The efficacy of incorporating motivational interviewing to cognitive behavior therapy for anxiety disorders: A review and meta-analysis

doi:10.1016/j.cpr.2018.04.004

Clinical Psychology Review

Volume 62, June 2018, Pages 1-10

https://doi.org/10.1016/j.cpr.2018.04.004 Get rights and content

Highlights

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Reviews the current literature on Motivational Interviewing (MI) as an adjunct to Cognitive Behavior Therapy (CBT) for anxiety disorders
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Presents a meta-analysis indicating that MI as an adjunct to CBT (MI + CBT) improves anxiety symptoms in comparison to CBT alone.
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Discusses limitations and key future research directions in the area of MI + CBT

Abstract

Motivational Interviewing (MI) has been suggested as an adjunct to Cognitive Behavior Therapy (CBT) for anxiety disorders. Although preliminary evidence suggests that MI as a prelude to CBT (MI + CBT) improves various aspects of treatment from initial engagement, overall symptom reduction, and treatment drop out rate, results are inconsistent. The current meta-analysis combined the findings of 12 trials examining the efficacy of MI + CBT in comparison to CBT alone. Across studies, MI + CBT outperformed standard CBT in terms of overall anxiety symptom reduction, Hedges g = 0.59. Drop out rates were not significantly different between groups. Moderator analyses revealed no significant differences based on specific anxiety diagnosis or dose of MI. The findings of this meta-analysis suggest that MI as an adjunct to CBT for anxiety disorders improves treatment outcome, in comparison to CBT alone. Limitations of the study and future research directions are explored.

Section snippets

Anxiety disorders

Anxiety disorders are considered to be the most common class of psychological disorders (Merikangas et al., 2010). In the U.S., lifetime prevalence rates stand at 31% and 12-month prevalence rates at 19%; almost double that of mood disorders and 5 times higher than substance use disorders (Kessler et al., 2009). Anxiety disorders are often debilitating, affecting many areas of functioning including employment (Waghorn, Chant, White, & Whiteford, 2005), academic performance (Seipp, 1991),

Cognitive behavior therapy for anxiety disorders

Cognitive Behavior Therapy (CBT) is widely acknowledged as an efficacious and effective treatment for anxiety disorders and is one of the most researched psychotherapies with substantial theoretical and clinical evidence (Butler, Chapman, Forman, & Beck, 2006). Meta-analytic findings suggest that CBT is one of the most efficacious psychotherapies for anxiety disorders (Tolin, 2010), and that efficacy holds across anxiety disorders regardless of the specific diagnosis (Norton & Price, 2007). CBT

Non-response rates in cognitive behavior therapy

Numerous factors have been offered to explain non-response and dropout rates in CBT, including poor therapeutic alliance (Safran & Muran, 2000; Westra, Constantino, & Aviram, 2011a), low therapist adherence to protocol (DeRubeis & Feeley, 1990), resistance and non-adherence to treatment activities (Leahy, 2001; Sanderson & Bruce, 2007), and low client motivation (Antony, Ledley, & Heimberg, 2005; Arkowitz, Westra, Miller, & Rollnick, 2008; Drieschner, Lammers, & Staak, 2004); as well as

Client motivation

Client motivation has been identified as an individual difference characteristic that is susceptible to change through intervention (Simoneau & Bergeron, 2003). Definitions of this construct vary, yet client motivation is generally understood as both the internal and external drive that underpins the commencement, management, intensity, and perseverance of behavioral change in treatment (Vallerand & et Thill, 1993). It is considered a fluctuating construct (Miller, 1985) and hence has likely

Motivational interviewing

The relationship between motivation and treatment outcome in anxiety disorders has paved the way for new research examining ways to enhance motivation in treatment. The majority of this research draws upon Motivational Interviewing (MI) strategies in conjunction with standard psychotherapy protocols. MI is a treatment which first emerged in the treatment of alcohol use disorders (see Miller, 1983). MI has been successful in this area of research (e.g. Hettema, Steele, & Miller, 2005) and is now

Motivational interviewing as an adjunct to CBT for anxiety disorders

MI principles appear to align with CBT for anxiety disorders at both a theoretical and practical level. The aim of MI, to help individuals overcome ambivalence about change, may be especially useful in anxiety presentations. It is possible for individuals to hold both positive and negative beliefs about their anxiety and their necessity to change. For example, individuals with GAD might be distressed about the amount of time they spend worrying but also believe that worrying is beneficial, in

State of the current research

In 2004 the first published study, a series of three case studies, which incorporated MI into CBT for anxiety disorders emerged (Westra, 2004). These case studies presented a basis for ongoing research in the area by showing that the inclusion of MI as a prelude to CBT is feasible, and may provide therapeutic benefit by increasing engagement and motivation. From this time, numerous case studies, open trials, and randomized controlled trials (RCTs) have been completed across a wide range of

Purpose of the current study

The purpose of the meta-analysis was to address some of these gaps in the literature and examine the efficacy of MI in the treatment of anxiety disorders. Efficacy was operationalized as treatment outcome and participant drop out rates. This study also explored if any factors, such as number of MI sessions, would be associated with greater improvement. As of yet, no meta-analysis has been conducted examining MI in the context of anxiety disorders. It was hypothesised that MI, as an adjunct to

Method

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines (Liberati et al., 2009) were used to conduct this meta-analysis. Articles were first sourced through a thorough search of studies across the following electronic databases: PsychInfo, PubMed, Cochrane Library, and ProQuest. As no previous meta-analysis has been published on MI in anxiety disorders, liberal search terms based on past meta-analyses on MI (e.g. Burke, Arkowitz, & Menchola, 2003; Lundahl,

Symptom reduction

As predicted, the adjunct of MI to standard CBT had a moderate significant effect on symptom reduction compared to CBT alone (Hedges g = 0.59, 95% CI = 0.41–0.78, z = 6.24, p < 0.001), suggesting that pre-treatment MI is associated with greater anxiety symptom improvement than CBT alone. The distribution of the observed effect size was not significant (Q = 13.85, df = 11, p = 0.24). Approximately 20% of the variance in the observed effects is due to variance in the true effects (I² = 20.55),

Discussion

Although numerous meta-analyses and reviews have examined the efficacy of MI for substance use disorders and psychiatric disorders, this is the first to examine MI as an adjunct to CBT for anxiety disorders. RCTs that have been conducted in this area have provided inconclusive results, and emphasis has often been placed on drop out rates, treatment adherence, and engagement rather than treatment outcome. The findings of this meta-analysis suggest that MI as an adjunct to CBT for anxiety

Study limitations

Several limitations can be identified in this meta-analysis, the most patent relating to the inconclusive findings of the validity assessment. Many studies did not adequately report randomization procedures (e.g. using a computer random number generator), or how participant allocation was concealed from investigators and personal. Furthermore, despite therapists often being blind to treatment condition, it was unclear whether participants were blind to treatment condition (performance bias).

Author disclosure

The authors disclose that no actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within two years of beginning the submitted work that could inappropriately influence, or be perceived to influence, our work.

Isabella Marker is a doctoral student in clinical psychology at Monash University. Her research interests lie in the discrepancies in treatment outcome in evidence-based therapies for emotional disorders. She is particularly interested in the role of client motivation in therapy. Her current research examines client motivation in the context of transdiagnostic cognitive behaviour therapy for anxiety disorders.

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Mapping motivation prior to psychotherapy may be useful to identify patients with low levels of motivation and who may need further clinical attention, either in the form of more motivational support or being offered other forms of treatment. Specific interventions targeting patients' motivation, such as motivational interviewing (MI), have been shown effective in improving psychotherapy engagement and lead to enhanced outcomes in other clinical populations (Marker and Norton, 2018; Ryan et al., 2011). Moreover, the effectiveness of MI has demonstrated cross-cultural generalizability (Oh and Lee, 2016).
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Peter J. Norton is professor of clinical psychology at Monash University, and Clinic Lead for the Monash FEAR Clinic, and Director of the Monash Psychology Centre. Professor Norton's research has been focused on developing and evaluating transdiagnostic and diagnosis-specific factors across anxiety and other emotional disorders, and translating these factors into efficacious and efficient transdiagnostic interventions.

^☆: This material is the result of work supported with resources and the use of facilities at Monash University, Clayton, Victoria, Australia. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of Monash University.

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ReviewThe efficacy of incorporating motivational interviewing to cognitive behavior therapy for anxiety disorders: A review and meta-analysis☆

Highlights

Abstract

Section snippets

Anxiety disorders

Cognitive behavior therapy for anxiety disorders

Non-response rates in cognitive behavior therapy

Client motivation

Motivational interviewing

Motivational interviewing as an adjunct to CBT for anxiety disorders

State of the current research

Purpose of the current study

Method

Symptom reduction

Discussion

Study limitations

Author disclosure

Journal of Anxiety Disorders

Behaviour Research and Therapy

Clinical Psychology Review

Clinical Psychology Review

Cognitive and Behavioral Practice

Clinical Psychology Review

Behavior Therapy

Journal of Clinical Epidemiology

Journal of the American Academy of Child & Adolescent Psychiatry

Addictive Behaviors

Clinical Psychology Review

Cognitive and Behavioral Practice

Clinical Psychology Review

Addictive Behaviors

Cognitive and Behavioral Practice

Addictive Behaviors

Cognitive and Behavioral Practice

Behaviour Research and Therapy

Clinical Psychology Review

Behaviour Research and Therapy

Journal of Anxiety Disorders

Diagnostic and statistical manual of mental disorders

Client commitment language during motivational interviewing predicts drug use outcomes

Journal of Consulting and Clinical Psychology

Improving outcomes and preventing relapse in cognitive-behavioral therapy

Beyond worry: How psychologists help with anxiety disorders

Learning, applying, and extending motivational interviewing

Integrating motivational interviewing and cognitive behavioral therapy in the treatment of depression and anxiety

Journal of Cognitive Psychotherapy

Motivational interviewing in the treatment of psychological problems

The impact of motivational interviewing on resistance in cognitive behavioural therapy for generalized anxiety disorder

Psychotherapy Research

Responsive management of early resistance in cognitive–behavioral therapy for generalized anxiety disorder

Journal of Consulting and Clinical Psychology

The efficacy of cognitive–behavioral therapy and the problem of drop-out

Journal of Clinical Psychology

Unified Protocol for Transdiagnostic Treatment of Emotional Disorzders

Motivational interviewing as an adjunct to cognitive behavioral therapy for anxiety

Journal of Clinical Psychology

Resistance/reactance level

Journal of Clinical Psychology

Motivational interviewing as an augmentation to increase effectiveness in cognitive processing therapy for PTSD: An initial trial

Comprehensive meta-analysis: Version 2 [computer software]

Introduction to meta-analysis

The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials

Journal of Consulting and Clinical Psychology

One-year follow-up of psychotherapy and pharmacotherapy for cocaine dependence

Archives of General Psychiatry

Trauma-focused exposure therapy for chronic posttraumatic stress disorder in alcohol and drug dependent patients: A randomized controlled trial

Psychology of Addictive Behaviors

Determinants of change in cognitive therapy for depression

Cognitive Therapy and Research

Motivational interviewing and the stages of change

Integrating motivational interviewing into the treatment of anxiety

Bias in meta-analysis detected by a simple, graphical test

BMJ

Attachment in individuals with social anxiety disorder: The relationship among adult attachment styles, social anxiety, and depression

Emotion

Success and failure in the behavioral treatment of obsessive-compulsives

Journal of Consulting and Clinical Psychology

Manual for the Client Language EAsy Rating (CLEAR) coding system: Formerly “Motivational Interviewing Skill Code (MISC) 1.1”

Review
The efficacy of incorporating motivational interviewing to cognitive behavior therapy for anxiety disorders: A review and meta-analysis☆