Complementary Therapies in Clinical Practice 39 (2020) 101122

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Complementary Therapies in Clinical Practice

journal homepage: http://www.elsevier.com/locate/ctcp

Integrative therapy (short-term psychodynamic psychotherapy &

cognitive-behavioral therapy) and cognitive-behavioral therapy in the
treatment of generalized anxiety disorder: A randomized controlled trial
Marzieh Orvati Aziz a, *, Seyed Abolghasem Mehrinejad b, Kianoosh Hashemian b,
Mehrangiz Paivastegar b
a
Faculty of Psychology and Educational Sciences, Alzahra University, Tehran, Iran
b
Alzahra University, Tehran, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Background: and purpose: Cognitive-behavioral therapy and psychodynamic psychotherapy are common psy­
Generalized anxiety disorder chotherapies used for mental disorders. The purpose of the present article was to achieve an integration of
Cognitive-behavioral therapy cognitive-behavioral therapy and short-term psychodynamic psychotherapy that enjoys simultaneously the ef­
Integrative therapy
fects of cognitive-behavioral therapies and the stability of short-term psychodynamic psychotherapies.
Short-term psychodynamic psychotherapy
Materials and methods: It was a pre-test/post-test experimental study. Selected based on a purposive non-
probabilistic sampling method, the sample studied here consisted of 36 people diagnosed with generalized
anxiety according to Clinical Diagnostic Interview, psychiatrist diagnosis and Hamilton Rating Scale for Anxiety
(HRSA). They were divided randomly into three 12 person groups: two treated groups by integrative therapy and
cognitive-behavioral therapy, and one control group. Only pre-test and post-test were employed for the control
group without any kind of treatment. To select patients and evaluate the effects of each type of treatments, the
“Hamilton Rating Scale for Anxiety” and “Beck Depression Inventory” were applied for the pre-test/post-test and
the differential diagnosis, respectively. The results obtained were analyzed by covariance and ANOVA analyses
using SPSS software.
Results: The results of the study indicate the efficacy of both cognitive-behavioral therapy and integrative therapy
in the treatment of generalized anxiety and integrative therapy was more effective in the treatment of gener­
alized anxiety compared to cognitive-behavioral therapy.
Conclusion: Integrative treatment not only to be effective in the treatment of generalized anxiety disorder and the
reduction of its symptoms, but also to be more effective than cognitive-behavioral therapy.

1. Introduction responders in specific mental disorders have not been acceptable,

especially if long-term outcomes are taken into account. This is the case
Anxiety disorders are among the most common mental diseases and for depressive disorders and some anxiety disorders such as social
form the largest group of mental disorders. They often show a chronic phobias or generalized anxiety disorders. The randomized controlled
trend [1]. International studies have shown that out of every three trials have provided some evidences, which show that psychodynamic
people, one is affected by an anxiety disorder during his/her lifetime, psychotherapy is superior to control conditions and is generally as
and the risk of being affected by anxiety disorders is 14–29% [2]. effective as already established treatments for specific mental disorders
Cognitive-behavioral therapy and psychodynamic psychotherapy are [3].
common psychotherapies used for mental disorders of adolescents. In the present article, both approaches have been given serious
Although cognitive-behavioral therapy has yielded effective outcomes attention, because therapists can simultaneously benefit from their
in most cases of mental disorder, the positive outcome rates of treatment positive features in the treatment of the generalized anxiety disorders

* Corresponding author.
E-mail addresses: m.orvatiaziz.1981@gmail.com (M. Orvati Aziz), S.mehrinejad@alzahra.ac.ir (S.A. Mehrinejad), drhashemian@yahoo.com (K. Hashemian),
mpaivastegar@alzahra.ac.ir (M. Paivastegar).

https://doi.org/10.1016/j.ctcp.2020.101122
Received 14 September 2019; Received in revised form 26 January 2020; Accepted 20 February 2020
Available online 22 February 2020
1744-3881/© 2020 Elsevier Ltd. All rights reserved.
M. Orvati Aziz et al. Complementary Therapies in Clinical Practice 39 (2020) 101122

simply by integrating these two approaches. Examining carefully the relationship between psychoanalysis and
Generalized anxiety disorder is characterized by persistent and learning theory, Marmor (1969, 1971) concluded that all psychother­
excessive distress and worries about various things, including job per­ apies include fundamental principles of learning, and these two ap­
formance and academic achievement that one finds difficult to control. proaches should be regarded as complementary views about human
In addition, the person experiences physical symptoms that include functioning, not competing ones [12].
restlessness, nervousness, being easily fatigued, difficulty in concen­ It is not the first effort to integrate different approaches, as some
trating or mind going blank, irritability, muscle tension, and sleep attempts, including Lawson’s research, have been made in this field and
disturbance [4]. There is a high comorbidity of generalized anxiety in relation to such theories as the communication theory. However, to
disorder with social anxiety, depression, bipolar, and some personality the best of our knowledge, there has been no attempt to integrate the
disorders. In clinical settings, it has been reported that 55–60% of those short-term or long-term psychodynamic psychotherapy with cognitive-
diagnosed with this disorder were female. It is slightly more common in behavioral therapy. Although no fixed and established list of common
women than men and the median age of its onset is about 30 years. It is factors across different psychotherapy approaches exists, but there is
unlikely for people with generalized anxiety disorder to be recovered consensus that such a list would include the therapeutic alliance, ther­
spontaneously, and it becomes chronic if not treated [1,4,5]. The psy­ apist and client expectations of positive change, beneficial therapist
chodynamic psychotherapy is characterized by the discovery of the as­ qualities such as attention, empathy and positive regard, providing logic
pects of self that have remained unknown. Evidence suggests that the for the client problems, and the use of systematic therapeutic proced­
benefits of psychodynamic psychotherapy are lasting and sustainable ures. But still there are discrepancies in the case formulation, over­
and go far beyond the symptom remission [6]. Psychodynamic psy­ coming the patient’s resistance, the ways of exposure, and the rate of
chotherapy can include both long-term and short-term treatments. The attention to the index of transition between the two approaches [3,
short-term treatment is generally time-limited and needs 16–30 sessions 12–15].
on average; although a range of 7–40 sessions has been reported [3,7]. As stated earlier, attempts have been made to integrate different
Generalized anxiety disorder is caused by weakening or disintegra­ approaches. On the one hand, the integration of cognitive therapy with
tion of defense mechanisms. The constant experience of high levels of psychoanalysis and that of psychoanalysis with behavioral therapy
anxiety, lack of failure experiences, and new sources of anxiety in indicate that not only integration is not an emerging action in the field of
everyday life are the main causes of this consequence. If a person is treatment, but also it is theoretically and practically feasible. On the
constantly punished for expressing the drives of the id, his/her anxiety other hand, the discrepancies between various schools of psychotherapy
will be continuously high. As a result, his/her defense mechanisms has been more about techniques rather than basics to the extent that it
would become unable to cope with those levels of anxiety, which would can be said that all approaches express one word in a variety of ways [6].
inevitably cause the disintegration of defense mechanisms [8]. Differences in techniques are common and inevitable; as such differ­
Cognitive-behavioral therapy usually formulates and individualizes ences can be seen even among the therapists of a school. In contrast with
time-limited therapy goals, and aims to directly target symptoms, reduce differences in techniques, other differences can be expressed in an in­
distress, re-evaluate thinking and promote constructive behavioral re­ tegrated form, because there are no conflicts preventing them from
sponses. The treatment mainly focuses on “here and now”. Generally being used simultaneously. For example, none of the psychotherapy
speaking, cognitive-behavioral therapy is one of the shortest psycho­ schools deny the effect of people’s past and their experiences on the
therapies in time. The duration of cognitive-behavioral therapy usually formation of behaviors or feelings. Even the behavioral therapy that
ranges from 10 to 20 sessions, which varies based on patient comor­ focuses on “here and now” and the influence of learning on behavior,
bidity, pre-defined treatment goals and the specific conditions of the acknowledges the fact that learning has already happened and its effects
health care system [3]. can be seen in the form of behavior. Wachtel (1977–1997) showed in his
Cognitive models of emotional disorders are based on this belief that theoretical approach that the behaviorism and psychoanalysis could be
events are not solely responsible for causing negative emotions such as integrated. In fact, none of the schools ignore the importance of this
anxiety or sadness, and it is the people’s expectations from and in­ possibility, and the only difference is in the level of importance they
terpretations of those events which causes those negative effects. Ac­ attach to it. The existence of a concept called schema in the
cording to Beck, people with chronic anxiety have beliefs and cognitive-behavioral therapy that was developed later by Young reflects
assumptions based on which consider a wide range of situations the importance of the past in cognitive-behavioral therapy and its effects
threatening. When generalized anxiety occurs in someone, changes in on irrational beliefs, cognitive errors and disorder. Moreover, a tech­
concentration and behavior contribute to the continuity (and even nique like homework has no contradiction with psychodynamic psy­
aggravation) of the problem. People with generalized anxiety do not chotherapy and can be used along with its techniques to make
consistently avoid particular external situations, but often avoid them in behavioral changes. The insights gained at the treatment session affect
more delicate and unstable ways which makes negative beliefs firmer [5, the thinking process of the client. They are carried out of the treatment
9–11]. session and offer more depth in the client’s insights. In the same way,
According to London (1964 as cited in Stricker39) only two ap­ one of the techniques used by the cognitive-behavioral therapy to in­
proaches to treatment of generalized anxiety disorders can be distin­ crease people’s knowledge of the cause of behavior and problem is the
guished: action-oriented and insight-oriented approaches, which can be follow-up questions, used to refine the client’s cognition and identify
integrated effectively. Most of the names referring to the action-oriented his/her cognitive distortions. In fact, it is somehow the same resistance
approach, such as behavioral therapy, encourage clients to act and and defense mechanisms introduced in the psychodynamic psycho­
change their behaviors, while the insight-oriented approach, such as therapy and psychoanalysis, as Beck himself acknowledged [13]. The
psychodynamic psychotherapy, seeks to discuss topics of concern to principles of psychodynamic psychotherapy such as resistance, trans­
raise awareness, and the point that is always evident is that the most ference, interpretation and exposure can be found in all therapies,
effective and lasting therapeutic changes require an increase in including cognitive-behavioral therapy, and this is a fact that cannot be
perception and behavioral change. In the same vein, Frank (1961) denied. This is the reason why this study tries to use a method for the
claimed that all approaches to psychotherapy were based on similar treatment of mental disorders based on the above-mentioned facts: a
principles and the second approach was in fact an attempt to translate a method that simultaneously includes the stability of psychodynamic
therapeutic language, usually psychoanalysis, into another language, psychotherapies and the effectiveness of cognitive-behavioral therapies
usually the learning theory. This view reached its climax in the work of [3,16–18].
Dollard and Miller (1950) who claimed that the major difference be­ To prepare a model for the integration, the six-factor model of
tween approaches has a linguistic rather than intrinsic nature. Saunders (2008) and the eight-factor model of Lawson (2012) were

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M. Orvati Aziz et al. Complementary Therapies in Clinical Practice 39 (2020) 101122

employed: independent of any one of these three periods, since the process of
mutual influence can be transferred from time to time. The schematic
1) Teaching cognitive-behavioral skills to enhance performance. diagram of this model has been presented in Fig. 1.
2) Penetrating in the resistance pattern by challenging cognitive dis­ To date, research on the efficacy of the two techniques has been
tortions and defense mechanisms. conducted separately. Some studies in the field of cognitive-behavioral
3) Reconstructing cognitive distortions and defense mechanisms that therapy, including Mahdi et al. (2015), Borza (2017) [19], Kishita and
lead to negative emotions. Laidlaw (2017) [20], Sharma, Mehta, and Sagar (2016) [21], Hall et al.
4) Making cognitive-behavioral interventions to increase the general­ (2016) [22], Cuijpers et al. (2014) [23], Fonzo et al. (2014) [24], and
izability of treatment out of the treatment setting. Mahoney et al. (2016) [25], have shown that cognitive-behavioral
5) Identifying the transference pattern of the client in relation to the therapy is effective in the treatment of generalized anxiety disorder.
therapist and other people in his/her life. Some studies in the field of psychodynamic psychology, including
6) Making Trauma-related interventions that target post-trauma Lilliengren et al. (2017) [26], Monti, Tonetti, & Ricci Bitti, (2014) [27],
symptoms. Salzer et al. (2011) [28], Keefe et al. (2014) [29], and Leichsenring et al.
7) Modifying affective, communicative, and emotional experiences. (2009) [30] have demonstrated the efficacy of psychodynamic psy­
8) Investigating reactions, summarizing them, and receiving feedback. chology in the treatment of generalized anxiety disorder.
Accordingly, research conducted on cognitive-behavioral therapy
The Hazlett-Stevens protocol was employed for the preparation of indicates the efficacy of this technique in the treatment of mood and
the treatment protocol in this research, which consisted of 15 sessions. anxiety disorders. However, there is evidence suggesting that the effects
The overall structure of the integrative sessions included reviewing, of cognitive-behavioral therapy will not last forever and the symptoms
challenging, determining the strategy and assignments, summarizing, return after a while. There is also evidence that psychodynamic psy­
and receiving feedback. chotherapy has a longer-term effect than cognitive-behavioral therapy.
The structure of the cognitive-behavioral sessions has been as fol­ Experiences in the past play a significant role in the process of formation
lows: setting the agenda, making the patient aware of the latest infor­ and treatment of the disorder and their effects cannot be ignored un­
mation, reviewing assignments and particular strategies of cognitive- doubtedly. Therefore, those experiences should be considered and
behavioral therapy, assigning homework and assessing reactions to treated in the process of treatment. Additionally, to the best of our
the sessions. knowledge, no research was conducted on the integration of the two
The authors derived their initial model of treatment from short-term techniques up to the time of conducting the research. Therefore,
psychodynamic psychotherapy and cognitive-behavioral approaches. considering the above-mentioned facts shows the importance and ne­
The integrative model (cognitive-behavioral and psychodynamic model) cessity of this research. This research is an effort to answer the question
has tried to address the factors created in the past such as cognitive of whether the integration of the two techniques is effective in the
errors, behavioral patterns and past experiences by unlocking the un­ treatment of the disorders or not.
conscious, gaining insight and modifying the behaviors and thoughts in
the present. However, those affected by past experiences lack the skills 2. Methodology
needed to o their problems. The initial problem can be overcome, and
the ego can become more powerful only by creation of insight and A pre-test/post-test experimental research method is used in the
modification of behaviors and thoughts. present study. The statistical population in this research consisted of 36
Therefore, there is a need for learning new skills which in turn people with anxiety disorder. The subjects were evaluated according to
strengthens the ego and the individual self-efficacy. In all of these stages, Clinical Diagnostic Interview based on DSM5 diagnostic criteria, psy­
the past, present and future influence each other. This influence is chiatrist diagnosis, Hamilton Rating Scale for Anxiety (HRSA). Because

Fig. 1. Integrated treatment model.

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M. Orvati Aziz et al. Complementary Therapies in Clinical Practice 39 (2020) 101122

of high comorbidity of generalized anxiety disorder with depression, Table 1

Beck Depression Inventory was used for differential diagnosis. In the The guideline for cognitive-behavioral therapy.
case of depression, it is determined whether it was of primary or sec­ Session (1) Assessment: DSM interview, Beck Anxiety Inventory, and Beck
ondary type, and those with a primary depression were excluded from Depression Inventory;
the sample studied. Ultimately, 36 people were selected using a pur­ Behavioral interventions: psychological training, normalization of
concern
posive non-probabilistic sampling method based on the above-
Homework: worksheet (1)
mentioned screening method. They were divided randomly into three Session (2) Assessment: Reviewing assignments, the client status
groups with 12 people in each: integrative therapy, cognitive-behavioral Behavioral interventions: exercise, treatment of insomnia if
therapy, and control group. The inclusion criteria for selecting subjects necessary, scheduling think-time
were the presence of DSM-5 diagnostic criteria for generalized anxiety, Cognitive interventions: identifying areas of concern and anxious
thoughts
psychiatrist diagnosis, the score higher than mean in Hamilton Anxiety
Homework: worksheet (1)
Rating Scale (HRSA) and the presence of secondary depression. The Session (3) Assessment: Reviewing assignments, the client status
study subjects ranged in age from 18 to 35 years. The exclusion criteria Behavioral interventions: exercise, mindfulness
were the absence of DSM-5 diagnostic criteria for generalized anxiety Cognitive interventions: identifying areas of concern and anxious
thoughts, and challenging negative automatic thoughts Homework:
and the presence of primary depression.
worksheet (1)
For each person in test groups (integrative therapy and cognitive- Session (4) Assessment: Reviewing assignments, the client status
behavioral therapy groups), the process of treatment, the number of Behavioral interventions: teaching self-assertiveness and
sessions, and any other essential information were explained and their communication skills
informed consent was obtained. For the people with secondary depres­ Cognitive interventions: identifying and challenging negative
automatic thoughts, creating alternative interpretations or predictions
sion caused by generalized anxiety, the treatment of generalized anxiety
Homework: worksheet (2), practicing learned skills
started only after finalizing the treatment of depression. Session (5) Assessment: Reviewing assignments, the client status
The treatment process in each test group included a 15-session pro­ Behavioral interventions: reward management, scheduling activities
tocol consisting of individual treatment for every 12 people in each to monitor feelings of pleasure, mastery, and anxiety, resolving
conflicts
group. Each of the subjects was assessed at the beginning and the end of
Cognitive interventions: identifying and challenging negative
the treatment. The control group was also assessed twice with a distance automatic thoughts, creating alternative interpretations or
of three to four months according to the time length of the treatment, predictions, using acceptance and metacognitive strategies
except that no therapeutic measure was taken for the control group. The Homework: worksheet (2), practicing reward management/
research process lasted three years. The guidelines for both treatment scheduling activities
Session (6) Assessment: Reviewing assignments, the client status
techniques have been presented in Tables 1 and 2.
Behavioral interventions: investigating the resources of stress in the
patient’s life, generalizing mindfulness to new situations
2.1. Data collection method Cognitive interventions: identifying inefficient basic assumptions
(downward arrow)
Homework: worksheet (2), practicing learned skills
Hamilton Rating Scale for Anxiety (HRSA): It was developed by Max
Session (7) Assessment: Reviewing assignments, the client status
Hamilton in 1959. The inventory includes 14 items defined by a series of Behavioral interventions: teaching problem-solving skills
symptoms, and measures both psychic anxiety and somatic anxiety. Cognitive interventions: continuing the identification of inefficient
Research on the test of this inventory on an Iranian sample showed a basic assumptions, distinguishing the probability of occurrence, the
correlation coefficient of 0.75 and test-retest reliability of 0.81 [31]. possibility of occurrence, and reasonableness
Homework: worksheet (2), practicing learned skills
Beck Depression Inventory: it is a 21-question self-report inventory. Session (8) Assessment: Reviewing assignments, the client status
Each of its items includes 4 phrases and each phrase is given a score from Behavioral interventions: Helping to exposure avoided situations
0 to 3, from which the client selects one. In the study by Ghasemzadeh Cognitive interventions: identifying and challenging inefficient basic
(2005), the reliability coefficient of the overall inventory and its test- assumptions, predicting the most terrible phobia of the patient, mental
imagery
retest reliability coefficient have been reported to be 0.87 and 0.74
Homework: worksheet (2), practicing learned skills and exposure
respectively [35]. Session (9) Assessment: Reviewing assignments, the client status
Behavioral interventions: teaching anger management skills (if
3. Results necessary), continuing exposure
Cognitive interventions: continuing the identification of inefficient
basic assumptions, creating a new view, clarifying the relationship
The results of the Shapiro-Wilk test for test groups and control group between the concern and schemas
indicated that the significance level for all variables in all three groups Homework: worksheet (2), practicing learned skills
was less than (0.05) (P < 0.05). Therefore, the null hypothesis and Session Assessment: Reviewing assignments, the client status
consequently, the normal distribution of the variables were confirmed (10) Behavioral interventions: Behavioral change in lifestyle, exposure
Cognitive interventions: Identifying and modifying maladaptive
with a confidence level of 95%.
personal schemas
Data on baseline characteristics of the groups are presented in Homework: worksheet (3), practicing learned skills
Table 3. Session Assessment: Reviewing assignments, the client status
Descriptive indicators for all three treatment groups are presented in (11) Behavioral interventions: Behavioral change in lifestyle, self-efficacy
Table 4. skill
Cognitive interventions: Identifying and modifying maladaptive
First hypothesis: Cognitive-behavioral therapy is effective in personal schemas
reducing the symptoms of generalized anxiety. The descriptive in­ Homework: worksheet (3), practicing learned skills
dicators of the study variables were investigated. The mean of the Session Assessment: Reviewing assignments, the client status
cognitive-behavioral therapy group (M ¼ 10.67) was lower than that of (12) Behavioral interventions: Devil’s advocacy technique
Cognitive interventions: Identifying and modifying maladaptive
the control group (M ¼ 29.75). To evaluate the assumption of homo­
personal schemas
geneity of variances, Levene’s test was carried out. The Levene’s test Homework: worksheet (3), practicing learned skills, behavioral
showed p ¼ 0.229 which shows a significance level higher than p ¼ 0.05, experiment
indicating the homogeneity of variances of the variables. In the Session Assessment: Reviewing assignments, the client status
assumption of homogeneity of regression slopes, F(1,20) ¼ 2.510 was not (13) Cognitive interventions: Identifying and modifying maladaptive
personal schemas, investigating worrying metacognitive beliefs,
statistically significant (P ¼ 0.129) with a confidence level of 95% and
(continued on next page)
therefore, the regression slopes were homogeneous.

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M. Orvati Aziz et al. Complementary Therapies in Clinical Practice 39 (2020) 101122

Table 1 (continued ) Table 2

identifying beliefs related to failure and solving them
The guideline for integrative therapy (short-term psychodynamic psychotherapy
Homework: worksheet (3), practicing learned skills and cognitive-behavioral therapy).
Session Assessment: Reviewing assignments, the client status Session (1) Assessment: (Psychodynamic interview, Beck Anxiety Inventory, and
(14) Behavioral interventions: completing gradually treatment, Beck Depression Inventory), identifying developmental stages, the
determining long-term and short-term goals affected person’s needs, defense mechanisms, anxious thoughts,
Cognitive interventions: creating new assumptions and schemas, and neurotic style, identifications, problem background
effective assumptions Homework: recording anxious thoughts and situations, exercise
Homework: worksheet (3), implementing self-designed assignments Session (2) Assessment: following up, reviewing
to cope with future problems Psychodynamic techniques: identifying anxious thoughts, schemas,
Session Assessment: Reviewing assignments, the client status resistance and defense mechanisms Summarizing and receiving
(15) Behavioral interventions: completing gradually treatment, feedback
identifying effective behavioral techniques to cope with possible future Homework: recording anxious thoughts and situations, exercise
problems Session (3) Assessment: following up, reviewing
Cognitive interventions: reviewing learned skills and practicing Psychodynamic techniques: identifying anxious thoughts, schemas,
them resistance and defense mechanisms
Homework: practicing learned skills Solution: mindfulness, abdominal breathing, Summarizing and
receiving feedback
Homework: recording anxious thoughts and situations, exercising,
After analyzing the Analysis of Covariance (ANCOVA) assumptions, practicing the skill
this hypothesis was analyzed by analysis of variance (ANOVA). Ac­ Session (4) Assessment: following up, reviewing
cording to the results from Table 5, after adjusting the pre-test effect Psychodynamic techniques: identifying and challenging anxious
thoughts, schemas, resistance and defense mechanisms
with F(1,22) ¼ 39.896, the value obtained was statistically significant (P Solution: mindfulness, abdominal breathing, creating alternative
¼ 0.0001). The change in the mean of the anxiety variable indicated that interpretations
the cognitive-behavioral therapy affected the reduction of anxiety in Summarizing and receiving feedback
subjects in the experimental group. This effect was shown to be about Homework: recording anxious thoughts and situations, exercising,
practicing the skill
64%.
Session (5) Assessment: following up, reviewing
Second hypothesis: Integrative therapy (cognitive-behavioral ther­ Psychodynamic techniques: identifying and challenging anxious
apy and psychodynamic therapy) is effective in reducing the symptoms thoughts, schemas, resistance and defense mechanisms Solution:
of generalized anxiety. The descriptive indicators of the study variables creating alternative interpretations
were investigated. The mean of the integrative therapy group (M ¼ 7) Summarizing and receiving feedback
Homework: recording anxious thoughts and situations, exercising,
was lower than that of the control group (M ¼ 29.75). To evaluate the practicing the skill
assumption of homogeneity of variances, Levene’s test was carried out. Session (6) Assessment: following up, reviewing
The Levene’s test showed p ¼ 0.084 which shows a significance level Psychodynamic techniques: identifying and challenging schemas,
higher than p ¼ 0.05, indicating the homogeneity of variances of the resistance and defense mechanisms, visualizing
Solution: investigating evidence and probabilities, profit and loss,
variables. In the assumption of homogeneity of regression slopes, F(1,20)
accepting the past and living in the present, Summarizing and
¼ 2.413 was not statistically significant (P ¼ 0.136) with a confidence receiving feedback
level of 95% and therefore, the regression slopes were homogeneous. Homework: recording anxious thoughts and situations, exercising,
After analyzing the Analysis of Covariance (ANCOVA) assumptions, practicing the skill
this hypothesis was analyzed by analysis of variance (ANOVA). Ac­ Session (7) Assessment: following up, reviewing
Psychodynamic techniques: identifying and challenging schemas,
cording to the results from Table 6, after adjusting the pre-test effect resistance and defense mechanisms, identifying the basis of avoidance
with F(1,22) ¼ 79.343, the value obtained was statistically significant (P behaviors, exposure to them
¼ 0.0001). The change in the mean of the anxiety variable indicated that Solution: mental imagery (downward arrow),
the integrative therapy affected the reduction of anxiety in subjects in Summarizing and receiving feedback
Homework: recording anxious thoughts and situations, exercising,
the experimental group. This effect was shown to be about 79%.
practicing the skill (exposure, behavioral experiment)
Third hypothesis: integrative therapy is more effective in reducing Session (8) Assessment: following up, reviewing
the symptoms of generalized anxiety than cognitive-behavioral therapy Psychodynamic techniques: identifying and challenging schemas,
alone. The descriptive indicators of the study variables were investi­ resistance and defense mechanisms
gated. The mean of the integrative therapy group (M ¼ 7) was lower Solution: exposure, the practice of confrontation, behavioral
experiment,
than that of the cognitive-behavioral therapy group (M ¼ 10.67). To Summarizing and receiving feedback
evaluate the assumption of homogeneity of variances, Levene’s test was Homework: recording anxious thoughts and situations, exercising,
carried out. The Levene’s test showed p ¼ 0.147 which shows a signif­ practicing the skill
icance level higher than p ¼ 0.05, indicating the homogeneity of vari­ Session (9) Assessment: following up, reviewing
Psychodynamic techniques: identifying and challenging schemas,
ances of the variables. In the assumption of homogeneity of regression
resistance and defense mechanisms
slopes, F(1,20) ¼ 0.081 was not statistically significant (P ¼ 0.779) with a Solution: creating new views, self-assertiveness skill, Summarizing
confidence level of 95% and therefore, the regression slopes were and receiving feedback
homogeneous. Homework: recording anxious thoughts and situations, exercising,
After analyzing the Analysis of Covariance (ANCOVA) assumptions, practicing the skill
Session Assessment: following up, reviewing
this hypothesis was analyzed by analysis of variance (ANOVA). Ac­
(10) Psychodynamic techniques: identifying and challenging schemas,
cording to the results from Table 7, after adjusting the pre-test effect resistance and defense mechanisms
with F(1,22) ¼ 4.543, the value obtained was statistically significant (P ¼ Solution: creating new views, problem-solving skill, Summarizing
0.044) with a confidence level of 95% (P < 0.05). There was a difference and receiving feedback
Homework: recording anxious thoughts and situations, exercising,
between the means of the two treatment techniques in the anxiety
practicing the skill
variable, which was statistically significant. Therefore, it can be Session Assessment: following up, reviewing
concluded that the integrative therapy was more effective in reducing (11) Psychodynamic techniques: identifying and challenging schemas,
anxiety than cognitive-behavioral therapy alone. resistance and defense mechanisms Solution: behavioral change in the
lifestyle, self-efficacy skill,
Summarizing and receiving feedback
(continued on next page)

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Table 2 (continued ) Table 6

Homework: recording anxious thoughts and situations, exercising,
Analysis of covariance to assess the effect of integrative therapy on reducing
practicing the skill anxiety.
Session Assessment: following up, reviewing Source Sum of df Mean F Sig Partial Eta
(12) Psychodynamic techniques: identifying and challenging schemas, Ssquares Square Squared
resistance and defense mechanisms Solution: Devil’s advocacy
technique, Anxiety. 201.700 1 201.700 4.854 0.039 0.188
Summarizing and receiving feedback pre
Homework: recording anxious thoughts and situations, exercising, group 3296.718 1 3296.718 79.343 0.0001 0.791
practicing the skill Error 872.550 21 41.550
Session Assessment: following up, reviewing Total 12283.000 24
(13) Psychodynamic techniques: identifying and challenging schemas,
resistance and defense mechanisms
Solution: modifying fundamental schemas and beliefs, creating new
behaviors Table 7
Summarizing and receiving feedback Analysis of Variances to assess the effect of integrative therapy and cognitive-
Homework: recording anxious thoughts and situations, exercising, behavioral therapy on reducing anxiety.
practicing new behaviors
Source Sum of df Mean F Sig Partial Eta
Session Assessment: following up, reviewing
Squares Square Squared
(14) Psychodynamic techniques: identifying and challenging schemas,
resistance and defense mechanisms Solution: practicing learned skills, group 80.667 1 80.667 4.543 0.044 0.171
Devil’s advocacy technique Error 390.667 22 17.758
Summarizing and receiving feedback Homework: practicing new Total 2344.000 24
behaviors and skills
Session Assessment: following up, reviewing
(15) Psychodynamic techniques: identifying and challenging schemas, effective than cognitive-behavioral therapy.
resistance and defense mechanisms, completing the treatment, It was shown that cognitive-behavioral therapy was effective in the
reviewing the learned skills and practicing them
treatment of generalized anxiety disorder, which is consistent with the
results of Borza (2017) [20], Fonzo et al. (2014) [24], Kishita and
Laidlaw (2017) [20], Mahoney et al. (2016) [25], Sharma et al. (2016)
Table 3 [21], Mahdi et al. (2015) [33], Cuijpers (2014) and [23] Stefan et al.
Baseline characteristics of the groups.
(2019) [34].
cognitive Integrative control To explain this result, it can be stated that cognitive-behavioral
behavioral therapy group therapy is a brief and structured kind of psychotherapy. Its supportive
Gender Female 75% 91.7% 83.3% context and techniques are associated with a collaborative therapeutic
Man 25% 8.3% 16.7% stance and as such it focuses on the key role of cognition and behavior in
Education Associate 16.6% 16.7% 25%
appearance and maintenance of mental diseases. The fundamental
Degree
Bachelor’s 66.6% 66.6% 53.3% assumption of this therapeutic approach is that maladaptive cognitions
degree contribute to the maintenance of behavioral problems and emotional
Master’s 16.6% 16.7% 16.7% disorders. The primary model assumes that therapeutic strategies lead to
Degree changes in emotional disturbances and behavioral problems by chang­
ing these maladaptive cognitions. Clients and therapists work together
on feelings, thoughts, and behavior by focusing on the present situation.
Table 4 Obtaining skills and assigning homework are among the cases that
Mean � Standard deviation of Anxiety and Age. distinguish cognitive-behavioral therapy from conversation-based
group Anxiety-pre Anxiety-pos Age therapies [30,32,35–37].
cognitive-behavioral 30.67 � 8.46 10.67 � 4.87 24.83 � 0.04 Worry, as the core component of all anxiety disorders, is a cognitive
integrative 36.67 � 8.92 7 � 3.44 24.92 � 5.25 activity. It is considered as the main symptom of generalized anxiety
Control 31 � 9.81 29.75 � 9.26 24.42 � 3.68 disorder. People diagnosed with generalized anxiety disorder suffer
from excessive worry [38]. Various cognitive-behavioral models
emphasize the fact that anxious people exaggerate negative events,
Table 5 neglect base rates, suffer from perfectionism and seek to be confirmed.
Analysis of Variances to assess the effect of cognitive-behavioral therapy on They are less likely to tolerate ambiguity and uncertainty [13].
reducing anxiety. Cognitive-Behavioral therapy is an effective and excellent thera­
Source Sum of df Mean F Sig Partial Eta peutic approach to change pathological worries to natural worries. It is
Squares Square Squared widely used to treat generalized anxiety disorder. However, there are
group 2185.042 1 2185.042 39.896 0.0001 0.645
still a large number of people who do not respond to this treatment [19,
Error 1204.917 22 54.769 24].
Total 13191.000 24 The results of this study demonstrated that integrative therapy was
effective in the treatment of generalized anxiety disorder. To the best of
our knowledge, up to the time of writing this article, no research has
4. Discussion and conclusion
been conducted on this subject. However, the results are consistent with
Keefe et al. (2014) [29], Salzer et al. (2011) [28], Lawson et al. (2013)
The purpose of this study was to compare the efficacy of integrative
[16], Lilliengren et al. (2017) [26], who investigated the efficacy of
therapy (a combination of short-term psychodynamic psychotherapy
psychodynamic psychotherapy and cognitive-behavioral therapy.
and cognitive-behavioral therapy) to that of cognitive-behavioral ther­
Gold and Stricker (2001) presented an assimilative model of inte­
apy in the treatment of generalized anxiety disorder. The results of the
gration using cognitive, behavioral, experiential, and other techniques
analysis of covariance (ANCOVA) and analysis of variance (ANOVA)
within a relational psychodynamic model. Active and exploratory
indicated that both types of therapy were effective in the treatment of
techniques may complement one another and allow for more mean­
generalized anxiety disorder. However, integrative therapy was more
ingful work within the session. An integrative approach is often

6
M. Orvati Aziz et al. Complementary Therapies in Clinical Practice 39 (2020) 101122

recommended to intervene at multiple levels of functioning. This inte­ Statement of human rights
gration facilitates deeper experiences of personal growth and provides a
didactic structure for patients to target behavioral changes and develop Informed consent: In accordance with the terms and conditions of
effective problem-solving strategies. Gold and Stricker (2001, 2012) Iran, informed consent was obtained from all individual participants
argue that early integration and an assimilative use of active, cognitive- included in the study. For each person in two experimental groups, the
behavioral techniques within a psychodynamic framework often accel­ process of treatment, the number of sessions, and so on were explained
erate and strengthen the development of a positive therapeutic alliance and their informed consent was obtained.
[39]. I have trained in cognitive-behavioral therapy and short-term psy­
The original concentration of Gold and Stricker (2001, 1996) was on chodynamic psychotherapy in Iran and I have been working in these
the use of the short-term psychodynamic psychotherapy (STPP) model fields for 5 years.
to examine treatment outcomes in relation to integrated therapeutic
interventions. The integration of cognitive-behavioral techniques in the Declaration of competing interest
short-term psychodynamic psychotherapy model has been significantly
associated with positive treatment outcomes in some functional areas. The authors declare that they have no conflict of interest in this
By increasing the use of cognitive-behavioral techniques within a psy­ study. It is also notable that no funding was received.
chodynamic session (psychoeducation and increased therapist activity),
the therapists can ensure a stronger emphasis on obligatory aspects of References
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