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The ''Anxiety Treatment Protocol'' : A Group Case Study Demonstration of a

Transdiagnostic Group Cognitive Behavioral Therapy for Anxiety Disorders
Peter J. Norton and Debra A. Hope
Clinical Case Studies 2008 7: 538 originally published online 23 July 2008
DOI: 10.1177/1534650108321307
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The Anxiety Treatment Protocol

A Group Case Study Demonstration of a
Transdiagnostic Group CognitiveBehavioral
Therapy for Anxiety Disorders

Clinical Case Studies

Volume 7 Number 6
December 2008 538-554
2008 Sage Publications
10.1177/1534650108321307
http://ccs.sagepub.com
hosted at
http://online.sagepub.com

Peter J. Norton
University of Houston

Debra A. Hope
University 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 quantitative 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-IV anxiety 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 disorders 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-IV anxiety disorder diagnoses within the same treatment groups. The purpose of this
article is to describe one such transdiagnostic group treatment protocol that has yielded

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: pnorton@uh.edu. 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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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 in
detail, followed by a summary of the available efficacy evidence. Finally, the article concludes 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 comprehensive reviews, see Barlow, 2000; Barlow et al., 2004; Norton, 2006, in press a). Several distinct lines of investigation appear to support the hypothesis that the DSM-IV anxiety
disorders may represent a single core pathology that may be elicited by different stimuli
and manifested in distinct ways. First, considerable research indicates that negative affectivity, 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 the DSM-IV anxiety disorders greatly exceed that which would be predicted 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 independent 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 alternative explanation appears less tenable in light of the third line of evidence: treatment outcome 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 diagnostic 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 considering 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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Clinical Case Studies

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 those
receiving treatment, despite depression not being targeted in treatment, whereas no change
in depression was noted for waitlist controls. Finally, using a separate sample recruited during 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 significant 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 treatment trials using similar, but independently developed, mixed-diagnosis anxiety treatments.
Erickson (2003) reported the results of an uncontrolled trial of a transdiagnostic CBT program for 70 individuals with an anxiety disorder diagnosis. His results suggested significant 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 improvements
that 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 questionnaires 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, further 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

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541

only supported through her husbands employment. She was raised in Europe, but immigrated to the United States in 2005 with her then-fianc/current husband. Kay and her husband have no children.

3 Presenting Complaints
Kay presented to the clinic for assistance for anxiety and panic attacks in social situations. 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 is
eating, alone, or has time to think. During the telephone intake, Ricardo began by reporting 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 moderate family history of anxiety and depression.
Kay indicated that she started experiencing panic attacks in social situations approximately 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 gradually 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 Assessment
All 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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Clinical Case Studies

(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 beginning 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 typical
group 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 sessions 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 features 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, including 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 avoidance, 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 intensity. Ricardo did not meet criteria for any other Axis I disorder.

6 Case Conceptualization
Consistent with transdiagnostic cognitivebehavioral models of anxiety, the cases were
conceptualized 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 avoidance, escape, or compulsive rituals. Attempts at avoiding then reinforce prior biased beliefs
and maintain the fears.

7 Course of Treatment and Assessment of Progress

The 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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Table 1
Participant Summary at Group Initiation
Client

Sex

Age

Ricardo
Kay
Client A
Client B
Client C
Client D
Client E

M
F
F
M
M
M
M

27
33
23
22
30
35
35

Client F

30

Diagnoses and CSR

PDA-6
SAD-5
PD-6
PD-4
SAD-6
SAD-5
SAD-6
(GAD-5)
GAD-5
SAD-5

Session 1 STAI

Session 1 WAI

56
53
41
32
48
46

46
80
56
84
59
72

51

72

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.

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 homework noncompliance is addressed in the session as a barrier to recovery. The interventions
in ATP draw heavily on standard cognitivebehavioral practice such as Becks cognitive
therapy (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 perceptions
of 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 who
stayed with the group made substantial clinical gains. We are continuing to refine our procedures and training but we hope this case description will offer some sense of how such a
transdiagnostic group could be conducted (see Table 2).

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Clinical Case Studies

Table 2
Session-by-Session Quantitative Summary
Ricardo

Kay

ADIS severity at posttreatment

Session

PDA-6

Pre

STAI

WAI

1
2
3
4
5
6
7
8
9
10
11
12

56
45
63
51
50
40
42

46

Post

SAD-5
GCS
37

64
44
66
54
58

54
45
37

59

46
41

ADIS severity at posttreatment

PDA-4

STAI

WAI

53

47
54
41
45
49
34

80

GCS
a

84
58
84
66
84
84

47
36
42

84

68
68

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 anxiety
disorder; 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.

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 anxiety, anxiety disorders, and the cognitivebehavioral model, to thoroughly describe the components 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 an
anxiety 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,

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Figure 1
Mean State Anxiety, Working Alliance, and Croup Cohesion scores across sessions.
80
70
60
50
40
30
20
10
0
STAI

WAI

GCS

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 importance 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 provoking 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 subsequent 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 to
clearly 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,

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Clinical Case Studies

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 homework 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 therapist 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, although
Ricardo showed a notable increase in anxiety. He indicated that the previous sessions discussion 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 dedicated 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 preceded 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 of
discomfort 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 confrontation 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 substantially, M = 58.80, sd = 9.65.
Kays exposure involved a role-played small-talk conversation at a party, with one of the
therapists 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 shaking] 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 conversation. Furthermore, despite her concerns about shaking, the other group members indicated 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 demonstration, 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 hallucination. 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 completing, his exposures during session. Attempts to develop a worry script for imaginal exposures of losing psychological control were delayed because of low homework compliance.
He then missed two exposure sessions because of self-described health reasons and tiredness, 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 holding 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 throughout
treatment. 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 cognitive 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 a
highly 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 interested in services because the sessions conflicted with her work schedule.

Phase 2
During the second phase of treatment, the protocol shifts from emphasizing the presenting fears to deeper schema-level beliefs that are seen as underlying each clients various
anxiety 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 cognitive restructuring but the emphasis is shifted from presenting fear to more global experiences 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 an
effort 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 the
preexposure 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 achievements 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 experiences among many positivesa tendency the other clients also describedand a discussion 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 consistently 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 termination 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 disadvantages. The group format offers less treatment time for any particular client. As can be seen in
the 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 therapist 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 individuals 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 completers. 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 moderately 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 anxiety-provoking situations to maintain the gains that she had made.
Ricardo showed improvements in his PD (CSR = 4) although the posttreatment assessors 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 psychotic 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 individual
cognitivebehavioral 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 further services. Client E no longer reported any symptoms of GAD (CSR = 0), although his
diagnosis 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 different diagnoses in the same treatment group. For example, one could develop a transdiagnostic 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 availability and out of pocket expenses for the client. Group treatment also has the advantage of
reducing 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 roleplay 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, who
present to clinic within a similar time frame, and who have similar availabilities for scheduling treatment. For example, assume that a therapist wishes to recruit six clients for a diagnosis-specific treatment group. Assuming that all new intakes had an anxiety disorder, it
would still require (based on National Comorbidity Survey prevalence estimates) an average 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 posttraumatic 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 diagnosis 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 disorders
in 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 commonalities 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 conducting 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 planning. When planning for treatment sessions, therapists must think of not only the individual 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 advantage of the group format and avoid potential pitfalls, specifically written for cognitive
behavioral groups.
Therapists are well trained to think in diagnostic categories. It requires a conscious conceptual 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!

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. Fellow
group members are often more insightful and more credible than the therapist.
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 considering 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 or
chronic 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 psychology at the University of NebraskaLincoln. Her work on psychopathology emphasizes information processing models that describe the role of attention and memory in social phobia and the impact of these cognitive
processes on interpersonal functioning. She also has ongoing research on both the outcome and the process of
psychotherapy.

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