Empiricism, Mechanism, and the Practice of Cognitive-Behavior Therapy
Jacqueline B. Persons, San Francisco Bay Area Center for Cognitive Therapy, and University of California, Berkeley

The thesis of this article is that a case formulation–driven approach to clinical work that relies on a case formulation and a hypothesis-testing approach to each case facilitates the use, in clinical settings, of empirically supported treatments (ESTs) that were developed in research settings. The two touchstones of a case formulation–driven approach to cognitive-behavior therapy (CBT) are, as the title of the article indicates, mechanism and empiricism. In a formulation-driven approach, the therapist relies on hypotheses about the mechanisms causing, maintaining, and promoting change in problem behaviors. The therapist also adopts an empirical approach to each case that includes hypothesis-testing and repeated data collection to evaluate the process and progress of treatment. This article describes the main features of a case formulation–driven approach to CBT, shows how it addresses many of the obstacles that impede practitioners from using empirically supported protocols in their daily clinical work, examines its intellectual origins and some data supporting its effectiveness, and concludes with a discussion of implications of the method for future developments in the field.

Beyond PTSD: Emotion Regulation and Interpersonal Problems as Predictors of Functional Impairment in Survivors of Childhood Abuse
Marylene Cloitre, Regina Miranda, K. Chase Stovall-McClough , Hyemee Han, New York University School of Medicine

This study sought to determine the relative contribution of problems in emotion regulation and interpersonal functioning compared to PTSD symptoms in predicting functional impairment among women with childhood abuse histories. One hundred sixty-four treatment-seeking women completed measures of emotion regulation, interpersonal problems, PTSD symptoms, and social adjustment. Severity of PTSD symptoms was a significant predictor of functional impairment. In addition, after controlling for the effects of PTSD symptomatology, emotion regulation and interpersonal problems were both significant predictors and together made contributions to functional impairment equal to that of PTSD symptoms. These data indicate that emotion regulation and interpersonal problems play an important role in functional impairment among women with a history of childhood abuse. These factors should be taken into account in treatment planning to ensure successful rehabilitation from the long-term effects of chronic childhood trauma.

Social Skills Training Augments the Effectiveness of Cognitive Behavioral Group Therapy for Social Anxiety Disorder
James D. Herbert, Drexel University, Brandon A Gaudiano, Brown University School of Medicine, Alyssa A. Rheingold, Medical University of South Carolina, Valerie H. Myers, Pennington Biomedical Research Center, Kristy Dalrymple and Elizabeth M. Nolan, Drexel University

Cognitive Behavioral Group Therapy (CBGT) is the most widely researched intervention program for social anxiety disorder (SAD, also known as social phobia), with a number of studies demonstrating its effectiveness. Another common treatment, social skills training (SST), has also been shown to be efficacious for SAD. The present study compared the standard CBGT intervention with a protocol in which SST was integrated into CBGT. Participants met diagnostic criteria for the generalized subtype of SAD, and most also met criteria for avoidant personality disorder and other comorbid Axis I disorders. The results revealed improvement in a variety of outcome measures for both treatments, but significantly greater gains for the CBGT plus SST condition. In fact, the effect sizes obtained for this treatment were among the largest found to date in any study of SAD. Clinical implications are discussed, and directions for future research are suggested.

Patients’ Perceptions of Pharmacological and Cognitive-Behavioral Treatments for Anxiety Disorders
Brett J. Deacon, Jonathan S. Abramowitz, Mayo Clinic, Rochester, MN

Cognitive-behavioral therapy (CBT) and pharmacotherapy are the most well-established treatments for anxiety disorders. This study examined how treatment-seeking anxiety disorder patients (N = 103) perceive the acceptability, believability, and effectiveness of these treatments. While both treatments were perceived favorably, CBT was rated as more acceptable and more likely to be effective in the long-term. Most patients also rated CBT as their treatment of choice. Patients taking medication reported equally favorable views of both treatments, whereas unmedicated patients rated CBT more favorably than medication. Psychotherapy history was less strongly related to treatment perceptions. Our results suggest that despite their favorable views of both treatments, patients tend to prefer CBT to medication for the treatment of anxiety disorders. Directions for future research are discussed.

Cognitive-Behavioral Therapy for Late-life Generalized Anxiety Disorder: Who Gets Better?
Julie Loebach Wetherell, University of California, San Diego, and VA San Diego Healthcare System, Derek R. Hopko, University of Tennessee, Knoxville, Gretchen J. Diefenbach, Institute of Living, Hartford Hospital, Patricia M. Averill , University of Texas – Houston Health Science Center, J. Gayle Beck, State University of New York, Buffalo, Michelle G. Craske , University of California, Los Angeles, Margaret Gatz, University of Southern California, Diane M. Novy, Melinda A. Stanley, University of Texas – Houston Health Science Center

The authors pooled data from three independently conducted treatment outcome studies to examine predictors of outcome from group-administered cognitive-behavioral therapy (CBT) for older adults with generalized anxiety disorder (GAD). Data were collected from 65 patients with a mean age of 67.7 years (SD = 6.6). Average reliable change indices (RCI) based on 3 outcome measures were calculated at posttreatment and at 6-month follow-up. Approximately half of patients achieved a significant RCI at posttreatment and two-thirds achieved a significant RCI at follow-up. Factors associated with better outcomes included better homework adherence, higher baseline GAD severity, and presence of a comorbid psychiatric diagnosis. Results suggest that at-home practice is associated with better and longer-lasting outcomes from CBT in older adults with GAD.

Thought and Imaginal Activity During Worry and Trauma Recall
Evelyn Behar, Pennsylvania State University , Andrea R. Zuellig, Eating Disorders Institute, Methodist Hospital, T.D. Borkovec, Pennsylvania State University

The present study examined the frequency with which participants experienced thoughts and images, as well as relaxed, anxious, and depressed affect, when worrying and when recalling past traumatic events. Unselected participants in Study 1, and participants selected on the basis of their GAD and past trauma status in Study 2, engaged in 5-minute counterbalanced worry and trauma recall inductions. Results indicated that while worry was experienced primarily as verbal thought, trauma recall was primarily experienced as imaginal. Furthermore, while both worry and trauma recall were associated with increased anxious and depressed affect, worry was particularly associated with anxious affect in the selected sample, and trauma recall was particularly associated with depressed affect in both unselected and selected samples. Finally, for individuals with both GAD and trauma symptoms, prior worrying was associated with decreased anxious and depressed affect during a subsequent trauma recall task. Theoretical and clinical implications of these findings are discussed.

Self-Competence and the Prediction of Bulimic Symptoms in Older Women
Kathryn H. Gordon, Jill M. Denoma, Florida State University, Anna M. Bardone , University of Missouri–Columbia, Lyn Y. Abramson, University of Wisconsin–Madison, Thomas E. Joiner, Jr., Florida State University

Previous research in undergraduate women has demonstrated that an individual’s level of self-competence was a stronger predictor of bulimic symptom change than their level of self-liking (Bardone, Perez, Abramson, & Joiner, 2003). The authors examined whether self-competence would similarly predict bulimic symptom change in a sample of older women. In April 2000, a large group of adults attending mood disorder conferences completed questionnaires about eating disorder symptoms and self-esteem. Approximately 2.5 years later, 150 women, 45 years of age and older, were contacted for a follow-up study. Eighty-eight women completed follow-up eating disorder and self-esteem measures. Consistent with prior research, self-competence emerged as a stronger predictor of bulimic symptom change than self-liking, such that lower self-competence was associated with an increase in bulimic symptoms. The results indicate that self-competence may serve as a useful prognostic indicator and therapeutic target for older women seeking treatment for eating disorders.

Maternal Adjustment Following Preterm Birth: Contributions of Experiential Avoidance
Laurie A. Greco, Vanderbilt University Medical Center, Michelle Heffner, West Virginia University, Susannah Poe , Susan Ritchie , Mark Polak , Susan K. Lynch , West Virginia University School of Medicine

The birth of a preterm infant has been linked with parental distress and adjustment difficulties, yet little is known about the psychosocial factors contributing to this association. Using a cross-sectional design, we therefore examined maternal adjustment following preterm birth, with an emphasis on the potential role of experiential avoidance. We expected that high experiential avoidance, or unwillingness to experience private events (e.g., thoughts, emotions, bodily sensations), would mediate the relation between stress surrounding preterm birth and postdischarge adjustment difficulties. We further tested whether the association between experiential avoidance and maternal maladjustment was moderated or offset by high levels of child sociability or perceived social support. Sixty-six mothers with a preterm infant previously hospitalized in the Neonatal Intensive Care Unit (NICU) completed measures of NICU-related stress, experiential avoidance, postdischarge adjustment, perceived social support, and child temperament. As expected, experiential avoidance partially mediated the association between NICU-related stress and adjustment difficulties. Child sociability and perceived social support did not moderate the relation between experiential avoidance and adjustment, suggesting that high levels of experiential avoidance correlate with adverse outcomes irrespective of these variables. Some implications and recommendations for future research are discussed.

Domains of Risk in the Developmental Continuity of Fire Setting
Carolyn A. McCarty, Robert J. McMahon, University of Washington, Conduct Problems Prevention Research Group

Juvenile fire setting is a serious, dangerous, and costly behavior. The majority of research examining youth fire setting has been cross-sectional. We sought to examine early risk attributes that could differentiate fire setters from non–fire setters, in addition to examining their association with the developmental continuity of fire-setting behavior into late childhood. Using a sample of 361 youth drawn from 4 different U.S. communities, this study examined the association between a broad array of risk variables from the child, parent, and family domains, and fire setting behavior over the course of 2 developmental periods: prior to 4th grade, and between 4th and 6th grade. Youth were classified into 1 of 4 groups (non–fire setters, desisters, later-onset fire setters, and persisters) based on their reported fire-setting behavior during these periods. Children who set fires had higher levels of risk on most of the variables assessed. Persistence of fire setting was associated with elevated parental depressive symptoms and more interparental conflict and ineffective discipline. The findings highlight the need for multicomponent preventive interventions to address the breadth of risk experienced by fire-setting youth and their families.

Factors Influencing the Link Between Social Anxiety and Peer Acceptance: Contributions of Social Skills and Close Friendships During Middle Childhood
Laurie A. Greco , West Virginia University and Vanderbilt University Medical Center, Tracy L. Morris, West Virginia University

Childhood social anxiety consistently has been linked with low levels of peer acceptance, yet little is known about the factors contributing to this association. We therefore examined the mediating and moderating role of social skills and close friendships, two conceptually and empirically relevant variables which were hypothesized to contribute to the social anxiety–peer acceptance relationship. Fifty teachers and 333 children (M = 9.54 years) participated in this study. Sociometric procedures and standardized questionnaires were used to assess: (a) self-reported social anxiety and friendship quality, (b) teacher-rated social skills, and (c) peer-derived acceptance and friendship quantity scores. As expected, childhood social anxiety was associated with low levels of peer acceptance, and this relation was mediated in part by social skills difficulties. Friendship quality (but not quantity) moderated this process for girls, suggesting that high negativity within girls’ best friendships may exacerbate risk for undesirable peer outcomes. Interestingly, friendship quantity and positive friendship quality did not serve a protective function for boys or girls. Some implications, methodological limitations, and suggestions for future research are discussed.