Comparison Between Cognitive–Behavioral Therapy

Comparison Between Cognitive–Behavioral Therapy

Adult Attachment as a Moderator of Treatment Outcome for Generalized Anxiety Disorder: Comparison Between Cognitive–Behavioral Therapy

(CBT) Plus Supportive Listening and CBT Plus Interpersonal and Emotional Processing Therapy

Michelle G. Newman, Louis G. Castonguay, Nicholas C. Jacobson, and Ginger A. Moore The Pennsylvania State University

Objective: To determine whether baseline dimensions of adult insecure attachment (avoidant and anxious) moderated outcome in a secondary analysis of a randomized controlled trial comparing cognitive–behavioral therapy (CBT) plus supportive listening (CBT � SL) versus CBT plus interpersonal and emotional processing therapy (CBT � I/EP). Method: Eighty-three participants diagnosed with generalized anxiety disorder (GAD) were recruited from the community and assigned randomly to CBT � SL (n � 40) or to CBT � I/EP (n � 43) within a study using an additive design. PhD-level psychologists treated participants. Blind assessors evaluated participants at pretreatment, posttreatment, 6-month, 12-month, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (Penn State Worry Questionnaire, Hamilton Anxiety Rating Scale, Clinician’s Severity Rating). Avoidant and anxious attachment were assessed using self-reported dismissing and angry states of mind, respectively, on the Perceptions of Adult Attachment Questionnaire. Results: Consistent with our prediction, at all assessments higher levels of dismissing styles in those who received CBT � I/EP predicted greater change in GAD symptoms compared with those who received CBT � SL for whom dismissiveness was unrelated to the change. At postassessment, higher angry attachment was associated with less change in GAD symptoms for those receiving CBT � I/EP, compared with CBT � SL, for whom anger was unrelated to change in GAD symptoms. Pretreatment attachment- related anger failed to moderate outcome at other time points and therefore, these moderation effects were more short-lived than the ones for dismissing attachment. Conclusions: When compared with CBT � SL, CBT � I/EP may be better for individuals with GAD who have relatively higher dismissing styles of attachment.

What is the public health significance of this article? When choosing a treatment for individuals with generalized anxiety disorder, this study suggests the potential importance of taking adult attachment into account.

Keywords: GAD, emotional processing, attachment, interpersonal problems, CBT

According to attachment theory, children’s experiences with care- givers are internalized as cognitive–affective models of interpersonal relationships (e.g., Ainsworth, Blehar, Waters, & Wall, 1978). Such internal working models are carried forward into adulthood and in- fluence the quality of close relationships (e.g., parent–child, romantic relationships; Bowlby, 1973; Bowlby, 1969; Hazan & Shaver, 1994), including the therapeutic relationship (e.g., Dozier, Cue, & Barnett, 1994; Skourteli & Lennie, 2011). Insecure attachment has been linked theoretically and empirically to interpersonal problems and difficul- ties regulating emotion (e.g., Cassidy & Berlin, 1994; Moutsiana et al., 2015). Although attachment has been conceptualized as a typol-

ogy, dimensions better characterize the quality of attachment in both childhood and adulthood (Fraley & Spieker, 2003; Fraley & Waller, 1998). In adulthood, insecure attachment has been characterized along two primary dimensions (Brennan, Clark, & Shaver, 1998; Fraley & Shaver, 2000): avoidance and anxiety. These dimensions specify behavioral response styles in close relationships, and therefore, may be useful in guiding predictions about interpersonal behavior within the therapeutic relationship and thus, treatment response (e.g., Bowlby, 1973; Mikulincer & Shaver, 2008).1

1 Numerous terms are used in the attachment literature depending on the ages of individuals studied and methods for assessing attachment. For readability, we adopt Brennan’s (Brennan et al., 1998) dimensional model of adult attachment and use the terms avoidance (or avoidant) and anxiety (or anxious). These map onto categorical patterns of insecure attachment and are functionally equivalent across development (Fraley & Spieker, 2003; Fraley & Shaver, 2000). Avoidant and anxious dimensions respec- tively also map onto the dismissing and angry current states of mind subscales of the Perceptions of Adult Attachment Questionnaire (PAAQ) used in this study. Thus, we use the terms dismissing (or dismissiveness) and angry (or anger) to refer to the analogous current states of mind assessed dimensionally in the current study.

This article was published Online First June 8, 2015. Michelle G. Newman, Louis G. Castonguay, Nicholas C. Jacobson, and

Ginger A. Moore, Department of Psychology, The Pennsylvania State University. A National Institute of Mental Health Research Grant RO1 MH58593-02

supported this study. We thank Thomas D. Borkovec for his crucial collabo- ration on the original RCT.

Correspondence concerning this article should be addressed to Michelle G. Newman, Department of Psychology, The Pennsylvania State University, 371 Moore Building, University Park, PA 16802-3103. E-mail:

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