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Cognitive‐behavioral therapy (CBT) for generalized anxiety disorder:

Contrasting various CBT approaches in a randomized clinical trial

Article  in  Journal of Clinical Psychology · April 2019

DOI: 10.1002/jclp.22779

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Received: 4 December 2018 | Revised: 11 February 2019 | Accepted: 19 March 2019

DOI: 10.1002/jclp.22779

RESEARCH ARTICLE

Cognitive‐behavioral therapy (CBT) for

generalized anxiety disorder: Contrasting
various CBT approaches in a randomized
clinical trial

Simona Stefan1* | Ioana A. Cristea1 | Aurora Szentagotai Tatar1 |

Daniel David2,3*

1
Department of Clinical Psychology and
Psychotherapy, Babeş‐Bolyai University,
Cluj‐Napoca, Romania
2
Department of Clinical Psychology and
Psychotherapy/International Institute for the
Advanced Study of Psychotherapy and
Applied Mental Health, Babeş‐Bolyai
University, No 37 Republicii Street,
Cluj‐Napoca, Romania
3
Department of Oncological Sciences, Icahn
School of Medicine at Mount Sinai, New York,
New York
Correspondence
Daniel David, Department of Clinical
Psychology and Psychotherapy/International
Institute for the Advanced Study of
Psychotherapy and Applied Mental Health,
Babeş‐Bolyai University, No 37 Republicii
Street, 400015 Cluj‐Napoca, Romania.
Email: daniel.david@ubbcluj.ro
Funding information
Albert Ellis Institute; International Institute
for the Advanced Studies of Psychotherapy
and Applied Mental Health
Abstract
Objective: Cognitive‐behavior therapy (CBT) is considered
the “golden standard” psychotherapy for generalized
anxiety disorder (GAD) but, at this point, we have
little information about differences among various CBT
approaches.
Method: We conducted a randomized controlled trial to
compare three CBT protocols for GAD: (a) Cognitive
Therapy/Borkovec’s treatment package; (b) Rational Emo-
tive Behavior Therapy, and (c) Acceptance and Commitment
Therapy/Acceptance‐based behavioral therapy. A number of
75 patients diagnosed with GAD, aged between 20 and 51
(m = 27.13; standard deviation = 7.50), 60 women and
11 men, were randomized to the three treatment arms.
Results: All treatments were associated with large pre‐post
intervention reductions in GAD symptoms and dysfunctional
automatic thoughts, with no significant differences between
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

*Stefan and David have contributed equally to this work.

J. Clin. Psychol. 2019;1–15. wileyonlinelibrary.com/journal/jclp © 2019 Wiley Periodicals, Inc. | 1

2 | STEFAN ET AL.

each of the three cognitive‐behavior therapy approaches are

discussed.

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.

2 | OVERVIEW OF THE PRESENT STUDY

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

3.1 | Protocol and design

We conducted a randomized control trial to test the efficacy of three different forms of CBT: CT/BTP, REBT, and
ACT/ABBT, in treating GAD. We provided treatment in outpatient settings. The trial was approved by the
University IRB (approval number 13744) and was registered on ClinicalTrials.Gov (ID: NCT03650465), before
finalizing the whole data set collection and running any data analyses on the full sample.

3.2 | Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of
the institution and with the 1964 Helsinki declaration and its later amendments. Informed consent: Informed
consent was obtained from all individual participants included in the study.

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

F I G U R E 1 Flow‐chart of participants’ allocation to treatment groups. ACT: acceptance and commitment

therapy; CT: cognitive therapy; REBT: rational emotive behavior therapy
6 | STEFAN ET AL.

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.

3.6 | Outcome measures

Primary and secondary outcomes were measured at pretreatment, every session, and posttreatment. Diagnosis and
comorbidities were assessed using the Structured Clinical Interview for DSM‐IV (SCID; First et al., 1996), which
was administered at pretreatment and at Posttreatment, for those participants completing the trial.

3.7 | Primary outcomes

Generalized Anxiety Disorder Questionnaire IV (GAD‐Q‐IV; Newman et al., 2002) is a 9‐item self‐report measuring the
DSM‐IV criteria for GAD. Most items are dichotomous and assess whether certain criteria are likely or not to be
present, one item is open‐ended, and two items relating to functional impairment and distress are scored on scales
ranging from 0 (none) to 8 (very severe). The GAD‐Q‐IV was designed as a screening tool for GAD, and it can be
scored both in a dimensional and in a categorical manner. The scale has proven to be a reliable (k = 0.64, α = 0.87)
and valid instrument (Newman et al., 2002). The GADQ has been adapted and previously used with Romanian
population (e.g., Stefan & David, 2014).
Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990) is a 16‐item
instrument designed to measure trait worry in terms of frequency and controllability. The items are
answered on a 5‐point Likert scale ranging from 1 (not at all typical of me) to 5 (very typical of me). The scale
has shown good internal consistency, with Cronbachʼs α ranging from 0.86 to 0.93 in both clinical samples
and normal population (Molina & Borkovec, 1994). In terms of validity, PSWQ scores are significantly higher
for individuals diagnosed with GAD than for individuals meeting only some of the criteria (Meyer et al.,
1990), or for individuals diagnosed with other anxiety disorders (Brown, Barlow, & Liebowitz, 1994). The
PSWQ has been adapted and previously used on Romanian population (e.g., Pasarelu, Dobrean, Predescu,
Sipos, & Lupu, 2015).

3.8 | Secondary outcomes/hypothesized mechanisms of change

Automatic Thoughts Questionnaire (ATQ; Hollon & Kendall, 1980) is a 15‐item measure of negative automatic
thoughts, typically related to many stressful experiences (e.g., depressed mood, anxious symptoms). The items are
phrased as negative thoughts and participants are asked to estimate their frequency on a 5‐point Likert scale
(1 – never; 5 – almost always). The ATQ has shown a high internal consistency (α = 0.92) and high construct and
criterion‐related validity. In this study, we used a modified version of ATQ, in which, apart from estimating the
frequency/occurrence (ATQ‐Freq) of the negative automatic thoughts, we also included a measure of their
believability/credibility (ATQ‐Believ), asking the participants to rate the degree they believe in the content of the
items, on a 5‐point Likert scale (1 – not at all; 5 – totally). The ATQ has been adapted for Romanian population with
good psychometric properties (David, 2007).

3.9 | Data analyses

Analyses were conducting using an intent‐to‐treat (ITT) approach, using a last observation carried forward principle
for imputing missing postintervention data. As such, all randomized participants who completed at least their initial
evaluation (i.e., 71) were included in the analyses. We used repeated measures ANOVA procedures to test for time‐
treatment interactions on outcome measures. Effect sizes were calculated using the index Hedges’ g, which is a
8 | STEFAN ET AL.

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

4.1 | Power analysis

We conducted a sensitivity (post‐hoc) analysis using the G*Power software. Our focus was repeated
measures analysis of variance looking for within‐between interactions. We assumed a p of 0.05, N = 71 (the
number of participants included in the ITT analyses), power = 0.90, and 2 repeated measures (baseline and
postintervention). Correlations between baseline and post‐intervention ITT scores ranged from 0.30 to 0.39
for our four outcome measures. Sensitivity analysis indicated we would be able to detect interaction effects
as small as 0.25.

4.2 | Pretreatment analyses

There were no significant differences among patients in the three groups concerning demographic and
pretreatment variables (see Table 1). The female/male ratio was 17/6 in the CT/BTP group, 21/3 in the REBT
group, and 22/2 in the ACT/ABBT group, so the number of males was higher in the CT/BTP group (6 compared to 3
and 2, respectively). Mean age was 28.08 (SD = 8.17) in the CT/BTP group, 27.92 (SD = 7.90) in the REBT group,
and 25.86 (SD = 6.70) in the ACT/ABBT group. A total of 10 patients in the CT/BTP group had baseline
comorbidities (e.g., depression, social phobia, specific phobia, personality disorders), and 11 for the REBT and ACT/
ABBT group, respectively. There were no significant pretreatment differences between the three groups in terms of
symptoms and diagnosis severity, all s > 0.05.

T A B L E 1 Demographics and pretreatment variables (total N = 71)

CT/BTP REBT ACT/ABBT
Variables (N = 23) (N = 24) (N = 24)
Gender
Male 6 3 2
Female 17 21 22
Age, mean + SD, (years) 28.08 (8.17) 27.92 (7.90) 25.86 (6.70)
Baseline comorbidities
Any psychiatric condition 10 11 11
Depression 4 6 5
Social phobia 6 6 5
Specific phobia 4 5 4
Personality disorders 2 3 2
Note. ACT: acceptance and commitment therapy; ABBT: acceptance‐based behavioral therapy; CT: cognitive therapy; BTP:
Borkovec’s treatment package; REBT: Rational Emotive Behavior Therapy; SD: standard deviation.
STEFAN ET AL. | 9

4.3 | Attrition–drop‐out/nonmaximum completers information

Initially, 75 patients diagnosed with GAD were randomized into the CT/BTP condition (N = 24), the REBT
condition (N = 25), and the ACT/ABBT condition (N = 26). In the CT/BTP group, 23 participants received
allocated intervention, and in the REBT and ACT/ABBT, 24, thus having total 4 pretreatment drop‐outs (see
Figure 1). 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. The number of patients not completing the 20 sessions protocol was balanced between
groups, the main reported reason being patients’ unavailability for treatment, due to time‐related or practical
issues. Of the treatment drop‐out patients, two received one and two sessions, respectively. The rest of
nonmaximum completers received more than five sessions. Patients who did not complete the full 20 sessions
protocol did not differ from maximum completers in terms of demographic variables, like age, t(69) = 0.156;
p = 0.876, or education level, χ2(4) = 3.300; p = 0.509, or in terms of pretreatment variables – worry levels,
t(69) = −0.371; p = 0.712, or GAD symptoms, t(69) = −0.051; p = 0.960.

4.4 | Outcome analyses

The means and standard deviations for the pretreatment and posttreatment outcomes in the three treatment
conditions are displayed in Table 2.

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.

5 | TRE ATMENT EF FECTS

5.1 | Time–treatment interaction

We conducted repeated measures ANOVA with Time (pre‐ and posttreatment) as a within subject factor and
Treatment (CT/BTP, REBT, ACT/ABBT) as a between subjects factor. Analyses showed significant main effects of
Time for all variables considered: (a) GAD‐Q‐IV, F(1, 68) = 60.24, p < 0.001; (b) PSWQ, F(1, 68) = 58.33,
p < 0.001; (c) ATQ‐Freq, F(1, 68) = 64.04, p < 0.001; and (d) ATQ‐Believ, F(1, 68) = 48.18, p < 0.001. The main
effects of Treatment, as well as the Time X Treatment interaction effect were not significant for any of the variables
considered (all ps > .05). Table 2 displays the significant main effects of Time, as well as the nonsignificant
interaction effects. Figures displaying treatment changes are included in the Supporting Information material.
We repeated the repeated measures ANOVA with the completers only and, similarly, we found significant main
effects of Time on all outcomes: (a) GAD‐Q‐IV, F(1, 36) = 39.59, p < 0.001; (b) PSWQ, F(1, 36) = 47.12,
p < 0.001; (c) ATQ‐Freq, F(1, 36) = 59.73, p < 0.001; (d) ATQ‐Believ, F (1, 36) = 38.79, p < 0.001, and no Time
× Treatment interaction effects.

5.2 | Response rates

The overall response rate was 73.2% for GAD‐Q‐IV scores, meaning that 52 out of the 71 participants scored below
the cut‐off point (i.e., 9), and 81.7% for PSWQ scores, with 58 out of the 71 participants scoring below the cut‐off
point (i.e., 65). Per groups, response rates based on GAD‐Q‐IV scores were as follows: in the CT/BTP group, 16 out
of 23 (69.6%) patients had scores below the cut‐off point, in the REBT group, 17 of 24 (70.8%), and in the ACT/
 10

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).

5.4 | Additional post hoc/a posteriori analyses

Our trial was an exploratory one, not particularly designed for superiority, equivalence, and/or non‐inferiority. We
found no significant differences between the three forms of CBT, so superiority is not even post hoc supported. If
one wants to explore the equivalence status, we must follow another logic. First of all, we must establish an
equivalence interval. Analyzing the literature (see also Steinert, Munder, Rabung, Hoyer, & Leichsenring, 2017), a
clinically meaningful minimum effect size for anxiety disorders in the context of the CBT treatments might be a
medium one: Cohen's d = 0.60 (Norton & Barrera, 2012). Thus, a prespecified equivalence interval could be
(−0.60 to + 0.60). The Cohenʼs d effect size and 90% equivalence confidence intervals for our comparisons are as
follows (the positive effect size is in favor of the first arm in the comparison): (a) CT/BTP versus ACT/ABBT:
d = 0.029 (−0.451 to 0.509); (b) REBT versus ACT/ABBT: d = 0.177 (−0.299 to 0.653); (c) REBT versus CT/BTP:
d = 0.15 (−0.331 to 0.631). In this context, the equivalence can be established between CT/BTP and ACT/ABBT.
Although REBT seems to be superior to the other two arms, the difference is however not statistically significant
(p > 0.05). In a non‐inferiority framework, the Cohenʼs d effect size and 95% equivalence confidence intervals for
our comparisons are as follows (the positive effect size is in the favor of the first arm in the comparison): (a) CT/BTP
versus ACT/ABBT: d = 0.029 (−0.5430 to 0.601); (b) REBT versus ACT/ABBT: d = 0.177 (−0.399 to 0.744);
(c) REBT versus CT/BTP: d = 0.15 (−0.423 to 0.723). If we choose the same clinically meaningful minimum effect
size for anxiety disorders in the context of the CBT treatments (a non‐inferiority margin of d = −0.60), then all
treatments are non‐inferior as compared to this standard.

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

Simona Stefan http://orcid.org/0000-0003-1073-1993

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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

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