Henny A. Westra

Preparing Clients for Cognitive Behavioral Therapy: A Randomized Pilot Study of Motivational Interviewing for Anxiety

Although CBT is a well-supported treatment for anxiety, recovery rates and compliance with treatment procedures are less than optimal. Using adjunctive brief preparatory interventions may help bolster response rates and engagement with therapy procedures. Motivational Interviewing (MI: Miller, W. R., & Rollnick, S. (1991, 2002). Motivational interviewing: preparing people to change addictive behavior. New York: Guilford) is a client-centered, directive method for enhancing motivation for change and has been demonstrated to be a valuable treatment prelude in the addictions domain. Prior to group cognitive behavioral therapy, 55 individuals with a principal anxiety diagnosis (45% panic disorder, 31% social phobia, and 24% generalized anxiety disorder) were randomly assigned to receive either three sessions of MI adapted for anxiety or no pretreatment (NPT). The MI pretreatment group, compared to NPT, showed significantly higher expectancy for anxiety control and greater homework compliance in CBT. Although both groups demonstrated clinically significant anxiety symptom improvements, the MI pretreatment group had a significantly higher number of CBT responders compared to NPT. At 6-month follow-up, both groups evidenced maintenance of gains. These results provide suggestive evidence that brief pretreatments, such as MI, may enhance engagement with and outcome from CBT. The promising results also justify the future investigation of these effects using more powerful designs which may discern whether the effects are specific to MI or to some type of pretreatment.

Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: a preliminary randomized controlled trial.

Seventy-six individuals with a principal diagnosis of generalized anxiety disorder (GAD) were randomly assigned to receive either an MI pretreatment or no pretreatment (NPT), prior to receiving CBT. Significant group differences favoring the MI-CBT group were observed on the hallmark GAD symptom of worry and on therapist-rated homework compliance, which mediated the impact of treatment group on worry reduction. Adding MI pretreatment to CBT was specifically and substantively beneficial for individuals with high worry severity at baseline. There was evidence of relapse at 6-month follow-up for high severity individuals who received MI-CBT, but significant moderator effects favoring the high severity MI-CBT group were again apparent at 12-months post-treatment. Pending replication in a more controlled test, these findings suggest that MI may be a promising adjunct to CBT for GAD for those of high severity, a group which has been less responsive to CBT in past research.

Expectancy, Homework Compliance, and Initial Change in Cognitive-Behavioral Therapy for Anxiety.

Belief in ones ability to change is an important cognitive variable related to treatment gains. This study investigated pretreatment expectancy for anxiety change and early homework compliance in relation to initial and total cognitive change in group cognitive-behavioral therapy (CBT) for anxiety. Participants, who met diagnostic criteria for at least 1 anxiety disorder, completed 10 sessions of group CBT. Early homework compliance mediated the relationship between expectancy for anxiety change at baseline and initial change in CBT. In addition, initial cognitive symptom improvement mediated the relationship between homework compliance and posttreatment outcome. These results suggest that expectancy for change is an important cognitive variable that may provide the initial impetus and subsequent momentum for therapeutic involvement and gains.

Stages of change in anxiety: psychometric properties of the University of Rhode Island Change Assessment (URICA) scale

Readiness for change is increasingly cited as an important variable in the health behaviours literature, yet there remains a dearth of research related to this construct in mental health. This study examined the psychometric properties of the University of Rhode Island Change Assessment (URICA) scale in two samples. In Study 1 (n = 252), undergraduates completed the URICA and were administered measures of hopelessness, the consequences of worry, self-esteem, anxious symptomatology, and social desirability. The reliability and validity of the URICA were generally supported, although the goodness-of-fit with the intended subscales was only moderate. The Precontemplation, Contemplation and Maintenance subscales correlated as expected with ancillary measures, but the Action subscale did not. In Study 2 (n = 81), individuals with panic disorder were administered the URICA at initial assessment and following cognitive behavioural therapy. The URICA demonstrated excellent reliability, significantly predicted treatment retention and dropout, and showed modest utility for predicting treatment outcome. Confirmatory factor analysis, however, revealed an inadequate fit to the intended subscales. The implications of these findings are discussed and directions for future research highlighted.

Changes in self-schema structure in cognitive therapy for major depressive disorder: a randomized clinical trial.

Negative cognitive structure (particularly for interpersonal content) has been shown in some research to persist past a current episode of depression and potentially to be a stable marker of vulnerability for depression (D. J. A. Dozois, 2007; D. J. A. Dozois & K. S. Dobson, 2001a). Given that cognitive therapy (CT) is highly effective for treating the acute phase of a depressive episode and that this treatment also reduces the risk of relapse and recurrence, it is possible that CT may alter these stable cognitive structures. In the current study, patients were randomly assigned to CT+ pharmacotherapy (n = 21) or to pharmacotherapy alone (n = 21). Both groups evidenced significant and similar reductions in level of depression (as measured with the Beck Depression Inventory-II and the Hamilton Rating Scale for Depression), as well as automatic thoughts and dysfunctional attitudes. However, group differences were found on cognitive organization in favor of individuals who received the combination of CT+ pharmacotherapy. The implications of these results for understanding mechanisms of change in therapy and the prophylactic nature of CT are discussed.

Managing resistance in cognitive behavioural therapy: The application of motivational interviewing in mixed anxiety and depression

While cognitive behavioural therapy is highly effective in the treatment of anxiety and depression, a substantive number of individuals either refuse treatment, fail to respond to treatment or respond only partially. Arguably, ambivalence about change or about engaging in treatment tasks may in part be related to incomplete recovery rates in cognitive behavioural therapy. Motivational interviewing is a client-centred, directive treatment originally developed in the addictions domain whose goal is to enhance motivation for change by understanding and resolving ambivalence. This method has consistently received support for enhancing outcomes in the addictions domain, particularly when used as an adjunct to further treatment. As yet, motivational methods have not been generalized to the treatment of prevalent mental health problems, such as anxiety and depression. The present paper presents the application of a treatment targeting motivation (motivational interviewing adapted for anxiety and depression) to the management of resistance in cognitive behavioural therapy for 3 clients with mixed anxiety and depression. Motivational interviewing is conceived as an adjunct to highly effective traditional cognitive behavioural therapy methods, which is indicated for use with clients resistant to and significantly ambivalent about change-based techniques for managing anxiety or alleviating depression.

COGNITIVE BEHAVIOURAL THERAPY AND PHARMACOTHERAPY: COMPLEMENTARY OR CONTRADICTORY APPROACHES TO THE TREATMENT OF ANXIETY?

Considerable controversy exists regarding the practice of combining Cognitive Behavioural Therapy (CBT) with Pharmacotherapy (PT) in the management of anxiety. This paper considers whether these two forms of treating anxiety disorders can be effectively combined to enhance treatment outcome. Despite the theoretical appeal of a combined approach, a critical review of treatment outcome findings across CBT and various anxiolytic medications and their combination, suggests a failure of these treatments to operate in a complementary fashion. A detrimental impact of anxiolytic medication on CBT outcome is particularly salient for high potency benzodiazepines. Low potency benzodiazepines and antidepressants generally have a negligible impact with no clear evidence of treatment enhancement and some negative combined treatment effects on medication withdrawal and at long-term follow-up. Thus, we address potential mechanisms that may explain this treatment noncomplementarity and in some cases, treatment incompatibility. Cognitive factors influencing treatment outcome (catastrophic beliefs, self-efficacy, selective attention, and memory) are highlighted in view of the empirically supported mediating role of these variables in accounting for treatment responsiveness. Potential effects of anxiolytic medication on cognitive change in CBT are postulated. A number of suggestions for future research and clinical practice are proposed on the basis of this review.

Integrating Motivational Interviewing and Cognitive Behavioral Therapy in the Treatment of Depression and Anxiety

Many clients engaging in Cognitive Behavioral Therapy (CBT) for depression and anxiety are ambivalent about change, and about taking necessary actions to bring about change such as exposure or behavioral activation exercises. Given the focus of motivational interviewing (MI) on enhancing readiness for change, it is of great interest to investigate applications of MI to prevalent disorders such as depression and anxiety. After exploring the rationale for integrating MI with CBT for these disorders, we outline unique features of MI that may render it a useful complement to CBT, such as its focus on resolving ambivalence for change and specific strategies for responding to resistance. We suggest several possible ways in which MI may be combined with CBT. Finally, we discuss our clinical experience with adapting MI to the treatment of depression and anxiety, including case illustrations of each, and discuss some of the unique issues arising in generalizing MI for use with these populations.

Naturalistic manner of benzodiazepine use and cognitive behavioral therapy outcome in panic disorder with agoraphobia.

Benzodiazepines (BZs) are commonly used in conjunction with cognitive behavioral therapy (CBT) in the treatment of panic disorder with agoraphobia (PDA). However, empirical evidence provides little support for the utility of this combined treatment approach over CBT alone. Westra and Stewart [Clin. Psychol. Rev. 18 (1998) 307] have proposed that pm or as-needed use of BZs may inhibit positive CBT outcome to a greater extent than regularly scheduled BZ use. Using a naturalistic design, the present study investigated the impact of manner of BZ use on treatment outcome from CBT in 43 patients with PDA. Among various BZ parameters (chronicity, frequency, dose, and frequency of prn use), pm use of BZs for coping with anxiety symptoms was a significant negative predictor of degree of change in both anxiety sensitivity and anxious arousal from pre- to post-CBT. Although no significant between-group differences were evident in pre-treatment symptomatology, unmedicated subjects demonstrated the most positive overall CBT outcome, while pm BZ users evidenced the fewest gains. Regular BZ users were generally not significantly differentiated from unmedicated subjects in CBT outcome and both tended to obtain post-treatment scores in the nonclinical range. Implications of these findings for clinical management of BZ use throughout CBT for PDA are discussed.

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

Abstract The present study simultaneously examined observed resistance and homework compliance in Cognitive Behavioural Therapy (CBT) between those with severe generalized anxiety disorder who did (n =18) and did not (n =17) receive Motivational Interviewing (MI) prior to CBT. Large effects for reduced resistance early in CBT were observed in the MI pretreatment group relative to the no-pretreatment group. Moreover, receiving four sessions of MI was associated with significantly lower levels of resistance, compared to receiving four sessions of CBTalone. Using path analysis, resistance, but not homework compliance, was found to strongly and directly mediate the relationship between treatment group and worry reduction. Findings suggest that MI improves treatment outcomes when added to CBT for generalized anxiety by reducing client resistance to, and increasing client engagement with treatment.