Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder
Abstract
Nondirective (ND), applied relaxation (AR), and cognitive behavioral (CBT) therapies for generalized anxiety disorder (GAD) were compared. The latter 2 conditions were generally equivalent in outcome but superior to ND at postassessment. The 3 conditions did not differ on several process measures, and ND created the greatest depth of emotional processing. Follow-up results indicated losses in gains in ND, maintained gains in the other 2 conditions, especially CBT, and highest endstate functioning for CBT. AR and CBT thus contain active ingredients in the treatment of GAD; support exists for further development of imagery exposure methods or cognitive therapy because of their likely role in promoting maintenance of change with this disorder. Expectancy for improvement was also associated with outcome, suggesting the need for further research on this construct for understanding the nature of GAD and its amelioration.
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Borkovec and Costello (1993) reported that reflective listening scored significantly higher than cognitive therapy and SCD on objective ratings of emotional processing depth.
“Borkovec and Costello (1993) found that a reflective listening condition was significantly superior to cognitive therapy and SCD treatments on objectively coded ratings of depth of emotional processing (using the Experiencing Scale (Klein, Mathieu Coughlan, & Kiesler, 1986; Klein, Mathieu, Gendlin, & Kiesler, 1969), one of the most reliable methods of assessing change process in experiential ther”
From A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry (2011) · cites this paper as Borkovec & Costello, 1993
Objective coding showed SCD produced less depth of emotional processing than reflective listening.
“Also, as noted earlier, depth of emotional processing in response to SCD was objectively coded as inferior to reflective listening (Borkovec & Costello, 1993), suggesting that SCD may not be optimal for emotional processing.”
From A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry (2011) · cites this paper as Borkovec & Costello, 1993
Randomized controlled trials demonstrated that applied relaxation was more efficacious than a nondirective, reflective listening therapy.
“For example, randomized controlled trials demonstrated that AR was more efficacious than a nondirective, reflective listening therapy (Borkovec & Costello, 1993) and roughly as efficacious as cognitive therapy (Arntz, 2003; Öst & Breitholtz, 2000), cognitive behavioral therapy (Borkovec & Costello, 1993; Dugas et al., 2010), and worry exposure (Hoyer et al., 2009) in treating GAD.”
From A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder (2013) · cites this paper as Borkovec & Costello, 1993
Applied relaxation was roughly as efficacious as cognitive behavioral therapy in treating generalized anxiety disorder.
“For example, randomized controlled trials demonstrated that AR was more efficacious than a nondirective, reflective listening therapy (Borkovec & Costello, 1993) and roughly as efficacious as cognitive therapy (Arntz, 2003; Öst & Breitholtz, 2000), cognitive behavioral therapy (Borkovec & Costello, 1993; Dugas et al., 2010), and worry exposure (Hoyer et al., 2009) in treating GAD.”
From A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder (2013) · cites this paper as Borkovec & Costello, 1993
Borkovec and Costello (1993) reported that 44% of AR recipients met high end-state functioning criteria at post-treatment.
“Borkovec and Costello (1993) found 44% of individuals receiving AR met criteria for high end state functioning at post-treatment”
From A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder (2013) · cites this paper as Borkovec and Costello (1993)
AR produced notably better outcomes here than in earlier trials.
“As a result, our AR outcomes were notably stronger than those found in previous trials.”
From A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder (2013) · cites this paper as Borkovec and Costello (1993)
Applied Relaxation has been shown to be more effective than nondirective therapy for generalized anxiety disorder.
“AR has been shown to be more effective than a nondirective therapy (Borkovec & Costello, 1993)”
From A Fresh Look at Potential Mechanisms of Change in Applied Relaxation for Generalized Anxiety Disorder: A Case Series (2012) · cites this paper as Borkovec & Costello, 1993
Applied Relaxation aims to teach clients to notice the earliest signs of anxiety and to respond with relaxation before the anxiety cycle strengthens.
“AR is aimed at teaching clients to notice the earliest signs of anxiety and to react with a different response, namely relaxation, before the cycle of anxiety has a chance to strengthen.”
From A Fresh Look at Potential Mechanisms of Change in Applied Relaxation for Generalized Anxiety Disorder: A Case Series (2012) · cites this paper as Borkovec & Costello, 1993
In the Applied Relaxation model, anxiety responses develop over time, with each channel amplifying the others and increasing the intensity of the anxious response.
“These responses are proposed to develop over time, with each channel amplifying the others, increasing the intensity of the anxious response.”
From A Fresh Look at Potential Mechanisms of Change in Applied Relaxation for Generalized Anxiety Disorder: A Case Series (2012) · cites this paper as Borkovec & Costello, 1993
Applied Relaxation is based on the premise that anxiety involves an interacting system of cognitive, physiological, affective, and behavioral responses.
“As described in Borkovec and Costello (1993), AR is based on the premise that anxiety involves an interacting system of cognitive, physiological, affective, and behavioral responses.”
From A Fresh Look at Potential Mechanisms of Change in Applied Relaxation for Generalized Anxiety Disorder: A Case Series (2012) · cites this paper as Borkovec & Costello, 1993
The effect of applied relaxation on GAD symptoms in the current trial was larger than in previous trials.
“The effect of AR on GAD symptoms in the current trial was larger than in previous trials (Borkovec & Costello, 1993; Wells et al., 2010), possibly due to the extended length of the treatment and/or the emphasis on recognizing tension and deploying relaxation skills in the moment.”
From Interpersonal Problems, Mindfulness, and Therapy Outcome in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder (2015) · cites this paper as Borkovec & Costello, 1993
The Cuijpers et al. (2014) meta-analysis concluded that CBT may be effective and may be more effective than applied relaxation in the long term, based on four studies reporting 12-month follow-up assessments.
“In looking at longer term follow-up, the Cuijpers et al. (2014) meta-analysis concluded that CBT may be effective and may be more effective than applied relaxation (AR) in the long-term based on the four studies reporting 12-month follow-up assessments (Barlow, Brown, & Rapee, 1992; Borkovec & Costello, 1993; Dugas et al., 2010; Öst & Breitholtz, 2000).”
From Do treatment responders maintain their gains following a randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder? (2025) · cites this paper as Borkovec & Costello, 1993
The Penn State Worry Questionnaire has demonstrated sensitivity to change across 6-week and 12-week therapeutic interventions for generalized anxiety disorder.
“The PSWQ has been reported to discriminate patients with GAD from community controls and patients with other anxiety disorders (Brown et al. 1992) and has demonstrated sensitivity to change across both 6-week and 12-week therapeutic interventions for GAD (Borkovec and Costello 1993).”
From CALM Pregnancy: results of a pilot study of mindfulness-based cognitive therapy for perinatal anxiety (2014) · cites this paper as Borkovec and Costello 1993
The CBT protocol used in this study was based on elements of earlier CBT protocols for generalized anxiety disorder in younger adults and was modified for flexible delivery to older adults in primary care.
“The CBT protocol utilized in this study is based on elements of prior CBT protocols for GAD in younger adults (Borkovec & Costello, 1993; Craske, Barlow, & O’Leary, 1992) and modified to include a flexible delivery format to meet the needs of older adults in primary care medical settings (Stanley, Diefenbach, & Hopko, 2004).”
From Cognitive-behavioral therapy for late-life anxiety: Similarities and differences between Veteran and community participants (2015) · cites this paper as Borkovec & Costello, 1993
High remission rates of anxiety symptoms in GAD were outlined following CBT interventions.
“As reflected in our results, high remission rates of anxiety symptoms in GAD were outlined following CBT interventions (Borkovec and Costello, 1993; Kim et al., 2009).”
From Standard CBT versus integrative and multimodal CBT assisted by virtual-reality for generalized anxiety disorder (2022) · cites this paper as Borkovec and Costello, 1993
In the Borkovec and Costello study, CBT and AR were equivalent at posttreatment and both conditions led to maintenance of treatment gains, with some evidence of further gains in CBT.
“Overall, the results show that CBT and AR were equivalent at posttreatment and that both conditions led to the maintenance of treatment gains, with some evidence of further gains in CBT.”
From A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. (2010) · cites this paper as Borkovec and Costello (1993)
Borkovec and Costello (1993) are the only researchers who have compared a GAD-specific form of cognitive-behavioral therapy (CBT) to AR alone.
“To our knowledge, Borkovec and Costello (1993) are the only researchers who have compared a GAD-specific form of cognitive-behavioral therapy or CBT (based on the avoidance model of worry) to AR alone.”
From A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. (2010) · cites this paper as Borkovec and Costello (1993)
Only the Borkovec and Costello study allows for a direct comparison of GAD-specific CBT and AR.
“Thus, only the Borkovec and Costello study allows for a direct comparison of GAD-specific CBT and AR.”
From A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. (2010) · cites this paper as Borkovec and Costello (1993)
The data suggest that AR leads to the maintenance of treatment gains following treatment, which is in line with previous clinical trials of AR for GAD.
“At the very least, the data suggest that AR leads to the maintenance of treatment gains following treatment, which is in line with previous clinical trials of AR for GAD (e.g., Arntz, 2003; Barlow et al., 1992; Borkovec & Costello, 1993; Öst & Breitholtz, 2000).”
From A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. (2010) · cites this paper as Borkovec & Costello, 1993
These findings are somewhat at odds with Borkovec and Costello (1993), who found evidence for the superiority of CBT over AR at 12-month follow-up.
“These finding are somewhat at odds with those of Borkovec and Costello (1993), who found evidence for the superiority of CBT over AR at 12-month follow-up.”
From A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. (2010) · cites this paper as Borkovec and Costello (1993)
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“The PSWQ has been reported to discriminate patients with GAD from community controls and patients with other anxiety disorders (Brown et al. 1992) and has demonstrated sensitivity to change across both 6-week and 12-week therapeutic interventions for GAD (Borkovec and Costello 1993).”
Treatment Expectancy Affects the Outcome of Cognitive-Behavioral Interventions in Chronic Pain
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Unique and common mechanisms of change across cognitive and dynamic psychotherapies.
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Self-citation
- Authors
- Borkovec, T. D., & Costello, E.
- Affiliations
- Pennsylvania State University (US)
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 1993
- Volume
- 61
- Issue
- 4
- Pages
- 611-619
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- OpenAlex
- W2151361778
- Cited by
- 756
- References
- 31
- Citations by year
- 2026: 6 · 2025: 12 · 2024: 20 · 2023: 19 · 2022: 13 · 2021: 30 · 2020: 19 · 2019: 26 · 2018: 21 · 2017: 26 · 2016: 25 · 2015: 27 · 2014: 36 · 2013: 29 · 2012: 34
- FWCI
- 13.48
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute of Mental Health (R01MH039172, MH-39172)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- generalized anxiety disorder, applied relaxation, cognitive behavioral therapy, non-directive therapy, treatment outcomes, maintenance of change, emotional processing, treatment expectancy, psychotherapy comparison
- MeSH terms
- Adaptation, Psychological, Adult, Anxiety Disorders, Female, Humans, Male, Medical Records, Person-Centered Psychotherapy, Relaxation Therapy, Severity of Illness Index, Cognitive Behavioral Therapy, Treatment Outcome
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