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Cited by 31Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesMindfulness and Compassion InterventionsPsychotherapy Techniques and Applications

Interpersonal Problems, Mindfulness, and Therapy Outcome in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder

Open access
Millstein, Daniel J., Orsillo, Susan M., Hayes-Skelton, Sarah A., Roemer, Lizabeth·2015·Cognitive Behaviour Therapy
DOI 10.1080/16506073.2015.1060255PMC PMC4679662
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Abstract

Objective: To better understand the role interpersonal problems play in response to two treatments for generalized anxiety disorder (GAD); an acceptance-based behavior therapy (ABBT) and applied relaxation (AR), and to examine how the development of mindfulness may be related to change in interpersonal problems over treatment and at follow-up. Method: Eighty-one individuals diagnosed with GAD (65.4% female, 80.2% identified as white, average age 32.92) were randomized to receive 16 sessions of either ABBT or AR. GAD severity, interpersonal problems, and mindfulness were measured at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up. Results: Mixed effect regression models did not reveal any significant effects of pre-treatment interpersonal problems on GAD severity over treatment. After controlling for post-treatment GAD severity, remaining post-treatment interpersonal problems predicted 6- but not 12-month GAD severity. Participants in both conditions experienced a large decrease in interpersonal problems over treatment. Increases in mindfulness over treatment and through follow-up were associated with decreases in interpersonal problems, even when accounting for reductions in overall GAD severity. Conclusions: Interpersonal problems may be an important target of treatment in GAD, even if pre-treatment interpersonal problems are not predictive of outcome. Developing mindfulness in individuals with GAD may help ameliorate interpersonal difficulties among this population. © 2015 Swedish Association for Behaviour Therapy.

Integrity signals

Registry

Crossref · 10.1080/16506073.2015.1060255

Cites

51 of 51 references verified0 citation errors · 0 not checkable

Statistics

12 tests recomputed · 1 with the reported and recomputed p on opposite sides of .05

Claims the paper makes

3 of 24 cited sources checked · 3 supported · 0 flagged

  • Findingown data

    There were no significant differences between acceptance-based behavior therapy and applied relaxation in change in interpersonal problems over time.

    “However, there was no main effect of treatment type (ABBT vs. AR) or time by treatment interaction, indicating that there were not significant differences between the two treatments.”
    • Also stated in: § Discussion · plain
      “Despite theory and previous research suggesting that ABBT, with its unique emphasis on cultivating mindfulness, would be particularly beneficial in addressing interpersonal problems, ABBT and AR had similar effects.”
    Quote in the paperSubstantial claim
  • Findingown data

    Post-treatment vindictive and overly nurturant interpersonal problem subscales remained significantly associated with 6-month follow-up GAD severity after controlling for post-treatment GAD severity.

    “However, when controlling for post-treatment GAD severity through partial correlations only the vindictive [r(55) = .28, p < .05] and overly nurturant [r(55) = .37, p <.01] post-treatment subscales remained significantly associated with 6-month follow-up GAD severity”
    Quote in the paperSubstantial claim
  • Findingown data

    Pre-treatment interpersonal problems did not significantly predict GAD severity over the course of treatment in either acceptance-based behavior therapy or applied relaxation.

    “Mixed effect regression models did not reveal any significant effects of pre-treatment interpersonal problems on GAD severity over treatment.”
    • Also stated in: § Effects of Interpersonal Problems on Treatment Outcome · plain
      “There was no significant main effect of baseline interpersonal problems on GAD severity, and there were no significant interactions between baseline IIP-SC scores and treatment type or time on outcome.”
    • Also stated in: § Discussion · plain
      “In the current study we found no effect of pre-treatment interpersonal problems on response to either ABBT or AR from pre to 12-month follow-up.”
    Quote in the paperSubstantial claim
  • Findingown data

    Participants in both acceptance-based behavior therapy and applied relaxation experienced a large decrease in interpersonal problems from pre-treatment through 12-month follow-up.

    “Participants in both conditions experienced a large decrease in interpersonal problems over treatment.”
    • Also stated in: § Effects of Treatment on Interpersonal problems · hedged
      “There was a large negative effect of time on interpersonal problems (Table 3), indicating a significant decrease in interpersonal problems through 12-month follow-up for both treatments.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Post-treatment exploitable and nonassertive subscales trended toward significant association with 6-month follow-up GAD severity after controlling for post-treatment GAD severity.

    “although two subscales, (exploitable [r(55) = .26, p = .056]. and nonassertive [r(55) = .27, p = .052]) trended toward significance.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 17
  • Classified as probably not a substantial claim. 10

  • May combine two claims.

    Study design and conductown data

    Both interventions were faithfully and competently administered according to adherence ratings.

    “Sessions were randomly selected and rated for adherence, suggesting that both interventions were faithfully and competently administered (see Hayes-Skelton et al., 2013).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Hayes-Skelton et al., 2013 source

  • May combine two claims.

    Premisecitation

    Acceptance-based behavior therapy is a relatively new GAD treatment that has shown efficacy.

    “Acceptance-based behavior therapy (ABBT) is a new approach to treatment for GAD with demonstrated efficacy (Hayes-Skelton, Roemer, & Orsillo, 2013; Roemer & Orsillo, 2007; Roemer et al., 2008) that integrates acceptance and mindfulness with traditional behavioral approaches.”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Hayes-Skelton, Roemer, & Orsillo, 2013 source
    • cites Roemer & Orsillo, 2007 source
    • cites Roemer et al., 2008 source

  • May combine two claims.

    Findingown data

    Post-treatment intrusiveness was initially correlated with 12-month GAD severity, but this association was not significant after controlling for post-treatment GAD severity.

    “Initially there was a significant correlation between post-treatment intrusiveness [r(50) = .29, p = .04] and 12-month GAD severity, however this relationship was no longer significant when post-treatment GAD severity was controlled for through a partial correlation [r(50) = .05, p = .78].”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Increases in mindfulness over treatment and follow-up were associated with decreases in interpersonal problems, even after accounting for reductions in GAD severity, explaining an additional 18% of variance at post-treatment, 22% at 6-month follow-up, and 19% at 12-month follow-up.

    “Increases in mindfulness over treatment and through follow-up were associated with decreases in interpersonal problems, even when accounting for reductions in overall GAD severity.”
    • Also stated in: § Relationship Between Mindfulness and Interpersonal Problems · hedged
      “Multiple linear regression analyses (Tables 6, 7, and 8) suggested that an increase in mindfulness predicted a decrease in interpersonal problems over and above the effects of changes in GAD severity at post, 6- and 12-month follow-up.”
    • Also stated in: § Relationship Between Mindfulness and Interpersonal Problems · plain
      “Specifically, change in mindfulness explained an additional 18% of the variance in interpersonal problems at post, 22% of the variance at 6-months, and 19% of the variance in change in interpersonal problems above and beyond change in GAD severity at 12-months.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    The distributions of GAD CSRs, IIP-SC scores, and FFMQ scores did not violate assumptions of normality.

    “Inspection of the histograms for all three variables over time revealed no violations of assumptions of normality, suiting them for the proposed analyses.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    There were no significant baseline differences between treatment groups in GAD severity, age, gender, or ethnicity.

    “No significant differences in GAD severity, age, gender, or ethnicity emerged by treatment group.”
    • Also stated in: § Results · plain
      “One-way ANOVA’s did not reveal pre-treatment differences in interpersonal problems [F (1,77) = 0.24, p =. 62], GAD severity [F (1,79) = 0.37, p =. 55], or mindfulness [F (1,77) = 0.06, p =. 81].”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Using only one self-report instrument for interpersonal functioning might lower the external validity of the results.

    “Although the IIP-C is a commonly used measure of interpersonal problems with strong convergent validity, reliance on a single self-report measure of interpersonal functioning may reduce the external validity of the findings.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Although cognitive behavioral therapy appears efficacious for GAD, a substantial proportion of patients may not achieve high-end state functioning by treatment completion.

    “Although cognitive behavioral therapy appears efficacious for GAD (Colvin, Ouimet, Seeds, & Dozois, 2008), a quarter (Ladouceur et al., 2000) to three quarters (Waters & Craske, 2005) of patients may not achieve high-end state functioning by treatment completion.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Colvin, Ouimet, Seeds, & Dozois, 2008

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Ladouceur et al., 2000 source
    • cites Waters & Craske, 2005

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    People with GAD report greater marital dissatisfaction and more interpersonal problems overall compared with controls.

    “Individuals with GAD report more marital dissatisfaction (Whisman, Sheldon, & Goering, 2000) and overall interpersonal problems (Eng & Heimberg, 2006) than control participants.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Whisman, Sheldon, & Goering, 2000 source
    • cites Eng & Heimberg, 2006 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Missing data increased from pre-treatment to follow-up but did not differ significantly between treatments.

    “Fewer than 5% of GAD CSRs, IIP-SC scores, and FFMQ scores were missing across measures at pre-treatment. This quantity grew at post (between 19.8 and 22.2%), 6-month follow-up (between 32.1 and 33.3%), and 12-month follow-up (between 38.3 and 39.5%) with no significant differences in missing data between treatments.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Interpersonal difficulties might be a valuable focus for GAD treatment, even though baseline interpersonal problems did not forecast outcome.

    “Interpersonal problems may be an important target of treatment in GAD, even if pre-treatment interpersonal problems are not predictive of outcome.”
    • Also stated in: § Discussion · hedged
      “For GAD, a clinical presentation that includes interpersonal difficulties, ameliorating interpersonal problems may be beneficial.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductnone given

    Sample diversity was low, which restricts how broadly the results can be generalized.

    “The lack of diversity in the current sample also limits the generalizability of the findings.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Participants were randomized to receive either acceptance-based behavior therapy or applied relaxation.

    “Eighty-one individuals diagnosed with GAD (65.4% female, 80.2% identified as White, average age 32.92) were randomized to receive 16 sessions of either ABBT or AR.”
    • Also stated in: § Participants · plain
      “Participants were 81 individuals in a randomized controlled trial (see Hayes-Skelton, Roemer, & Orsillo, 2013 for complete details) comparing an acceptance-based behavior therapy (ABBT) with applied relaxation (AR) for the treatment of GAD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Some pre-treatment interpersonal problems were negatively correlated with 6-month follow-up endstate functioning, but not at 12 or 24 months.

    “Although some pre-treatment interpersonal problems (domineering, intrusive, and vindictive subscale scores) were negatively correlated with 6-month follow-up endstate functioning”
    • Also stated in: § Conclusions · plain
      “these relationships were no longer significant at 12 or 24-month follow-up”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Borkovec et al., 2002 source

  • May combine two claims.

    Interpretationown data

    The association between mindfulness increase and interpersonal problem decrease was stronger from pre-treatment to 6-month follow-up and still present but less robust through 12-month follow-up, suggesting enduring benefits.

    “This association was even stronger when looking from pre-treatment through 6-month follow-up, and still present though less robust through 12-month follow-up, suggesting enduring benefits for cultivating mindfulness in this population.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Unmeasured mechanisms might explain the improvements in interpersonal problems better than the variables studied.

    “Finally, mechanisms not examined in the current study may better account for improvements in interpersonal problems.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The FFMQ had internal consistency (Cronbach's α = .88-.94) in this sample.

    “Total scores were calculated for pre, post, 6-month, and 12-month follow-up (Cronbach’s αs = .88-94).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The ADIS-IV GAD Clinician Severity Ratings had interrater reliability (ICC = .73).

    “a second rater scored 30% of interviews, yielding an interclass correlation (ICC) between raters of .73 for GAD CSRs.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The WAI-C and WAI-T had internal consistencies of .84 and .76, respectively.

    “WAI-C and WAI-T internal consistencies were .84 and .76, respectively.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Personality disorders involving interpersonal functioning deficits are frequently comorbid with GAD.

    “Moreover, personality disorders, involving interpersonal functioning deficits (Hengartner, Muller, Rodgers, Rossler, & Ajdacic-Gross, 2013), are frequently comorbid with GAD (Grant et al., 2005).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Hengartner, Muller, Rodgers, Rossler, & Ajdacic-Gross, 2013 source
    • cites Grant et al., 2005 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The IIP-SC had internal consistency (Cronbach's α = .90-.95) in this sample.

    “The IIP-SC was administered at pre, post, 6-month, and 12-month follow-up (Cronbach’s αs = .90-.95).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Interpersonally oriented psychodynamic psychotherapy for GAD led to reductions in interpersonal problems at post-treatment, though not more than a supportive listening control.

    “An interpersonally oriented psychodynamic psychotherapy for GAD led to reductions in interpersonal problems at post-treatment (Crits-Cristoph, Connolly, Azarian, Crits-Cristoph, & Shappell, 1996), though not more than a supportive listening control (Crits-Christoph et al., 2005).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Crits-Cristoph, Connolly, Azarian, Crits-Cristoph, & Shappell, 1996

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Crits-Christoph et al., 2005 source

  • May combine two claims.

    Premisecitation

    Research indicates that mindfulness-based programs improve empathy, relationship satisfaction for couples, and feelings of social connection.

    “Mindfulness-based interventions have been shown to enhance empathic perspective taking (Birnie, Speca, & Carlson, 2010), couples’ relationship satisfaction (Carson, Carson, Gil, & Baucom, 2004), and social connectedness (Cohen & Miller, 2009).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Birnie, Speca, & Carlson, 2010 source
    • cites Carson, Carson, Gil, & Baucom, 2004 source
    • cites Cohen & Miller, 2009 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    After treatment, several interpersonal problem types-intrusive, vindictive, domineering, nonassertive, and self-sacrificing-were significantly linked to 6-month endstate functioning when baseline anxiety was controlled.

    “In the CBT study noted above, (Borkovec et al., 2002) post-treatment intrusive, vindictive, domineering, nonassertive, and self-sacrificing interpersonal problems significantly correlated with 6-month endstate functioning, controlling for baseline anxiety scores.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Borkovec et al., 2002 source

  • May combine two claims.

    Premisecitation

    Crits-Christoph and colleagues (2005) found only 2 of 27 correlations between pre-treatment IIP scores and residualized changes in anxiety, worry, and depression were significant; baseline overly nurturant problems were associated with decreased change in anxiety and worry.

    “Only 2 of 27 possible correlations between pre-treatment IIP scores and residualized changes in anxiety, worry, and depression were significant; baseline overly nurturant problems were associated with decreased change in anxiety and worry, but not depression.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Crits-Christoph, Gibbons, Narducci, Schamberger, & Gallop, 2005 source
25 of 25

Statistics that don’t add up

Each reported p-value recomputed from its test statistic and degrees of freedom.

  • Inconsistent p-value across alpha = .05: r(55) = .27, p = .052

    Major

    The paper reports p = .052 here; recomputing from the test statistic and its degrees of freedom gives p = .042 (two-tailed). The two fall on opposite sides of alpha = .05. The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p = .052 · recomputed p = .042

  • Inconsistent p-value: r(50) = .05, p = .78

    Minor

    The paper reports p = .78 here; recomputing from the test statistic and its degrees of freedom gives p = .725 (two-tailed). The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p = .78 · recomputed p = .725

2 of 2

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Doesn’t add upr(55) = 0.27reported p = .052 · recomputed p = .042The two fall on opposite sides of .05

    “r(55) = .27, p = .052”

  • Doesn’t add upr(50) = 0.05reported p = .78 · recomputed p = .725

    “r(50) = .05, p = .78”

  • ConsistentF(1, 62) = 0.003reported p = .96 · recomputed p = .956

    “F (1, 62) = 0.003, p = .96”

  • Consistentr(67) = 0.12reported p = .35 · recomputed p = .326

    “r (67) = .12, p = .35”

  • Consistentr(55) = 0.42reported p < .01 · recomputed p = .001

    “r(55) = .42, p < .01”

  • Consistentr(55) = 0.3reported p < .05 · recomputed p = .023

    “r(55) = .30, p < .05”

  • Consistentr(55) = 0.37reported p < .01 · recomputed p = .005

    “r(55) = .37, p < .01”

  • Consistentr(55) = 0.41reported p < .01 · recomputed p = .002

    “r(55) = .41, p < .01”

  • Consistentr(55) = 0.53reported p < .01 · recomputed p < .001

    “r(55) = .53, p < .01”

  • Consistentr(55) = 0.28reported p < .05 · recomputed p = .035

    “r(55) = .28, p < .05”

  • Consistentr(55) = 0.26reported p = .056 · recomputed p = .051

    “r(55) = .26, p = .056”

  • Consistentr(50) = 0.29reported p = .04 · recomputed p = .037

    “r(50) = .29, p = .04”

12 of 12

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Discussion treats two nonsignificant subscale associations as significant

    Minor

    The discussion says four post-treatment subscales remained correlated with six-month GAD severity after controlling for post-treatment severity. The results say only vindictive and overly nurturant problems remained significantly associated; exploitable and nonassertive problems only trended toward significance.

1 of 1

Cites

Flagged first, then by citations

5 of the 56 references couldn’t be matched to a known paper.

Research works printed but not linked: 1

  1. 10.1037/0022-006X.68.6.957171 · DOI

Cited by

Sorted by citations

Related

Authors
Millstein, D. J., Orsillo, S. M., Hayes-Skelton, S. A., & Roemer, L.
Affiliations
  • Suffolk University (US)
  • University of Massachusetts Boston (US)
Corresponding author
Millstein, Daniel J.
ORCID
Venue
Cognitive Behaviour Therapy
Publisher
Informa UK Limited
Published
2015-07-31
Volume
44
Issue
6
Pages
491-501
ISSN
  • 1650-6073 (ISSN-L)
  • 1651-2316
DOI
10.1080/16506073.2015.1060255
PMC
PMC4679662
OpenAlex
W2214363669
Cited by
31
References
56
Citations by year
2025: 5 · 2024: 3 · 2023: 1 · 2022: 3 · 2021: 2 · 2020: 6 · 2019: 6 · 2018: 3 · 2017: 1 · 2016: 1
FWCI
2.51
Type
journal article
Language
en
Open access
Locations
  • Cognitive Behaviour Therapy (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (MH074589)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
generalized anxiety disorder, interpersonal problems, mindfulness, applied relaxation, treatment outcomes, predictors of treatment response, follow-up maintenance
MeSH terms
Adult, Anxiety Disorders, Female, Humans, Interpersonal Relations, Male, Relaxation Therapy, Treatment Outcome, Young Adult, Mindfulness, Acceptance and Commitment Therapy

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