TREATMENT SUMMARY Summary date: 2118111 Date of fust session: 12/8/10Theravist: Kara Lustig Date of termination: 2/16/10# of sessions: 8M e of Treatment:r e c e i v e d Acceptance-Based Behavior Therapy (based on Lizabeth Roemerand Susan Orsillos protocol) as part of the Generalized Anxiety Disorder treatment study. Thetreatment includes hditional CBT components in addition to components and exercises fromacceptance and mindfulness-based treatments. Treatment included psychoeducation about thenature and function of anxiety, the function of emotions, the ways that the struggle to control andavoid internal experiences can maintain anxiety, the possibility of acceptance and willimgness asalternatives to control, and the importance of valued actions. Mindfulness skills were alsointroduced and practiced as a method aimed at facilitating acceptance and willingness. Finally,the concept of valued action was introduced and the client was encouraged to explore the areasof living that were important to h m and to consider the ways in which anxiety and worry had iinterfered in those areas of living.Summarv of Treatment:a t t e n d e d 8 sessions of weekly therapy, which included one initial session, 5protocol sessions, one non-protocol session to address clients questions/concerns about therapy, and one termination session. In general, r e g u l a r l y kept appointments, and missed one ofthese appointments. At the beginning of therapy, reported frequent worry about a rangeof topics. Some of these worries were re focuscd and involved topics such as work andhealth. Many of the worries involved ruminations about past social interactions. He expressedconcerned about the nature of his anxiety and its impact on his ability to concentrate.The first several weeks of treatment focused on educating about the acceptance-basedbehavioral model of generalized anxiety disorder. He learned about the cycle of anxiety, thefunction of emotions&d worry, and how attempts to control emotions regarded as negative canmaintain anxiety, interfere with the recognition of pertinent information, and inhibit takingactions that may address the source of the anxiety. Through treatment he became more aware ofthe ways in which he had made choices in his life based on managing his emotions and avoiding - -anxiety, and ways in which these types of choices sometimes are contradictory to what wasimportant to him. F i n a l l y , l e a m e d about the ways that mindfulness practice may help toincrease his awareness of his internal experiences and his reactions to those experiences. Thegoal of this increased awareness was to ex~and reuertoire of possible behavioral responses to" theanxiety provoking situations beyond avoidance and escape. it her complementary componentof treatment includes identifyingvalues. Treatment ended before sessions focused on howc o u l d take action in service of those values.Overall, had difficulty engaging in the treatment. Like many clients, although heexpressed some initial uncertainty as to whether the treatment would be helpful for him, he alsoexpressed a willingness to try some of the suggested methods and strategies. By his report, theclient engaged in mindfulness practice and found some aspects of this practice helpful. However,
as treatment progressed, he continued to express ambivalence and indecisivenessin regards towhether he should quit or m a i n in treatment. In particular, he reported difficulty engaging i nthe vaIues component of treatment. He initially expressed ambivaFence regarding whether hewanted to be connected to people or not, but over the course of therapy he became more certainthat he did not want to have relationshiws with people. since by his rcnort he did not t n ~ sfthem.Phe client also experienced diKficulty developing a posilive working alliance with his Ihcrapist.At session 1, he expressed feelings of attraction toward thc thempist and he became significantly .distressed in response to these feelings.Correction :It is true that by my report I became more certain that I did not want to have rela-tionships with people, and it can probably hardly be said that "trust issues" dontexist, but I do not recall ever explictly stating (nor was 1 able to find in my writings)any conviction connecting lack of desire in relationships and problems trustingpeople. This association likely was the product of a conjecture, misunderstanding,or diagnosis on the part of the therapist rather than the result of an actual report onmy part. For a more accurate self-report, the therapist might have wanted to refer tothe relationship obstacles listed in the "Values Assignment" dated January 17th,201 1, which include self-centeredness, indifference, communication ability etc. Ifthe therapist referred to a specific sentence in the Reaction Page" dated February4th, 201 1 in which I responded to the therapists previous assertion that a positivetherapistklient relationship could help me discover my capacity to have a relation-ship (e.g, "I told you that 1 did not want to have a relationship and I also told youthat 1 did not want to deal with these feelings ever again"), the therapist might nothave correctly surmised the feelings that I was specifically referring to, which werenot feelings of distnist but. as I painfully hinted at during the sessions and in thewriting assignments, very uncomfortable and painful feelings of emotional depen-dency and emotional vulnerability that arose as a result of my having an intimate,emotional connection with the therapist, feelings that I hadnt experienced beforeand that I do not wish to experience ever again and that have nothing to do withtrusting or not trusting the other person.
He also develomd a belief that Qe them~ist x hadp w s e l v elicited this attraction (or "transference" as he labeled it), which led him to fceldcccived and distrustful of therapy. Correction: A more accurate statement might have been "he also developed a suspicion that per- haps the therapist purposely, accidentally, or unconsciously elicited this attraction. "In response to these concerns, after four protocol sessions, a non-protocol session was scheduledto allow the client to express his concerns and to discuss whether or not he wanted to continuewith treatment. Although he expressed a willhgness to continue i treatment, over the next nseveral weeks his self-~ported distress, distrus~,struggles with the therapeutic relationship andworry increased. At session 6 ,laid out a number of guidelines for therapy, including thatthere be no open e n d 4 questions. statements of understanding, or smiling, and that the thempistspeak only in a monotone voice. He also described goals for therapy that are inconsistent withthose infierent in the research protocol (e.g., countemcting his transference toward the therapist).Therefore, after consultation, it was decidd that the treatment was no longer clinically indicatedand treatment was terminated in session 7.During this termination session, the client reportedthat he found &at the mindfulness exercises heEpful and that he had begun checking email lessFrequently, which he saw as a positive behavioral change. He was emailed a list of referrals forfurther treatment that would allow more flexibility so that his interpersonal patterns could beaddressed more directIy, in addition to his anxiety and worry.During the termination session, Therefore, he wasnot assessed post-treatment. Ho ernail that his datashould not be destroyed, data will not be destroyed until he confrms this request.C r e to : o r ci nThis part is false. When the therapist offered the option of having the data destroyed (thetherapist brought up the subject), I never directed her to destroy anything. I indicated tothe therapist that telling her to destroy the data did not guarantee that the data would bedestroyed. After the therapist assured me that my decision would be respected, I told thetherapist that 1 thought Id be happy if the data was destroyed. At the end of the session Iasked the therapist one last time if my data was going to be destroyed. To the ears of thetherapist my statements and questions might have sounded like a request to have my datadestroyed, but if you analyze my words (watch the videotapes), I didn". This report wouldhave been less inaccurate if the therapist had written something along the lines of "theclient seemed to express a desire that the data be destroyed" or "he client was ofFered theoption of having the data destroyed, and he seemed receptive to the idea." Regardless ofthe therapists poor interpretation and/or poor choice of wording, my desire that the datanot be destroyed stands.
e x p r e s s e d suicidal ideation in his monitoring and writing h u g b u t treatment. Risk wasassessed i session E,2 and 4, and no intent or risk was discerned. He requested that suicide risk nno longer be assessed at session 6 as he felt #at it reflected a false concm for his well-being.Therapist assessed risk at session 7 but the client left the sessionrather than responding. Drs. ,Roema and Smith were c o d t e d and the client was deemed not to be i imminent risk based on nhis history, consideration of risk factors, and the absence of expressed suicidal ideation inboththe previous weeks monitoring and &e find session.Questionnaire Datir:As part of the research s t u d y , completed diagnostic interviews pre treatment.Additionally, he completed a number of questionnaire measures pre treatment and followingsessions 4. O v e r a U , q w r t e d nodemte levels of generalEzed anxiety prior to be-3therapy. He received a principal diagnosis of G e n d i z e d Anxiety Disorder based on the ADTS-IV interview, as well as additional diagnoses of Social Anxiety (gen), Depressive Disorder NOS ,Prior to treatment, r e p o r t e d moderate levels of m s anddepression, strong levels of m y and minimal levels of anxiety. See the table below for n,specific scores. He did not completed post-treatment measures. However, his self-report ofdepressive, anxious, and stress symptoms prior to the t e a t i o n session are included below.
His stress and depression scores were comparable to his reports prior to treatment, and hisanxiety score was slightly elevated from pre-treatment, but only in the mild range. . MEASURE PRE-TREATMENT POST-TREATMENT . (at session 7) CSR - GAD 3 - moder~te CSR - Social 4 m~&~itc CSR - DD NOS ?- - . subc?:ntc3,,[ ~ DASS - Depression 1 E 43s zn~dcrstte 10 - moderate DASS - Anxiety 1 Q-minirnd 5 - mild DASS - Stress 8 ~~toderatt; 9 - moderate PSWQ 66-5l~o11g 1 Q ~ DKara Lustig Lizabeth Roemer Ph.D.Research ~ s s o c i a 6 Licensed Psychologist Adjunct Associate Professor