Impact of Cognitive Behavior Therapy in Reducing Anxiety among Adult men and women

The effect of Cognitive Behavior Therapy intervention in reducing the magnitude of neurotic anxiety was examined in a select sample of 40 men and women in 55–60 years. Subjects with moderate levels of neuroticism were exposed to CBT. The CBT using a pre-post test design was found to be effective in reducing levels of neurotic anxiety. Neuroticism may be characterized by an enduring tendency to experience certain negative emotional states such as anxiety, worry, apprehension and a volatile sensitivity to stimuli. It can result in depression, anxiety, fear, guilt, ideas of self reference and destruction (Barlow, 2002; Craske, 1999). Though many pharmacological treatments for anxiety disorders exist, in the western literature cognitive – behavioral treatments for anxiety disorders per se was found to be effective (Barlow & Lehman, 1996). Dobson (1989) suggests that Cognitive therapy is found to be powerful and perhaps more effective for neurotic clients than behavior therapy, pharmacotherapy, and other psycho therapies. A series of studies on Cognitive and Behavioral treatments for Generalized Anxiety Disorder (GAD) adopted a variety of cognitive behavioral techniques including cognitive restructuring of “worry” thoughts, progressive relaxation training, and exposure to anxiogenic thoughts or situations that trigger such thoughts, and positive self-talk (eg., Chambless & Gills, 1993; Stanley, Beck & Glassco,1996. Cognitive behavioral therapy (CBT) has been demonstrated to be effective with younger adults too. Several randomized controlled trials have investigated and demonstrated that they clinically reduced symptoms of anxiety in group and individual CBT in late life (Stanley, Beck & Glassco, 1996; Stanley., Beck, Novy, Averill, Swann, Diefenbach, & Hopko, 2003). In a cognitive model of generalized anxiety disorder (GAD), Wells (1995) proposed that pathological worry is maintained by maladaptive meta cognitions (negative beliefs on worry concerning its uncontrollability and anger), negative appraisal of worry [meta worry] and linked behaviors (Wells & Carter, 2001). Persons with GAD were compared with sex-matched groups (social phobia, panic disorder) of non-patients on measures of negative meta cognitions and worry. It was found that clients with high GAD showed higher negative meta cognitive belief and higher meta worry scores. It suggests that differences in negative meta cognitions are independent of general frequency of worry (Norton & Price, 2007). Group cognitive behavior therapy for patients with social anxiety disorder demonstrated greater gains on behavioral measures (Chen, Yunu, Tetsuji, Sei, Tadashi, Norio, Yumiko, & Tosli, 2007). Butler (1993) and Butler and Anastasiades (1988) reported better outcome for less anxious and more depressed patients in behavior therapy and CBT. A positive relation to CBT treatment has observed for GAD in older people (Wetherell, Hopko, Diefenbach, Averill., Beck, Craske, Gatz, Novy, & Stanley, 2005). The aforementioned review of some relevant studies showed that Cognitive Behavior therapy was effective in reducing different types of anxiety symptoms in western context. As there is a paucity of research in this area on Indian sample, the present study has been contemplated with the following objective: (i) To examine the effect of Cognitive Behavior Therapy in strengthening the coping skills and feelings of control over the lives of people with anxiety. Sample, method and tools The total sample for the study (main sample) was 360 men and women from Chittoor and Nellore districts of Andhra Pradesh pursuing various formal jobs viz., school teachers, bank employees, college teachers, engineers and other administrative staff across the age groups of 25-60 years. . A sub sample of 40 subjects with moderate neuroticism levels in 55 to 60 years ( X = 57.2 yrs) were selected from the main sample of 360 men and women to constitute the intervention sample. They were randomly divided into Experimental group (N=20) with a mean age of 56.8 yrs and control group (N=20) with a mean age of 57.2 yrs and were matched on characteristics like gender, educational status, physical health and location. Intervention programme was carried out for four weeks for only the subjects in the experimental group and no such training for the control group subjects. Measures used: The sample characteristics were gathered through a Personal Data Form. Anxiety Scale was constructed afresh and standardized on Indian sample by drawing items from neuroticism scale and Generalized Anxiety tools (Gayathri, 2011) to measure neurotic anxiety (test – retest r = 0.89). The Cognitive – behavior intervention module was administered to the sample in the Experimental Group with a focus to correct people’s misconceptions, strengthen their coping skills and feelings of control over their own lives, and facilitate constructive self-talk or the things people typically say to themselves as they confront different types of situations ( Gayathri, 2011). In the cognitive behavior Intervention phase, the subject is systematically made to become aware of thoughts, beliefs and related situations and emotions with an objective to rationally identify the inaccuracies in thinking associated with the problem in question and made to challenge them. The focus was made to change the thoughts and beliefs suitably as needed for cognitive restructuring. The exercise was repeated until the behavior in question is replaced or extincted. On an average, the CBT intervention was carried out in four weeks over 16 sessions. Results and discussion The pre test was the base line total score in anxiety facet of neuroticism and post test score was the total score on anxiety

Though many pharmacological treatments for anxiety disorders exist, in the western literature cognitive -behavioral treatments for anxiety disorders per se was found to be effective (Barlow & Lehman, 1996). Dobson (1989) suggests that Cognitive therapy is found to be powerful and perhaps more effective for neurotic clients than behavior therapy, pharmacotherapy, and other psycho therapies. A series of studies on Cognitive and Behavioral treatments for Generalized Anxiety Disorder (GAD) adopted a variety of cognitive behavioral techniques including cognitive restructuring of "worry" thoughts, progressive relaxation training, and exposure to anxiogenic thoughts or situations that trigger such thoughts, and positive self-talk (eg., Chambless & Gills, 1993;Stanley, Beck & Glassco,1996. Cognitive behavioral therapy (CBT) has been demonstrated to be effective with younger adults too. Several randomized controlled trials have investigated and demonstrated that they clinically reduced symptoms of anxiety in group and individual CBT in late life (Stanley, Beck & Glassco, 1996;Stanley., Beck, Novy, Averill, Swann, Diefenbach, & Hopko, 2003). In a cognitive model of generalized anxiety disorder (GAD), Wells (1995) proposed that pathological worry is maintained by maladaptive meta cognitions (negative beliefs on worry concerning its uncontrollability and anger), negative appraisal of worry [meta worry] and linked behaviors (Wells & Carter, 2001). Persons with GAD were compared with sex-matched groups (social phobia, panic disorder) of non-patients on measures of negative meta cognitions and worry. It was found that clients with high GAD showed higher negative meta cognitive belief and higher meta worry scores. It suggests that differences in negative meta cognitions are independent of general frequency of worry (Norton & Price, 2007).
Group cognitive behavior therapy for patients with social anxiety disorder demonstrated greater gains on behavioral measures (Chen, Yunu, Tetsuji, Sei, Tadashi, Norio, Yumiko, & Tosli, 2007). Butler (1993) and Butler and Anastasiades (1988) reported better outcome for less anxious and more depressed patients in behavior therapy and CBT. A positive relation to CBT treatment has observed for GAD in older people (Wetherell, Hopko, Diefenbach, Averill., Beck, Craske, Gatz, Novy, & Stanley, 2005). The aforementioned review of some relevant studies showed that Cognitive Behavior therapy was effective in reducing different types of anxiety symptoms in western context. As there is a paucity of research in this area on Indian sample, the present study has been contemplated with the following objective: (i) To examine the effect of Cognitive Behavior Therapy in strengthening the coping skills and feelings of control over the lives of people with anxiety.

Sample, method and tools
The total sample for the study (main sample) was 360 men and women from Chittoor and Nellore districts of Andhra Pradesh pursuing various formal jobs viz., school teachers, bank employees, college teachers, engineers and other administrative staff across the age groups of 25-60 years. . A sub sample of 40 subjects with moderate neuroticism levels in 55 to 60 years ( X = 57.2 yrs) were selected from the main sample of 360 men and women to constitute the intervention sample. They were randomly divided into Experimental group (N=20) with a mean age of 56.8 yrs and control group (N=20) with a mean age of 57.2 yrs and were matched on characteristics like gender, educational status, physical health and location. Intervention programme was carried out for four weeks for only the subjects in the experimental group and no such training for the control group subjects.

Measures used:
The sample characteristics were gathered through a Personal Data Form. Anxiety Scale was constructed afresh and standardized on Indian sample by drawing items from neuroticism scale and Generalized Anxiety tools (Gayathri, 2011) to measure neurotic anxiety (test -retest r = 0.89).
The Cognitive -behavior intervention module was administered to the sample in the Experimental Group with a focus to correct people's misconceptions, strengthen their coping skills and feelings of control over their own lives, and facilitate constructive self-talk or the things people typically say to themselves as they confront different types of situations ( Gayathri, 2011).
In the cognitive behavior Intervention phase, the subject is systematically made to become aware of thoughts, beliefs and related situations and emotions with an objective to rationally identify the inaccuracies in thinking associated with the problem in question and made to challenge them. The focus was made to change the thoughts and beliefs suitably as needed for cognitive restructuring. The exercise was repeated until the behavior in question is replaced or extincted. On an average, the CBT intervention was carried out in four weeks over 16 sessions.

Results and discussion
The pre -test was the base line total score in anxiety facet of neuroticism and post test score was the total score on anxiety after exposing to interventions. The efficacy of intervention was tested by comparing the pre and post levels of anxiety in the sample of Experimental and Control groups (Table 1) and in the specific gender groups (Table 2). There is a significant reduction of neurotic anxiety in experimental group after exposing the sample to CBT. Findings of the present study are in concurrence with the earlier researches reported, especially in the reduction of behavioral manifestations of anxiety (Hooke & Page, 2002;Critis-Christoph, 2002). Suveg et al's (2009) study outcome suggest that cognitive-behavioral therapy can be effective in addressing some of the associated symptoms and adaptive functioning deficits typically linked to anxiety in young adults (Suveg, Jennifer, Brewer, Flaunerny, Elizabeth & Kendall, 2009). Studies that utilized a variety of cognitive behavioral techniques including cognitive restructuring of "worry" thoughts, progressive relaxation training, exposure to anxiogenic thoughts or situations that trigger, anxiety related thoughts and positive self talk and their results suggest that cognitive behavior therapy had a considerable impact on decreasing anxiety and worry (Dobson, 1989;Dobson et al, 1996;Beck et al., 1979). Thus the outcome of the present study strongly recommend the use of CBT in the reduction of manifestations of neurotic anxiety in the age group of 55 -60 yrs in the Indian context.  There is a significant difference was noticed (pre and post interventions) in gender groups, where female group scored higher than male group (Table II). Similar gender trends were observed in a study by Benjamin, Paul, Sorensen., & Jeffrey, (2007), where women scored higher than men on neuroticism. Jorm's (1987) study reported sex difference where females having higher scores and it also indicates that prevalence was greater in young and middle aged adults than in children or the very elderly. The magnitude of difference between pre and post intervention among female sample was higher. The gender difference has a special significance in traditional cultures like India. Especially, the gender discriminatory practices and socialization process impose certain restrictions on female gender to condition her behavioral dispositions. Being a woman, she is discriminated in many domains of life. It is quite obvious that with gender specific socializationfemininity and norms (irrespective of their age), she has to compromise with many situations and has to adapt to the conditions. In general, it is stated that females were having higher levels of neurotic anxiety than males, suggesting that this trait may be related to female gender.
This study especially in Indian context including those pertaining to the small tryout of intervention in a small sample have implications with regard to mental health policy related to neurotic anxiety among community living adults and health care providers in young and middle adulthood in India. Community Mental Health workers should also be motivated to carryout awareness camps on mental health care e.g., simple steps to overcome anxiety, worry and depression across the adulthood especially from middle age onwards. This will improve access to mental health care services at the community level. Regular mental health camps as part of community education or awareness programmes are necessary to ensure better mental health in adulthood.