Cognitive-behavior therapy (CBT) has shown to be efficacious for treating anxiety, yet some clients “either fail to respond, respond only partially, or relapse at follow-up” (Westra, Constantino, & Antony, 2016, p. 768). As reported by Hunot, Churchhill, Teixeria, and Silva de Lima (2007; as cited in Westra et al., 2016), only 46% of clients with Generalized Anxiety Disorder (GAD) demonstrated significant improvement after therapy. One factor that may contribute to poorer outcomes is ambivalence. Ambivalence in anxiety is holding positive beliefs about worry and being reluctant to change or let go of the worry (Westra & Arkowitz, 2010; as cited in Westra et al., 2016). Additionally, therapeutic directness or demands related to change might be met with resistance (Westra et al., 2016). Thus, additional components that work with ambivalence may boost treatment outcomes by working through resistance, all while remaining anchored in CBT.
Motivational Interviewing (MI) is a treatment with a focus on ambivalence (Miller & Rollnick, 2002). Here the therapist is not the advocate for change, rather therapists assist clients to be their own advocate for change (Westra et al., 2016). With specific strategies, MI helps reduce resistance and “increases intrinsic motivation” for change (Westra et al., 2016, p. 769). In their study, Westra, Constantino, and Antony (2016) investigated the effects of integrating MI and CBT for severe GAD. In the study, one group received 15 weekly session of CBT alone (CBT-alone) and another group had 4 sessions of MI followed by 11 sessions of CBT integrated with MI (MI-CBT). Initially, there were no posttreatment differences between groups; yet, at the 6- and 12-month follow-up, several group differences emerged. The MI-CBT group reported a continued improvement on self-reported worry and general distress after treatment ended. MI-CBT clients also had significantly higher rates of recovery and clinically significant change (five times as likely to not meet diagnostic criteria for GAD). Westra et al. (2016) indicated that similar sleeper-type effects are often reported with MI use in treating other disorders.
So, why did clients continue to improve after treatment? Westra et al. (2016) indicated that the opportunity to explore ambivalence and becoming more committed to change might help clients not respond to worry, thus reducing relapse rates. Additionally, the authors suggested that MI techniques fostered the development of personal agency, which may have led to the client’s belief that they are capable of change, resulting in internalization of this belief. By “rolling with resistance” and viewing the “client-as-expert” helped to “promote internal attributions for progress” (Westra et al., 2016, p. 777). With this model, the efficacy of CBT treatment for GAD is maintained, yet by integrating MI where clients can openly explore resistance may help clients become more receptive to traditional CBT techniques.
References
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York, NY: Guilford Press.
Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Integrating motivational interviewing with cognitive-behavioral therapy for severe generalized anxiety disorder: An allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical Psychology, 84(9), 768-782.
Dannie S. Harris, MA
WKPIC Doctoral Intern