The client received 8 sessions of Acceptance-Based Behavior Therapy for generalized anxiety disorder. While the client engaged with some mindfulness exercises and saw some positive behavioral changes, he struggled to engage fully with the treatment. He developed distrust of the therapist and concerns about elicited feelings of attraction and vulnerability. Treatment was terminated early due to inconsistencies between the client's treatment goals and the research protocol. Questionnaires administered before and after treatment showed moderate levels of anxiety, depression, and stress.

1. TREATMENT SUMMARY
Summary date: 2118111
Date of fust session: 12/8/10
Theravist: Kara Lustig Date of termination: 2/16/10
# of sessions: 8
M e of Treatment:
r e c e i v e d Acceptance-Based Behavior Therapy (based on Lizabeth Roemer
and Susan Orsillo's protocol) as part of the Generalized Anxiety Disorder treatment study. The
treatment includes hditional CBT components in addition to components and exercises from
acceptance and mindfulness-based treatments. Treatment included psychoeducation about the
nature and function of anxiety, the function of emotions, the ways that the struggle to control and
avoid internal experiences can maintain anxiety, the possibility of acceptance and willimgness as
alternatives to control, and the importance of valued actions. Mindfulness skills were also
introduced 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 areas
of living that were important to h m and to consider the ways in which anxiety and worry had
i
interfered 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, 5
protocol sessions, one non-protocol session to address client's questions/concerns about therapy,
and one termination session. In general, r e g u l a r l y kept appointments, and missed one of
these appointments. At the beginning of therapy, reported frequent worry about a range
of topics. Some of these worries were re focuscd and involved topics such as work and
health. Many of the worries involved ruminations about past social interactions. He expressed
concerned 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-based
behavioral model of generalized anxiety disorder. He learned about the cycle of anxiety, the
function of emotions&d worry, and how attempts to control emotions regarded as negative can
maintain anxiety, interfere with the recognition of pertinent information, and inhibit taking
actions that may address the source of the anxiety. Through treatment he became more aware of
the ways in which he had made choices in his life based on managing his emotions and avoiding
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anxiety, and ways in which these types of choices sometimes are contradictory to what was
important to him. F i n a l l y , l e a m e d about the ways that mindfulness practice may help to
increase his awareness of his internal experiences and his reactions to those experiences. The
goal of this increased awareness was to ex~and reuertoire of possible behavioral responses to
" the
anxiety provoking situations beyond avoidance and escape. it her complementary component
of treatment includes identifyingvalues. Treatment ended before sessions focused on how
c o u l d take action in service of those values.
Overall, had difficulty engaging in the treatment. Like many clients, although he
expressed some initial uncertainty as to whether the treatment would be helpful for him, he also
expressed a willingness to try some of the suggested methods and strategies. By his report, the
client engaged in mindfulness practice and found some aspects of this practice helpful. However,

2. as treatment progressed, he continued to express ambivalence and indecisivenessin regards to
whether he should quit or m a i n in treatment. In particular, he reported difficulty engaging i n
the vaIues component of treatment. He initially expressed ambivaFence regarding whether he
wanted to be connected to people or not, but over the course of therapy he became more certain
that 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" don't
exist, 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 trusting
people. 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 on
my part. For a more accurate self-report, the therapist might have wanted to refer to
the relationship obstacles listed in the "Values Assignment" dated January 17th,
201 1, which include self-centeredness, indifference, communication ability etc. If
the therapist referred to a specific sentence in the 'Reaction Page" dated February
4th, 201 1 in which I responded to the therapist's previous assertion that a positive
therapistklient 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 you
that 1 did not want to deal with these feelings ever again"), the therapist might not
have correctly surmised the feelings that I was specifically referring to, which were
not feelings of distnist but. as I painfully hinted at during the sessions and in the
writing 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 hadn't experienced before
and that I do not wish to experience ever again and that have nothing to do with
trusting or not trusting the other person.

3. He also develomd a belief that Qe them~ist
x
had
p w s e l v elicited this attraction (or "transference" as he labeled it), which led him to fcel
dcccived 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 scheduled
to allow the client to express his concerns and to discuss whether or not he wanted to continue
with treatment. Although he expressed a willhgness to continue i treatment, over the next
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several weeks his self-~ported distress, distrus~,struggles with the therapeutic relationship and
worry increased. At session 6 ,laid out a number of guidelines for therapy, including that
there be no open e n d 4 questions. statements of understanding, or smiling, and that the thempist
speak only in a monotone voice. He also described goals for therapy that are inconsistent with
those 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 indicated
and treatment was terminated in session 7.During this termination session,' the client reported
that he found &at the mindfulness exercises heEpful and that he had begun checking email less
Frequently, which he saw as a positive behavioral change. He was emailed a list of referrals for
further treatment that would allow more flexibility so that his interpersonal patterns could be
addressed more directIy, in addition to his anxiety and worry.
During the termination session, Therefore, he was
not assessed post-treatment. Ho ernail that his data
should not be destroyed, data will not be destroyed until he confrms this request.
'C r e to :
o r ci n
This part is false. When the therapist offered the option of having the data destroyed (the
therapist brought up the subject), I never directed her to destroy anything. I indicated to
the therapist that telling her to destroy the data did not guarantee that the data would be
destroyed. After the therapist assured me that my decision would be respected, I told the
therapist that 1 thought I'd be happy if the data was destroyed. At the end of the session I
asked the therapist one last time if my data was going to be destroyed. To the ears of the
therapist my statements and questions might have sounded like a request to have my data
destroyed, but if you analyze my words (watch the videotapes), I didn". This report would
have been less inaccurate if the therapist had written something along the lines of "the
client seemed to express a desire that the data be destroyed" or '"he client was ofFered the
option of having the data destroyed, and he seemed receptive to the idea." Regardless of
the therapist's poor interpretation and/or poor choice of wording, my desire that the data
not be destroyed stands.

4. e x p r e s s e d suicidal ideation in his monitoring and writing h u g b u t treatment. Risk was
assessed i session E,2 and 4, and no intent or risk was discerned. He requested that suicide risk
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no 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
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his history, consideration of risk factors, and the absence of expressed suicidal ideation in'both
the previous week's 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 following
sessions 4. O v e r a U , q w r t e d nodemte levels of generalEzed anxiety prior to be-3
therapy. 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 and
depression, 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 of
depressive, anxious, and stress symptoms prior to the t e a t i o n session are included below.

5. His stress and depression scores were comparable to his reports prior to treatment, and his
anxiety 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 ~ D
Kara Lustig Lizabeth Roemer Ph.D.
Research ~ s s o c i a 6 Licensed Psychologist
Adjunct Associate Professor