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Generalised anxiety: A controlled treatment study
00057967187$3.00+0.00
Behav.Res.Ther.Vol.25,No. 6,pp.493-502,1987 F'rinlcd in Great Britain. All rights reserved
Copyright 0 1987Pergamon Journals Ltd
GENERALISED ANXIETY: A CONTROLLED TREATMENT STUDY COLIN BLOWERS,’JOHN COBB*and ANDREWMATHEWS~ ‘Psychology Department, New Sussex Hospital, Windlesham Road, Brighton, England, ‘Priory Hospital, Priory Lane, Roehampton, London SW15, England, and ‘Department of Psychology, St George’s Hospital Medical School, University of London, London SW17, England (Received 29 March 1987)
Summary-The effects of anxiety management training were evaluated by allocating 66 generally anxious clients to either a wait list condition, non-directive counselling, or a combination of relaxation and brief cognitive therapy. Anxiety management was significantly more effective than the wait list condition on a number of relevant measures at post-treatment, but there were relatively few differencs between anxiety management and non-directive counselhng, either at post-treatment or at 6 months follow-up. Those differences which were found could plausibly be explained in terms of the demand characteristics of training in relaxation or cognitive therapy. It was concluded that anxiety management is clearly better than a non-treatment control condition, but that its superiority to plausible alternatives which lack the specific components thought to be responsible for improvement has yet to be demonstrated.
Generalised anxiety is an extremely common problem, and one which consumes more clinical resources than do phobic conditions (Shepherd, Cooper, Brown and Malten, 1966; Lader and Marks, 1971). Treatment with drugs such as the benzodiazepines has proved unsatisfactory due to problems of tolerance and dependence (Committee on the Review of Medicines, 1980). There is thus a pressing need for short-term, cost-effective psychological treatment based on empirical evidence of clinical efficacy. Success in treating phobic anxiety using behavioural methods (Foa and Kozak, 1985) has prompted many therapists to turn their attention to the wider problems of generalised anxiety and panic disorders. In contrast to phobias, for which specific treatment techniques such as exposure have been shown to be effective, generalised anxiety is managed by a wide range of techniques, commonly used in differing combinations. Anxiety management packages may include various types of relaxation (Mathews, 1984), imagery (Suinn and Richardson, 1971), breathing control (Clark, 1986), cognitive methods (Beck and Emery, 1985), assertive and communication skills training (Stavynsky, 1982) and problem solving (Emery, 1985). Attempts to tease out the contribution of individual specific treatment components are confounded by the fact that several specific ingredients may be identified among each of the above categories. Despite the fact that anxiety management training packages are widely used in clinical practice at the present time, there is very little evidence supporting the superiority of such packages over alternative treatment approaches. Relatively few studies have been reported so far which involve some degree of experimental control. In one of the first such reports, Woodward and Jones (1980) studied 27 clients who were allocated to three different treatment methods and a no-treatment control group. Although all active treatments were superior to the no-treatment control on some analyses, the measures which showed these effects were not central to the presenting problem of anxiety. Combined treatment, including relaxation, desensitisation and cognitive restructuring, was superior to more limited treatment, involving either restructuring, or systematic desensitisation alone. However, this superiority was limited to relatively irrelevant measures, treatments were incompletely specified, and the follow-up was for only 4 weeks. In a subsequent study, Jannoun, Oppenheimer and Gelder (1982) used a time series design to study 27 generally anxious clients who were treated with a combination of self-monitoring, instruction booklets, muscular relaxation and positive self-instructions; after varying periods on a wait list. Various measures showed that very little change occurred while on the waiting list, Requests for reprints should be addressed to Andrew Mathews. 493
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compared with the significant improvement that followed cognitive-behavioural treatment. An even more complex treatment package was used by Barlow, Cohen, Waddel, Vermilyea, Kfosko, B&chard and DiNardo (l~g4), who allocated 20 clients (11 suffering from panic disorder and nine from generalised anxiety), to either an active treatment condition or to a wait list. The 18 sessions of treatment included progressive muscular relaxation, EMG feedback, brief cognitive therapy, and a variety of other techniques. Outcome in the treated group was superior to that in the wait list condition on a wide range of measures, and this superiority was maintained at S-month follow-up. A more recent and ambitious study reported by Lindsay, Gamsu, McLaughlin, Hood and Espie (1987) again employed a wait list condition, and allocated 40 generally anxious clients either to this, or to one of three active treatment methods. These were brief cognitive therapy, anxiety management based on relaxation, or drug treatment with a benzodiazepine (Lorazepam). Unfortunately, due to concern about possible drug dependency probiems, the dose used was tapered off in the fourth and last week of treatment, so that clients were essentially drug free by post-treatment reassessment. As a result, no meaningful comparison between psychological and ~ha~acolo~cal treatment was possible. Comparisons among psychological treatment renditions showed a clear trend for self-rating measures to favour cognitive therapy, although perhaps due to the small number of Ss in each group, there were no significant differences between the two active treatment conditions, both being significantly superior to the wait list group. While each of these individual studies has methodological problems, in combination they provide evidence that various anxiety management packages produce significantly more change than do no-treatment control conditions. Unfortunately, it is not possible to conclude that the specific components involved in anxiety management have a significant impact, since none of the comparisons between different psychological treatment methods have revealed significant differences in anxiety symptoms, and no study included a control for non-specific treatment effects. Anxious ctients often improve when taken into treatment, particularly if the treatment is intense and novel, and for this reason anxiety management packages can only be properly evaluated in comparison with a control condition that is matched for relevant non-specific variables, The present study was planned to allow a large-scale replication of the finding that anxiety management produces a better outcome than an equivalent period without treatment. In addition, the design used allowed us to test the null-hypothesis that an active treatment package focusing on specific techniques for coping with the symptoms of anxiety adds nothing to the non-specific factors involved in most plausible psychological treatments, Apart from the wait list control condition, a non-directive counselling condition was included, as a highly plausible and possibly effective alternative method, which did not contain any of the specific components included in anxiety management. The anxiety management package chosen was similar in some respects to that used in many clinics. However, as a first step towards evaluating particular components usually included in anxiety management training, only relaxation and brief cognitive therapy were used as primary therapeutic techniques. METHOD
From a large pool of anxious clients referred for treatment by their general p~cti~o~e~, 55 were randomly allocated to one of three groups: anxiety management training (AMP, non-directive counselling (NDC), or wait list control (WL). All clients were assessed at the time of acceptance into the trial, and again 10 weeks later, at the end of treatment in the case of the first two groups. Wait list control subjects were offered treatment at this point, but were not followed up. However, those in the two active treatment groups were followed up for a further 6 months, and assessed again at: the end of this period.
Selection of Ss for the treatment study depended on their meeting standard inclusion criteria, as determined by an independent assessor. These were: (1) the main complaint was of generalised anxiety, using the criteria for that diagnosis given in DSM-III; (2) the presence of mild depressive, phobic or obsessional s~ptoms was acceptable, provided they did not meet other diagnostic
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criteria, and did not require treatment in their own right; (3) any other diagnosed psychiatric conditions were absent; (4) the anxiety state had been relatively continuous for at least 3 months; (5) no psychotropic medication was being taken, or if so, it had been stable for the last 3 months; (6) a score of at least eight was obtained on the anxiety sub-scale of the Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983); and (7) age was in the range 18-65 yr. The sex distribution, mean ages and HAD scores for each group are shown in Table 1. There were no significant differences when these means were compared. Procedure Following a screening interview, and full pre-treatment assessment (see following section) all clients who met the above criteria and who agreed to participate, were randomly allocated to one of the three groups (20 to AMT, 22 to NIX and 24 to WL). Clients were given a full account of the study prior to the invitation to participate, and understood that they might be allocated to a wait list condition. It was made clear that in the event of being allocated to the wait list, the name of a therapist would be provided, and clients would be able to make contact with this therapist should an emergency arise. Otherwise, treatment would be offered after a waiting period of approximately 3 months. Those patients who failed to meet the criteria, or declined to participate, were offered an alternative treatment, or referred elsewhere. Those allocated to the two active treatments (AMT or NDC) were given eight sessions of individual treatment lasting appro~mately 45 min each. The frrst six sessions were spaced at weekly intervals, but session 7 and 8 were at fortnightly intervals, making a total of IO weeks in active treatment. Those clients who dropped out after initial assessment and acceptance, but before having completed four sessions of treatment, were deemed not to have had an adequate trial of treatment, and were subsequently replaced. However, those who dropped out after four sessions of treatment were not replaced, but were reassessed as far as possible at the appropriate time, and included in the analysis. After 10 weeks, Ss from both active treatment groups and the wait list control were reassessed. Wait list Ss were then removed from the study, and offered treatment as required. Those from the two active treatment groups entered a follow-up period, during which they were seen by the therapist on two occasions to monitor progress and discuss difficulties. These sessions again lasted for 45 min, and occurred 1 month and 6 months after the post-treatment assessment, Immediately prior to this last session they were seen for a final reassessment. Treatments Apart from their contrasting features, anxiety management training and non-directive counselling were similar in a number of important respects. (1) A detailed rationale and description of the treatment procedure to be used was described in a written booklet, given to each client on acceptance. (2) It was made clear to both groups that treatment involved self-help, and the use of psychological as opposed to drug methods of reducing anxiety. Rather than being directly instructed to stop taking tranquillizers, clients were told that they could consult their general practitioner at any time should they wish to stop taking medication or seek medical advice. (3) Clients in both groups were asked to keep fairly detailed diaries, with entries to be made concerning thoughts, feelings or topics that they would like discussed at the next Trident sesssion. (4) As indicated earlier, the duration and spacing of therapy sessions was standard across both groups, so that the amount of attention and encouragement received from therapists was equivalent. Features that distinguished the two active treatment groups are described in more detail below.
Tabk I. Numbers, ages, sex distribution and clinical severity (HAD anxiety scores) for the tbrce randomly aiiocated groups, and those who dropped out after being accepted for treatments, but before final assessment Wait list
Anxiety managmeent
NUmbCr %FV) HAD anx.
%! 12112 13.5
::.I 9/l 1 13.8
Non-directive counselling
Drop outs
22 36.6 14/s 14.2
29 34.2 i-5114 t5.t
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Anxiety management training Clients entering anxiety management training were first given a booklet entitled Coping with Anxiety. This booklet provided a rationale to the effect that anxiety could be controlled using relaxation and the modification of upsetting thoughts. In the first few sessions clients were taught a brief form of relaxation based on that described by Bernstein and Borkovec (1973). Rather than spend much time on prolonged periods of relaxation, however, over the first few sessions clients were taught the rapid induction of relaxation at times of increased anxiety, using a cue such as the taking of a deep breath. Cue-controlled relaxation was emphasised since this could be used more appropriately whenever anxiety arose in everyday situations. Regular homework practice was encouraged, but the time spent on practising relaxation during sessions was reduced after the first two or three visits, so that most of the remaining treatment time could be devoted to brief cognitive therapy. The cognitive component of treatment was based on that described by Beck and Emery (1985), but was used in abbreviated form. Diary records of the thoughts experienced at times of increased anxiety were introduced from the first session. In subsequent sessions, increasing time was devoted to obtaining a full record of anxiety-provoking thoughts, either from the diary or from other techniques such as role play or induced anxiety. By the third session, therapists began to encourage clients to challenge the validity of these cognitions using a variety of methods. These included searching for present or historical counter-evidence, assessing the realistic probability of disasters, assessing coping resources should the worst happen, distinguishing between thoughts and facts, adopting the role of an objective observer, and so on. Whenever possible therapists searched for homework tasks that would throw light on the validity of the thought content being discussed, but avoided giving instructions that might be interpreted as encouraging systematic and regular exposure to anxiety-provoking situations. In later stages of treatment, therapists encouraged the formulation of alternative and more realistic thoughts, and clients were asked to practise using such thoughts whenever they noticed increases of anxiety during everyday life. Non -directive counselling Clients entering this treatment were given an equivalent booklet, in this case entitled Understanding Anxiety, which offered a rationale to the effect that they could be helped by becoming aware of and understanding their own thoughts and feelings, and would find the symptoms of anxiety less upsetting and easier to control as a result. It was made clear that therapists would not offer solutions or give directions, since each individual was different, but attempt to guide clients towards their own personal solution. Sessions took the form of clients being encouraged to talk about any aspect of their difficulties, while the therapist offered a non-directive approach based on that described by Rogers (1957). No relaxation instructions were given, nor any direct advice concerning anxiety management. Instead, therapists used reflection as their primary technique: that is, they re-phrased what the client said in such a way as to indicate sympathy and understanding of what was being expressed. Therapists attempted to display empathy and warmth towards their clients, but avoided direct interpretations or offering solutions. For example, if asked for advice, therapists reflected the question back by asking clients what they themselves thought would be best. Although some therapists were initially hesitant about their ability to stick closely to this format, they subsequently reported that it was always possible to do so, and that the method proved acceptable to most clients. The diaries used in this treatment modality matched the non-directive format, in that instructions were given to record any events or thoughts that clients might wish to discuss in the next session. Therapists All therapists were trained nurses, who were further qualified as behaviour therapists. A total of four therapists were involved, two of whom (one male and one female) were primarily based at the Hove Centre for Community Mental Health, and saw clients there or at other health centres in the Brighton area. Another two therapists (one male and one female) saw clients as out-patients at St George’s Hospital London. Approximately two-thirds of all the clients treated in this study were seen in the Brighton area, and the remaining third in London. Referrals were randomly allocated to individual therapists within each location.
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Assessment measures
There were seven main assessment inst~ents, three of which were based solely on self-report, and the remaining four on ratings made by an independent assessor during a structured interview. A total of five assessors were involved, all of whom were clinically trained, and had extensive experience with anxious clients. The same assessor was involved in pre- and post-treatment interviews with any one client, and assessors were balanced across treatments. The interview-based measures were: (1) The Clinical Anxiety Scale (Snaith, Baugh, Clayden, Husain and Sipple, 1982), which includes seven O-4 ratings of specific anxiety symptoms, (2) Social Adjustment, which includes five O-8 rating scales of the extent to which anxiety interferes with different aspects of everyday life, (3) Panic-which includes seven O-8 ratings concerned with frequency and severity of panic attacks, and (4) Problem ratings-which includes eight O-8 ratings of the two main physical and mental anxiety symptoms reported by each client. The self-report measures were: (I) the Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983), which provides separate measures of anxiety and depressive symptoms, (2) the Spielberger Trait Anxiety Scale (Spielberger, Gorsuch and Lushene, 1970), and (3) the St George’s Anxiety Questionnaire, which includes 27 items intended to tap the subjects’ own opinion about the nature and origin of their anxiety symptoms. Assessments were made under blind conditions; that is by interviewers who remained ignorant of the treatments to which clients were allocated. Blind conditions were maintained at posttreatment and on follow-up by requesting clients not to mention anything about their treatment (or lack of it) or to mention any therapist with whom they might have had contact. To sample the reliability of ratings made by assessors, 20 additional ratings on the Clinical Anxiety scale (tension), Social Adjustment and Clinical Severity scales were carried out on randomly chosen Ss by a second assessor, 10 at pre-treatment, and 10 at post-treatment. After eliminating dropouts, reliability coefficients were calculated for 16 observations, and satisfactory correlations were obtained for clinical severity (0.82) and social adjustment (0.85), but not for CAS tension (0.25). Dropouts
There was a total of 29 dropouts within the first half of treatment, or during the wait period. These included those who failed initial treatment appoin~ents (5); others who dropped out during active treatment, after an average of 2.2 sessions (19); and those who could not be re-assessed after the wait period (5). The numbers from each treatment condition did not differ significantly, nor were there any obvious differences distinguishing the dropouts from those remaining in the study (see Table 1). RESULTS Analysis
Outcome data were analysed using analyses of covariance, with post-treatment or follow-up scores as the dependent variable, and pre-treatment scores as the covariate. Analysis of posttreatment data involved all three groups, and when covariance yielded significant results, differences between individual pairs of means were examined using Tukey tests. No follow-up data was obtained from waiting list clients, since they had by then received varying amounts of different treatments, and for this reason only analyses of covariance were carried out at follow-up comparing the two active treatment groups. Treatment inregrity check
Twenty tape-recorded treatment interviews (IO from each active t~atment) were chosen at random, and their content rated by a blind assessor (Frank McCaffery). Tapes were sampled for two consecutive 5-min periods, taken from approximately the mid-point of the interview. Each 5-min segment was independently rated for therapist directiveness, therapist empathy, client responsiveness, and finally for probable treatment identity. Of the 10 anxiety management tapes, both 5-min sections were rated as ‘clearly AMT’ in nine, and the remaining one was rated ‘unclear’ or ‘in the main AMT’ for the two respective sections. Non-directive counselling was identified
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Table 2. Corrected post-treatment scores and significant differences for assessors’ rating scores
Clinical Anxiety Scale: Tension StartlC Panic ratings: Understanding Cause (physical) Harmful Problem ratings: Disabling (cognitive) Uncontrollable (cognitive) Intensity (cognitive) Intensity (physical) Adjustment ratings: Social impairment
Wait
NDC
AMT
2.3
I .6
1.7 1.7
1.5’ 0.7t
4.0 3.2 3.7
4.5 2.3 3.4
6.0’ 1.7”
3.1 3.6 4.6 5.1
2.5 2.8 3.1 3.2f
1.5’ 2.0’ 2.7’ 2.8’
3.2
2.1
1.7’
I.?+
‘AM7 significantly better than Wait. tAMT si~ifi~otly better than NIX and Wait. $NDC sigttikantly better than Wait.
unequivocally for both sections in six tapes, and ‘in the main NDC’ for at least one section in the remaining four. Thus all 20 tapes were assigned to their correct treatment condition, although more clearly so in the case of anxiety management training. There were no differences between treatments for ratings of client responsiveness (maximum score in 36 of 40 ratings) or therapist empathy (intermediate score in 37 or 40 ratings). However, there was a difference in rated therapist directiveness, since a maximum score was given for 18 of 20 ratings of AMT tapes, and a minimum score for 15 of 20 ratings of NDC tapes, with intermediate scores being assigned to the remaining sections. It is thus clear that the treatment could be easily disting~shed, and that therapists were seen as more directive when carrying out AMT. Post-treatment
outcome
Clinical Anxiety Scale. Of seven sub-scales, only two revealed significant differences, both showing that anxiety management was associated with better outcome than was the equivalent wait period. Psychic tension ratings did not change in the wait group but improved in the anxiety management group (F2,63= 4.7, P < 0.01; Tukey AMT vs WL, P < 0.05). Rated startle response decreased after anxiety management while increasing slightly after both of the two other conditions (Fz.63= 5.8, P < 0.01; Tukey AMT vs NDC and WI;, P < 0.01). No other comparison of non-directive counselling with either of the other conditions reached acceptable levels of significance (see Table 2). Panic rating scales. Only those who asserted that they had panic attacks at least occasionally were rated on these scales, thus reducing the sample analysed to 56. There were no significant treatment differences in ratings of panic severity or frequency, but anxiety management was associated with greater belief at post-treatment that the cause of panic was understood ( F2,52= 4.5, P < 0.02; Tukey AMT vs WL P < 0.05). There was a related tendency to believe panic attacks to be psychological rather than physical in origin (I&, = 3.7, P < 0.04; Tukey ANT vs WL, P < 0.05). Finally, those receiving anxiety management came to believe that panic attacks were probably harmless, while both other groups remained equally unsure about whether they were harmless or not ( F2,52= 12.1, P
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the case of physical intensity (Tukey NDC vs WL, P < 0.05). Anxiety management alone was significantly superior to the wait list condition in enhancing perceived control of cognitive symptoms (&, = 3.3, P < 0.05; Tukey ‘P < 0.05) and in causing them to be seen as less disabling (F2,s, = 4.0, P < 0.03; Tukey P < 0.05). St George’s Anxiety Questionnaire. The first five items on this questionnaire deal with self-rated frequency and severity of anxiety symptoms, with perceived ability to cope or need to rely on others, and hopefulness about ability to reduce anxiety (see Table 3). All of these analyses revealed highly significant F values, with anxiety management being associated with the best response (Tukey AMT vs WL, P < 0.05) or better in all cases). Results of non-directive counselling lay between those for the other two groups, but did not differ significantly from either of them except in the case of comparisons with the wait group for severity and ability to cope (Tukey NDC vs WL, P < 0.05). Section 2 of the questionnaire deals with the use of specific coping methods; in comparison with wait group subjects, those who had received anxiety management reported less use of tranquillizers or GP attendance (Tukey AMT vs WL, both P < 0.01) while those receiving non-directive counselling reported less dependence on help from others (Tukey NDC vs WL, P < 0.05). Not surprisingly, since anxiety management actually involved relaxation training, this group reported more use of relaxation than did either of the other groups (Tukey AMT vs NDC and WL, P < 0.01). There were no significant differences between groups in the third section of the questionnaire dealing with beliefs about six different aetiological factors. In the fourth section, respondents are asked to report on which of five coping methods they had found most helpful. Again the anxiety mangement group reported that relaxation was more helpful (Tukey AMT vs NDC and WL, P < O.Ol), but the other items revealed only non-significant trends for the same group to favour talking oneself out of worrying and being able to understand one’s fears. Finally, ratings of self-concern about physical and cognitive symptoms showed again that anxiety management was more effective than the wait period for both (Tukey AMT vs WL, P < O.Ol), while non-directive counselling was more effective than the wait period only for physical symptoms (Tukey NDC vs WL, P < 0.05). Clinical severity ratings. Despite trends favouring both active treatments, neither the overall rating of severity by the assessor, nor self-rated anxiety and depression symptoms on the Hospital Anxiety and Depression Scale, revealed significant treatment effects on analysis of covariance. Unexpectedly however, the Spielberger Trait Anxiety Inventory proved more sensitive to treatment effects ( F2,62= 4.4, P < 0.02), with non-directive counselling being followed by more change than the wait list condition (Tukey NDC vs WL, P < 0.05). The effects of AMT on trait anxiety scores were not significantly different those of either other group.
Table 3. Corrected post-treatment scores and significant differences for sclf-rated questionnaire scores St George’s Questionnaire Frequency Severity Unable Hopeless Reliance on others (Coping methods) Help from others Tranquillizers Relaxation GP attendance (Helpfulness) Relaxation (Symptoms) Physical Cognitive Spiclberger Trait Score
Wait
NDC
AMT
4.7 4.6 4.0 3.5 2.9
4.0 3.v 3.0 2.2
3.4’ 3.5. 2.8’ 2.5* 2.0.
2.9 3.1 2.9 1.8
I .8t 2.0 3.3 1.3
2.4 1.1’ 5.3: 0.6.
3.1
3.3
5.3t
4.8 4.4 53.3
3.4? 3.8 47.v
3.3’ 2.8’ 48.5
lAMT significantly better than Wait. tNDC better than Wait. tAMT significantly better than NDC and Wait.
3.0t
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follow-up scores and significant between treatment groups
Panic ratings: Harmful of panics St George’s Questionnaire: Plan to handle stress Use of relaxation Worrying seem as cause Able to talk self out of worry *Signiticant
difference
differences
NDC
AMT
3.3
2.1.
1.8 2.5 3.5 2.6
2.5. 5.1’ 4.8’ 3.8’
between AMT and NDC
Outcome at follow -up Consistent with the post-treatment picture, relatively few differences between the two active conditions were found at follow-up. There were none for the Clinical Anxiety Scale, for ratings of adjustment, or for overall clinical severity. The previous difference found between groups for ratings of harm due to panic remained significant (F,,s, = 4.8, P < O&l),with only a trend for cognitive aspects of the problem to be seen as less disabling in the anxiety management group (F,,, = 3.2, P < 0.10). On the St George’s Anxiety Questionnaire, four items clearly distinguished the two treatment groups; self-reported use of plans in coping with stress (F,,, = 6.9, P < 0.02), use of relaxation 12.4, P < 0.01), belief that worry about the future plays a causal role (Fi.34 = 4.5, P < O-05), (FLM = and ability to talk oneself out of worrying ( F,,34 = 4.3, P -K0.05). All four analyses indicated greater change following anxiety management than non-directive counselling (see Table 4). DISCUSSION The clearest findings of the present study were that there were surprisingly few significant differences is outcome between the two active treatment conditions being compared, although anxiety management training was consistently superior to the no-treatment wait condition. Immediately after treatment, those who had received anxiety management training had improved si~ifi~ntly more than wait group subjects on 10 out of the almost 30 ratings made by blind assessors. There was much weaker evidence from post-treatment assessor’s ratings that nondirective counselling was more effective than the equivalent wait period; only one out of the same number of ratings achieved significance at the 5% level. While there is thus no convincing evidence from independent sources that non-directive counselling was effective, only two ratings (startle reactions, and belief that panics are harmful) successfully differentiated anxiety management from the non-directive condition. A reasonable conclusion would therefore be that anxiety management training is indeed effective, but that its superiority to a less structured and less directive alternative remains to be proven. Turning to the self-report questionnaire data, a similar pattern emerged, with anxiety management training producing more evidence for improvement than occurred during the wait period (on 11 out of 30 scores), while non-directive counselling was associated with a similar pattern but with somewhat fewer si~ificant differences. The only two questions that revealed differential effects separating the two active treatments can easily be ascribed to the fact that they dealt with a component of anxiety management training itself, relaxation practice. A small number of self-reported differences of a similar type were evident at &month follow-up. The previous lessened beliefs in the harmfulness of panics following anxiety management training persisted, as did the reported use of relaxation, The same Ss also reported three related beliefs; that they tended to plan out methods of handling stress, that worry about the future was a cause of their anxiety, and that they were more able to talk themselves out of such worries. While this apparently meaningful pattern of responses might be used to argue that anxiety management had indeed achieved some of its specific goals, it is at least equally plausible to argue that the observed pattern simply reflects therapeutic demand. Just as the reported use of relaxation changed more in anxiety management, presumably because expticit instructions were given to this effect, so it seems likely that the instructions to use cognitive strategies would lead to reports of their successful
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employment. Thus, while the reported confidence in being able to cope with anxiety may indeed be valuable, there was little objective basis for such confidence, in as far as one can judge from assessors or self-ratings of severity. If reports of less reliance on medication or on medical advice and support following anxiety management could be validated by collecting relevant data, this would provide more direct evidence of inceased self-reliance. It was not our intention to include the non-directive counselling condition as the best possible alternative treatment, but rather as a control procedure containing possibly active non-specific components, such as therapist’s support and raised expectancies of improvement. Therapists in this study were skilled and experienced in behaviour therapy, but not formally trained in non-directive counselling. To the extent that they were less skilled and/or less enthusiastic about the latter treatment, this would constitute a bias against the efficacy of counselling. The relatively small differences achieved between the two active treatment conditions therefore raises the question of how much of the effects attributed to specific components in anxiety management training are in fact a function of non-specific factors present in many different psychological treatments. Therapists in the present study sometimes commented that, despite the presentation of very different rationales and procedures, Ss improving with either treatment often described similar cognitive changes. In part these descriptions reflected the adoption of common cognitive strategies that they had tried and found effective, such as distraction, but in part may have arisen out of a re-conceptualisation of anxiety as a problem to be tackled, rather than as a catastrophic and uncontrolIable threat. Such a suggestion implies, not that the effects of anxiety management training should be attributed to vague constructs such as ‘expectancy’, but rather that at least a proportion of Ss receiving less directive treatments will discover and utilise specific coping strategies for themselves, leading to similar cognitive changes. An alternative view of the present results would be that the anxiety management methods used were relatively weak, and that with different methods, or in more skilled hands, they would have been more clearly superior to a non-directive control. While this may well be true, it can also be argued that the methods and level of skill represented in the present study are very similar to those available in other clinics, so that our results probably correspond to what can be expected elsewhere. Unfortunately, the lack of common measures across studies severely limits the comparisons that can be made between the present study and others using similar populations. One of the few measures that have been used across many studies is Spielberger’s Trait Anxiety Inventory [see Mathews (1984) for a review]. Although intended as a stable measure of personality, in fact it has been found to change in a consistent and meaningful way following psychological treatment. Across a number of studies of clinic patients with general anxiety symptoms, change scores varied from a low of 2.5 following group psychotherapy (Townsend , House and Addario, 1975) to a high of 9.0 following anxiety management training (Jannoun et al., 1982). Within this range the changes observed in the present study (Wait f0.4, NDC -5.6, AMT -4.O), are only modest, but are almost identical to that reported by Barlow et uf. (1984), following treatment with an 18 session anxiety management package (No Treatment + 2.1, AMT - 4.4). Thus, while the present results do not appear to represent the best that has been achieved, they are at least comparable with those reported from some other leading centres. A further argument against the suggestion that the failure to distinguish between anxiety management and non-directive counselling was due to unusually weak treatment effects is provided by related data recently obtained by Borkovec, Mathews, Chambers, Ebrahimi, Lytle and Nelson (1987, in press). In these reports, data were presented on the effects of relaxation combined with either brief cognitive therapy or non-directive counselling in a volunteer sample complaining of generalised anxiety; and on these treatment conditions compared with coping desensitisation in a clinic sample. Although cognitive therapy added more to relaxation than did non-directive counselling in the case of volunteer Ss, in the clinic sample there were no outcome differences between any of the treatment combinations. Comparisons of magnitude of effect, using Spielberger Trait Scores, shows that all three groups showed a somewhat more marked improvement than was obtained in the present study (relaxation plus non-directive counselling -8.9; relaxation plus cognitive therapy - 8.3; relaxation plus coping desensitization - 10.2). Thus, while overall effect sizes were larger, the general pattern of equivalence between non-directive counselling and more specific co~itiv~~havioural treatments was confirmed.
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The question remains of why the actual magnitude of changes achieved in the present study were relatively modest. In a recent comparison of anxiety management with a wait condition carried out by Butler, Cullington, Hibbert, Klimes and Gelder (in press) an exceptionally high change score of 12.1 on the Spielberger trait measure was achieved in the group allocated to an anxiety management package. Detailed comparison of the content of this package with that of anxiety management in the present study suggests that the main difference concerns the extent of exposure to anxiety provoking cues. In the present study, real-life exposure practice was deliberately eliminated so that the effects of brief training in relaxation and cognitive coping could be evaluated in isolation. However, in a earlier review (Mathews, 1984) it was argued that anxiety arousal may indeed be a crucial feature of more successful treatments, perhaps because this exposes clients to relevant anxiety-evoking stimuli, whether internal or external in nature. Comparisons of effect size across the various studies discussed here would appear to support a role for exposure, and suggests that in its absence, relaxation and cognitive methods may be only slightly more potent than are relatively non-dir~tive and non-structured methods of psy~holo~~al ~ounselling. The present results can thus be used to argue for treatment involving a combination of exposure to anxiety-arousing situations, and simultaneous practice in cognitive coping methods. Acknowledgements-This research was supported by a grant from the South East Thames Regional Health Authority. We are grateful for the help provided by Siaeda Cullen, Frank McCafferey, Allison Abraham, Brian Copley, Colin Ma&sod and Shirley Mercer for carrying out treatment and assessments, and in particular for Siaeda Cullen’s and Frank McCafferey’s additionai help with planning and implementation. Thanks are also due to Anne Gunnel1 and Margaret Reuben for their help with administration of the study.
REFERENCES BarlowD. H., Cohen A. S., WaddelM. T., Vermilyea B. B., Klosko J. S., Blanchard E. B, and DiNardo P. A. (1984) Panic and generalised anxiety disorders: nature and treatment. Behau. Tfrer. If, 431-449. Beck A. T. and Emery G. (1985) Anxiety Disorders and Phobias: A Cogniriue Perspective. Basic Books, New York. Bernstein D. and Borkovec T. D. (1973) Progressive Reiuxution Training. Research Press, Champaign, Il. Borkovw: T. D., Mathews A. M., Chambers A., Ebrahimi S., Lytle R. and Nelson R. (1987) The effects of relaxation training with cognitive therapy of non-directive therapy and the role of relaxation-induced anxiety in the treatment of generalised anxiety. J. consult. cfin. Psychof. (in press). Butler G., Cullington A., Hibbert G., Klimes I. and Gelder M. Anxiety management for persistent general&d. anxiety. Br. J. Psychiut. (in press). Clark D. A. (1986) A cognitive approach to panic. Behmt. Res. Ther. 24(4), 461-470. Committee on the Review of Medicines (1980) Systematic review of the benzodiazepines. Br. med. J. 280, 910-912. Emergy G. (1985) Cognitive therapy: techniques and applications. Part II, In Anxiety Disorders and Phobias. Basic Books, New York. Foa E. and Kozak M. J. (1985) Treatment of anxiety disorders: implications for psychopathology. In Anxiety and rhe Anxiety Disorders (Edited by Tuma A. H. and Maser J. D.). Lawrence Erlbaum, Hillsdale, NJ. Jannoun L., Openheimer C. and Gelder M. (1982) A self-help treatment program for anxiety state patients. Behuu. Titer. 13, 103-111. Lader M. and Marks I. M. (I9711 Cf~nfcuf Anxiety, Hein~ann Medical, London. Lindsay W., Gamsu C., McLaughlin E., Hood E. and Espie C. (1987) A controlled trial of treatment for generalised anxiety. Br. J. clin. Psychol. 26, 3-16. Mathews A. M. (1984) Anxiety and its management. In Current Themes in Psychiatry (Edited by Gaind R. and Hudson B.), Vol. 3. Spectrum Publications, New York. Rogers C. R. (1957) The necessary and sufficient conditions of therapeutic personality change. J. consub. Psychoi. 21, 95-103.
Shepherd M., Cooper B., Brown A. and Malten G. (1966) Psychiatric Zffness in Gene& Practice. Oxford University Press, Oxford. Snaith R., Baugh S., Clayden A., Husaia A. and Sipple M. (1982) The clinical anxiety scale. Br. J. Psychiat. 141, 518-523. Spielbergcr C. D., Gorsuch R. L. and Lushene R. R. (1970) Manualfor the State-Trait Anxiety Inventory. Consulting Psychological Press, Palo Alto, CA. Stravynsky A., Marks I. M. and Yule W. (1982) Social skills problems in neurotic out-patients: social skills training with and without cognitive modification. Archs gen. Psych&t. 39, 1378-1385, Suinn R. M. and Richardson F. (1971) Anxiety management training: a non-specific behavior therapy program for anxiety control. Be/r&. Ther. 2, 498-510. Townsend R. E., House J. F. and Addario D. (1975) A comparison of biof~back-m~iated relaxation and group therapy in the treatment of chronic anxiety. Am. J. Psychiut. 132, 598-601. Woodward R. and Jones R. B. (1980) Cognitive restructuring treatment: a controlled trial with anxious patients. Behnu. Res. The. 18(s), 401-407. Zigmond A. S. and Snaith R. P. (1983) The hospital anxiety and depression scale. Acta psych& scund. 67, 361-370.
Behav.Res.Ther.Vol.25,No. 6,pp.493-502,1987 F'rinlcd in Great Britain. All rights reserved
Copyright 0 1987Pergamon Journals Ltd
GENERALISED ANXIETY: A CONTROLLED TREATMENT STUDY COLIN BLOWERS,’JOHN COBB*and ANDREWMATHEWS~ ‘Psychology Department, New Sussex Hospital, Windlesham Road, Brighton, England, ‘Priory Hospital, Priory Lane, Roehampton, London SW15, England, and ‘Department of Psychology, St George’s Hospital Medical School, University of London, London SW17, England (Received 29 March 1987)
Summary-The effects of anxiety management training were evaluated by allocating 66 generally anxious clients to either a wait list condition, non-directive counselling, or a combination of relaxation and brief cognitive therapy. Anxiety management was significantly more effective than the wait list condition on a number of relevant measures at post-treatment, but there were relatively few differencs between anxiety management and non-directive counselhng, either at post-treatment or at 6 months follow-up. Those differences which were found could plausibly be explained in terms of the demand characteristics of training in relaxation or cognitive therapy. It was concluded that anxiety management is clearly better than a non-treatment control condition, but that its superiority to plausible alternatives which lack the specific components thought to be responsible for improvement has yet to be demonstrated.
Generalised anxiety is an extremely common problem, and one which consumes more clinical resources than do phobic conditions (Shepherd, Cooper, Brown and Malten, 1966; Lader and Marks, 1971). Treatment with drugs such as the benzodiazepines has proved unsatisfactory due to problems of tolerance and dependence (Committee on the Review of Medicines, 1980). There is thus a pressing need for short-term, cost-effective psychological treatment based on empirical evidence of clinical efficacy. Success in treating phobic anxiety using behavioural methods (Foa and Kozak, 1985) has prompted many therapists to turn their attention to the wider problems of generalised anxiety and panic disorders. In contrast to phobias, for which specific treatment techniques such as exposure have been shown to be effective, generalised anxiety is managed by a wide range of techniques, commonly used in differing combinations. Anxiety management packages may include various types of relaxation (Mathews, 1984), imagery (Suinn and Richardson, 1971), breathing control (Clark, 1986), cognitive methods (Beck and Emery, 1985), assertive and communication skills training (Stavynsky, 1982) and problem solving (Emery, 1985). Attempts to tease out the contribution of individual specific treatment components are confounded by the fact that several specific ingredients may be identified among each of the above categories. Despite the fact that anxiety management training packages are widely used in clinical practice at the present time, there is very little evidence supporting the superiority of such packages over alternative treatment approaches. Relatively few studies have been reported so far which involve some degree of experimental control. In one of the first such reports, Woodward and Jones (1980) studied 27 clients who were allocated to three different treatment methods and a no-treatment control group. Although all active treatments were superior to the no-treatment control on some analyses, the measures which showed these effects were not central to the presenting problem of anxiety. Combined treatment, including relaxation, desensitisation and cognitive restructuring, was superior to more limited treatment, involving either restructuring, or systematic desensitisation alone. However, this superiority was limited to relatively irrelevant measures, treatments were incompletely specified, and the follow-up was for only 4 weeks. In a subsequent study, Jannoun, Oppenheimer and Gelder (1982) used a time series design to study 27 generally anxious clients who were treated with a combination of self-monitoring, instruction booklets, muscular relaxation and positive self-instructions; after varying periods on a wait list. Various measures showed that very little change occurred while on the waiting list, Requests for reprints should be addressed to Andrew Mathews. 493
494
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compared with the significant improvement that followed cognitive-behavioural treatment. An even more complex treatment package was used by Barlow, Cohen, Waddel, Vermilyea, Kfosko, B&chard and DiNardo (l~g4), who allocated 20 clients (11 suffering from panic disorder and nine from generalised anxiety), to either an active treatment condition or to a wait list. The 18 sessions of treatment included progressive muscular relaxation, EMG feedback, brief cognitive therapy, and a variety of other techniques. Outcome in the treated group was superior to that in the wait list condition on a wide range of measures, and this superiority was maintained at S-month follow-up. A more recent and ambitious study reported by Lindsay, Gamsu, McLaughlin, Hood and Espie (1987) again employed a wait list condition, and allocated 40 generally anxious clients either to this, or to one of three active treatment methods. These were brief cognitive therapy, anxiety management based on relaxation, or drug treatment with a benzodiazepine (Lorazepam). Unfortunately, due to concern about possible drug dependency probiems, the dose used was tapered off in the fourth and last week of treatment, so that clients were essentially drug free by post-treatment reassessment. As a result, no meaningful comparison between psychological and ~ha~acolo~cal treatment was possible. Comparisons among psychological treatment renditions showed a clear trend for self-rating measures to favour cognitive therapy, although perhaps due to the small number of Ss in each group, there were no significant differences between the two active treatment conditions, both being significantly superior to the wait list group. While each of these individual studies has methodological problems, in combination they provide evidence that various anxiety management packages produce significantly more change than do no-treatment control conditions. Unfortunately, it is not possible to conclude that the specific components involved in anxiety management have a significant impact, since none of the comparisons between different psychological treatment methods have revealed significant differences in anxiety symptoms, and no study included a control for non-specific treatment effects. Anxious ctients often improve when taken into treatment, particularly if the treatment is intense and novel, and for this reason anxiety management packages can only be properly evaluated in comparison with a control condition that is matched for relevant non-specific variables, The present study was planned to allow a large-scale replication of the finding that anxiety management produces a better outcome than an equivalent period without treatment. In addition, the design used allowed us to test the null-hypothesis that an active treatment package focusing on specific techniques for coping with the symptoms of anxiety adds nothing to the non-specific factors involved in most plausible psychological treatments, Apart from the wait list control condition, a non-directive counselling condition was included, as a highly plausible and possibly effective alternative method, which did not contain any of the specific components included in anxiety management. The anxiety management package chosen was similar in some respects to that used in many clinics. However, as a first step towards evaluating particular components usually included in anxiety management training, only relaxation and brief cognitive therapy were used as primary therapeutic techniques. METHOD
From a large pool of anxious clients referred for treatment by their general p~cti~o~e~, 55 were randomly allocated to one of three groups: anxiety management training (AMP, non-directive counselling (NDC), or wait list control (WL). All clients were assessed at the time of acceptance into the trial, and again 10 weeks later, at the end of treatment in the case of the first two groups. Wait list control subjects were offered treatment at this point, but were not followed up. However, those in the two active treatment groups were followed up for a further 6 months, and assessed again at: the end of this period.
Selection of Ss for the treatment study depended on their meeting standard inclusion criteria, as determined by an independent assessor. These were: (1) the main complaint was of generalised anxiety, using the criteria for that diagnosis given in DSM-III; (2) the presence of mild depressive, phobic or obsessional s~ptoms was acceptable, provided they did not meet other diagnostic
Generalised
anxiety:
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treatment
495
study
criteria, and did not require treatment in their own right; (3) any other diagnosed psychiatric conditions were absent; (4) the anxiety state had been relatively continuous for at least 3 months; (5) no psychotropic medication was being taken, or if so, it had been stable for the last 3 months; (6) a score of at least eight was obtained on the anxiety sub-scale of the Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983); and (7) age was in the range 18-65 yr. The sex distribution, mean ages and HAD scores for each group are shown in Table 1. There were no significant differences when these means were compared. Procedure Following a screening interview, and full pre-treatment assessment (see following section) all clients who met the above criteria and who agreed to participate, were randomly allocated to one of the three groups (20 to AMT, 22 to NIX and 24 to WL). Clients were given a full account of the study prior to the invitation to participate, and understood that they might be allocated to a wait list condition. It was made clear that in the event of being allocated to the wait list, the name of a therapist would be provided, and clients would be able to make contact with this therapist should an emergency arise. Otherwise, treatment would be offered after a waiting period of approximately 3 months. Those patients who failed to meet the criteria, or declined to participate, were offered an alternative treatment, or referred elsewhere. Those allocated to the two active treatments (AMT or NDC) were given eight sessions of individual treatment lasting appro~mately 45 min each. The frrst six sessions were spaced at weekly intervals, but session 7 and 8 were at fortnightly intervals, making a total of IO weeks in active treatment. Those clients who dropped out after initial assessment and acceptance, but before having completed four sessions of treatment, were deemed not to have had an adequate trial of treatment, and were subsequently replaced. However, those who dropped out after four sessions of treatment were not replaced, but were reassessed as far as possible at the appropriate time, and included in the analysis. After 10 weeks, Ss from both active treatment groups and the wait list control were reassessed. Wait list Ss were then removed from the study, and offered treatment as required. Those from the two active treatment groups entered a follow-up period, during which they were seen by the therapist on two occasions to monitor progress and discuss difficulties. These sessions again lasted for 45 min, and occurred 1 month and 6 months after the post-treatment assessment, Immediately prior to this last session they were seen for a final reassessment. Treatments Apart from their contrasting features, anxiety management training and non-directive counselling were similar in a number of important respects. (1) A detailed rationale and description of the treatment procedure to be used was described in a written booklet, given to each client on acceptance. (2) It was made clear to both groups that treatment involved self-help, and the use of psychological as opposed to drug methods of reducing anxiety. Rather than being directly instructed to stop taking tranquillizers, clients were told that they could consult their general practitioner at any time should they wish to stop taking medication or seek medical advice. (3) Clients in both groups were asked to keep fairly detailed diaries, with entries to be made concerning thoughts, feelings or topics that they would like discussed at the next Trident sesssion. (4) As indicated earlier, the duration and spacing of therapy sessions was standard across both groups, so that the amount of attention and encouragement received from therapists was equivalent. Features that distinguished the two active treatment groups are described in more detail below.
Tabk I. Numbers, ages, sex distribution and clinical severity (HAD anxiety scores) for the tbrce randomly aiiocated groups, and those who dropped out after being accepted for treatments, but before final assessment Wait list
Anxiety managmeent
NUmbCr %FV) HAD anx.
%! 12112 13.5
::.I 9/l 1 13.8
Non-directive counselling
Drop outs
22 36.6 14/s 14.2
29 34.2 i-5114 t5.t
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BLOWERS etd..
Anxiety management training Clients entering anxiety management training were first given a booklet entitled Coping with Anxiety. This booklet provided a rationale to the effect that anxiety could be controlled using relaxation and the modification of upsetting thoughts. In the first few sessions clients were taught a brief form of relaxation based on that described by Bernstein and Borkovec (1973). Rather than spend much time on prolonged periods of relaxation, however, over the first few sessions clients were taught the rapid induction of relaxation at times of increased anxiety, using a cue such as the taking of a deep breath. Cue-controlled relaxation was emphasised since this could be used more appropriately whenever anxiety arose in everyday situations. Regular homework practice was encouraged, but the time spent on practising relaxation during sessions was reduced after the first two or three visits, so that most of the remaining treatment time could be devoted to brief cognitive therapy. The cognitive component of treatment was based on that described by Beck and Emery (1985), but was used in abbreviated form. Diary records of the thoughts experienced at times of increased anxiety were introduced from the first session. In subsequent sessions, increasing time was devoted to obtaining a full record of anxiety-provoking thoughts, either from the diary or from other techniques such as role play or induced anxiety. By the third session, therapists began to encourage clients to challenge the validity of these cognitions using a variety of methods. These included searching for present or historical counter-evidence, assessing the realistic probability of disasters, assessing coping resources should the worst happen, distinguishing between thoughts and facts, adopting the role of an objective observer, and so on. Whenever possible therapists searched for homework tasks that would throw light on the validity of the thought content being discussed, but avoided giving instructions that might be interpreted as encouraging systematic and regular exposure to anxiety-provoking situations. In later stages of treatment, therapists encouraged the formulation of alternative and more realistic thoughts, and clients were asked to practise using such thoughts whenever they noticed increases of anxiety during everyday life. Non -directive counselling Clients entering this treatment were given an equivalent booklet, in this case entitled Understanding Anxiety, which offered a rationale to the effect that they could be helped by becoming aware of and understanding their own thoughts and feelings, and would find the symptoms of anxiety less upsetting and easier to control as a result. It was made clear that therapists would not offer solutions or give directions, since each individual was different, but attempt to guide clients towards their own personal solution. Sessions took the form of clients being encouraged to talk about any aspect of their difficulties, while the therapist offered a non-directive approach based on that described by Rogers (1957). No relaxation instructions were given, nor any direct advice concerning anxiety management. Instead, therapists used reflection as their primary technique: that is, they re-phrased what the client said in such a way as to indicate sympathy and understanding of what was being expressed. Therapists attempted to display empathy and warmth towards their clients, but avoided direct interpretations or offering solutions. For example, if asked for advice, therapists reflected the question back by asking clients what they themselves thought would be best. Although some therapists were initially hesitant about their ability to stick closely to this format, they subsequently reported that it was always possible to do so, and that the method proved acceptable to most clients. The diaries used in this treatment modality matched the non-directive format, in that instructions were given to record any events or thoughts that clients might wish to discuss in the next session. Therapists All therapists were trained nurses, who were further qualified as behaviour therapists. A total of four therapists were involved, two of whom (one male and one female) were primarily based at the Hove Centre for Community Mental Health, and saw clients there or at other health centres in the Brighton area. Another two therapists (one male and one female) saw clients as out-patients at St George’s Hospital London. Approximately two-thirds of all the clients treated in this study were seen in the Brighton area, and the remaining third in London. Referrals were randomly allocated to individual therapists within each location.
Generalised anxiety: a controlled treatment study
497
Assessment measures
There were seven main assessment inst~ents, three of which were based solely on self-report, and the remaining four on ratings made by an independent assessor during a structured interview. A total of five assessors were involved, all of whom were clinically trained, and had extensive experience with anxious clients. The same assessor was involved in pre- and post-treatment interviews with any one client, and assessors were balanced across treatments. The interview-based measures were: (1) The Clinical Anxiety Scale (Snaith, Baugh, Clayden, Husain and Sipple, 1982), which includes seven O-4 ratings of specific anxiety symptoms, (2) Social Adjustment, which includes five O-8 rating scales of the extent to which anxiety interferes with different aspects of everyday life, (3) Panic-which includes seven O-8 ratings concerned with frequency and severity of panic attacks, and (4) Problem ratings-which includes eight O-8 ratings of the two main physical and mental anxiety symptoms reported by each client. The self-report measures were: (I) the Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983), which provides separate measures of anxiety and depressive symptoms, (2) the Spielberger Trait Anxiety Scale (Spielberger, Gorsuch and Lushene, 1970), and (3) the St George’s Anxiety Questionnaire, which includes 27 items intended to tap the subjects’ own opinion about the nature and origin of their anxiety symptoms. Assessments were made under blind conditions; that is by interviewers who remained ignorant of the treatments to which clients were allocated. Blind conditions were maintained at posttreatment and on follow-up by requesting clients not to mention anything about their treatment (or lack of it) or to mention any therapist with whom they might have had contact. To sample the reliability of ratings made by assessors, 20 additional ratings on the Clinical Anxiety scale (tension), Social Adjustment and Clinical Severity scales were carried out on randomly chosen Ss by a second assessor, 10 at pre-treatment, and 10 at post-treatment. After eliminating dropouts, reliability coefficients were calculated for 16 observations, and satisfactory correlations were obtained for clinical severity (0.82) and social adjustment (0.85), but not for CAS tension (0.25). Dropouts
There was a total of 29 dropouts within the first half of treatment, or during the wait period. These included those who failed initial treatment appoin~ents (5); others who dropped out during active treatment, after an average of 2.2 sessions (19); and those who could not be re-assessed after the wait period (5). The numbers from each treatment condition did not differ significantly, nor were there any obvious differences distinguishing the dropouts from those remaining in the study (see Table 1). RESULTS Analysis
Outcome data were analysed using analyses of covariance, with post-treatment or follow-up scores as the dependent variable, and pre-treatment scores as the covariate. Analysis of posttreatment data involved all three groups, and when covariance yielded significant results, differences between individual pairs of means were examined using Tukey tests. No follow-up data was obtained from waiting list clients, since they had by then received varying amounts of different treatments, and for this reason only analyses of covariance were carried out at follow-up comparing the two active treatment groups. Treatment inregrity check
Twenty tape-recorded treatment interviews (IO from each active t~atment) were chosen at random, and their content rated by a blind assessor (Frank McCaffery). Tapes were sampled for two consecutive 5-min periods, taken from approximately the mid-point of the interview. Each 5-min segment was independently rated for therapist directiveness, therapist empathy, client responsiveness, and finally for probable treatment identity. Of the 10 anxiety management tapes, both 5-min sections were rated as ‘clearly AMT’ in nine, and the remaining one was rated ‘unclear’ or ‘in the main AMT’ for the two respective sections. Non-directive counselling was identified
COHN
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Table 2. Corrected post-treatment scores and significant differences for assessors’ rating scores
Clinical Anxiety Scale: Tension StartlC Panic ratings: Understanding Cause (physical) Harmful Problem ratings: Disabling (cognitive) Uncontrollable (cognitive) Intensity (cognitive) Intensity (physical) Adjustment ratings: Social impairment
Wait
NDC
AMT
2.3
I .6
1.7 1.7
1.5’ 0.7t
4.0 3.2 3.7
4.5 2.3 3.4
6.0’ 1.7”
3.1 3.6 4.6 5.1
2.5 2.8 3.1 3.2f
1.5’ 2.0’ 2.7’ 2.8’
3.2
2.1
1.7’
I.?+
‘AM7 significantly better than Wait. tAMT si~ifi~otly better than NIX and Wait. $NDC sigttikantly better than Wait.
unequivocally for both sections in six tapes, and ‘in the main NDC’ for at least one section in the remaining four. Thus all 20 tapes were assigned to their correct treatment condition, although more clearly so in the case of anxiety management training. There were no differences between treatments for ratings of client responsiveness (maximum score in 36 of 40 ratings) or therapist empathy (intermediate score in 37 or 40 ratings). However, there was a difference in rated therapist directiveness, since a maximum score was given for 18 of 20 ratings of AMT tapes, and a minimum score for 15 of 20 ratings of NDC tapes, with intermediate scores being assigned to the remaining sections. It is thus clear that the treatment could be easily disting~shed, and that therapists were seen as more directive when carrying out AMT. Post-treatment
outcome
Clinical Anxiety Scale. Of seven sub-scales, only two revealed significant differences, both showing that anxiety management was associated with better outcome than was the equivalent wait period. Psychic tension ratings did not change in the wait group but improved in the anxiety management group (F2,63= 4.7, P < 0.01; Tukey AMT vs WL, P < 0.05). Rated startle response decreased after anxiety management while increasing slightly after both of the two other conditions (Fz.63= 5.8, P < 0.01; Tukey AMT vs NDC and WI;, P < 0.01). No other comparison of non-directive counselling with either of the other conditions reached acceptable levels of significance (see Table 2). Panic rating scales. Only those who asserted that they had panic attacks at least occasionally were rated on these scales, thus reducing the sample analysed to 56. There were no significant treatment differences in ratings of panic severity or frequency, but anxiety management was associated with greater belief at post-treatment that the cause of panic was understood ( F2,52= 4.5, P < 0.02; Tukey AMT vs WL P < 0.05). There was a related tendency to believe panic attacks to be psychological rather than physical in origin (I&, = 3.7, P < 0.04; Tukey ANT vs WL, P < 0.05). Finally, those receiving anxiety management came to believe that panic attacks were probably harmless, while both other groups remained equally unsure about whether they were harmless or not ( F2,52= 12.1, P
Generaliscd
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study
499
the case of physical intensity (Tukey NDC vs WL, P < 0.05). Anxiety management alone was significantly superior to the wait list condition in enhancing perceived control of cognitive symptoms (&, = 3.3, P < 0.05; Tukey ‘P < 0.05) and in causing them to be seen as less disabling (F2,s, = 4.0, P < 0.03; Tukey P < 0.05). St George’s Anxiety Questionnaire. The first five items on this questionnaire deal with self-rated frequency and severity of anxiety symptoms, with perceived ability to cope or need to rely on others, and hopefulness about ability to reduce anxiety (see Table 3). All of these analyses revealed highly significant F values, with anxiety management being associated with the best response (Tukey AMT vs WL, P < 0.05) or better in all cases). Results of non-directive counselling lay between those for the other two groups, but did not differ significantly from either of them except in the case of comparisons with the wait group for severity and ability to cope (Tukey NDC vs WL, P < 0.05). Section 2 of the questionnaire deals with the use of specific coping methods; in comparison with wait group subjects, those who had received anxiety management reported less use of tranquillizers or GP attendance (Tukey AMT vs WL, both P < 0.01) while those receiving non-directive counselling reported less dependence on help from others (Tukey NDC vs WL, P < 0.05). Not surprisingly, since anxiety management actually involved relaxation training, this group reported more use of relaxation than did either of the other groups (Tukey AMT vs NDC and WL, P < 0.01). There were no significant differences between groups in the third section of the questionnaire dealing with beliefs about six different aetiological factors. In the fourth section, respondents are asked to report on which of five coping methods they had found most helpful. Again the anxiety mangement group reported that relaxation was more helpful (Tukey AMT vs NDC and WL, P < O.Ol), but the other items revealed only non-significant trends for the same group to favour talking oneself out of worrying and being able to understand one’s fears. Finally, ratings of self-concern about physical and cognitive symptoms showed again that anxiety management was more effective than the wait period for both (Tukey AMT vs WL, P < O.Ol), while non-directive counselling was more effective than the wait period only for physical symptoms (Tukey NDC vs WL, P < 0.05). Clinical severity ratings. Despite trends favouring both active treatments, neither the overall rating of severity by the assessor, nor self-rated anxiety and depression symptoms on the Hospital Anxiety and Depression Scale, revealed significant treatment effects on analysis of covariance. Unexpectedly however, the Spielberger Trait Anxiety Inventory proved more sensitive to treatment effects ( F2,62= 4.4, P < 0.02), with non-directive counselling being followed by more change than the wait list condition (Tukey NDC vs WL, P < 0.05). The effects of AMT on trait anxiety scores were not significantly different those of either other group.
Table 3. Corrected post-treatment scores and significant differences for sclf-rated questionnaire scores St George’s Questionnaire Frequency Severity Unable Hopeless Reliance on others (Coping methods) Help from others Tranquillizers Relaxation GP attendance (Helpfulness) Relaxation (Symptoms) Physical Cognitive Spiclberger Trait Score
Wait
NDC
AMT
4.7 4.6 4.0 3.5 2.9
4.0 3.v 3.0 2.2
3.4’ 3.5. 2.8’ 2.5* 2.0.
2.9 3.1 2.9 1.8
I .8t 2.0 3.3 1.3
2.4 1.1’ 5.3: 0.6.
3.1
3.3
5.3t
4.8 4.4 53.3
3.4? 3.8 47.v
3.3’ 2.8’ 48.5
lAMT significantly better than Wait. tNDC better than Wait. tAMT significantly better than NDC and Wait.
3.0t
COLIN BLOWERS
500 Table
4. Corrected
et al.,
follow-up scores and significant between treatment groups
Panic ratings: Harmful of panics St George’s Questionnaire: Plan to handle stress Use of relaxation Worrying seem as cause Able to talk self out of worry *Signiticant
difference
differences
NDC
AMT
3.3
2.1.
1.8 2.5 3.5 2.6
2.5. 5.1’ 4.8’ 3.8’
between AMT and NDC
Outcome at follow -up Consistent with the post-treatment picture, relatively few differences between the two active conditions were found at follow-up. There were none for the Clinical Anxiety Scale, for ratings of adjustment, or for overall clinical severity. The previous difference found between groups for ratings of harm due to panic remained significant (F,,s, = 4.8, P < O&l),with only a trend for cognitive aspects of the problem to be seen as less disabling in the anxiety management group (F,,, = 3.2, P < 0.10). On the St George’s Anxiety Questionnaire, four items clearly distinguished the two treatment groups; self-reported use of plans in coping with stress (F,,, = 6.9, P < 0.02), use of relaxation 12.4, P < 0.01), belief that worry about the future plays a causal role (Fi.34 = 4.5, P < O-05), (FLM = and ability to talk oneself out of worrying ( F,,34 = 4.3, P -K0.05). All four analyses indicated greater change following anxiety management than non-directive counselling (see Table 4). DISCUSSION The clearest findings of the present study were that there were surprisingly few significant differences is outcome between the two active treatment conditions being compared, although anxiety management training was consistently superior to the no-treatment wait condition. Immediately after treatment, those who had received anxiety management training had improved si~ifi~ntly more than wait group subjects on 10 out of the almost 30 ratings made by blind assessors. There was much weaker evidence from post-treatment assessor’s ratings that nondirective counselling was more effective than the equivalent wait period; only one out of the same number of ratings achieved significance at the 5% level. While there is thus no convincing evidence from independent sources that non-directive counselling was effective, only two ratings (startle reactions, and belief that panics are harmful) successfully differentiated anxiety management from the non-directive condition. A reasonable conclusion would therefore be that anxiety management training is indeed effective, but that its superiority to a less structured and less directive alternative remains to be proven. Turning to the self-report questionnaire data, a similar pattern emerged, with anxiety management training producing more evidence for improvement than occurred during the wait period (on 11 out of 30 scores), while non-directive counselling was associated with a similar pattern but with somewhat fewer si~ificant differences. The only two questions that revealed differential effects separating the two active treatments can easily be ascribed to the fact that they dealt with a component of anxiety management training itself, relaxation practice. A small number of self-reported differences of a similar type were evident at &month follow-up. The previous lessened beliefs in the harmfulness of panics following anxiety management training persisted, as did the reported use of relaxation, The same Ss also reported three related beliefs; that they tended to plan out methods of handling stress, that worry about the future was a cause of their anxiety, and that they were more able to talk themselves out of such worries. While this apparently meaningful pattern of responses might be used to argue that anxiety management had indeed achieved some of its specific goals, it is at least equally plausible to argue that the observed pattern simply reflects therapeutic demand. Just as the reported use of relaxation changed more in anxiety management, presumably because expticit instructions were given to this effect, so it seems likely that the instructions to use cognitive strategies would lead to reports of their successful
Genera&d anxiety: a controlled treatment study
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employment. Thus, while the reported confidence in being able to cope with anxiety may indeed be valuable, there was little objective basis for such confidence, in as far as one can judge from assessors or self-ratings of severity. If reports of less reliance on medication or on medical advice and support following anxiety management could be validated by collecting relevant data, this would provide more direct evidence of inceased self-reliance. It was not our intention to include the non-directive counselling condition as the best possible alternative treatment, but rather as a control procedure containing possibly active non-specific components, such as therapist’s support and raised expectancies of improvement. Therapists in this study were skilled and experienced in behaviour therapy, but not formally trained in non-directive counselling. To the extent that they were less skilled and/or less enthusiastic about the latter treatment, this would constitute a bias against the efficacy of counselling. The relatively small differences achieved between the two active treatment conditions therefore raises the question of how much of the effects attributed to specific components in anxiety management training are in fact a function of non-specific factors present in many different psychological treatments. Therapists in the present study sometimes commented that, despite the presentation of very different rationales and procedures, Ss improving with either treatment often described similar cognitive changes. In part these descriptions reflected the adoption of common cognitive strategies that they had tried and found effective, such as distraction, but in part may have arisen out of a re-conceptualisation of anxiety as a problem to be tackled, rather than as a catastrophic and uncontrolIable threat. Such a suggestion implies, not that the effects of anxiety management training should be attributed to vague constructs such as ‘expectancy’, but rather that at least a proportion of Ss receiving less directive treatments will discover and utilise specific coping strategies for themselves, leading to similar cognitive changes. An alternative view of the present results would be that the anxiety management methods used were relatively weak, and that with different methods, or in more skilled hands, they would have been more clearly superior to a non-directive control. While this may well be true, it can also be argued that the methods and level of skill represented in the present study are very similar to those available in other clinics, so that our results probably correspond to what can be expected elsewhere. Unfortunately, the lack of common measures across studies severely limits the comparisons that can be made between the present study and others using similar populations. One of the few measures that have been used across many studies is Spielberger’s Trait Anxiety Inventory [see Mathews (1984) for a review]. Although intended as a stable measure of personality, in fact it has been found to change in a consistent and meaningful way following psychological treatment. Across a number of studies of clinic patients with general anxiety symptoms, change scores varied from a low of 2.5 following group psychotherapy (Townsend , House and Addario, 1975) to a high of 9.0 following anxiety management training (Jannoun et al., 1982). Within this range the changes observed in the present study (Wait f0.4, NDC -5.6, AMT -4.O), are only modest, but are almost identical to that reported by Barlow et uf. (1984), following treatment with an 18 session anxiety management package (No Treatment + 2.1, AMT - 4.4). Thus, while the present results do not appear to represent the best that has been achieved, they are at least comparable with those reported from some other leading centres. A further argument against the suggestion that the failure to distinguish between anxiety management and non-directive counselling was due to unusually weak treatment effects is provided by related data recently obtained by Borkovec, Mathews, Chambers, Ebrahimi, Lytle and Nelson (1987, in press). In these reports, data were presented on the effects of relaxation combined with either brief cognitive therapy or non-directive counselling in a volunteer sample complaining of generalised anxiety; and on these treatment conditions compared with coping desensitisation in a clinic sample. Although cognitive therapy added more to relaxation than did non-directive counselling in the case of volunteer Ss, in the clinic sample there were no outcome differences between any of the treatment combinations. Comparisons of magnitude of effect, using Spielberger Trait Scores, shows that all three groups showed a somewhat more marked improvement than was obtained in the present study (relaxation plus non-directive counselling -8.9; relaxation plus cognitive therapy - 8.3; relaxation plus coping desensitization - 10.2). Thus, while overall effect sizes were larger, the general pattern of equivalence between non-directive counselling and more specific co~itiv~~havioural treatments was confirmed.
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COLIN BLOWERS et al.,
The question remains of why the actual magnitude of changes achieved in the present study were relatively modest. In a recent comparison of anxiety management with a wait condition carried out by Butler, Cullington, Hibbert, Klimes and Gelder (in press) an exceptionally high change score of 12.1 on the Spielberger trait measure was achieved in the group allocated to an anxiety management package. Detailed comparison of the content of this package with that of anxiety management in the present study suggests that the main difference concerns the extent of exposure to anxiety provoking cues. In the present study, real-life exposure practice was deliberately eliminated so that the effects of brief training in relaxation and cognitive coping could be evaluated in isolation. However, in a earlier review (Mathews, 1984) it was argued that anxiety arousal may indeed be a crucial feature of more successful treatments, perhaps because this exposes clients to relevant anxiety-evoking stimuli, whether internal or external in nature. Comparisons of effect size across the various studies discussed here would appear to support a role for exposure, and suggests that in its absence, relaxation and cognitive methods may be only slightly more potent than are relatively non-dir~tive and non-structured methods of psy~holo~~al ~ounselling. The present results can thus be used to argue for treatment involving a combination of exposure to anxiety-arousing situations, and simultaneous practice in cognitive coping methods. Acknowledgements-This research was supported by a grant from the South East Thames Regional Health Authority. We are grateful for the help provided by Siaeda Cullen, Frank McCafferey, Allison Abraham, Brian Copley, Colin Ma&sod and Shirley Mercer for carrying out treatment and assessments, and in particular for Siaeda Cullen’s and Frank McCafferey’s additionai help with planning and implementation. Thanks are also due to Anne Gunnel1 and Margaret Reuben for their help with administration of the study.
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