A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies
Open accessAbstract
OBJECTIVE: Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintained by emotional processing avoidance and interpersonal problems. METHOD: This is the first randomized controlled trial to test directly whether cognitive-behavioral therapy (CBT) could be augmented with the addition of a module targeting interpersonal problems and emotional processing. Eighty-three primarily White participants (mean age = 37) with a principle diagnosis of GAD were recruited from the community. Participants were assigned randomly to CBT plus supportive listening (n = 40) or to CBT plus interpersonal and emotional processing therapy (n = 43) within a study using an additive design. Doctoral-level psychologists with full-time private practices treated participants in an outpatient clinic. Using blind assessors, participants were assessed at pretreatment, posttreatment, 6-month, 1-year, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (the Penn State Worry Questionnaire; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990; Hamilton Anxiety Rating Scale; M. Hamilton, 1959; assessor severity rating; State-Trait Anxiety Inventory-Trait Version; C. D. Spielberger, R. L. Gorsuch, R. Lushene, P. R. Vagg, & G. A. Jacobs, 1983) as well as with indices of clinically significant change. RESULTS: Mixed models analysis of all randomized participants showed very large within-treatment effect sizes for both treatments (CI = [-.40, -.28], d = 1.86) with no significant differences at post (CI = [-.09, .07], d = .07) or 2-year follow-up (CI = [-.01, .01]), d = .12). There was also no statistical difference between compared treatments on clinically significant change based on chi-square analysis. CONCLUSIONS: Interpersonal and emotional processing techniques may not augment CBT for all GAD participants. Trial Registry name: Clinical Trials.gov, Identifier: NCT00951652.
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PSWQ scores at pre-treatment in the GAD subsample were considerably lower than those in recently published randomized trials for GAD.
“In addition, the Penn State Worry Questionnaire scores at pre-treatment in the GAD subsample were considerably lower that those in recently published randomized trials for GAD (Newman et al., 2011; Roemer et al., 2008), which may hold implications for the interpretation of findings in this subgroup.”
From Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders (2012) · cites this paper as Newman et al., 2011
The Abstract (Method) identifies this as a randomized GAD trial, and Measures (Procedure) says the PSWQ was administered at pretreatment. The retrieved passages do not give its pretreatment score, so they cannot establish that the citing paper’s GAD subsample scored considerably lower. (LLM, conf=0.72)
Experimental — accuracy not yet measuredMost studies find that fewer than 65% of clients meet criteria for high end-state functioning at post-treatment.
“However, GAD remains one of the least successfully treated of the anxiety disorders (Waters & Craske, 2005), with most studies finding that fewer than 65% of clients meet criteria for high end-state functioning at post-treatment (e.g., Ladouceur et al., 2000; Newman et al., 2011) and few studies examining the impact of treatment on quality of life.”
From A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder (2013) · cites this paper as Newman et al., 2011
The Results section (Effect of Treatment on GAD Symptom Severity; page unavailable) reports high end-state functioning in 52.9% of one treatment group at two-year follow-up, consistent with the claim’s general point that fewer than 65% can reach that outcome. But the other group reached 68.8%, and these figures are for follow-up, not post-treatment. This single trial does not establish what most studies find at post-treatment. (LLM, conf=0.76)
Experimental — accuracy not yet measuredABBT's end-state functioning resembled Ladouceur et al. (2000) and exceeded every condition in Newman et al. (2011) and Borkovec et al. (2002) by more than 5 percentage points at post-treatment and 6-month follow-up.
“the current study found that end state functioning for ABBT was similar to Ladouceur et al. (2000) and more than 5 percentage points higher than any condition in Newman et al. (2011) and Borkovec et al. (2002) at post-treatment and 6-month follow-up.”
From A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder (2013) · cites this paper as Newman et al. (2011)
The Results (Statistical Analyses; page unavailable) define end-state functioning, and the Results (Effect of Treatment on GAD Symptom Severity; page unavailable) report it for both Newman trial conditions at two-year follow-up. The passages retrieved do not give end-state percentages at post-treatment or six months, so they cannot establish that ABBT exceeded every Newman condition by more than five percentage points at those times. (LLM, conf=0.76)
Experimental — accuracy not yet measuredAt follow-up, CBT plus interpersonal and emotional processing therapy was associated with more participants no longer diagnosable with generalized anxiety disorder (75% vs 63.6%) and higher responder status on interpersonal problems (83.9% vs 66.7%), but these differences were not statistically significant.
“At follow-up, CBT+I/EP was associated with more participants no longer diagnosable with GAD (75% vs. 63.6%) and higher responder status on interpersonal problems (83.9% vs. 66.7%), although these differences were not statistically significant.”
From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [51]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredIn a randomized controlled trial of CBT plus interpersonal and emotional processing therapy versus CBT plus supportive listening, the groups did not differ on treatment expectancy, credibility, or attrition.
“The groups did not differ on treatment expectancy, credibility, or attrition.”
From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [51]
The Results > Process Measures section reports no significant difference between CBT + I/EP and CBT + supportive listening in treatment expectancy or credibility. Results > Statistical Analyses reports 13 dropouts and a nonsignificant condition-by-dropout interaction for symptom change, but does not establish that attrition rates did not differ between groups. (LLM, conf=0.82)
Experimental — accuracy not yet measured
Both CBT plus interpersonal and emotional processing therapy and CBT plus supportive listening produced large pre-post improvements in generalized anxiety disorder symptom severity (d = 1.86), depression, and interpersonal problems, with gains maintained at two-year follow-up.
“Both groups experienced large pre-post improvements for GAD symptom severity (d = 1.86), depression, and interpersonal problems, maintaining gains at two-year follow-up.”
From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [51]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredRecent randomized controlled trials indicate that targeting interpersonal and emotion-focused aspects of generalized anxiety disorder produces effects comparable to existing CBTs.
“Recent randomized controlled trials informed by these models indicate that targeting intolerance of uncertainty (Dugas et al., 2010), and the interpersonal and emotion focused aspects of GAD (Newman et al., 2011) yield effects comparable to existing CBTs for GAD.”
From A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder (2013) · cites this paper as Newman et al., 2011
The pre-to-post Cohen's d values of 1.36 to 1.61 were somewhat lower than the d of 1.86 for a symptom severity composite (Newman et al., 2011) and fell between the effect sizes for Metacognitive Therapy (PSWQ d=3.41) and Applied Relaxation (PSWQ d=0.95; Wells et al., 2010).
“compared to other GAD RCTs our pre to post treatment Cohen’s d effect sizes of 1.36 to 1.61 are slightly smaller than the Cohen’s d of 1.86 for a symptom severity composite variable (Newman et al., 2011) and in between the effect sizes for Metacognitive Therapy (PSWQ d=3.41) and Applied Relaxation (PSWQ d=0.95; Wells et al., 2010)5.”
From A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder (2013) · cites this paper as Newman et al. (2011)
The proportion of ABBT and AR clients achieving clinically meaningful change was similar to most previously reported treatment effects for GAD.
“it appears as though the percentage of clients in ABBT (and AR) who experienced clinically meaningful change was comparable to most other reported treatment effects for clients with GAD.”
From A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder (2013) · cites this paper as Newman et al. (2011)
Clients experienced clinically meaningful change through 24-month follow-up.
“Keeping these limitations, as well as the limitations of comparing outcomes across studies (i.e., different populations, research/therapy team effects, measurement differences) and the differences between examining maintenance and efficacy in mind, similar to other trials of long term outcome following treatment of GAD (i.e., Newman et al., 2011 and Dugas et al., 2010), we also found that clients”
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 Newman et al., 2011
Newman et al.'s (2011) integrated 14-session cognitive behavioral and interpersonal plus emotional processing therapy produced effect sizes comparable to this study.
“Newman et al.'s (2011) evaluation of an integrated, 14-session CBT and interpersonal plus emotional processing therapy also resulted in comparable effect sizes to our study.”
From Group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder: An effectiveness trial (2015) · cites this paper as Newman et al.'s (2011)
Studies that have attempted to increase the efficacy of CBT for GAD by offering more comprehensive CBT have also produced inconclusive results.
“Other studies, which have attempted to increase the efficacy of CBT for GAD by offering more comprehensive CBT, have also produced inconclusive results (e.g., Newman et al., 2011).”
From Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder (2022) · cites this paper as Newman et al., 2011
Previous attempts to increase the efficacy of CBT for GAD using more comprehensive methods have been met with limited success.
“Relatedly, previous attempts to increase the efficacy of CBT for GAD using more comprehensive methods have been met with limited success.”
From Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder (2022) · cites this paper as Newman et al., 2011
Studies that have attempted to increase the efficacy of CBT for GAD by offering more comprehensive CBT have produced inconclusive results.
“Other studies, which have attempted to increase the efficacy of CBT for GAD by offering more comprehensive CBT, have also produced inconclusive results (e.g., Newman et al., 2011).”
From Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder (2022) · cites this paper as Newman et al., 2011
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“For example, the current study found that end-state functioning for ABBT was similar to that in Ladouceur et al. (2000) and was more than 5 percentage points higher than any condition in Newman et al. (2011) and Borkovec, Newman, Pincus, and Lytle (2002) at posttreatment and 6-month follow-up.”
BackgroundMethodResultInfluentialInterpersonal pathoplasticity in individuals with generalized anxiety disorder
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CRITICAL REVIEW OF OUTCOME RESEARCH ON INTERPERSONAL PSYCHOTHERAPY FOR ANXIETY DISORDERS
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Confessions of a New York rupture researcher: An insider’s guide and critique
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THE IMPACT OF STRESSFUL LIFE EVENTS ON RELAPSE OF GENERALIZED ANXIETY DISORDER
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Treatment development: can we find a better way?
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Shin, K. E., & Newman, M. G. (2019) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2019.04.005 · Cited by 75 · see citing works
Self-citationNewman, M. G., Przeworski, A., Consoli, A. J., & Taylor, C. B. (2014) · Psychotherapy · doi:10.1037/a0032519 · Cited by 71 · see citing works
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Prospective Investigation of the Contrast Avoidance Model of Generalized Anxiety and Worry
Crouch, T. A., Lewis, J. A., Erickson, T. M., & Newman, M. G. (2016) · Behavior Therapy · doi:10.1016/j.beth.2016.10.001 · Cited by 63 · see citing works
Self-citationDugas, M. J., Sexton, K. A., Hebert, E. A., Bouchard, S., Gouin, J.-P., & Shafran, R. (2022) · Behavior Therapy · doi:10.1016/j.beth.2022.05.003 · Cited by 58 · see citing works
Role of Atypical Antipsychotics in the Treatment of Generalized Anxiety Disorder
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Constantino, M. J., Boswell, J. F., Bernecker, S. L., & Castonguay, L. G. (2013) · Cited by 56 · see citing works
Self-citationMcEvoy, P. M., Erceg-Hurn, D. M., Anderson, R. A., Campbell, B. N. C., Swan, A., Saulsman, L. M., Summers, M., & Nathan, P. R. (2015) · Journal of Affective Disorders · doi:10.1016/j.jad.2014.12.046 · Cited by 54 · see citing works
Zhu, Z., Zhang, L., Jiang, J., Li, W., Cao, X., Zhou, Z., Zhang, T., & Li, C. (2014) · Europe PMC (PubMed Central) · doi:10.11919/j.issn.1002-0829.214173 · Cited by 54 · see citing works
Kusec, A., Tallon, K., & Koerner, N. (2016) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2016.1171391 · Cited by 53 · see citing works
Zainal, N. H., & Newman, M. G. (2017) · Journal of Affective Disorders · doi:10.1016/j.jad.2017.11.084 · Cited by 54 · see citing works
Self-citationNasiri, F., Mashhadi, A., Bigdeli, I., Chamanabad, A. G., & Ellard, K. K. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2019.11.064 · Cited by 46 · see citing works
Newman, M. G., Castonguay, L. G., Jacobson, N. C., & Moore, G. A. (2015) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0039359 · Cited by 51 · see citing works
Self-citationDennhag, I., Gibbons, M. B. C., Barber, J. P., Gallop, R., & Crits-Christoph, P. F. (2012) · Psychotherapy Research · doi:10.1080/10503307.2012.674790 · Cited by 51 · see citing works
Distress Tolerance and Pathological Worry: Tests of Incremental and Prospective Relationships
Macatee, R. J., Capron, D. W., Guthrie, W., Schmidt, N. B., & Cougle, J. R. (2015) · Behavior Therapy · doi:10.1016/j.beth.2015.03.003 · Cited by 49 · see citing works
LaFreniere, L. S., & Newman, M. G. (2023) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000794 · Cited by 48 · see citing works
Self-citationClinical experiences in conducting empirically supported treatments for generalized anxiety disorder
Szkodny, L. E., Newman, M. G., & Goldfried, M. R. (2014) · Behavior Therapy · doi:10.1016/j.beth.2013.09.009 · Cited by 47 · see citing works
Self-citationNewman, M. G., & Fisher, A. J. (2013) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0031690 · Cited by 45 · see citing works
“Similar to other treatment studies (Clark et al., 1999; Newman et al., 2011), we created a single continuous variable to represent GAD severity.”
ResultSelf-citationLaFreniere, L. S., & Newman, M. G. (2016) · Depression and Anxiety · doi:10.1002/da.22507 · Cited by 40 · see citing works
Self-citationClinical experiences in conducting cognitive-behavioral therapy for social phobia
McAleavey, A. A., Castonguay, L. G., & Goldfried, M. R. (2014) · Behavior Therapy · doi:10.1016/j.beth.2013.09.008 · Cited by 42 · see citing works
Self-citationNewman, M. G., Jacobson, N. C., Erickson, T. M., & Fisher, A. J. (2017) · Behavior Therapy · doi:10.1016/j.beth.2016.05.005 · Cited by 41 · see citing works
“Similar to other treatment studies (Newman et al., 2011), we created a single continuous variable to represent GAD symptom severity.”
Self-citationMaladaptive Core Beliefs and their Relation to Generalized Anxiety Disorder
Koerner, N., Tallon, K., & Kusec, A. (2015) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2015.1042989 · Cited by 41 · see citing works
Comparing a trauma focused and non trauma focused intervention with war affected Congolese youth
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Beukes, E. W., Andersson, G., Fagelson, M. A., & Manchaiah, V. (2021) · Internet Interventions · doi:10.1016/j.invent.2021.100402 · Cited by 37 · see citing works
“Results are, however, not dissimilar to previous dismantling and mantling studies of CBT for depression (Dimidjian et al., 2006), anxiety (Newman et al., 2011) and panic disorder (Schmidt et al., 2000) indicating that adding or removing components theorized to be critical does not always change…”
ResultPenedo, J. M. G., Constantino, M. J., Coyne, A. E., Westra, H. A., & Antony, M. M. (2017) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000233 · Cited by 38 · see citing works
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Self-citationMcEvoy, P. M., Burgess, M. M., & Nathan, P. (2013) · Journal of Affective Disorders · doi:10.1016/j.jad.2013.04.005 · Cited by 34 · see citing works
Testing a procedural variant of written imaginal exposure for generalized anxiety disorder
Fracalanza, K., Koerner, N., & Antony, M. M. (2014) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2014.05.011 · Cited by 33 · see citing works
O'Brien, K., O'Keeffe, N., Cullen, H., Durcan, A., Timulák, L., & McElvaney, J. (2017) · Psychotherapy Research · doi:10.1080/10503307.2017.1373206 · Cited by 33 · see citing works
Millstein, D. J., Orsillo, S. M., Hayes-Skelton, S. A., & Roemer, L. (2015) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2015.1060255 · Cited by 31 · see citing works
“However, in a subsequent evaluation, this treatment was no more effective in targeting interpersonal problems than a CBT plus supportive listening comparison condition (Newman et al., 2011).”
BackgroundSauer-Zavala, S. E., Boswell, J. F., Bentley, K. H., Thompson‐Hollands, J., Farchione, T. J., & Barlow, D. H. (2017) · Cognitive Therapy and Research · doi:10.1007/s10608-017-9855-8 · Cited by 31 · see citing works
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LaFreniere, L. S., & Newman, M. G. (2022) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2022.102659 · Cited by 28 · see citing works
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Self-citationNewman, M. G., Basterfield, C., Erickson, T. M., Caulley, E., Przeworski, A., & Llera, S. J. (2022) · Expert Review of Neurotherapeutics · doi:10.1080/14737175.2022.2125800 · Cited by 27 · see citing works
“Subsequently, a randomized controlled trial tested CBT+I/EP (N = 43) against CBT plus supportive listening [CBT + SL; N = 40; 51], controlling for therapist contact.”
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Chairwork in Cognitive Behavioural Therapy: A Narrative Review
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Exploring DBT skills training as a treatment avenue for generalized anxiety disorder
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Within-day sudden gains and generalized anxiety disorder psychotherapy outcome.
Newman, M. G., Schwob, J. T., & Rackoff, G. N. (2022) · Psychotherapy · doi:10.1037/pst0000445 · Cited by 19 · see citing works
Self-citationA Bowen Family Systems Model of Generalized Anxiety Disorder and Romantic Relationship Distress.
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Therapeutic strategies and techniques in early cognitive-behavioral therapy.
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Pediatric anxiety associated with altered facial emotion recognition
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Worry and Generalized Anxiety Disorder: A Review
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Self-citationAnxiety Regulation: A Developmental Psychopathology Perspective
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Cognitive Behavioural Chairwork
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Aderka, I. M., Beard, C., Lee, J., Weiss, R. B., & Björgvinsson, T. (2015) · Journal of Affective Disorders · doi:10.1016/j.jad.2015.05.054 · Cited by 12 · see citing works
- Authors
- Newman, M. G., Castonguay, L. G., Borkovec, T. D., Fisher, A. J., Boswell, J. F., Szkodny, L. E., & Nordberg, S. S.
- Affiliations
- Pennsylvania State University (US)
- ORCID
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2011-04
- Volume
- 79
- Issue
- 2
- Pages
- 171-181
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- PMC
- PMC3078794
- OpenAlex
- W1992605652
- Cited by
- 174
- References
- 32
- Citations by year
- 2026: 3 · 2025: 6 · 2024: 6 · 2023: 7 · 2022: 10 · 2021: 15 · 2020: 11 · 2019: 5 · 2018: 9 · 2017: 15 · 2016: 12 · 2015: 16 · 2014: 19 · 2013: 21 · 2012: 10
- FWCI
- 23.09
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- ScholarSphere (Penn State Libraries) (submittedVersion, cc-by)
- Funders
- National Institute of Mental Health (RO1 MH58593-02)
- 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, cognitive behavioral therapy, emotion-focused therapy, interpersonal psychotherapy, augmentation therapy, interpersonal problems, outpatient psychotherapy
- MeSH terms
- Adaptation, Psychological, Adolescent, Adult, Aged, Anxiety Disorders, Emotions, Humans, Middle Aged, Patient Compliance, Severity of Illness Index, Cognitive Behavioral Therapy, Treatment Outcome, Patient Selection, Self Report
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