Comparing the predictive capacity of observed in-session resistance to self-reported motivation in cognitive behavioral therapy

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Abstract

Self-report measures of motivation for changing anxiety have been weakly and inconsistently related to outcome in cognitive behavioral therapy (CBT). While clients may not be able to accurately report their motivation, ambivalence about change may nonetheless be expressed in actual therapy sessions as opposition to the direction set by the therapist (i.e., resistance). In the context of CBT for generalized anxiety disorder, the present study compared the ability of observed in-session resistance in CBT session 1 and two self-report measures of motivation for changing anxiety (the Change Questionnaire & the Client Motivational for Therapy Scale) to (1) predict client and therapist rated homework compliance (2) predict post-CBT and one-year post-treatment worry reduction, and (3) differentiate those who received motivational interviewing prior to CBT from those who received no pre-treatment. Observed in-session resistance performed very well on each index, compared to the performance of self-reported motivation which was inconsistent and weaker relative to observed resistance. These findings strongly support both clinician sensitivity to moments of client resistance in actual therapy sessions as early as session 1, and the inclusion of observational process measures in CBT research.

Section snippets

Methods

Data for the present study derive from a larger randomized controlled trial (RCT) investigating the efficacy of adding a motivational interviewing (MI) pre-treatment, compared to no pre-treatment (4-week waiting period), prior to CBT for GAD (Westra, Arkowitz, & Dozois, 2009). For the evaluation of the capacity of each measure to predict homework compliance and outcome, the CBT alone group (no pre-treatment; N = 38) was used in order to avoid any influence of having received MI on these

Results

Client demographics and means and standard deviations for all measures are presented in Table 1. The sample was between the ages of 18 and 66, not engaged in concurrent psychotherapy, ethnically diverse, generally well-educated, had a chronic worry problem, and 63% had at least 1 other clinically significant diagnosis beyond GAD. Correlations between the various measures evaluated in the present study are presented in Table 2. No significant correlations were observed among the measures of

Discussion

Of the three measures of motivation evaluated in the present study (observed early resistance and two self-report measures: the Change Questionnaire, CQ and the Client Motivation for Therapy Scale, CMOTS), higher observed resistance in CBT session 1 was the most consistent and strongest predictor of both proximal (lower homework compliance) and distal (less worry reduction post-CBT and at one-year follow-up) outcomes in CBT. Higher levels of early resistance also significantly distinguished

Acknowledgements

This study was generously supported by a grant from the National Institute of Mental Health R34-MH072615 and a New Investigator Award from the Canadian Institute of Health Research awarded.

Much thanks to the outstanding resistance coders at York who were involved in the present study, Adi Aviram, Angela Kertes, Mariyam Ahmed, & Laura Connors.

References (57)

  • E. Aharonovich et al.

    Cognition, commitment language, and behavioral change among cocaine-dependent patients

    Psychology of Addictive Behaviors

    (2008)
  • Ahmed, M., Westra, H. A., & Constantino, M. J. (2010). Interpersonal process during resistance in CBT associated with...
  • P.C. Amrhein et al.

    Client commitment language during motivational interviewing

    Journal of Consulting & Clinical Psychology

    (2003)
  • M.M. Antony et al.

    Improving outcomes and preventing relapse in cognitive-behavioural therapy

    (2005)
  • H. Arkowitz et al.

    Motivational interviewing in the treatment of psychological problems

    (2008)
  • Aviram, A., Westra, H.A., & Kertes, A. (2010). The impact of motivational interviewing on resistance in CBT for GAD: A...
  • Beutler, L. E., Harwood, T. M., Michelson, A., Song, X., & Holman, J. Resistance/reactance level. In: J. Norcross...
  • L.E. Beutler et al.

    Resistance in psychotherapy: what conclusions are supported by research

    Journal of Clinical Psychology in Session: Psychotherapy in Practice

    (2002)
  • J.L. Binder et al.

    “Negative process”: a recurrently discovered and underestimated facet of therapeutic process and outcome in the individual psychotherapy of adults

    Clinical Psychology: Science and Practice

    (1997)
  • M.M. Bischoff et al.

    Client resistance as predicted by therapist behavior: a study of sequential dependence

    Counseling Psychology

    (1995)
  • T.D. Borkovec et al.

    Efficacy of applied relaxation and cognitive behavioral therapy in the treatment of generalized anxiety disorder

    Journal of Consulting and Clinical Psychology

    (1993)
  • T.D. Borkovec et al.

    Treatment of nonphobic anxiety disorders: a comparison of nondirective, cognitive, and coping desensitization therapy

    Journal of Consulting and Clinical Psychology

    (1988)
  • T.D. Borkovec et al.

    A component analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems

    Journal of Consulting and Clinical Psychology

    (2002)
  • M.M. Brogan et al.

    Predicting termination and continuation status in psychotherapy using the transtheoretical model

    Psychotherapy

    (1999)
  • T.A. Brown et al.

    ADIS: Anxiety disorders interview schedule for DSM IV

    (1994)
  • M.J. Bryant et al.

    Therapist skill and patient variables in homework compliance: controlling an uncontrolled variable in cognitive therapy outcome research

    Cognitive Therapy and Research

    (1999)
  • D.D. Burns et al.

    Therapeutic empathy in cognitive-behavioral therapy: does it really make a difference?

  • Chamberlain, P., Davis, J.P., Forgatch, M., Frey, J., Patterson, G.R., Ray, J., et al. (1985). The therapy process...
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      For example, measurements of motivation largely rely on pre-treatment self-report questionnaires, susceptible to social desirability bias. Other measures, such as third-party observer ratings, have shown to be better predictors of outcome (Westra, 2011), yet they are lacking in the anxity field, and have thus far only been utilized in early sessions of therapy. Follow-up data was also rarely available, or assessments differed to those at post-treatment.

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