (CSR=

0), although hisdiagnosis of social phobia was now deemed to be of subclinical severity (CSR = 3). Those

three clients who discontinued treatment declined posttreatment assessments; therefore,

their diagnostic severity is unknown.

11 Treatment Implications of the Case

As the initial theoretical and empirical rationale indicates, developing theory provides

a strong conceptual rationale for commonalities among the anxiety disorders. This does

not, however, automatically imply that one should treat individuals presenting with dif-ferent diagnoses in the same treatment group. For example, one could develop a transdi-

agnostic intervention but deliver it in an individual format. Although there may be

situations in which individual treatment is preferred, a group format has a number of

advantages, as have been outlined by various authors (Bieling, McCabe, & Antony, 2006;

Heimberg & Becker, 2002). The most obvious advantages of group treatment are reduced

costs for clients and greater efficiency of therapist time. One therapist can treat eight

individuals in a 2-hr group versus eight individual sessions, usually for a reduced per

client fee. This may make treatment more available both in terms of therapist availabil-

ity and out of pocket expenses for the client. Group treatment also has the advantage ofreducing a clients sense of isolation as he or she sees other individuals struggling with

similar concerns. Groups can instill hope for change as clients see others achieve success,

even if they have not yet met their own therapeutic goals. Groups may also empower

clients by decreasing their own self-focus as they attempt to help others. Finally, the

group format may facilitate some cognitivebehavioral strategies, such as other group

members providing realistic information for cognitive restructuring or serving as role-

play partners for in-session exposure exercises.

Despite the advantages of group treatments, one significant limitation is that they are less

practical in settings with a smaller population base or greater therapist saturation. Indeed,

it is often difficult to obtain sufficient numbers of patients with the same diagnosis, whopresent to clinic within a similar time frame, and who have similar availabilities for sched-

uling treatment. For example, assume that a therapist wishes to recruit six clients for a diag-

nosis-specific treatment group. Assuming that all new intakes had an anxiety disorder, it

would still require (based on National Comorbidity Survey prevalence estimates) an aver-

age of 21 intakes before one would expect to have recruited 6 individuals with a primary

diagnosis of specific phobia to form the group. It would require 25 intakes for a 6-person

social phobia group, 31 intakes for a panic/agoraphobia group, 50 intakes for a posttrau-

matic stress disorder (PTSD) group, 53 intakes for a GAD group, and 199 intakes for an

OCD group. In contrast, if a clinician wanted to recruit six clients with any anxiety diag-

nosis for a transdiagnostic group treatment, only six intakes would be required.



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12 Recommendations to Clinicians and Students

The purpose of this article was to describe the implementation of a cognitivebehavioral

group treatment designed to efficiently treat individuals with a variety of anxiety disordersin a single therapy group. The treatment is based on emerging conceptualizations of the

commonalities among anxiety disorders. We hoped to illustrate that therapists experienced

with the standard evidence-based practice for anxiety disorders can readily translate their

work into a cost-effective group treatment, as we have outlined in the ATP. The common-

alities among clients with different diagnoses facilitate a positive group process that offers

advantages beyond individual therapy. These advantages include the feedback from group

members that aids cognitive restructuring and the practical assistance of having readily

available role-players and audience members. Participants in our program have often cited

the opportunity to help others and learn from their experiences as beneficial aspects of the

group format.We have developed a short list of tips for our therapists based on our experience con-

ducting and supervising the transdiagnostic groups. Theses tips include the following:

1 Good group treatment is more than multiple individual sessions in the same room at the

same time. Facilitating the advantages of group process requires skill and careful plan-

ning. When planning for treatment sessions, therapists must think of not only the individ-

ual clients but also the group as a whole, including multiple group members in each

activity as much as possible. Bieling et al. (2006) offer excellent tips on how to take full advan-

tage of the group format and avoid potential pitfalls, specifically written for cognitive

behavioral groups.2 Therapists are well trained to think in diagnostic categories. It requires a conscious con-

ceptual shift to think creatively about

(a) commonalities among clients with different diagnoses;

(b) fear and avoidance hierarchies that cut across diagnoses;

(c) core beliefs or functional analyses that fit across diagnoses.

It has been our experience that clients make this conceptual shift much more easily than

do the therapists!

3 Remember that the group itself is potentially therapeutic. The therapist does not have to

do all of the work, especially if he or she has set the stage for good group process. Fellowgroup members are often more insightful and more credible than the therapist.

4 Encourage attendance and have a plan for the session, regardless of who attends. Group

members miss sessions for a variety of reasons and it is important to be prepared. Also,

facilitate good attendance by highlighting its importance with individuals who are con-

sidering the group and planning with clients about how to avoid avoidance of group

activities. Because avoidance behavior is a primary coping strategy for many individuals

with anxiety disorders, this needs to be specifically addressed. In individual treatment,

sessions can be rescheduled. In group treatment, the session occurs even if someone is

absent.

Interested clinicians may contact the first author (PJN) about obtaining a copy of the full

treatment manual.



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Note

1 Client names and identifying information have been heavily altered to protect confidentiality, although

details of the in-session experience are retained for descriptive purposes.

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Peter J. Norton, PhD from the University of NebraskaLincoln, 2003, is an associate professor at the

University of Houston. He has published numerous research articles on the topics of anxiety disorders orchronic pain. His current research focus is on evaluating the efficacy of transdiagnostic treatments and mediator

of treatment outcome. His work also explores cross-cultural expressions of fear and anxiety.

Debra A. Hope, PhD from the University at AlbanyState University of New York, 1990, is a professor of psy-

chology at the University of NebraskaLincoln. Her work on psychopathology emphasizes information pro-

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processes on interpersonal functioning. She also has ongoing research on both the outcome and the process of

psychotherapy.


behavioral therapy for anxiety disorders

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