What is a recommended cognitive behavioral therapy (CBT) plan for an adult male patient with insecure attachment, anxiety, and depression, who exhibits demand-making behavior due to insecurity?

Cognitive Behavioral Therapy Plan for Insecurity-Driven Anxiety and Depression

For an adult male with insecure attachment, anxiety, and depression manifesting as demand-making behavior, implement a structured CBT protocol of 12-14 individual sessions over 3-4 months, specifically targeting attachment-related cognitive distortions and interpersonal patterns, as this approach demonstrates superior outcomes for individuals with avoidant attachment styles compared to other psychotherapeutic modalities. 1, 2

Core Treatment Framework

Primary CBT Structure

• Deliver 12-14 individual face-to-face CBT sessions over 3-4 months with a trained psychologist or mental-level counselor, as this format shows the strongest evidence for anxiety and depression with comorbid presentations 3, 4
• Sessions should be 45-60 minutes weekly initially, then biweekly as symptoms stabilize 3
• Include relapse prevention strategies in the final 2-3 sessions 4

Attachment-Specific Modifications

For patients with higher avoidant attachment (dismissing styles), standard CBT protocols are particularly effective and should be prioritized over interpersonal approaches 1, 2. The evidence shows:

• Avoidantly attached individuals demonstrate significantly greater reduction in depression severity and higher remission rates with CBT compared to interpersonal psychotherapy 1
• Those with dismissing attachment styles show greater improvement in generalized anxiety symptoms when CBT is combined with interpersonal/emotional processing components 2

For patients with anxious attachment (preoccupied/angry styles), augment standard CBT with:

• Explicit focus on integrative self-knowledge, self-control, and self-compassion as these mediate the relationship between insecure attachment and depression 5
• Mindfulness-based components, as mindfulness serves as both a mediator and protective moderator in the attachment-depression pathway 5

Specific CBT Components to Address Insecurity

Cognitive Restructuring for Attachment-Based Distortions

• Identify and challenge core beliefs about self-worth, abandonment fears, and interpersonal expectations that drive demand-making behavior 3
• Target rumination patterns common to both anxiety and depression using transdiagnostic approaches 3
• Address catastrophic thinking about relationship loss or rejection that fuels demanding behaviors 3

Behavioral Interventions

• Implement graded exposure to situations that trigger insecurity-driven demands, starting with lower-stakes interpersonal scenarios 3
• Practice alternative communication strategies that express needs without demanding behaviors 3
• Develop distress tolerance skills for managing anxiety when needs are not immediately met 3

Self-Regulation Skills Training

• Build self-compassion through structured exercises, as this directly mediates the insecure attachment-depression relationship 5
• Teach self-control strategies to interrupt automatic demand-making responses 5
• Integrate mindfulness practices (5-10 minutes daily) to increase awareness of attachment-triggered emotional states 5

Format Considerations

Delivery Options

• Face-to-face individual therapy is the gold standard for complex presentations with attachment issues 3
• If access barriers exist (cost, geography, severity of social anxiety), consider guided internet-delivered CBT with regular therapist contact as an alternative, which shows moderate effectiveness for depression and anxiety 6
• Avoid unguided self-help for this complex presentation, as attachment issues require therapeutic relationship for optimal outcomes 3

Pharmacotherapy Integration

While CBT is the primary intervention, consider concurrent SSRI therapy (sertraline 50-100mg or escitalopram 10-20mg) if:

• Symptoms are moderate to severe 7
• Functional impairment is significant 3
• Patient preference supports combined treatment 3

The combination of CBT and medication may allow for lower medication doses while maintaining therapeutic benefit, particularly important if emotional blunting emerges 7

Monitoring and Adjustment

Assessment Points

• Evaluate anxiety, depression, and attachment-related behaviors at weeks 2,4,8, and 12 7
• Use standardized measures (PHQ-9 for depression, GAD-7 for anxiety) plus functional assessment of demand-making behaviors 3

Treatment Modifications

• If minimal improvement by session 6-8, consider adding interpersonal/emotional processing components specifically for dismissing attachment styles 2
• For persistent anxious attachment patterns, increase emphasis on mindfulness and self-compassion modules 5

Critical Pitfalls to Avoid

• Do not use brief interventions (≤6 sessions) for this complex presentation; the evidence supports 12-14 sessions minimum 3, 4
• Avoid benzodiazepines for anxiety management due to dependence risk and cognitive impairment that interferes with CBT learning 8
• Do not ignore comorbid depression when treating anxiety, as 75% of anxiety interventions also reduce depressive symptoms 3
• Recognize that attachment-related anger may predict poorer short-term response to CBT with interpersonal components; adjust expectations and extend treatment duration if needed 2