Effectiveness of Autonomy-Groups in Patients with Anxiety Disorders: A RCT

Concept of Autonomy (-Connectedness)
In Western culture, autonomy is considered to be a successful and healthy
outcome of the process of becoming an adult person. In that case, the process
covers good attachment experiences in early childhood, and the person acquires
the capacity of maintaining a good balance between dependence and separation
(e.g., Bowlby, 1969; 1973; Mahler, Pine & Bergman, 1975). The modern concept of
autonomy contains both the awareness of one*s goals, wishes and needs and the
ability to realize these, and the capacity to start and maintain meaningful
social relationships. As the ability to maintain relationships is also labeled
**connectedness**, the term **autonomy-connectedness** is a more adequate and
complete term for what the concept refers to (Bekker & van Assen, 2006).
Autonomy-connectedness has three components. The first one is Self-Awareness,
defined as the capacity to be aware of one*s own opinions, wishes, and needs,
and the capacity to express these in social interactions. The second component,
Sensitivity to Others, is the sensitivity to the opinions, wishes, and needs of
other people; empathy; and capacity and need for intimacy and separation. The
third component, Capacity for Managing New Situation, stands for (un)-easy
feeling in new situations, flexibility, tendency to explore, and dependence on
familiar structures (Bekker & van Assen, 2006). From the attachment theory
perspective, this drive for exploration follows from secure attachment.

Autonomy-connectedness is related to attachment-styles, gender, and several
mental disorders
Autonomy development is based on experiences with attachment-figures, started
from early childhood (Bekker, 1993; 2008). In short, two styles can be
distinguished: secure and insecure attachment. A secure attachment style
results from good and positive interpersonal experiences. The child experienced
availability and adequate responses from the primary attachment figure when
needed. Insecure attachment is a result of negative interpersonal experiences,
in which the child did not experience consistent availability and adequate
responses from the primary attachment-figure.
Autonomy problems are related to insecure attachment styles, such as avoidant
and anxious attachment (e.g., Bekker, Bachrach & Croon, 2007). In the case of
avoidant attachment, a relatively low self-awareness coincides with extreme low
sensitivity to others, and in the case of anxious attachment, low
self-awareness goes together with extremely high sensitivity to others.
Insecure attachment and autonomy problems as well as their sex differences are
clinically relevant. Although relatively high levels of sensitivity to others
might belong to the normal feminine identity, extremely high sensitivity to
others reflecting neediness (Rude & Burnham, 1993) is a risk factor for
psychopathology with a higher prevalence in women than in men, e.g., depression
and anxiety (Bekker & Belt, 2006; Bekker & Croon, 2010) and eating disorders
(Van Loenhout, Bekker, & Kuipers, under review). In a similar way,
under-sensitivity to others might substantially affect psychopathology with a
higher prevalence in men. For example, antisocial behaviour might be affected
by extreme tendencies toward detachment and separation, i.e., by
under-sensitivity to others, especially to potential victims (e.g., Bekker,
Bachrach & Croon, 2007; Hoffmann, Powlishta, & White, 2004).

Autonomy-connectedness and mental health care: The need for empirical support
Practice-based evidence shows that autonomy deficits are related with mental
disorders, particularly those characterized by oversensitivity to others, with
a higher prevalence among women (e.g., anxiety disorders, depression, and
eating-disorders). Consequently, AGs were provided as a therapy, in the
Netherlands from 1970, to women with autonomy problems. Also here, autonomy
problems were usually defined as problems with (a) one*s self-awareness or
identity; (b) the ability to set and/or express boundaries to others; (c) one*s
over-sensitivity and/or over-responsibility to others; and (d) decision making
(Bekker, 1993; 2008).
The therapeutic results of these AGs are generally considered very promising,
but up till now, only one pilot study (van Houten & Vossen, 2008) has been
conducted that focused on the effect of autonomygroups. It appeared that AG
with patients with severe anxiety-disorders who had insufficiently profited
from cognitive-behavior therapy, reduced their anxiety- and other related
problems to a large extent. Yet, this study had no control-group, and its
sample size was very low (N=6). Clearly, more research is needed to show the
effectiveness of the AG. This is an important target when taking into account
the current emphasis on the necessity of **evidence-based** treatment.
Patients within autonomygroups usually have different types of symptoms and
disordes and therefore make up a heterogeneous group, which makes effectiveness
study somewhat complex. In this study, the effectiveness of autonomygroups will
be examined with patients of a more homogenous group, to overcome this
complexity. According to Bekker and Croon (2010), autonomy-connectedness seem
very important in treating anxiety. In the Netherlands, there are several
GGZinstitutions, including GGZiIngeest, that offer autonomygroups specifically
to patients with anxiety disorders for some years now. Hence, this study
focuses on the effectiveness of AGs for patients with anxiety disorders.

Objective
To investigate the effectiveness of autonomygroups for (Dutch) patients with
anxiety disorders.
Research questions
(1) *Do patients with anxiety disorders show a significant increase of autonomy
after the autonomygroup?*
(2) *Do patients with anxiety disorders show a significant decline in their
symptoms after the autonomygroup?*
Hypotheses
(1) Patients with anxiety disorders show an increase of autonomy after the
autonomygroup..
(2) Patients with anxiety disorders show a decrease of their symptoms after the
autonomygroup.

Procedure:
Dutch GGZ institutions (including GGZ inGeest at Amsterdam) that offer Autonomy
Groups (AG) to patients with anxiety disorders will be involved in this study.
Patients meeting inclusion and exclusion criteria are asked to participate in
the study. AG*s consist of 15 sessions once in a week, taking 2 to 2,5 hours.
Every AG has an average of 8 patients with a maximum of 10. Patients are
randomised over two conditions: AG and a control-group (waiting list). In this
study, a Randomized Controlled Trial (RCT) design is used. Measurements will
take place at 3 moments (before the treatment (T1), half way the treatment
(T2), after the treatment (T3). Before each measurement the researcher will
deliver the envelopes with the questionnaires to the therapist, who will hand
out the envelopes to their patients within the autonomygroup. These patients
will be offered time to fill in the questionnaires at the GGZ inGeest. After
filling in the questionnaire, the patients will be asked to put the filled-in
questionnaires back into the envelope and return it to their therapists.
Regarding the control-group, the secretary within GGZ inGeest will send the
envelopes to the patient*s home addresses, where they can fill in the
questionnaires, After filling in, the patients can return the filled-in
questionnaire back to GGZ inGeest with a retour-envelop which is included.
Ethical issues: For medical ethical reasons, patients will be informed about
the research during the intake-procedures. Shortly before the therapy starts,
all patients in the AGs receive additional information in which all steps of
the research are being explained. In addition, the informed consent is
included, in which the patients can confirm their commitment to the research.
Furthermore, the patients will be informed about the three times of
measurements during the treatment. This means that some identification of the
patients is needed to connect the data of the several measurements with the
right patient. Therefore, in each measurement the patient is asked to write
down his/her name. It is guaranteed that the patient*s name will be removed
immediately after the data collection. Finally, patients are also informed that
there will be no consequences when they decide, during the therapy, not to
participate the study any longer; the patients are able to continue the
therapy. The control-group will receive the same information as the patients in
the autonomygroup together with some extra information explaining the design of
the study, and why it is important that they wait for 15 weeks before they
receive their treatment. In addition, they will get the opportunity to let know
whether they agree with this design, or when (at a later stage) they no longer
want to participate. In addition, when in their opinion the waiting period is
too long, they will be either offered the treatment as soon as possible, or
another treatment that is comparable to the AGs. Filling in the set of
questionnaires (in each measurement) will take 1 hour. Finally, the therapists
will not see the filled-in questionnaires of the patients. Only the researcher
will see their names when relating the names with numbers. After the data
collection, the names will be removed from the system. The filled-in
questionnaires will be property of the GGZinstitutions..

Patients randomised to the intervention condition receive a grouptraining to
increase their autonomy. They recieve 15 sessions of 2 hours.
Patients randomised to the controlcondition do not receive treatment
('waitinglist control condition').

not applicable