Stefan Et Al-2019-Journal of Clinical Psychology
Stefan Et Al-2019-Journal of Clinical Psychology
Stefan Et Al-2019-Journal of Clinical Psychology
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DOI: 10.1002/jclp.22779
RESEARCH ARTICLE
1
Department of Clinical Psychology and
Psychotherapy, Babeş‐Bolyai University, Abstract
Cluj‐Napoca, Romania Objective: Cognitive‐behavior therapy (CBT) is considered
2
Department of Clinical Psychology and
the “golden standard” psychotherapy for generalized
Psychotherapy/International Institute for the
Advanced Study of Psychotherapy and anxiety disorder (GAD) but, at this point, we have
Applied Mental Health, Babeş‐Bolyai
little information about differences among various CBT
University, No 37 Republicii Street,
Cluj‐Napoca, Romania approaches.
3
Department of Oncological Sciences, Icahn Method: We conducted a randomized controlled trial to
School of Medicine at Mount Sinai, New York,
New York compare three CBT protocols for GAD: (a) Cognitive
Therapy/Borkovec’s treatment package; (b) Rational Emo-
Correspondence
Daniel David, Department of Clinical tive Behavior Therapy, and (c) Acceptance and Commitment
Psychology and Psychotherapy/International Therapy/Acceptance‐based behavioral therapy. A number of
Institute for the Advanced Study of
Psychotherapy and Applied Mental Health, 75 patients diagnosed with GAD, aged between 20 and 51
Babeş‐Bolyai University, No 37 Republicii (m = 27.13; standard deviation = 7.50), 60 women and
Street, 400015 Cluj‐Napoca, Romania.
Email: [email protected] 11 men, were randomized to the three treatment arms.
Results: All treatments were associated with large pre‐post
Funding information
Albert Ellis Institute; International Institute intervention reductions in GAD symptoms and dysfunctional
for the Advanced Studies of Psychotherapy automatic thoughts, with no significant differences between
and Applied Mental Health
groups. Correlation analyses showed similar associations
between changes in symptoms and changes in dysfunctional
automatic thoughts.
Conclusions: All three approaches appear to be similarly
effective. Implications for the theoretical models underlying
KEYWORDS
cognitive‐behavioral therapy, generalized anxiety disorder,
randomized controlled trial
1 | INTRODUCTION
Generalized anxiety disorder (GAD) is diagnostically centered around the experience of persistent and excessive
worry, more days than not, for at least 6 months (American Psychiatric Association, 2000). GAD is one of the most
enduring anxiety disorders, being associated with significant distress and impairment (Kessler, Walters, &
Wittchen, 2004), as well as frequent comorbidities, especially depression (Hoge, Ivkovic, & Fricchione, 2012). It is
also relevant to note that GAD is chronic, in many cases lasting for a decade or longer (Kessler & Wittchen, 2002),
with low rates of spontaneous remission or complete recovery (Tyrer & Baldwin, 2006).
Both psychotherapy and pharmacotherapy are efficacious treatments for GAD (see Bandelow et al., 2015;
Newman, Llera, Erickson, Przeworski, & Castonguay, 2013). So far, cognitive‐behavioral therapy (CBT) has received
the most extensive empirical support for GAD, its efficiency being supported by a number of meta‐analyses
(Carpenter et al., 2018; Covin, Ouimet, Seeds, & Dozois, 2008; Cuijpers et al., 2014). Currently, CBT is considered
an empirically/research‐supported treatment for GAD, according to the definition of Chambless and Hollon (1998),
being the only treatment listed by the American Psychological Association’s (APA) division 12 as having strong
empirical support (i.e., for GAD).
However, a few important points must be considered regarding GAD and its psychotherapeutic treatment.
First, although CBT is an effective treatment, studies have also shown that only about 50% of patients achieve a
high level of functioning afterwards (Erickson & Newman, 2005) or that the number needed to treat (NNT) for the
efficacy of CBT is 2.23, meaning that two patients need to be treated for one positive outcome (Cuijpers et al.,
2014). Second, CBT encompasses various theoretical models and, consequently, various therapeutic approaches/
strategies. Indeed, even though there are many studies testing the efficacy of CBT, they focus on different CBT
approaches and are often based on separate and sometimes even divergent theoretical models of GAD.
Probably the most studied CBT model for GAD is a Borkovec’s cognitive avoidance model (Borkovec & Costello,
1993). The model revolves around the concept of worry as a verbal attempt to problem‐solve possible future
negative events, with the goal of reducing or inhibiting aversive mental imagery, emotional experience, and bodily
sensations (see Sibrava & Borkovec, 2006 for a review). Consequently, worry becomes self‐reinforcing. The
therapeutic approach derived from this model includes applied relaxation as well as traditional cognitive therapy
methods (e.g., cognitive restructuring of dysfunctional thoughts, generating alternative and more accurate
thoughts, and behavioral experiments), as described by Beck and Emery (1985). However, other more recent
theoretical and therapeutic models of GAD exist, such as the intolerance of uncertainty model (Ladouceur et al.,
2000; see also Ellis, 1977 and his concept of frustration intolerance), the metacognitive model (Wells & King, 2006),
or acceptance‐based behavior therapy (Roemer & Orsillo, 2005). For instance, a recent study (Nordahl et al., 2018)
compared Cognitive Therapy/Borkovec’s treatment package (CT/BTP) with metacognitive therapy (MCT) for GAD,
and the results showed MCT to be more effective than CT/BTP, with higher recovery rates, maintained at follow‐
up. Still, this result is preliminary and needs replication before we can consider it established, especially taking into
account the large confidence interval around the effect size.
Consequently, blanket statements regarding the efficacy of CBT for GAD remain hard to formulate. This has
important implications on articulating treatment guidelines, because even if CBT is recommended by institutions
such as the National Institute for Health and Care Excellence (National Institute for Health & Care Excellence
STEFAN ET AL. | 3
NICE, 2011) as a first line treatment for GAD, the particular form of CBT recommended is not clearly specified,
under the assumption that all CBT approaches are equal. Therefore, information is missing as to how distinct forms
of CBT models and their recommended therapeutic approaches fare with each other.
The goal of the present study was to contrast three forms of CBT, based on different models regarding GAD: (a)
Cognitive Therapy/Borkovec’s treatment package (CT/BTP); (b) Rational Emotive Behavior Therapy (REBT; Ellis,
1977); and (c) Acceptance and Commitment Therapy/ Acceptance‐based behavioral therapy (ACT/ABBT; Hayes,
Strosahl, & Wilson, 2012).
At a conceptual level, we wanted to compare forms of CBT with distinct approaches to dysfunctional thoughts.
A fundamental postulate of the cognitive model of psychopathology is that the modification of dysfunctional
thoughts (i.e., cognitive change) is central to treating psychological disorders, as “all therapies work by altering
dysfunctional cognitions, either directly or indirectly” (Clark, 1995, p. 158). Both classic Beckʼs cognitive therapy
(CT; Beck, 1976), which is integrated in Borkovecʼs GAD treatment package (CT/BTP), and REBT focus on changing
dysfunctional thoughts, but they differ fundamentally in their approach to achieving this change, by preferentially
(although not exclusively) focusing on “cold” (descriptions/inferences in CT/BTP—e.g., “They criticize me”) versus
“hot” (evaluations/appraisal in REBT— e.g., “They should not criticize me and it if awful if they do”) cognitions
(Lazarus, 1991).
ACT—defined here as a contextual form of CBT—, following a contextual behavioral science approach (Hayes,
Levin, Plumb‐Vilardaga, Villatte, & Pistorello, 2013), in contrast to both CT and REBT, does not directly attempt to
modify the content of thoughts, but aims to change the individualʼs relationship to dysfunctional thoughts (i.e., the
function of thoughts), a process through which cognitions are thought to become somehow “neutralized” (i.e.,
defused) and the anxiety/distress related to them is reduced and/or accepted. In this sense, we wanted to see how
these three forms of CBT impact dysfunctional automatic thoughts and whether changes in dysfunctional
automatic thoughts relate differently to symptom changes across groups. We chose dysfunctional automatic
thoughts as a potential change mechanism rather than core beliefs because previous research showed that they are
more closely related to the anxious symptoms (Cristea, Montgomery, Szamoskozi, & David, 2013), so it is more
likely their change would be immediately predictive of symptom reduction. Also, it is a potential mechanism
targeted by all three interventions, although their approaches differ. To capture the two possible ways in which
dysfunctional automatic thoughts could be potentially modified, we included a measure sensitive to modifications in
the content of the thoughts (i.e., frequency/occurrence), as well as one susceptible to changes in the individual's
relationship to the thoughts (i.e., believability/credibility).
At a practical level, we wanted to investigate how different forms of CBT perform when compared to each
other in the same experimental design. Although Borkoveʼs CT/BTP is already well‐investigated for GAD, there
are less studies comparing it with other CBT approaches. REBT has shown efficiency for anxiety problems (see
David, Cotet, Matu, Mogoase, & Stefan, 2018), but so far, it has not been specifically investigated for GAD. ACT
and ACT‐based therapies, like acceptance‐based behavioral therapy (ABBT), have been shown to be effective
for GAD (Hayes, Orsillo, & Roemer, 2010; Treanor, Erisman, Salters‐Pedneault, Roemer, & Orsillo, 2011). One
study (Avdagic, Morrissey, & Boschen, 2014) directly compared group‐delivered CBT and ACT in the treatment
of GAD and found similar results at post‐intervention, with a steeper reduction in worry for the ACT group.
Also, the processes targeted by each intervention (e.g., intolerance of uncertainty, experiential avoidance)
changed in a similar manner across groups. This study, however, focused only on group therapy and compared
ACT with CBT following the protocol of Zinbarg, Craske, Barlow, and O’Leary (1993), which is closer to the
beckian approach.
4 | STEFAN ET AL.
3 | METHOD
3.3 | Participants
Our inclusion criterion was primary diagnosis of generalized anxiety disorder (GAD). Our exclusion criteria were:
severe major depression, bipolar disorder, panic disorder, substance use/abuse/dependence, psychotic disorders,
suicidal or homicidal ideation, organic brain syndrome, disabling medical conditions, mental retardation, recent
concurrent treatment with psychotropic drug (less than 3 months), and/or psychotherapy outside study. Patients
with comorbid anxiety disorder diagnoses (e.g., social phobia, specific phobia) were recruited in the trial provided
their primary diagnosis was GAD, but we excluded patients with panic disorder because the focus of treatment for
this condition is substantially different.
Initially, 146 participants were screened for GAD symptoms. A total of 71 were further excluded for not
meeting the inclusion criteria or meeting the exclusion criteria, refusal to participate or due to the fact that they
were undergoing pharmacotherapy (i.e., starting a new treatment in the last 3 months). Participants were recruited
through several mental health services (until summer 2018—see ClinicalTrials.Gov (ID: NCT03650465): (1) the
authors’ university; (2) the national Association for Cognitive‐Behavioral Therapies; (3) private practice of team
members; and (4) public service announcements. The 75 randomized participants were diagnosed with generalized
anxiety disorder (GAD) as their primary diagnosis, following DSM‐IV, by the Structured Clinical Interview for DSM‐
IV (SCID; First, Spitzer, Gibbon, & Williams, 1996). The SCID was administered by three clinical psychologists,
others than the therapists delivering the interventions. Out of the initial lot, 71 participants completed the baseline
measures and received the allocated intervention, and 4 participants declined participation. The number of
maximum completers was 39, 13 in the CT/BTP group, 12 in the REBT group, and 14 in the ACT/ABBT group. Out
of those who did not complete the full intervention, 3 only completed the baseline assessment, and 2 received 1
and 2 sessions, respectively, the rest receiving more than 5 sessions. The participants were aged between 20 and
51 (m = 27.13; SD = 7.50), 60 were females and 11 were males. A flow diagram of the progress through the
phases of the trial is presented in Figure 1.
3.4 | Assignment
Eligible participants were randomly allocated by use of a random number generator to CT/BTP, REBT, and ACT/
ABBT conditions.
Interventions (all protocols are available under request)
Treatment reflected standard practice for CT/BTP, REBT, and ACT/ABBT and it included 20 individual 50‐min
sessions for all groups. The first 8 sessions were delivered twice a week, whereas sessions 9–20 were conducted on
STEFAN ET AL. | 5
a weekly basis. A protocol was developed for each intervention and they were approved by the Institutional Review
Board at the authors’ university. Adherence to study protocol was systematically assessed and monitored. All
sessions were delivered at the Babes‐Bolyai Psytech Psychology Clinic, a clinical service unit at Babes‐Bolyai
University, Romania.
The CT/BTP protocol was derived from Borkovec and Costello's (1993) therapeutic approach, relying on
principles of CT for anxiety (Beck & Emery, 1985) and including applied relaxation. CT/BTP sessions were highly
structured, containing the following elements (see also Beck, 1995): (a) mood check and bridging from previous
sessions; (b) setting an agenda; (c) reviewing homework; (d) discussing the issues on the agenda and setting new
homework; and (e) summarizing and feedback. The CT/BTP protocol included several directions as primary goals in
therapy: providing a cognitive conceptualization of the problem, identifying and restructuring automatic thoughts,
intermediate and core beliefs through cognitive (e.g., changing automatic thoughts using a collaborative
empiricisms approach, teaching the patient to search for evidence and form alternative ways of thinking), and
behavioral techniques (i.e., behavioral experiments), enhancing adaptive behavior (i.e., activity scheduling, dealing
with avoidance behavior, social skills training), and using applied relaxation as a coping strategy.
The REBT protocol was based on the approach of Dryden and DiGiuseppe (1990), having as a central tenet changing
dysfunctional emotions (e.g., anxiety) into functional ones (e.g., healthy anxiety/concern), by changing irrational beliefs
(rigid thinking/catastrophizing/frustration intolerance/global evaluation) into rational ones (flexible thinking/nuanced
evaluation of badness/frustration tolerance/nuanced evaluation of self, others, and life), using cognitive (e.g., logical/
empirical/functional/metaphorical), emotive, and behavioral (e.g., exposure/behavioral experiments) techniques. In its
elegant/specific form, used here, REBT is focused on changing the irrational beliefs (i.e., evaluative beliefs/appraisals – e.g.,
“They should not criticize me and it is awful if they do”), seen as the fundamental etiopathogenetic mechanism of GAD,
rather than descriptions/inferences (e.g., “They criticize me”), by moving from specific irrational beliefs to core irrational
beliefs. The REBT protocol also includes problems solving/skills training (targeting various activating events) and various
relaxation techniques (as coping interventions). The structure of an REBT session parallels the CT/BTP session structure
including the same elements, but often with a different content.
The ACT/ABBT protocol was derived from the principles and techniques proposed by Eifert and Forsyth (2005)
and Roemer and Orsillo (2005). From this perspective, GAD is maintained by dysfunctional reactions to internal
experiences (i.e., emotions, thoughts, bodily sensations), experiential avoidance, and behavioral restriction, so the
treatment aims to address all of these problems. The structure of the ACT/ABBT session parallels the one of the
CT/BTP and REBT protocols. From the ACT/ABBT point of view, it is not the worry or the negative emotions that
are problematic, but the rigid unwillingness to have these internal experiences (Hayes et al., 2010). Therefore, the
treatment protocol aims to help the patients accept their thoughts and feelings, while acting according to their
values, and not to change the content of thoughts, like in the CT/BTP and REBT approaches. In this sense, ACT/
ABBT includes three major treatment goals: (a) education about the nature of anxiety, worry, and the role of
experiential avoidance; (b) practicing mindfulness and acceptance skills when dealing with disturbing internal
experiences; and (c) identifying values and following valued action paths when facing obstacles. The techniques
include mindfulness exercises, cognitive diffusion techniques, acceptance and value identification exercises, and
behavioral prescriptions for committing to valued action.
3.5 | Therapists
As specified above, the clinical protocols were delivered by experienced clinicians, also formally certified in CBT by
specialized professional associations. Therapists’ age varied between 26 and 36 years, having 2–12 years of
experience, 11 were female and 2 were male. Moreover, they obtained additional specific training for each clinical
modality (e.g., by intensive training/workshops) from certified supervisors and/or advanced practitioners in the
particular approach (i.e., Academy of Cognitive Therapy for CT/BTP, Albert Ellis Institute for REBT, Association for
Contextual Behavior Science for ACT). Therapists were nested in treatments, meaning that they only provided one
STEFAN ET AL. | 7
treatment form throughout the project. Throughout the project, meetings were held by the senior author (DD),
involving all therapists, to assess the quality of therapy sessions, potential difficult clients, and deviations from the
protocol.
transformation of Cohens d corrected for small sample sizes (Lipsey & Wilson, 2001). We defined response rates as
posttreatment scores lower than previously established cut‐off points used in delimiting clinical GAD, namely 9 for
GAD‐Q‐IV (Newman et al., 2002), and 65 for PSWQ (Fresco, Mennin, Heimberg, & Turk, 2003). We checked
whether changes in symptom scores (i.e., GAD‐Q‐IV and PSWQ) were related to changes in cognitive factors (i.e.,
ATQ), as theory would predict. To this purpose, we computed the delta change scores for pre‐ and posttreatment
values for all outcomes and correlated them using Spearmanʼs nonparametric coefficient to adjust for small
sample size.
4 | RES U LTS
4.5 | Pretreatment
We assessed pretreatment group differences by using one‐way ANOVAs, and we found no significant differences
among conditions in terms of GAD‐Q‐IV scores, F(2, 68) = 0.052, p = 0.949; PSWQ, F(2, 68) = 0.202, p = 0.817;
ATQ‐Freq scores, F(2, 68) = 1.707, p = .189; and ATQ‐Believ scores, F(2, 68) = 1.467, p = 0.238.
T A B L E 2 Means (and standard deviations) of outcome variables (N = 71) at ,pretreatment, and posttreatment (intent‐to‐treat), time x treatment interaction, treatment
|
effects (per group and global), prepost effect sizes, and response rates
ACT/ABBT, Prepost ES (Hedges’ g); 95%
CT/BTP, N = 23 REBT, N = 24 N = 24 Time × Tx p value Time effect (p value) CI and p value
GADQ
Pre 9.39 (1.94) 9.59 (2.53) 9.54 (2.00) F (2, 68) = 0.156; F(1, 68) = 60.24; 1.09; [0.75, 1.44]; < 0.001
p = .856 < 0.001
Post (ITT) 6.33 (3.80) 5.96 (3.81) 6.29 (3.18)
Pre‐post ES (Hedges’ g); 95% CI 0.90; [0.42, 1.40]; 1.06; [0.53, 1.58]; 1.17; [0.47, 1.89];
and p value < 0.001 < 0.001 = 0.001
Response rate (%) 69.6 70.7 79.2
PSWQ
Pre 64.04 (10.42) 65.54 (10.41) 65.83 (10.11) F (2, 68) = F(2, 68) = 58.33; 1.05; [0.72, 1.39]; < 0.001
0.380;p = .685 < 0.001
Post (ITT) 54.13 (11.34) 52.42 (11.47) 54.46 (11.58)
Pre‐post ES (Hedges’ g); 95% CI 0.88; [0.26, 1.50]; 1.15; [0.71; 1.60]; 1.01; [0.41, 1.61];
and p value = 0.005 < 0.001 = 0.001
Response rate 82.6% 83.3% 79.2%
ATQ ‐Freq
Pre 42.04 (13.73) 44.21 (14.30) 48.92 (11.00) F (2, 68) = 0.09; F(1, 68) = 64.04; 1.05; [0.74 – 1.37]; < 0.001
p = .913 < 0.001
Post 29.04 (15.08) 29.67 (11.20) 34.25 (13.16)
Pre‐post ES (Hedges’ g); 95% CI 0.87; [0.37, 1.37]; 1.09; [0.52, 1.65]; 1.16; [0.56, 1.75];
and p value = 0.001 < 0.001 < 0.001
ATQ‐believ
Pre 44.91 (13.00) 46.46 (13.20) 51.17 (13.06) F (2, 68) = 0.140; F(1, 68) = 48.18; 0.94; [0.63, 1.26]; < 0.001
p = .870 < 0.001
Post 32.52 (16.99) 31.50 (13.09) 37.38 (16.17)
Prepost ES (Hedges’ g); 95% CI 0.79; [0.22, 1.36]; 1.10; [0.58, 1.62]; 0.90; [0.38, 1.43];
and p value = 0.007 < 0.001 = 0.001
Note. ACT: acceptance and commitment therapy; ABBT: acceptance‐based behavioral therapy; CT: cognitive therapy; BTP: Borkovec’s treatment package; ATQ‐Believ: Automatic
Thoughts Questionnaire (believability); ATQ‐Freq: Automatic Thoughts Questionnaire (frequency); GAD‐Q‐IV: Generalized Anxiety Disorder Questionnaire IV; PSWQ: Penn State
Worry Questionnaire; Tx: treatment.
STEFAN
ET AL.
STEFAN ET AL. | 11
ABBT, 19 out of 24 (79.2%). Considering the scores on PSWQ, 19 out of 23 patients in the CT/BTP group scored
below the cut‐off point (82.6%), 20 of 24 (83.3%) scored below the threshold in the REBT group, while in the ACT/
ABBT group the response rate reached 19 out of 24 (79.2%).
5.3 | Correlations
As predicted, there were significant and high positive correlations between pre‐post changes in global GAD
symptoms and pre‐post changes in both the frequency/occurrence and believability/credibility of dysfunctional
automatic thoughts in CT/BTP (GAD‐Q‐IV/ATQ‐Freq: r = .625, p = .001; GAD‐Q‐IV/ATQ‐Believ: r = .489,
p = .018). For REBT, as predicted, we found a correlation between changes in GAD symptoms and changes in the
believability of dysfunctional automatic thoughts (GAD‐Q‐IV/ATQ‐Believ: r = .669, p < .001), and also between
changes in GAD symptoms and changes in the frequency of dysfunctional automatic thoughts (GAD‐Q‐IV/ATQ‐
Freq: r = .637, p < .001). In the ACT/ABBT group, both changes in the frequency and believability of dysfunctional
thoughts were correlated with changes in GAD symptoms: GAD‐Q‐IV/ATQ‐Freq, r = .731, p < 0.001 and GAD‐Q‐
IV/ATQ‐Believ., r = .468, p = .021.
Changes in worry (PSWQ) had a very similar pattern in relationship to changes in the dysfunctional automatic
thoughts. Indeed, changes in PSWQ scores were correlated with changes in both the frequency and the
believability of dysfunctional automatic thoughts in the CT/BTP group: PSWQ/ATQ‐Freq, r = .562, p = .005, and
PSWQ/ATQ‐Believ, r = .678, p < .001. The same pattern was found for REBT (PSWQ/ATQ‐Freq, r = .703,
p < .001, and PSWQ/ATQ‐Believ., r = .635, p = .001). For ACT/ABBT, again, frequency correlated with changes
in worry (PSWQ/ATQ‐Freq, r = .681, p < .001), and so did believability (PSWQ/ATQ‐Believ., r = .441, p = .031).
6 | D IS C U S S IO N
The goal of the present randomized clinical trial was to contrast three forms of CBT, based on different models
regarding GAD. This is important both theoretically and practically, as CBT is recommended as a first line
12 | STEFAN ET AL.
treatment for GAD, without specifying which particular CBT approaches might be more efficient and for which
types of patients.
Our results suggested there were no significant differences between the three CBT forms (i.e., CT/BTP, REBT,
and ACT/ABBT) in reducing generalized anxiety symptoms and worry ‐ the cardinal symptom of GAD ‐, measured
with two well‐established scales: GAD‐Q‐IV and PSWQ. Also, there were no significant differences between the
three treatments (i.e., CT/BTP, REBT, and ACT/ABBT) in the reduction of both frequency and believability of
dysfunctional automatic thoughts from pre to posttreatment. We also looked at the associations between changes
in GAD symptoms and worry and changes in dysfunctional thoughts respectively. In all three groups, changes in
GAD symptoms and worry were positively associated with changes in the frequency of occurrence and in the
believability of these thoughts.
From a practical stance, there appear to be no significant differences between the three CBT protocols. Thus,
treatment could be made more accessible depending on the clients’ preferences/values and/or psychotherapists’
availability. The Integrating and Multimodal CBT (IM‐CBT) framework, proposed by David and Freeman (2015),
could accommodate these results, offering a more personalized approach. However, a more detailed investigation –
who responds better to what – is needed.
7 | LIMITS
An important limitation of our study is that we did not have a larger sample. It is possible that we were not able to
observe differences between the groups because our reduced statistical power only allowed us to verify large
effect sizes. We conducted intent‐to‐treat analyses and reported an effect size index that is corrected for small
samples (Hedges’ g). Our sensitivity (post‐hoc) power analysis indicated we would have been able to observe
interaction effect sizes as small as 0.25, which is a small effect size. It is likely that differences between various
forms of psychotherapy are subtle and thus we were unable to capture them. Nonetheless, since ours was the first
study contrasting these three forms of cognitive‐behavioral therapy for GAD, we designed it as a preliminary study
looking for medium effects. Future studies, with larger samples and more statistical power, might be able to
evidence smaller, subtler differences. Larger sample sizes would also permit the accurate testing of potential
treatment moderators, like age and gender. However, the question is if these smaller differences could have a
clinical significance.
Another potential important limitation is the lack of a waitlist control group, which would have allowed for a
common frame of reference for the efficiency of each of the three treatments (i.e., how does each fare in contrast to
the waitlist) and the complete exclusion of the risk that the effects seen are not due to the interventions per se, but
to other external factors. Unfortunately, for procedural reasons (i.e., unavailability of participants, loss to
posttreatment evaluation), we were unable to maintain a waitlist group. However, given that one of our treatment
arms included an established intervention and our effects sizes for this treatment were similar to what was
reported in previous studies (Leichsenring et al., 2009) and meta‐analyses (Covin et al., 2008; Norton & Price,
2007), we can have some certainty the results are not due to the simple passage of time or to spontaneous
remission.
The attrition rate for the initial lot of 75 GAD patients presents as follows: 4 pretreatment drop‐outs, 2
treatment drop‐outs (equal/less than 5 session), 39 maximum completers (20 sessions), and the rest are
nonmaximum completers (more than 5 sessions). This rate is justified by the fact that: (a) our protocol included 20
sessions, whereas other studies generally include less; (b) some of the participants did not return for the
posttreatment assessment, so we could not document them as completers; and (c) we did not provide financial
compensation to participants for completing the study.
Finally, another limitation is the strong reliance on self‐report measures. Unfortunately, a considerable number
of participants did not return for posttreatment evaluations and we were limited in applying the diagnostic
STEFAN ET AL. | 13
interview. However, while we used self‐report measures for the primary and secondary symptoms, we focused on
well‐studied and acknowledged symptom measures, which have been used extensively in previous RCTs. Moreover,
this limitation is reduced because (a) all the results obtained here are consistent across the two measures (GAD‐Q‐
IV and PSWQ) of the same clinical condition (GAD) and (b) we found a consistency of self‐report measures and
clinical diagnosis interview at pretest. Last but not least, our choice of automatic thoughts as mechanism of change
was not the only option, as some authors argue that they are actually too proximal to the experience of emotion to
be considered true mechanisms. Testing for more theory‐driven mechanisms of change, like cognitive errors,
irrational beliefs, or experiential avoidance would be a valuable endeavor in future studies, since this would permit
a more accurate investigation of mechanism specificity in psychological interventions.
AC KNOW LE DGMEN TS
This research was supported by the Albert Ellis Institute, New York and by the International Institute for the
Advanced Study of Psychotherapy and Applied Mental Health, Cluj‐Napoca, Romania. The author Daniel
David is research director at Albert Ellis Institute, New York, and a supervisor at the Academy of Cognitive
Therapy.
OR CID
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S U P P O R T I N G I N F O RMA T I O N
Additional supporting information may be found online in the Supporting Information section at the end of the
article.
How to cite this article: Stefan S, Cristea IA, Szentagotai Tatar A, David D. Cognitive‐behavioral therapy
(CBT) for generalized anxiety disorder: Contrasting various CBT approaches in a randomized clinical trial. J.
Clin. Psychol. 2019;1–15. https://doi.org/10.1002/jclp.22779