Generalized anxiety disorder (GAD) is a chronic mental health condition characterized by excessive, uncontrollable worry and anxiety about multiple life domains, leading to significant distress and impairment.
Cognitive-behavioral therapy (CBT) is a well-established treatment for GAD that focuses on modifying anxious thoughts and behaviors through techniques such as cognitive restructuring and exposure.
Emotion-focused therapy (EFT) is a newer approach that aims to transform maladaptive emotions underlying GAD by promoting adaptive emotional processing through interventions like empathic exploration and chair dialogues.
Effective treatment of GAD is crucial, as the disorder is associated with substantial personal suffering, reduced quality of life, and increased healthcare utilization. Expanding the range of evidence-based treatment options, such as EFT, is important to optimize outcomes and accommodate individual patient preferences.
Timulak, L., Keogh, D., Chigwedere, C., Wilson, C., Ward, F., Hevey, D., Griffin, P., Jacobs, L., Hughes, S., Vaughan, C., Beckham, K., & Mahon, S. (2022). A comparison of emotion-focused therapy and cognitive-behavioral therapy in the treatment of generalized anxiety disorder: Results of a feasibility randomized controlled trial. Psychotherapy, 59(1), 84–95. https://doi.org/10.1037/pst0000427
Key Points
- Emotion-focused therapy (EFT) is a potentially promising treatment for generalized anxiety disorder (GAD) when compared to the established cognitive-behavioral therapy (CBT) treatment.
- The study showed no significant differences in outcomes between EFT and CBT for treating GAD, suggesting EFT is worthwhile to further explore as an alternative treatment option.
- Therapists were able to learn and deliver both EFT and CBT after a short training period, though adherence ratings were moderate, indicating room for improvement.
- The trial provided valuable learnings for planning a larger definitive noninferiority trial comparing EFT to CBT for GAD treatment.
Rationale
Generalized anxiety disorder (GAD) is a common, chronic mental health condition often treated in primary care settings (Wittchen et al., 2002).
While cognitive-behavioral therapy (CBT) is the best-established psychological treatment for GAD (National Institute for Health & Clinical Excellence, 2011), there have been calls to assess alternative treatments to increase client choice (Hunot et al., 2007).
Emotion-focused therapy (EFT) is a research-informed approach that focuses on transforming maladaptive emotions through adaptive emotional processing (Greenberg, 2015).
As GAD sufferers engage in emotional avoidance and worry to prepare for emotionally difficult situations (Behar et al., 2009; Newman & Llera, 2011), EFT represents a potentially useful treatment model.
Initial open trials of an EFT adaptation for GAD showed promising results (O’Connell Kent et al., 2021; Timulak et al., 2017). This feasibility randomized controlled trial sought to provide an initial assessment of the relative efficacy of EFT compared to CBT for GAD in an Irish public health service context.
Method
This randomized controlled trial compared the efficacy of EFT versus CBT for GAD. Both therapies were offered in 16-20 sessions.
Procedure
Participants were recruited from Irish public health service referrals, screened for GAD, and randomly assigned to receive either EFT (n=29) or CBT (n=29) delivered by therapists trained in both approaches. Assessments occurred at baseline, week 16, end of therapy, and 6-month follow-up.
Sample
58 adults (86.2% female, 93.1% White Irish/European) meeting DSM-5 criteria for GAD as the principal diagnosis. Mean age was 35. High comorbidity rates with other disorders (86%) and personality disorders (55%) were present.
Measures
The primary outcome was the Generalized Anxiety Disorder-7 (GAD-7), a self-report questionnaire assessing the severity of GAD symptoms over the past two weeks.
Secondary measures included the Generalized Anxiety Disorder Severity Scale (GADSS), an interview-based rating scale evaluating the severity and impairment associated with GAD; the Patient Health Questionnaire-9 (PHQ-9), a self-report measure of depression symptom severity; and the Clinical Outcome in Routine Evaluation-Outcome Measure (CORE-OM), a self-report questionnaire assessing general psychological distress across domains of well-being, problems, functioning, and risk.
Statistical Analysis
Intent-to-treat analyses using 2×4 repeated measures ANOVAs compared the two treatments at the four assessment points.
Multiple imputation addressed missing data. Within- and between-group effect sizes were calculated.
Results
Both EFT and CBT showed large pre-post improvements on all outcome measures that were maintained at 6-month follow-up, with no significant differences between the two treatments.
Drop-out rates were 10% for EFT and 27% for CBT (not statistically significant). Therapists achieved moderate treatment adherence/competence after brief training.
Insight
This study provides initial evidence that EFT may be a viable alternative to CBT for treating GAD, producing comparable outcomes.
The ability to broaden treatment options for this common disorder is noteworthy. While a trend favoring CBT was observed at week 16, possibly due to its greater focus on symptom change, this leveled out by the end of treatment.
The findings are particularly promising for EFT considering GAD was assessed using primarily symptom-focused measures, whereas the EFT approach targets core emotional vulnerabilities underlying the disorder.
Further research is warranted to more definitively establish the relative efficacy of EFT.
Strengths
This study had several methodological strengths, including:
- Randomized controlled design comparing EFT to an established treatment (CBT)
- Conducted in a routine public health service setting enhancing external validity
- Used multiple well-validated outcome measures
- Examined both within- and between-group effects
- Monitored treatment adherence/competence
- Intent-to-treat analyses and multiple imputation addressed missing data
- 6-month follow-up assessed maintenance of gains
Limitations
Despite strengths, this study also came with several limitations, including:
- Moderate therapist adherence/competence ratings after brief training indicate more extensive training may be beneficial
- Higher attrition in the CBT condition, while not statistically significant, could have impacted comparisons if non-completers differed from completers
- The predominantly female, White Irish sample may limit generalizability
- Lack of a no-treatment control group precludes establishing absolute efficacy of the treatments
- Exclusively relying on symptom-focused measures may not have fully captured EFT’s impact on emotional processing
Implications
The encouraging results for EFT in treating GAD are significant in expanding the range of evidence-based treatment options for this prevalent, impairing disorder.
The ability to provide effective alternatives to CBT offers greater flexibility in accommodating client preferences, which can influence outcomes. However, the findings also highlight the importance of providing therapists with sufficiently extensive training and supervision to ensure treatment fidelity.
Additionally, assessing change in emotional processing in future studies could provide a more complete picture of EFT’s therapeutic mechanisms.
Overall, while further research is needed, EFT shows promise as a treatment for GAD that warrants continued investigation.
References
Primary reference
Timulak, L., Keogh, D., Chigwedere, C., Wilson, C., Ward, F., Hevey, D., Griffin, P., Jacobs, L., Hughes, S., Vaughan, C., Beckham, K., & Mahon, S. (2022). A comparison of emotion-focused therapy and cognitive-behavioral therapy in the treatment of generalized anxiety disorder: Results of a feasibility randomized controlled trial. Psychotherapy, 59(1), 84–95. https://doi.org/10.1037/pst0000427
Other references
Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23(8), 1011–1023. https://doi.org/10.1016/j.janxdis.2009.07.006
Greenberg, L. S. (2015). Emotion-focused therapy. American Psychological Association.
Hunot, V., Churchill, R., Teixeira, V., & de Lima, M. S. (2007). Psychological therapies for generalised anxiety disorder. Cochrane database of systematic reviews, (1). https://doi.org/10.1002/14651858.CD001848.pub4
National Institute for Health and Clinical Excellence. (2011). Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: Management in primary, secondary and community care. Clinical
Guidelines, 113. https://www.nice.org.uk/guidance/cg113/resources/generalised-anxiety-disorder-and-panic-disorder-in-adults-management-pdf35109387756997
Newman, M. G., & Llera, S. J. (2011). A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry. Clinical Psychology Review, 31(3), 371–382. https://doi.org/10.1016/j.cpr.2011.01.008
O’Connell Kent, J. A., Jackson, A., Robinson, M., Rashleigh, C., & Timulak, L. (2021). Emotion-focused therapy for symptoms of generalised anxiety in a student population: An exploratory study. Counselling & Psychotherapy Research, 21(2), 260–268. https://doi.org/10.1002/capr.12346
Timulak, L., McElvaney, J., Keogh, D., Martin, E., Clare, P., Chepukova, E., & Greenberg, L. S. (2017). Emotion-focused therapy for generalized anxiety disorder: An exploratory study. Psychotherapy: Theory, Research, & Practice, 54(4), 361–366. https://doi.org/10.1037/pst0000128
Wittchen, H.-U., Kessler, R. C., Beesdo, K., Krause, P., Höfler, M., & Hoyer, J. (2002). Generalized anxiety and depression in primary care: Prevalence, recognition, and management. The Journal of Clinical Psychiatry, 63– (Suppl. 8), 24–34. https://www.psychiatrist.com/jcp/medical/primary-care/generalized-anxiety-depression-primary-care-prevalence/
Keep Learning
Here are some reflective questions related to this study that could prompt further discussion:
- How might the relative emphasis on symptom reduction versus emotional processing in CBT and EFT impact their therapeutic mechanisms and outcomes?
- To what extent do you think expanding treatment options for GAD beyond CBT is important? What factors would influence your recommendations as a clinician?
- How could future studies be designed to provide more definitive conclusions about the comparative efficacy of EFT and CBT for GAD? What additional outcome domains might be important to assess?
- Based on the study’s sample characteristics, what other populations would be important to examine to establish the generalizability of the findings? How might cultural factors influence the acceptability and effects of these treatments?
