Using Motivational Interviewing to Manage Process Markers of Ambivalence and Resistance in Cognitive Behavioral Therapy

Predicting resistance management skill from psychotherapy experience, intellectual humility and emotion regulation

Objective Resistance management in psychotherapy remains a foundational skill that is associated with positive client outcomes (Westra, H. A., & Norouzian, N. (2018). Using motivational interviewing to manage process markers of ambivalence and resistance in cognitive behavioral therapy. Cognitive Therapy and Research, 42(2), 193-203). However, little is known about which therapist characteristics contribute to successful management of resistance. Research has suggested that psychotherapy performance does not improve with experience (Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology, 63(1), 1-11), that psychotherapists lack humility (Macdonald, J., & Mellor-Clark, J. (2015). Correcting psychotherapists' blindsidedness: Formal feedback as a means of overcoming the natural limitations of therapists. Clinical Psychology & Psychotherapy, 22(3), 249-257), and that difficult therapeutic moments may dysregulate therapist emotions (Muran, J. C., & Eubanks, C. F. (2020). Therapist performance under pressure: Negotiating emotion, difference, and rupture. American Psychological Association). This study aimed to 1) identify whether psychotherapy experience (i.e., training versus no training and number of years of psychotherapy experience) was associated with resistance management skill, and 2) identify whether humility and difficulties regulating emotions among trained individuals were each associated with resistance management. Method: A sample of 76 trained and 98 untrained participants were recruited for the present study. All participants completed the Comprehensive Intellectual Humility Scale (CIHS, Krumrei-Mancuso, E. J., & Rouse, S. V. (2016). The development and validation of the comprehensive intellectual humility scale. Journal of Personality Assessment, 98(2), 209-221), the Difficulties in Emotion Regulation Scale (DERS; Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41-54), and the Resistance Vignette Task (RVT; Westra, H. A., Nourazian, N., Poulin, L., Hara, K., Coyne, A., Constantino, M. J., Olson, D., & Antony, M. M. (2021). Testing a deliberate practice workshop for developing appropriate responsivity to resistance markers: A randomized clinical trial. Psychotherapy, 58, 175-185 ) which was used to assess resistance management skill. Results: Trained individuals performed significantly better on resistance management than untrained individuals; however, years of experience within the trained sample were not associated with resistance management. Conversely, lower humility and greater difficulties regulating emotions were each associated with significantly poorer resistance management in trained individuals. Conclusion: These findings suggest the possibility of improving training to focus on key skills, like resistance management, through supporting humility and emotion regulation in training, as opposed to simply acquiring more experience.

Implementation and Adaptation of the Safewards Model in the New Zealand Context. Perspectives of Tāngata Whai Ora and Staff

The safety of service users and staff is paramount in cultivating a therapeutic environment within inpatient mental health units. The Safewards model, originating in the United Kingdom, aims to reduce conflict and containment rates through 10 interventions. This study used participatory action research to explore the perspective of tāngata whai ora and staff regarding the adaptation of the Safewards model to the unique New Zealand context. Such adaptation is critical due to significant health outcome disparities between Māori and non-Māori populations and the disproportionate representation of Māori within mental health services. In adhering to the principles of Te Tiriti o Waitangi, cultural adaptation becomes an imperative obligation. The study utilised qualitative content analysis and thematic analysis, drawing data from focus groups of staff (n = 15) and tāngata whai ora (n = 3). This study describes a New Zealand Safewards model, which must include Te Ao Māori, align with current practices, adapt Safewards interventions and gain acceptance. Organisational change management is pivotal in the integration of this model into nursing practice. The outcomes of this study hold the potential to contribute to the formulation and implementation of a New Zealand Safewards model, while also bearing relevance for the international adaptation of Safewards to culturally diverse countries and healthcare systems.

Who With Whom: Matching Therapist and Client in Correctional Institutions

The current study investigated variables that are being considered when assigning psychotherapists to individuals convicted of sexual and violent offences. Its main aim is to inform practitioners and researchers alike of potentially beneficial combinations between therapist and client and infer hypotheses for future studies. A mixed-methods approach, combining interviews and a follow-up questionnaire, was employed. Nineteen interviews with forensic practitioners working in socio-therapeutic facilities in Germany were conducted. Relevant matching criteria were extracted from all interviews. 1.) Capacities of therapist, 2.) therapist's professional background, 3.) (severity of) clinical disorder, 4.) personal fit, and 5.) fit of client into existing groups emerged as top five matching criteria. Directive therapists were viewed as a good match for antisocial or psychopathic offenders. Opinions diverged regarding personality similarity or complementarity in client-therapist dyads. A flexible matching approach may offer unique strengths to enhance treatment outcome. Implications and ideas for future research are discussed.

Behaviour change, the itchy spot of healthcare quality improvement: How can psychology theory and skills help to scratch the itch?

Despite the clear utility and transferability, National Health Service (NHS) quality improvement initiatives have yet to benefit fully from what is already known within health psychology. Thus far, evidence from established, seminal behaviour change theory and practice have been ignored in favour of newly developed models and frameworks. Further, whilst there is a growing interest in what is commonly referred to as 'human factors' of change and improvement, there is scant transferability of known psychologically informed implementation skills into routine NHS Improvement practice. The science and practice of healthcare improvement is growing, and the behaviour change aspect is critical to sustainable outcomes. Therefore, this paper offers practical guidance on how seminal psychological behaviour change theory and motivational interviewing (a person-centred skills-based approach specifically developed to support people through change) can be combined to better address individual and organisational change within a healthcare improvement context.

"I'm not here to push you:" raising adolescents' treatment engagement via autonomy support

More than 45% of adolescents with aggressive behavior problems drop out of treatment prematurely. Building on insights from self-determination theory, we examined in three studies whether clinicians can raise adolescents' treatment engagement by supporting their autonomy. In an interview study (Study 1), clinicians (N = 16; 43.8% female; ages 30-57) spontaneously described 12 times more autonomy-supportive than controlling strategies to engage adolescents. In a preregistered experiment (Study 2), clinicians (N = 68; 88.2% female; ages 23-65) were confronted with videos of adolescents displaying resistance. We manipulated the DSM diagnosis of adolescents to indicate either aggressive behavior problems or other problems. We found that, regardless of diagnosis, clinicians used both autonomy-supportive strategies (57.7% of responses) and controlling strategies (39.3%), suggesting that applying autonomy support can be challenging with any adolescent displaying resistance. In an experimental study (Study 3), adolescents (N = 252; 50.0% female; ages 12-17) reported higher therapeutic alliance (d = 0.95, 95% CI [0.80, 1.10]) and treatment engagement (d = 0.77, 95% CI [0.63, 0.91]) after listening to audio-recorded autonomy-supportive versus controlling responses from clinicians, regardless of whether these adolescents had aggressive behavior problems. Overall, this research suggests that clinicians can raise adolescents' treatment engagement through autonomy support.

The alliance in mental health care: conceptualization, evidence and clinical applications

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

Therapist's interventions immediately after exceeding the client's therapeutic zone of proximal development: A comparative case study

OBJECTIVE

When therapists' proposals are too demanding exceeding clients' readiness to move into change, clients may resist advancing. We aimed to understand how a therapist behaved immediately after the client resisted advancing into change within Cognitive-Behavioral Therapy.

METHODS

We analyzed a recovered and an unrecovered case, both with Major Depression, and followed by the same therapist. Through the Therapeutic Collaboration Coding System, we analyzed 407 exchanges of interest.

RESULTS

In both cases, clients resisted more in advancing at intermediate sessions, mainly by the therapist's challenges to raise insight and debate cognitive beliefs in the recovered case, and to seek experiential meanings in the unrecovered case. Immediately after clients resisted advancing, the therapist tended to insist on challenging them in the same direction. In the recovered case, the therapist did so continually throughout the therapy, sometimes balancing between insisting or stepping back. In the unrecovered case, the therapist insisted on challenging, but mostly at the final session. Occasionally, the therapist insisted on challenging, and clients resisted over consecutive exchanges.

CONCLUSION

Our results reinforce that to enact progress and change clients need to be pushed into change, however it requires therapists' skillful assessment of clients' tolerance to move in time.

How does hostile resistance interfere with the benefits of cognitive-behavioral therapy for panic disorder? The role of therapist adherence and working alliance

Objective Although clients' hostile behavior directed at therapists (hostile resistance) predicts worse outcomes in cognitive-behavioral therapy (CBT) for panic disorder, the process by which this happens remains unknown. This study examines two putative mechanisms: working alliance and therapist adherence. Method: Seventy-one adults with primary panic disorder received CBT in a larger trial. Hostile resistance and adherence in Sessions 2 and 10 were reliably coded using observer-rated measures; client- and therapist-rated questionnaires assessed working alliance. Outcome measures were attrition and symptomatic improvement, assessed at multiple timepoints with the Panic Disorder Severity Scale. Results: Hostile resistance was significantly related to both preexisting (r  = -.36, p  =  .04) and subsequent declines (r  = -.58, p  <  .0001) in the working alliance. Nevertheless, hierarchical linear modeling revealed that neither a declining alliance nor therapist adherence (whether treated as linear or curvilinear) was independently predictive of symptom change, nor did these factors mediate hostile resistance's association with worse symptomatic improvement. Exploratory logistic regressions similarly indicated that neither adherence nor alliance moderated whether hostilely resistant clients dropped out. Conclusion: This is the first study to establish a bidirectional association between hostile resistance and a declining working alliance. Findings also add to a mixed literature on the adherence-outcome relationship.

Propriedades Psicométricas da Versão Brasileira do Questionário de Ambivalência em Psicoterapia - QAP

Resumo Níveis elevados de ambivalência estão associados a piores resultados e abandono terapêutico. Este estudo teve como objetivo a adaptação transcultural e avaliação das propriedades psicométricas do Questionário de Ambivalência em Psicoterapia (QAP). Após adaptação cultural do instrumento, foram avaliados 181 indivíduos em psicoterapia de diversas abordagens, em clínicas-escola e consultórios particulares. O QAP foi avaliado quanto à estrutura interna e relação com variáveis externas. Na análise fatorial confirmatória, o modelo com melhor ajuste foi composto por três dimensões: duas de primeira ordem - Desmoralização e Alternância - e uma de segunda ordem - Ambivalência. A consistência interna foi 0,86. Na relação com variáveis externas, o QAP se correlacionou moderadamente com medidas de desconforto psicológico (OQ-45- Outcome Questionnaire) (r = 0,65) e motivação para mudança (URICA - University of Rhode Island Change Assessment): contemplação (r = 0,36) e manutenção (r = 0,37). A versão brasileira do QAP demonstrou ser um instrumento com boas características psicométricas, de aplicação rápida e fácil.

The Resistance Vignette Task: Validating a rapid measure of therapist skill at managing resistance

BACKGROUND

Therapist appropriate responsivity to client ambivalence and resistance is considered an important interpersonal skill to avoid disengagement and ensure a continued collaborative, productive process. The present study examined the predictive validity of the newly developed Resistance Vignette Task (RVT), a 10-item rapidly administered measure of therapist ability to appropriately respond to various presentations of client resistance.

METHODS

Following a resistance management workshop, the concurrent and prospective predictive capacity of RVT scores were examined through test interviews with ambivalent simulators and volunteers.

RESULTS

Prospectively, in test interviews with ambivalent interviewees, higher RVT scores immediately postworkshop were associated with significantly greater responsivity (appropriate responsivity and fewer responsivity errors) at 4-month follow-up. RVT scores at the 4-month follow-up point were also concurrently associated with significantly greater therapist responsivity and lower levels of interviewee resistance.

CONCLUSIONS

These findings provide further validation for the RVT as a measure of therapist responsivity in vivo, in actual interviews by predicting and being concurrently associated with therapist performance in response to client resistance. Thus, the RVT holds promise in advancing therapist training, as well as research on resistance as it represents an efficient measure of this key therapist skill.

What can clients tell us about whether to use motivational interviewing? An analysis of early-session ambivalent language

BACKGROUND

Although motivational interviewing (MI) is an effective method for promoting change in problematic alcohol and other drug use, it does not benefit all clients. Clinicians have little empirical guidance on who is likely to benefit from MI and who is not. We hypothesized that differences in clients' spontaneously offered language early in the session would predict their responsiveness to MI during the remainder of the session.

METHOD

The study obtained coding data from 125 counseling sessions from a large randomized controlled trial of clinician training. A cluster analysis created one group of clients whose language reflected ambivalence, and one group whose language reflected readiness to change. We conducted a univariate analysis of variance to compare the mean change in percent change talk across the session between groups.

RESULTS

Clients whose language reflected ambivalence early in the session had a greater change in their percent change talk during the remainder of the session, compared to those whose language reflected greater readiness to change (F (1,90) = 63.02, t = 7.94, p < .001). Surprisingly, the group whose language reflected readiness had a decrease in their percent change talk during the remainder of the session (M = -10.9%, SD = 16.3%). Adjusting the results for regression to the mean effects did not eliminate these differences.

CONCLUSION

Clients' language early in the session may offer clinicians some guidance on whether MI is likely to be useful or counterproductive in the treatment of substance use disorder.

Therapist affiliation and hostility in cognitive-behavioral therapy with and without motivational interviewing for severe generalized anxiety disorder

OBJECTIVE

Although therapist supportive, rather than directive, strategies have been particularly indicated during client resistance, little systematic research has examined how therapists responsively navigate resistance in different therapy approaches and how this responsiveness is related to outcome.

METHOD

In the context of disagreement episodes in cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD; Westra, H. A., Constantino, M. J., & Antony, M. M. 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. https://doi.org/10.1037/ccp0000098, 2016), the present study examined (1) the degree to which therapist management of resistance differed between therapists trained in CBT integrated with motivational interviewing (MI-CBT; i.e., training centered on the responsive management of resistance) and therapists trained in CBT-alone, and (2) the impact of specific therapist behaviors during disagreement on client worry outcomes immediately posttreatment and 1-year posttreatment. Episodes of disagreement were rated used the Structural Analysis of Social Behavior (Benjamin, L. S. Structural analysis of social behavior. Psychological Review, 81(5), 392-425. https://doi.org/10.1037/h0037024, 1974).

RESULTS

Therapists trained in MI-CBT were found to exhibit significantly more affiliative and fewer hostile behaviors during disagreement compared to those trained in CBT-alone; both of these, in turn, were found to mediate client 1-year posttreatment outcomes, such that increased affiliation during disagreement was associated with improved outcomes.

CONCLUSION

This study highlights the value of training therapists in the responsive detection and management of resistance, as well as the systematic integration of MI into CBT.

Premature termination of the unified protocol for the transdiagnostic treatment of emotional disorders: The role of ambivalence towards change

Ambivalence towards change is an expected, recurrent process in psychological change. However, the prolonged experience of ambivalence in psychotherapy contributes to client disengagement, which could result in treatment dropout. Considering the negative effects of premature termination of therapy and the convenience of the identification of clients who are at risk of dropping out before achieving good-outcome, the current study explored the predictive power of ambivalence for premature therapy termination using a multilevel time-backwards model (i.e., considering the session of the dropout as session zero and then modelling what occurred from the dropout until session 1). Participants included a total of 96 psychotherapy clients (38 dropouts) treated in a university-based clinic following the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Multilevel modelling using a time-backwards model to analyse dropout data provided evidence of the predictive power of ambivalence evolution throughout treatment on the decision to prematurely discontinue treatment (p < .0001; R² _adj  = .29). Specifically, good-outcome dropouts presented a decreasing ambivalence trend throughout treatment, whereas poor-outcome dropouts tended to experience the same levels of ambivalence before deciding to drop out (time × dropout; β₁₁  = .64, p = .014). Additionally, poor-outcome dropouts presented higher levels of ambivalence (β₀₁  = 9.92, p < .0001) in the last session. The results suggest that the pattern of client ambivalence towards change is a predictor of premature termination of therapy. Implications for clinical and research contexts are discussed.

A pilot study on the efficacy of motivational interviewing groups in alcohol use disorders

OBJECTIVES

The present pilot study was designed to measure the feasibility and efficacy of motivational interviewing (MI) in groups in France, using the Wagner and Ingersoll's method.

METHOD

Participants (N = 85) were people with an alcohol use disorder (AUD) recruited from addiction consultation centers: 37 received five sessions of 2-h MI groups and 48 were assigned to treatment-as-usual condition (TAU). The sample was middle-aged (M = 43.95, SD = 12.96).

RESULTS

MI in groups seems to lead to a significant decrease in alcohol use and anxiety and depressive symptoms of participants in the MI condition. Moreover, there seems to be an increase in subjective happiness scores after the MI groups. In addition, participants' reactions were very positive.

CONCLUSIONS

This study provides encouraging results in favor of the feasibility and efficacy of MI in groups. The use of MI in groups has many advantages in clinical settings.

From expert to coach: health coaching to support behavior change within physical therapist practice

Background: Negative health behaviors are a significant risk factor for non-communicable diseases (NCDs) and are responsible for 40-50% of the burden of disease in the US population. Physical therapists (PTs) have the capacity to effect behavior change in their patients to reduce their risk of disease and promote health. Competence in health behavior change is recommended for physical therapists. One way to achieve this competence is by learning and adopting a health coaching approach. Objectives: To provide a theoretical and practical approach to applying a health coaching approach in physical therapist clinical practice. Methods: 1) Describe a health coaching approach to facilitating behavior change; 2) present behavior change theories, communication strategies, and models underpinning health coaching; and 3) provide suggestions for ways PTs can integrate health coaching in clinical practice. Results: Health coaching is a dynamic and collaborative approach to health behavior change that harnesses the patient's or client's values and strengths to realize their goals for health. Conclusion: Adopting a health coaching approach may enhance adherence to physical therapists' recommendations as well as improve health outcomes.

The predictive value of patient, therapist, and in-session ratings of motivational factors early in remote cognitive behavioural therapy for severe health anxiety

OBJECTIVES

Remote psychotherapy and the prevalence of Severe Health Anxiety (SHA) are both growing as a result of the COVID-19 pandemic. Remotely delivered Cognitive Behavioural Therapy (rCBT) for SHA is evidenced as effective, but many who seek help do not benefit. Motivational processes can influence outcomes, but it is unclear what assessment methods offer the best clinical utility in rCBT for SHA.

DESIGN

This study compared the predictive validity of patient, therapist and in-session ratings of motivational factors taken at session two of rCBT for SHA among high healthcare users experiencing multimorbidity.

METHODS

Motivational factors were assessed for 56 participants who attended at least two sessions of CBT for SHA delivered via video-conferencing or telephone. Following session two, therapists and patients completed online assessments of patient motivation. Two trained observers also rated motivational factors and therapeutic alliance from in-session interactions using session two recordings and transcripts. Multilevel modelling was used to predict health anxiety and a range of secondary health outcomes from motivation assessments.

RESULTS

Where patients were more actively engaged in discussion of positive changes during session two, greater outcome improvements ensued in health anxiety and all secondary outcomes. Conversely, larger proportions of session two spent describing problems predicted poorer outcomes. Therapist and patient assessments of motivation did not predict health anxiety, but therapist assessments of client confidence and motivation predicted all secondary outcomes.

CONCLUSIONS

Motivation remains an important process in CBT when delivered remotely, and motivational factors may predict outcomes more consistently from in-session interactions, compared to self-reports.

The effect of motivational interviewing on ambivalence in social anxiety disorder

BACKGROUND

One reason that motivational interviewing (MI) is thought to translate well to a variety of treatment domains is due to the focus on client ambivalence.

AIMS

Therefore, the current study aimed to explore the construct of ambivalence in the context of MI and cognitive behavioural therapy (CBT) for social anxiety disorder (SAD).

METHOD

Participants were 147 individuals diagnosed with SAD who were randomised to receive either MI or supportive counselling prior to receiving group CBT for SAD.

RESULTS

The results suggested that MI was not related to decreases in general ambivalence or treatment ambivalence, although an indicator of treatment ambivalence was found to predict worse treatment outcome.

CONCLUSIONS

The findings suggest that three sessions of MI prior to CBT may not decrease ambivalence in participants with SAD, which may underscore the potential importance of tackling ambivalence as it arises during CBT.

Predicting outcomes and sudden gains from initial in-session interactions during remote cognitive-behavioural therapy for severe health anxiety

There has been a dramatic increase in remote psychotherapy since the onset of the COVID-19 crisis. There is also expected to be an increase in mental health problems in the wake of the COVID-19 pandemic. An increase in severe health anxiety (SHA) is particularly anticipated, for which cognitive-behavioural therapy (CBT) is a frontline treatment. However, it is unclear what interaction types are associated with outcome-improvement in remote-CBT (rCBT) for SHA. This study aimed to identify interaction types that predict outcomes and sudden gains in rCBT for SHA using initial therapy session content. Forty-eight participants in rCBT for SHA had interactions at their first sessions categorized and rated in terms of patient activation: an individual's confidence and ability to manage their health. Multilevel modelling assessed whether early interaction types predicted session-by-session wellbeing. For participants experiencing sudden gains (n = 12) interactions at the session directly prior to the gain were similarly categorized and rated. The scores were then compared with ratings for the preceding session. A smaller proportion of early sessions was taken up with problem descriptions among those with greater outcome improvements. There was also a significant reduction in the proportion of the session spent describing problems in the session directly prior to a sudden gain, as compared with the previous session. Conversely, clients with better outcomes made more positive evaluations of themselves and therapy, noticed more positive changes and made more contributions to structuring interactions at initial sessions. Specific early interaction types predict session-by-session outcomes and precede sudden gains in rCBT for SHA.

Development and validation of the Readiness for Therapy Questionnaire (RTQ)

BACKGROUND

Motivational factors are generally regarded as an important ingredient for change in therapy. However, there is currently a lack of available instruments that can measure clients' readiness for change in therapy.

AIM

The objective of this paper was to create an instrument, the Readiness for Therapy Questionnaire (RTQ), which could measure clients' readiness for change.

METHOD

The RTQ was created by researchers following analysis of themes drawn from a review of the literature and interviews with patients at the end of therapy. This included both people who completed therapy and those who dropped out. As part of the standard assessment process, the RTQ was administered to 349 participants (69.6% female and 30.4% male; mean age 37.1 years; 90.5% Caucasian) who were patients at a psychological therapy service for common mental health difficulties.

RESULT

An initial 12-item scale was reduced to 6 items. This scale significantly correlated with post-therapy PHQ-9 and GAD-7 scores and changes in these scores across therapy. After controlling for baseline scores and demographic variables, a logistic regression showed that scores on this 6-item measure pre-therapy significantly predicted three outcome variables: completing therapy, being recovered on both PHQ-9 and GAD-7 post-therapy, and having a reliable change in both the PHQ-9 and GAD-7 post-therapy. However, receiver operating characteristic (ROC) curve analysis showed the measure had poor sensitivity and specificity. Symptom severity did not have a significant impact on motivation to change.

CONCLUSION

The RTQ is potentially a valid measure with useful clinical applications in treatment of common mental health difficulties.

Motivational interviewing for social anxiety disorder: An examination of the technical hypothesis

ABSTRACT Background and objective: Motivational interviewing (MI) was originally developed to treat problematic drinking but is increasingly integrated into treatment for anxiety disorders. A causal model has been proposed which suggests technical and relational factors may account for the efficacy of MI. The technical hypothesis suggests that therapist MI-consistent behaviours are related to client change talk, and change talk is linked to treatment outcome. Research examining the technical hypothesis has typically been conducted in MI for substance use; therefore, the current study aimed to explore the technical hypothesis in MI for social anxiety disorder (SAD). Method: Participants diagnosed with SAD (n = 85) each received MI prior to receiving group cognitive-behavioural therapy (CBT). MI sessions were coded for behaviours relevant to the MI technical hypothesis. Results: The proportion of MI-consistent therapist behaviours and reflections of change language significantly predicted the proportion of change talk by the client during MI sessions; however, therapist and client behaviours did not predict treatment outcome. Conclusion: The findings support one path of the MI causal model in the context of social anxiety, though indicate that the occurrence of these behaviours during an MI pre-treatment may not extend to predict treatment outcome following CBT.

Ambivalence in Psychotherapy Questionnaire: Development and validation studies

Research emphasizes that individuals' engagement with change process is a significant predictor of therapeutic outcomes. Ambivalence is a natural phenomenon in change processes, but when individuals cannot overcome it, their problems may intensify. Ambivalence towards change, a client variable characterized by an intrapersonal conflict between two positions of the self, one in favour of change and another one in favour of the status quo, is shown to play a determinant role in psychotherapy. Despite its importance, few empirical studies have examined this process, and the considerable methodological differences among existing studies make it difficult to generalize results. Therefore, instruments measuring ambivalence in an effective way can help broaden the understanding of the process. First, we performed a content analysis of ambivalence events identified in psychotherapy sessions from previous studies using an observational coding system. The factor structure, reliability and validity of the measure were tested using 91 and confirmed with 223 psychotherapy clients at any time during the therapeutic process. A two-factor structure was found, suggesting two components of Ambivalence-Demoralization and Wavering. The results indicated that the Ambivalence in Psychotherapy Questionnaire exhibits good psychometric properties, including good convergent and divergent validity. The implications are discussed.

Ambivalence Predicts Symptomatology in Cognitive-Behavioral and Narrative Therapies: An Exploratory Study

Background: The identification of poor outcome predictors is essential if we are to prevent therapeutic failure. Ambivalence - defined as a conflictual relationship between two positions of the self: one favoring change and another one favoring problematic stability - has been consistently associated with poor outcomes. However, the precise relationship between ambivalence and clients' symptomatology remains unclear. Objective: This study aims at assessing ambivalence's power to predict symptomatology, using a longitudinal design. Methods: The complete 305 sessions of 16 narrative and cognitive-behavioral cases have been analyzed with the Ambivalence Coding System and outcome measures have been used for each session. Results: Ambivalence emerged as a significant predictor of subsequent symptomatology suggesting that ambivalence is not only related to treatment outcomes, but that it represents a strong predictor of subsequent symptomatology. Discussion: The implications of ambivalence's power to predict outcomes for research and clinical practice are discussed.

The predictive capacity of self-reported motivation vs. early observed motivational language in cognitive behavioural therapy for generalized anxiety disorder

Client motivation to change is often considered a key factor in psychotherapy. To date, research on this client construct has largely relied on self-report, which is prone to response bias and ceiling effects. Moreover, self-reported motivation has been inconsistently related to treatment outcome. Early observed client in-session language may be a more valid measure of initial motivation and thus a promising predictor of outcome. The predictive ability of motivational factors has been examined in addiction treatment but has been limited in other populations. Addressing this lack, the present study investigated 85 clients undergoing cognitive behavioural therapy (CBT) alone and CBT infused with motivational interviewing (MI-CBT) for severe generalized anxiety disorder. There were two aims: (1) to compare the predictive capacity of motivational language vs. two self-report measures of motivation on worry reduction and (2) to examine the influence of treatment condition on motivational language. Findings indicated that motivational language explained up to 35% of outcome variance, event 1-year post-treatment. Self-reported motivation did not predict treatment outcome. Moreover, MI-CBT was associated with a significant decrease in the most detrimental type of motivational language compared to CBT alone. These findings support the importance of attending to in-session motivational language in CBT and learning to respond to these markers using motivational interviewing.