New Perspectives In The Treatment Of TAG

Clients / patients with GAD report a higher frequency of past interpersonal traumatic events and a more insecure attachment to their main loved one in childhood (compared to the population without this diagnosis). Therefore, new perspectives point to the importance of addressing interpersonal issues in these patients.

All of these issues do not seem to be fully addressed in current cognitive-behavioral therapies. Such traumas may constitute deeper emotional issues that GAD patients avoid through worry.

Other new guidelines have been developed to overcome these limitations of the cognitive-behavioral perspective in GAD. Thus we find  Newman’s integrative therapy, Mennin’s emotion regulation therapy, and Roemer and Orsillo’s therapy based on acceptance as a treatment for GAD.

Newman’s integrative therapy

GAD patients not only worry, they behave, increasing the likelihood of negative interpersonal consequences. Thus, they prevent others from knowing who they are and what they feel to avoid the criticism and rejection they anticipate. They may also fail to communicate their needs and wants, expressing anger and disappointment when their emotional needs are not met.

Newman et al. (2004) have developed an integrative therapy for the treatment of GAD that is applied sequentially, in each 2-hour session, traditional CBT, together with interpersonal techniques. All this is aimed at intervening on the problems of the patient / client.

The goals of the interpersonal / experiential part are:

• Identify the interpersonal needs of the patient. Also the interpersonal ways in which you try to satisfy those needs and the underlying emotional experience.

• Generate more effective interpersonal behaviors to meet your own needs.

To achieve these goals, experiential therapy techniques are used, focusing attention on the emotional avoidance approach. On the other hand, it may only be useful for patients with certain types of interpersonal problems.

Mennin’s Emotion Regulation Therapy

Mennin (2004) has proposed emotion regulation therapy based on the idea that people with GAD experience negative emotions more easily. In addition, they have problems identifying and understanding their emotions, they value them negatively without accepting them, and they have difficulties regulating them.

Emotion regulation therapy integrates components of CBT with emotion-focused interventions that target deficits in emotional regulation . In addition, problems on the social plane of patients are also addressed.

Emotion regulation therapy has four phases:

• Psychoeducation on GAD, functional analysis of concerns and emotions and self-registration of concerns.
• The client learns to identify defensive and avoidant responses to emotion, such as worrying and seeking reassurance. Instead, learn somatic awareness skills or belief identification on troublesome core issues. Understanding and emotional acceptance are worked on, together with the identification and expression of one’s own needs and emotions.
• The skills learned are used in a variety of experiential exercises that are related to core issues, such as fear of loss, incompetence, and failure. These experiential exercises may include techniques such as the empty chair, the two-chair dialogue, and the imaginal exposition, techniques such as the downward arrow, and Socratic dialogue.

• Review of progress, termination of the therapeutic relationship, relapse prevention and future goals beyond therapy.

Emotion regulation therapy was superior to an attention control condition on a wide variety of measures (worry, anxiety, depression), with effect sizes ranging from moderate to large.

Roemer and Orsillo’s behavioral therapy based on acceptance

According to the Roemer and Orsillo model, people with GAD have a problematic relationship with their internal experiences. Within this component, two aspects are distinguished: the negative reaction to internal experiences and the fusion or overidentification with them.

• The negative reaction includes negative thoughts and meta-emotions (eg, fear of negative emotions), which cause difficulties in observing and accepting internal experiences.

• Merging with inner experiences implies seeing them as much more indicative of reality than they are. They consider that a transitory negative thought constitutes a defining characteristic of the person. This troublesome relationship with inner experiences leads to experiential avoidance.

Experiential avoidance is the deliberate or automatic avoidance of internal experiences perceived as threatening (eg, worrying to avoid more disturbing experiences). This avoidance would reduce discomfort, but only temporarily, and would help maintain the troubled relationship with inner experiences.

In addition, it would facilitate the appearance of behavioral restriction ; the person is less engaged in or less aware of valuable or meaningful activities when doing them. This behavioral restriction increases discomfort, thus generating more negative internal experiences and the cycle is perpetuated. Taking the above into account, Roemer and Orsillo (2007, 2009) have proposed acceptance-based behavioral therapy (TCBA).

Components of Acceptance-Based Behavior Therapy

• Approximations of mindfulness (mindfulness) and acceptance of one ‘s own experiences with behavioral principles to learn and practice new skills.
• Explaining and demonstrating a GAD model in which the role of experiential avoidance is highlighted and this model is connected with the treatment to be followed.
• A variety of mindfulness techniques are taught, focusing first on breathing, paying attention to sensations, and then emotions and thoughts.
• Clients are helped to:
  • Break the fusion between self-perception and internal experiences.
  • Identify the activities that they value in their life (in the interpersonal, work / educational area and personal interests).
  • Live the life you want,  focusing on actions despite the painful thoughts and feelings that may arise.

TCBA as a treatment for GAD would produce changes in key variables indicated by other theoretical models : difficulties in regulating emotion, fear of emotional responses, intolerance to uncertainty, and low perceived control.