by Joye C. Anestis
One of the main complaints voiced about the empirically-supported treatment (EST) movement goes something like this: "Cognitive-behavioral therapy (CBT) is the only treatment ever included on those lists. Almost all other treatments are ignored." And that statement is true - for the vast majority of mental illnesses, some form of CBT is considered to be the front-line empirically-supported treatment. There is one reason for this - few other forms of psychotherapy are being researched at all or at least in the manner necessary to be classified as empirically supported. CBT dominates lists of ESTs not because of favoritism but because of the simple fact that CBT is based in a strong research tradition. As empiricists, we at PBB are supporters of any treatments as long as they have been scientifically documented as efficacious and effective. So I am always excited when I find a good randomized controlled trial examining the utility of a treatment other than (or in addition to) CBT for a specific illness...such as the article I recently found from the American Journal of Psychiatry.
A multitude of independent studies and meta-analyses have demonstrated that CBT is an EST for generalized anxiety disorder (GAD), a common and debilitating mental illness. And, thus far, CBT is the only EST for GAD. Falk Leichsenring and colleagues in Germany conducted a randomized controlled trial to determine if a short-term, manualized psychodynamic therapy for GAD could produce results equivalent to those produced by CBT. I want to pause right here and applaud these authors for their study design right off the bat. It is much more useful in a study like this to compare an alternative treatment to the frontline treatment for that disorder (in this case, CBT). Other studies I have come across in the past have compared their new treatment to some other intervention which is not an EST for that disorder. While some information can be gleaned from this type of study, a direct comparison with an EST results in a much more rigorous study from which strong conclusions can be drawn. So kudos to Leichsenring right of the bat! Now back to my description...
The sample: Participants in this study were between the ages of 18 & 65 with a primary diagnosis of GAD. Exclusion criteria were: 1) the presence of an Axis III medical disorder that could interfere with treatment completion; 2) current or past history of schizophrenia, bipolar disorder, or cluster A or C personality disorder; 3) current or past neurological disorder; 4) alcohol or substance abuse/dependence, eating disorder, or major depression in the previous 12 months; and 5) current concomitant psychotherapy or pharmacological treatment. In all, 57 individuals were included (mean age 42.5, 80.7% female, 71.9% with comorbid mental illnesses).
The treatments: The treatments were administered in up to 30 50-minute individual therapy sessions and were conducted according to treatment manuals (I would normally provide a link to the manuals, but they are both in German!). The CBT manual was based on GAD literature and utilized components known to be effective for GAD such as relaxation techniques, problem solving, activity planning, homework assignments, worry exposure, and, of course, identifying, changing, and controlling worry thoughts. Mean number of sessions for subjects assigned to CBT was 28.8 (SD=3.4). The short-term psychodynamic therapy was based on Luborksy's (1984) supportive-expressive therapy, which has been adapted for the treatment of GAD. Since I am not an expert in psychodynamic terminology (and so don't trust myself to paraphrase accurately), I will let the authors describe the treatment for you: "The treatment used in this study focuses on the core conflictual relationship theme associated with symptoms of generalized anxiety disorder. Emphasis is put on a positive therapeutic alliance. As patients with the disorder are hypothesized the suffer from insecure attachment, a positive therapeutic alliance provides a corrective emotional experience and allows the patient to approach feared situations, both psychologically and behaviorally." (p. 3). "Therapists encourage new behaviors...the experiences the patient has when approaching feared situations are used to work on the core conflictual relationship theme..." (p. 3). Mean number of sessions for this group was 29.1 (SD=3.1). Treatments were administered by licensed psychotherapists who regularly use either CBT or psychodynamic therapy. As would be expected, CBT therapists were more familiar with the use of treatment manuals, but all therapists received training in the use of the treatment manuals by the developers of the German versions of the manuals. The therapists received continuous group supervision, and all of the sessions were audiotaped to ensure adherence to the manuals.
Conclusions: Patients were assessed at baseline, end of treatment, and then at 6 and 12-month follow-up, using a number of accepted measures of anxiety and depression (i.e., Penn State Worry Questionnaire, Hamilton Anxiety Rating Scale, State-Trait Anxiety Inventory, Beck Anxiety Inventory, Hospital Anxiety and Depression Scale, Beck Depression Inventory, Inventory of Interpersonal Problems). The results indicated that both treatments resulted in significant improvement on many measures of both anxiety and depressions at posttreatment and 6-month follow-up (the data for the 12-month follow-up are being reported in another article). However, the CBT group was superior in measures of trait anxiety (STAI), worrying (PSWQ), and depression (BDI). So while both treatments led to client improvement, CBT was beneficial across a greater number of symptom domains. The authors rightly note that the conclusions that can be drawn from these results are limited by their small sample size (n=57). It is plausible that more between-groups differences exist, but the 2 groups were not large enough to permit their detection. Furthermore, the authors spend a good deal of time commenting on the difference between the 2 groups on the measure of worry. As worry is the "hallmark" of GAD, it is imperative that any treatment of GAD work to decrease its frequency. CBT is much more tailored to decrease rates of worrying than is psychodynamic therapy, perhaps explaining the superiority of CBT in this study on measures of worry (e.g., the PSWQ). The authors suggest that the psychodynamic treatment used here, while promising, should be refined to address worrying more specifically.
In sum, this short-term psychodynamic therapy is promising for the treatment of GAD, but further research is needed before it is considered an EST. However, this an excellent first step toward understanding and perhaps identifying an alternative treatment for GAD. I am hopeful that other forms of therapy are being investigated and compared with the current frontline treatment for other specific disorders, so that we might further our knowledge and our ability to help a wide variety of clients.
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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