July 23, 2016

Dear Colleagues,

As Dr. Milton Spett summarized in a listserv post on the NJ-ACT listserv:

“Adams et al. (the Behavior Therapist, April, 2015) report on their meta-analysis of behavior therapy alone vs. behavior therapy plus cognitive therapy for anxiety disorders. They conclude that there is no evidence that adding cognitive interventions increases the effectiveness of behavior therapy alone. Many other studies, including studies of depression, have drawn the same conclusion. Several authors have argued that it is therefore more efficient to only provide behavior therapy.

“Effect Sizes for Treatment of Anxiety Disorders (Adams et al. 2015 study)



BT Alone


“And yet some studies have found that cognitive plus behavioral interventions are more effective than behavioral interventions alone. In addition, I have treated three OCD patients who did not benefit or only partially benefitted from behavior therapy (exposure and response prevention), but their OCD symptoms completely remitted after adding cognitive interventions or after substituting cognitive interventions for ERP. How can this be?

“One possibility is that most therapy research studies utilize only 8 to 20 sessions, and it takes longer for cognitive interventions to become maximally effective. If the treatments cited in this meta-analysis had continued longer, the advantage of BT + CT over BT alone may have become larger and statistically significant.”

And the commentary about the research (as follows) is posted by myself, as a representative of the National Social Anxiety Center (NSAC):

I wish highlight that social anxiety disorder appears to be an exception– in other words, working on the cognitive level and not just the behavioral level is crucial in overcoming social anxiety. A HUGE meta-analysis of social anxiety outcome studies conducted a year and a half ago and published in Lancet demonstrated that David Clark’s model of CBT for social anxiety is by far the most effective treatment for SA: much more than exposure therapy alone, medication or anything else studied. (Clarke’s individual CBT model was also demonstrated to be more effective than Heimberg’s group CBT for social anxiety model, although the latter was still as effective as meds, and more effective than exposure therapy alone.)

Here’s a link to that study’s abstract, from which you can get to the whole article and to illustrations.  Here’s a link to the chart that lists all the specific treatments that were studied and their effect sizes.

So possibly social anxiety is the exception to the rule that behavior therapy is as effective as CBT for anxiety disorders. Your thoughts?

Noah Clyman, LCSW-R, ACT
Clinical Director of NSAC New York City (NYC Cognitive Therapy)