Abstract
BACKGROUND:
Individuals with comorbid generalized anxiety disorder (GAD) and depression often experience impaired mentalized affectivity and interpersonal problems. The present study aimed to evaluate the efficacy of integrated cognitive-behavioral therapy (CBT) on mentalized affectivity and interpersonal problems in comorbid GAD and depressive patients.
MATERIALS AND METHODS:
This quasi-experimental study utilized a single-case method to examine the effectiveness of integrated CBT on mentalized affectivity and interpersonal problems in comorbid GAD and depressive patients of Isfahan, Iran in 2020. Four participants with GAD comorbid with depression were selected through convenient sampling and received individual integrated CBT intervention for 10 weeks. The Inventory of Interpersonal Problems-32 (IIP-32) and Mental Affect Scale (MAS) were administered at baseline; third, fifth, eighth, and tenth sessions and at 1 month follow-up to assess treatment outcomes.
RESULTS:
The visual design, improvement rate, and reliable change index (RCI) demonstrated that integrated CBT produced clinically and statistically significant changes and improvements in treatment goals (i.e., mentalized affectivity and interpersonal problems). Furthermore, the therapeutic effects were sustained during the follow-up phase.
CONCLUSION:
The results suggest that integrated CBT is a promising treatment for moderating mentalized affect and interpersonal problems in individuals with comorbid GAD and depression.
Keywords: Cognitive-behavioral therapy, comorbidity, depression, general anxiety disorder, interpersonal relations, mentalized affectivity
Introduction
People with generalized anxiety disorder (GAD) are constantly worried about the potential occurrence of unfortunate events, anticipate unfortunate events, become irritable, and experience muscle twitches, and psychosocial functioning is likely to be severely impaired.[1] GAD is associated with increased disability, cognitive impairment, life dissatisfaction, and low productivity in patients.[2] The average 12-month prevalence of the disease worldwide is 1.3%, ranging from 0.2% to 4.3% (APA, 2022). A recent study in Iran reported a lifetime prevalence of GAD in Iran of 2.6%.[3] Furthermore, 90% of these people suffer from at least one other mental disorder.[4] This disorder has a strong comorbidity with other anxiety disorders and depression.[5] Leahy et al.[6] reported a 42% comorbidity rate of GAD and depression. Recent meta-analytic results on the comorbidity between anxiety disorders and depression show that mood disorders and anxiety are strongly comorbid, regardless of changes in diagnosis type, study period, and age.[7] Comorbidity reduces diagnostic accuracy and thus reduces the effectiveness of treatment methods. Whichever of the two conditions occurs first, the risk of subsequently developing the other condition increases.[7] This reciprocal relationship in comorbid disorders suggests that these disorders may result from common risk factors.[7,8,9]
Research has shown that emotion dysregulation is one of the key features of GAD.[10] The emotion regulation process involves awareness, understanding, and identification of thoughts and emotions before, during, and after the refining and modulation of emotions.[11] People with GAD experience intense feelings and emotions, tend to catastrophize, may not be able to properly recognize and understand their emotions, and have trouble suppressing their emotions and negative emotions.[12] Emotion regulation has also been proposed as a common factor in the etiology of GAD comorbid with depression.[13] According to recent findings, the common feature of all emotional disorders is an excessive or inappropriate emotional reaction along with a person’s feeling that they are unable to control their emotions.[14]
Mentalized affectivity, as one of the new models of assessing emotion regulation, divides emotion regulation into three components. The first is emotion identification, which in its most basic form involves the labeling of emotions. It also encompasses deeper intricacies related to understanding emotions in the context of one’s personal history and exploring the meaning of emotions (for example, why do I feel this way?). The second aspect following the identification of emotions is their elaboration. Processing involves the modulation/regulation of emotions. This includes changing the emotion in some way, such as duration or intensity. The third process following processing is the expression of emotions. Expression encompasses the spectrum of communicating one’s thoughts and emotions from the inside out. A person’s story affects every aspect of emotional experience, from identification and processing to expression. Furthermore, these elements are related to a person’s sense of agency with emotions: with identification, there is the dawning of a sense of agency, with modulation of agency actualization, and with expression of results or of agency manifestations.[11] These three dimensions relate to personality traits, well-being, trauma, and mental disorders (including mood, anxiety, and personality disorders). People with GAD score higher than healthy people on the emotion expression component.[11]
According to the mentalized affectivity model, emotional regulation is influenced by personality, values, culture, personal history, and, most importantly, mentalization ability.[15] This concept has similarities with “emotional regulation,” but it emphasizes that emotions are regulated through the prism of historical memory. Jurist[15] states that addressing emotions based on mentalized affectivity will be beneficial for all therapists, regardless of their orientation.
Integrated models of psychopathology have suggested that the quality of interpersonal relationships, as one of the determinants of psychological well-being,[16] has a significant relationship with an increased risk of GAD.[17] Studies have shown that most of these patients have interpersonal issues at the core of their worry.[18] Interpersonal dysfunction has been proposed as an important maintenance factor in chronic worry and GAD.[19] Interpersonal dysfunctional processes that are typically associated with GAD may play a key role in the onset and persistence of GAD by distorting interpersonal cognition and problem behaviors[20] and chronically impacting psychological well-being[21] and physical well-being.[22] A wide range of different types of interpersonal problems occur in GAD and reduce the effectiveness of psychotherapy, suggesting the need to modify interventions for specific interpersonal problems in people with GAD.[23] Millstein, Orsillo, Hayes-Skelton, and Roemer[24] acknowledge that interpersonal problems in people with GAD may affect their response to treatment and that adding interpersonal components to cognitive-behavioral therapies can improve treatment. Interpersonal problems can also be an important goal in the treatment of GAD. Cognitive-behavioral therapy (CBT) is considered the first psychotherapy option for GAD, and its effectiveness is supported by several meta-analyses.[25] Although cognitive-behavioral therapies with research support have proven their effectiveness as the treatment of choice for GAD, the results of some studies show that only 50% of people with GAD achieve positive results from treatment,[26] and 50% of people who undergo cognitive-behavioral intervention at the end of treatment still have high symptoms and recurrence rates[18] and fail to achieve optimal treatment results.[27] Cognitive-behavioral therapy has less effect on the improvement of people with GAD than other anxiety disorders.[28] Research conducted in Iran also confirms this.[29]
Despite the development of new therapies, particularly third-wave therapies, their effectiveness has not yet reached the desired level. However, by integrating cognitive-behavioral therapy with components of other new therapies, better results can be expected.[30] Therefore, selecting and refining cognitive-behavioral therapy techniques that address the underlying processes of pathological worry can be one of the available and necessary solutions to increase the effectiveness of treatment in GAD.[31] According to researchers, combining approaches based on cognitive-behavioral therapy for treating GAD has been found to lead to better results.[30] Integrated psychotherapy approaches can be one of the solutions for researchers and therapists, especially for treating patients for whom a therapeutic approach is not effective.[32] Clinical therapists and researchers have resorted to integrated psychotherapeutic approaches to provide empirically supported and validated interventions for patients with complex problems or those for whom single-approach interventions have not been effective.[1] Therapists who offer an evidence-based therapy approach, according to the APA Association Working Group on Evidence-Based Therapy,[33] should integrate the most valid research and clinical findings, depending on the personality traits and needs of their clients.[34]
GAD results from the interaction of physiological, cognitive, and behavioral components. Therefore, treatment should be multifaceted, comprehensive, and integrated.[35] Researchers have expressed the necessity, importance, and usefulness of developing integrated and process-oriented models of GAD that are more effective and economical.[2,36] New patterns of GAD also emphasize the integration of therapeutic techniques.[6,37,38,39,40] Studies have confirmed the effectiveness of integrated psychotherapy interventions for GAD, particularly when coexisting with another disorder.[40]
Since human beings are an integrated and indivisible whole, their complete mental health is achieved when the unity and cohesion of this system are maintained, and its various components work in harmony with each other. The increasing attention of psychologists and therapists to this fact has led to widespread attention to holistic methods by psychotherapists in recent decades. Therefore, they are now looking for new ways that can affect the whole person in an integrated way and change all their cognitions, beliefs, emotions, and behaviors coherently and harmoniously, putting the person on the path of growth and evolution. While many scientific efforts are still needed to achieve effective interventions for reducing or eliminating emotional pain and suffering, a holistic view is a good way to achieve this goal. Previous studies have also highlighted the need for comprehensive and integrated therapies for patients with GAD. Given these patients’ extensive areas of worry, it seems impossible to challenge each worry in the treatment sessions. Therapists should try to improve these patients by considering the main and meta-diagnostic structures underlying the pathology and treatment of this disorder. Therefore, therapists should be aware of a wide range of treatment options and help GAD patients identify the best treatment option based on their individual needs.[39] Since GAD is a heterogeneous disorder in which the onset, type, and severity of anxiety vary from person to person, each patient needs individual treatment. As a result, the treatment of GAD and comorbid depression requires special proportions of psychotherapy compared to treating both disorders alone. Patterns of treatment that include common underlying etiological factors, as well as effective techniques for both these disorders, are essential. Paying attention to these matters and addressing common processes and transdiagnostic factors of CBTs in the pathology of anxiety and depression and evaluating of effectiveness of integrated CBT on mentalized affectivity and interpersonal problems is one of the innovations of the present research. This study aimed to investigate the effectiveness of the integrated cognitive-behavioral intervention on mentalized affectivity and interpersonal problems in people with GAD comorbid with depression.
Materials and Method
Study design and setting
A quasi-experimental design employing a single-case methodology with different subjects and continuous assessment was used to conduct the therapeutic intervention. The study included baseline, treatment, and 1-month follow-up stages.
Study participants and sampling
The statistical population consisted of individuals with GAD in the city of Isfahan, Iran, in 2020, from which four individuals with comorbid GAD and depression were selected using purposive sampling [Table 1].
Table 1.
Clinical history of the research subjects
| Subjects | Age | Gender | Education | Marital state | Occupation | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 55 | Female | Middle school | Married | Housewife | |||||
| 2 | 34 | Female | Diploma | Married | Housewife | |||||
| 3 | 22 | Female | Undergraduate | Single | Student | |||||
| 4 | 24 | Female | Undergraduate | Married | Student |
The inclusion criteria were as follows: a) a minimum of middle school education and age range of 20 to 55 years, b) the main and initial diagnosis of GAD based on the Structured Clinical Interview for DSM-5 (SCID-5-CV) and the Generalized Anxiety Disorder 7-item (GAD-7) questionnaire, c) symptoms of depression based on the SCID-5-CV and the Beck Depression Inventory-II (BDI-II), d) no psychiatric diagnosis other than GAD and depression based on the SCID-5-CV, e) no receipt of any intervention or medication other than research interventions, and f) participation in treatment sessions [Table 2] and completion of questionnaires. The exclusion criterion was the absence from more than two treatment sessions.
Table 2.
The structure and content of integrated CBT adapted from (Ghaderi et al., 2020)[38]
| Session | Session Purpose | Session Content | ||
|---|---|---|---|---|
| 1 | Psychological education | Creating a new attitude to the disorder, developmental analysis of the disorder formation process, identification of anxiety-related behavior, differentiation of causal anxiety and troublesome anxiety, efficient anxiety education, motivation for behavioral change, familiarity with the treatment and introduction of the treatment program. | ||
| 2 | Activating mindfulness and value-orientation | Monitoring of worries and timing of worries, confrontation with avoidance, prevention of behavioral responses, reward planning/scheduling of activities to monitor feelings of pleasure, mastery, anxiety, and fundamental acceptance. | ||
| 3-4 | Acceptance and Consciousness Awareness | Changing clients’ temporal orientation by helping the patient to focus on the present, living in the moment and staying in the present, fundamental acceptance, awareness, and observation of thoughts and feelings without trying to control or judging them, teaching problem-solving skills | ||
| 5-6 | Cognitive flexibility | Conceptualization and cognitive evaluation of generalized anxiety disorder, evaluation of negative evaluation, evaluation of the effectiveness of dysfunctional thoughts and attitudes, explanation of the relationship between concern and schemas; conscious attention to schemas and coping styles, | ||
| 7-8 | Emotional efficiency | Mindfulness and emotional awareness, familiarity with emotional avoidance and the consequences of emotion avoidance, teaching basic and advanced emotional regulation skills, and teaching ten ways to cope with emotions. | ||
| 9 | Interpersonal effectiveness | Identify the roots of interpersonal problems, identify key interpersonal maladaptive schemas and maladaptive coping behaviors resulting from the schema and evaluate its costs, clarify interpersonal goals and values, and increase behavioral flexibility. | ||
| 10 | Relapse prevention skills | Review and summarize sessions and key points raised, identify effective techniques for overcoming potential future problems and barriers, teach strategies for sustaining treatment achievements, and design a relapse prevention program. |
Data collection tool and technique
After identifying the sample members, questionnaires were administered to determine the baseline. Once the baseline in the research variables was established, the intervention was performed individually. Five participants took part in 1-hour weekly individual therapy sessions. The participants were evaluated to follow up on the treatment results at intervals of the third, sixth, eighth, and tenth sessions (completion of the treatment sessions) and 1-month follow-up using the Inventory of Interpersonal Problems-32 (IIP-32) and The Personality Inventory for DSM-5 Brief Form (PID-5-BF).
Inventory of Interpersonal Problems-32 (IIP-32). The IIP-32 is a self-report inventory with eight subscales reflecting different interpersonal problems. This form was designed by Barkham et al.[41] as a short version of the original form (127 questions) for use in clinical services. This scale has eight subscales: Assertiveness and Sociability, Openness, Caring, Aggression, Supportiveness and Involvement, and Dependency. Each item is rated on a 5-point Likert scale, ranging from 0 (not at all) to 4 (extremely). Cronbach’s alpha coefficients for this questionnaire have been reported in the range of 0.7 to 0.8.[42]
The Mentalized Affectivity Scale (MAS). The MAS is a new tool to measure the emotional domain developed by Greenberg et al.[11] This scale includes 60 questions and three subscales of identifying, processing, and expressing emotions. The creators of this scale reported high reliability and validity and believe that it can be used for clinical and nonclinical populations and in the fields of psychology, psychiatry, and neuroscience. The Persian version of this questionnaire has been standardized in Iran by Ghaderi et al.[43] The Cronbach’s alpha coefficient for the entire scale was 0.88. The composite reliability of the factors was in the range of 0.70–0.91.
Data analysis in this study involved various methods to evaluate the effectiveness of the treatment, including visual drawing or graphic diagram analysis, the Reliable Change Index (RCI), clinical significance, improvement percentage, and effect size.
The RCI was used to assess statistical significance. This index involves subtracting the post-test score from the pretest score and dividing the result by the standard error of the difference between the two scores. To be considered statistically significant, the absolute value of the RCI result must be equal to or greater than 1.96, indicating that the results are primarily due to the active factors and manipulation of the experimenter rather than measurement error.
The percentage of recovery formula was used to determine the rate of improvement in therapeutic targets as well as clinical significance. This formula involves subtracting the pretest score from the post-test score and dividing the result by the pretest score and then multiplying the result by 100.[44] These methods were employed to objectively evaluate the effectiveness of the treatment intervention.
Ethical consideration
In accordance with ethical considerations, participants in this study were assured that all information related to them would be kept strictly confidential. They were informed that the results of the research would be presented only in a generalized statistical format and not on an individual basis. Participants were given the option to decline participation in the research at any time.
Furthermore, participants were informed that following the completion of the study, they could attend a free consultation session to learn about the results of the treatment intervention and the results of the questionnaires before and after treatment. They were also given the opportunity to provide additional feedback and suggestions for improving the treatment process.
At the outset of the study, all volunteer participants received adequate explanations about the importance, methodology, duration, and conditions of conducting the research intervention and evaluations. These measures were taken to ensure that participants were fully informed and provided with the necessary information to make an informed decision about their participation in the study.
Data analysis
Data analysis in this study involved various methods to evaluate the effectiveness of the treatment, including visual drawing or graphic diagram analysis, the Reliable Change Index (RCI), clinical significance, improvement percentage, and effect size.
Results
Scores of repeated measures of interpersonal problems of research subjects during baseline, intervention, and follow-up sessions and improvement percentage indices are shown in Table 3.
Table 3.
Process of changing the scores of interpersonal problems of research subjects
| Subject | Baseline | The third session | The fifth session | The eighth session | The last session | Percentage of recovery (%) | Reliable change index | Total percentage of recovery | Effect-size | Follow-up | Follow-up percentage of recovery | Reliable change index | Total percentage of recovery | Effect-size | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Hard to be sociable | 1 | 10 | 12 | 5 | 5 | 5 | 50 | 2.05 | 55.75 | .92 | 6 | 40 | 1.64 | 75.41 | .89 | |||||||||||||||
| 2 | 11 | 11 | 10 | 7 | 7 | 36 | 1.64 | .89 | 7 | 36 | 1.64 | .89 | ||||||||||||||||||
| 3 | 12 | 10 | 7 | 4 | 4 | 66 | 3.29 | .97 | 7 | 41 | 2.05 | .92 | ||||||||||||||||||
| 4 | 14 | 8 | 4 | 4 | 4 | 71 | 4.34 | .98 | 7 | 50 | 2.88 | .96 | ||||||||||||||||||
| Too open | 1 | 6 | 5 | 5 | 2 | 5 | 16 | .49 | 45.5 | .44 | 5 | 16 | .49 | 25.32 | .44 | |||||||||||||||
| 2 | 11 | 6 | 5 | 5 | 4 | 63 | 3.43 | .96 | 6 | 45 | 2.45 | .92 | ||||||||||||||||||
| 3 | 6 | 5 | 4 | 1 | 1 | 83 | 2.94 | .92 | 3 | 50 | 1.47 | .83 | ||||||||||||||||||
| 4 | 10 | 8 | 9 | 10 | 8 | 20 | .98 | .70 | 8 | 20 | .98 | .70 | ||||||||||||||||||
| Too caring | 1 | 9 | 7 | 8 | 8 | 6 | 33 | 1.74 | 30.75 | .83 | 9 | 0 | 0 | 75.20 | 0 | |||||||||||||||
| 2 | 10 | 9 | 7 | 7 | 7 | 30 | 1.74 | .83 | 7 | 30 | 1.74 | .83 | ||||||||||||||||||
| 3 | 13 | 14 | 14 | 15 | 10 | 23 | 1.74 | .83 | 10 | 23 | 1.74 | .83 | ||||||||||||||||||
| 4 | 13 | 9 | 10 | 11 | 8 | 38 | 2.90 | .92 | 9 | 30 | 2.32 | .89 | ||||||||||||||||||
| Too aggressive | 1 | 8 | 8 | 3 | 2 | 3 | 62 | 2.08 | 53.25 | .89 | 4 | 50 | 1.66 | 45.75 | .89 | |||||||||||||||
| 2 | 4 | 3 | 1 | 1 | 1 | 75 | 1.25 | .83 | 2 | 50 | .83 | .70 | ||||||||||||||||||
| 3 | 15 | 14 | 12 | 11 | 11 | 26 | 1.66 | .89 | 10 | 33 | 2.08 | .92 | ||||||||||||||||||
| 4 | 12 | 10 | 7 | 6 | 16 | 50 | 2.50 | .94 | 6 | 50 | 2.5 | .94 | ||||||||||||||||||
| Hard to be supportive | 1 | 4 | 5 | 5 | 6 | 5 | 25 | .34 | 61 | .44 | 5 | 25 | .34 | 30.25 | .44 | |||||||||||||||
| 2 | 4 | 2 | 1 | 1 | 1 | 75 | 1.30 | .83 | 4 | 0 | 0 | 0 | ||||||||||||||||||
| 3 | 13 | 7 | 7 | 4 | 4 | 69 | 2.40 | .96 | 7 | 46 | 2.06 | .94 | ||||||||||||||||||
| 4 | 8 | 5 | 4 | 3 | 2 | 75 | 2.06 | .94 | 4 | 50 | 1.37 | .96 | ||||||||||||||||||
| Too dependent | 1 | 4 | 4 | 3 | 2 | 2 | 50 | .90 | 38.75 | .70 | 2 | 50 | .90 | 38.75 | .70 | |||||||||||||||
| 2 | 7 | 7 | 3 | 3 | 3 | 57 | 1.81 | .89 | 3 | 57 | 1.81 | .89 | ||||||||||||||||||
| 3 | 8 | 7 | 8 | 7 | 5 | 37 | 1.36 | .83 | 5 | 37 | 1.36 | .83 | ||||||||||||||||||
| 4 | 9 | 9 | 9 | 9 | 10 | 11 | .45 | .44 | 8 | 11 | .45 | .44 |
Based on the results of the study and the values of the RCI (RCI≥1.96), the integrated CBT intervention for the component of “Hard to be sociable” was statistically and clinically significant for the first, third, and fifth subjects in the intervention stage, with improvement rates of 50%, 66%, and 71%, respectively. However, the intervention was not significant for the second subject. The average improvement rate after treatment for all five subjects was 55.75%.
In the follow-up stage, based on the RCI value, the intervention was significant for the third and fourth fifth subjects but was not significant for the first and second subjects. The overall improvement rate during the follow-up period was 41.75%. The results for other dimensions of interpersonal problems can be seen in the table provided.
Figures 1-6 depict the changes in the participants’ scores during different stages of evaluation.
Figure 1.
The process of changing Hard to be sociable score
Figure 6.
The process of changing too be dependent score
Figure 2.
The process of changing too open score
Figure 3.
The process of changing too caring score
Figure 4.
The process of changing too aggressive score
Figure 5.
The process of changing hard to be supportive score
According to the results of the study and based on the Reliable Change Index (RCI ≥1.96), the integrated treatment intervention for the “Identifying emotions” component was statistically significant for the first and second subjects during both the intervention and follow-up phases. However, the intervention was not statistically significant for the third and fourth subjects. The results for other dimensions of mentalized affectivity can be seen in the Table 4 provided.
Table 4.
Process of changing the scores of mentalized affectivity of research subjects
| Subject | Baseline | The third session | The fifth session | The eighth session | The last session | Percentage of recovery | Reliable change index | Total percentage of recovery | Effect-size | Follow-up | Follow-up percentage of recovery | Reliable change index | Total percentage of recovery | Effect-size | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Identifying emotions | 1 | 93 | 92 | 118 | 125 | 134 | 44 | 2.27 | 30.75 | .99 | 131 | 40 | 2.11 | 28.5 | .99 | |||||||||||||||
| 2 | 107 | 123 | 137 | 143 | 154 | 43 | 2.61 | .99 | 152 | 42 | 2.50 | .99 | ||||||||||||||||||
| 3 | 118 | 130 | 135 | 133 | 149 | 26 | 1.72 | .99 | 146 | 23 | 1.55 | .99 | ||||||||||||||||||
| 4 | 145 | 145 | 150 | 160 | 160 | 10 | .83 | .99 | 159 | 9 | .77 | .99 | ||||||||||||||||||
| Processing emotions | 1 | 78 | 83 | 96 | 114 | 131 | 67 | 4.81 | 38.5 | .99 | 130 | 66 | 4.72 | 37.5 | .99 | |||||||||||||||
| 2 | 92 | 114 | 111 | 114 | 127 | 38 | 3.18 | .99 | 127 | 38 | 3.18 | .99 | ||||||||||||||||||
| 3 | 122 | 130 | 127 | 128 | 135 | 10 | 1.18 | .98 | 131 | 7 | .81 | .97 | ||||||||||||||||||
| 4 | 91 | 109 | 122 | 127 | 127 | 39 | 3.27 | .99 | 127 | 39 | 3.27 | .99 | ||||||||||||||||||
| Expressing emotions | 1 | 37 | 45 | 45 | 45 | 53 | 43 | 2 | 54.25 | .99 | 56 | 51 | 2.37 | 56.75 | .99 | |||||||||||||||
| 2 | 32 | 32 | 35 | 53 | 49 | 53 | 2.07 | .99 | 51 | 59 | 2.32 | .99 | ||||||||||||||||||
| 3 | 27 | 37 | 47 | 53 | 53 | 96 | 3.17 | .99 | 52 | 92 | 3.05 | .99 | ||||||||||||||||||
| 4 | 56 | 61 | 60 | 63 | 70 | 25 | 1.75 | .99 | 70 | 25 | 1.75 | .90 |
Figures 7-9 depict the changes in the participants’ scores during different stages of evaluation.
Figure 7.
The process of changing identifyng emotion
Figure 9.
The process of changing expressing emotion
Figure 8.
The process of changing processing emotion
Discussion
The present study aimed to evaluate the effectiveness of integrated CBT for individuals with comorbid GAD and depression, focusing on its impact on mentalized affectivity and interpersonal problems. Data analysis involved various methods, including visual drawing, RCI, clinical significance, improvement percentage, and effect size. The results showed that the Integrated CBT intervention was statistically and clinically significant in reducing the component of “Hard to be sociable” for the first, third, and fifth subjects in the intervention stage, but not for the second subject. The intervention was significant for the third and fourth and fifth subjects during follow-up. The intervention for the “Identifying emotions” component was statistically significant for the first and second subjects during both intervention and follow-up but not for the third and fourth subjects.
The results of the present study on the effectiveness of integrated CBT in reducing interpersonal problems and mentalized affectivity in patients with GAD are consistent with previous research that has shown the effectiveness of integrated interventions for emotional disorders.[35,37] These findings are also consistent with studies by Newman, Castonguay, Fisher, and Borkovec,[45] which demonstrated the effectiveness of CBT combined with interpersonal therapies and emotional regulation in patients with GAD. Additionally, these results are in line with the findings of research by Westra, Antony, and Constantino[46] and Gómez Penedo et al.,[47] which showed the effectiveness of CBT integrated with motivational interviewing in improving patients with GADs.
These findings are consistent with the results of research by Muir et al.,[24,48] Millstein et al.,[24] and Newman et al.,[45] which have shown the effectiveness of integrated interventions in treating emotional disorders such as anxiety. The consistency of these findings across studies suggests that integrated interventions, such as CBT combined with interpersonal therapies and motivational interviewing, can be effective in improving interpersonal problems and mentalized affectivity in patients with GAD.
An integrated treatment model helps to conceptualize the persistent processes which are common between emotional disorders for clients. This model also provides evidence-based treatment strategies in a single protocol based on clients’ needs and helps to answer clients’ questions and satisfy their needs in different areas and to provide the required skills for most areas of their life. Researchers have similarly pointed out that combining therapies in an integrated treatment protocol can be effective for GAD.[49] Proper use of common concepts and techniques of cognitive-behavioral approaches helps patients acquire the skills needed to increase motivation to treat and correct maladaptive coping strategies, reduce their anxiety in different areas, facilitate access to resources, and strengthen hope for the future. Psychological training, behavior and mindfulness, and value-oriented training, and also training and correction of interpersonal patterns, all of which have shown good results in previous studies, were part of the techniques used in the integrated treatment protocol. The cumulative effect of these interventions in an integrated protocol has met the different needs of clients. Such awareness gives patients the security they need to face the situations and decisions needed in life.
Therapeutic goals related to interpersonal problems that were pursued in the present study are identifying interpersonal needs, past and present patterns of interpersonal behaviors to meet these needs, finding the underlying emotional experiences, and introducing more effective interpersonal behaviors to better meet the needs. Part of the integrated protocol was designed to improve interpersonal skills and reduce patients’ interpersonal concerns. Addressing the interpersonal concerns and identifying the roots of interpersonal problems (such as attachments and traumatic experiences), identifying key interpersonal maladaptive schemas and maladaptive coping behaviors resulting from the schemas, evaluating the costs, as well as conscious attention to schemas, and clarifying interpersonal goals and values and increasing behavioral flexibility and avoiding response styles resulting from schemas all can be effective in reducing patients’ interpersonal problems. Identifying the patient’s interpersonal goals and values and mapping out important interpersonal relationships and their links to the underlying problematic behaviors will make clients committed to their values. It also causes patients to act on values in their relationships, rather than avoiding schema-induced behaviors. This can improve the quality of life, reduce interpersonal worries, and, consequently, reduce interpersonal problems. The reduction of interpersonal problems can also be attributed to the reduction of symptoms. Naturally, after reducing the symptoms and improving the quality of life of patients, their interpersonal problems will decrease to some extent. Because problems such as worry, anxiety, and depression are always associated with interpersonal dysfunctions, reducing these problems can reduce interpersonal problems in clients. Consistent with this claim, the results of studies also show that interpersonal dysfunction improves after psychotherapy.[19]
Also, since the problem for people with GAD is that the set of options available to them is limited to avoidance and worry, various integrated treatment interventions and practices in individual and interpersonal domains bring flexibility and new options to the client’s behavioral treasury, something that the client has not experienced for a long time. The most important benefit of these exercises is to expand the client’s behavioral treasury and makes it more resilient in the face of avoidant and worrying events. Using strategies based on acceptance and mindfulness facilitates dealing with all aspects of life, even the painful ones, and enables the client to respond consciously instead of automatically, which is very common in anxiety disorders. When a confrontation with a problem is combined with awareness and openness to experience, a context is provided in which the client can relate fully to many life events and do so without attempting to change that experience. Interpersonal effectiveness increases awareness of the habitual patterns that exacerbate or perpetuate symptoms. Hence, it makes possible the maximum satisfaction of personal desires and needs. As a result of interventions such as emotional efficiency skills, mindfulness, and cognitive flexibility, patients learn to accept their emotions, experience them, and provide a space for emotional growth.
In explaining these results, it can be said that emphasizing emotional awareness and emotion management skills in therapy sessions can be effective in improving and adjusting the three dimensions of mental emotionality. Skills such as conscious emotional attention and emotional awareness, familiarity with emotional avoidance and the consequences of avoiding emotions, and teaching different ways to cope with emotions can be effective in achieving results. In the developed integrated protocol, the client’s familiarity with emotion and the function of emotion in maintaining and perpetuating the patient’s problems were considered. Basic emotional skills include identifying emotions, how they act, components of emotion, components of an emotional response including emotion, emotion-based thoughts, bodily sensations, and emotion-based action (for example, avoidance). These findings are consistent with research by Muir et al.,[48] Millstein et al.,[24] and Newman et al.,[45] which have shown the effectiveness of integrated interventions in treating emotional disorders such as anxiety. The consistency of these findings across studies suggests that integrated interventions, such as CBT combined with interpersonal therapies and motivational interviewing, can be effective in improving interpersonal problems and mentalized affectivity in patients with GAD.
An integrated treatment model helps to conceptualize the persistent processes that are common between emotional disorders for clients. This model also provides evidence-based treatment strategies in a single protocol based on clients’ needs and helps to answer clients’ questions and satisfy their needs in different areas and provide the required skills for most areas of their life. Researchers have similarly pointed out that combining therapies in an integrated treatment protocol can be effective for GAD.[49] Proper use of common concepts and techniques of cognitive-behavioral approaches helps patients acquire the skills needed to increase motivation to treat and correct maladaptive coping strategies, reduce their anxiety in different areas, facilitate access to resources, and strengthen hope for the future. Psychological training, behavioral and mindfulness, and value-oriented training, and also training and correction of interpersonal patterns, all of which have shown good results in previous studies, were part of the techniques used in the integrated treatment protocol. The cumulative effect of these interventions in an integrated protocol has met the different needs of clients. Such awareness gives patients the security they need to face the situations and decisions needed in life.
Therapeutic goals related to interpersonal problems that were pursued in the present study are identifying interpersonal needs, past and present patterns of interpersonal behaviors to meet these needs, finding the underlying emotional experiences, and introducing more effective interpersonal behaviors to better meet the needs. Part of the integrated protocol was designed to improve interpersonal skills and reduce patients’ interpersonal concerns. Addressing the interpersonal concerns and identifying the roots of interpersonal problems (such as attachments and traumatic experiences), identifying key interpersonal maladaptive schemas and maladaptive coping behaviors resulting from the schemas, evaluating the costs, as well as conscious attention to schemas, and clarifying interpersonal goals and values and increasing behavioral flexibility and avoiding response styles resulting from schemas all can be effective in reducing patients’ interpersonal problems. Identifying the patient’s interpersonal goals and values and mapping out important interpersonal relationships and their links to the underlying problematic behaviors will make clients committed to their values. It also causes patients to act on values in their relationships, rather than avoiding schema-induced behaviors. This can improve the quality of life, reduce interpersonal worries, and, consequently, reduce interpersonal problems. The reduction of interpersonal problems can also be attributed to the reduction of symptoms. Naturally, after reducing the symptoms and improving the quality of life of patients, their interpersonal problems will decrease to some extent. Because problems such as worry, anxiety, and depression are always associated with interpersonal dysfunctions, reducing these problems can reduce interpersonal problems in clients. Consistent with this claim, the results of studies also show that interpersonal dysfunction improves after psychotherapy.[19]
Also, since the problem for people with GAD is that the set of options available to them is limited to avoidance and worry, various integrated treatment interventions and practices in individual and interpersonal domains bring flexibility and new options to the client’s behavioral treasury, something that the client has not experienced for a long time. The most important benefit of these exercises is to expand the client’s behavioral treasury and makes it more resilient in the face of avoidant and worrying events. Using strategies based on acceptance and mindfulness facilitates dealing with all aspects of life, even the painful ones, and enables the client to respond consciously instead of automatically, which is very common in anxiety disorders. When a confrontation with a problem is combined with awareness and openness to experience, a context is provided in which the client can relate fully to many life events and do so without attempting to change that experience. Interpersonal effectiveness increases awareness of the habitual patterns that exacerbate or perpetuate symptoms. Hence, it makes possible the maximum satisfaction of personal desires and needs. As a result of interventions such as emotional efficiency skills, mindfulness, and cognitive flexibility, patients learn to accept their emotions, experience them, and provide a space for emotional growth.
In explaining these results, it can be said that emphasizing emotional awareness and emotion management skills in therapy sessions can be effective in improving and adjusting the three dimensions of mental emotionality. Skills such as conscious emotional attention and emotional awareness, familiarity with emotional avoidance and the consequences of avoiding emotions, and teaching different ways to cope with emotions can be effective in achieving results. In the developed integrated protocol, the client’s familiarity with emotion and the function of emotion in maintaining and perpetuating the patient’s problems were considered. Basic emotional skills include identifying emotions, how they act, components of emotion, components of an emotional response including emotion, emotion-based thoughts, bodily sensations, and emotion-based action (for example, avoidance).
Limitations and recommendations
The present study has some limitations that should be acknowledged. First, the sample size was relatively small, consisting of only five participants, which may limit the generalizability of the findings. Second, the study employed a single-case methodology, which may limit the generalization of the findings to the larger population. Third, the study did not have a control group, which may limit the ability to draw causal inferences about the effectiveness of the integrated CBT intervention. Fourth, the study was conducted in a specific geographic location, which may limit the generalizability of the findings to other cultural contexts. Last, the study did not assess the long-term effects of the intervention, which may limit the generalizability of the findings regarding the sustainability of the treatment effects. Future research with larger sample sizes, control groups, and diverse cultural contexts is needed to confirm the effectiveness of integrated CBT interventions for individuals with comorbid GAD and depression.
Conclusion
These findings suggest that integrated CBT can be effective in reducing mentalized affectivity and interpersonal problems in individuals with comorbid GAD and depression. According to the obtained results, integrated CBT can be used by therapists and according to the conditions and needs of patients along with other treatment models of this disorder. Although many scientific efforts are still needed in order to achieve effective interventions for emotional disorders, an integrated approach will be a suitable method to achieve this goal. Integrative perspective will be effective in the expansion of behavioral therapy and will increase the quick access of clients to empirically verified interventions. It should be noted that research on the potential benefits of integrative therapies for the treatment of anxiety disorders is in the preliminary stages. Similarly, more research and clinical trials are necessary to determine the effectiveness and the best way to integrate interventions in anxiety patients.
Author’s contributions
All authors contributed equally to preparing all parts of the research.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
This research has been registered with the code IRCT20200918048749N1 in Iran’s clinical trial site. This article is taken from the PhD thesis of the first author with the code of ethics IR.UI.REC. 1398.013 is from University of Isfahan. Thanks to everyone who helped us with this research.
Funding Statement
research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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