Client Motivation and Engagement in Transdiagnostic Group Cognitive Behavioral Therapy for Anxiety Disorders: Predictors and Outcomes
- 136 Downloads
Client motivation is regarded as a key factor in cognitive behavioral therapy (CBT) for anxiety disorders. To date, client motivation has only been measured during individual-CBT, with little known about the predictive capacity of motivation in group settings. The current study aimed to explore the role of client motivation in group-CBT. Measuring motivation during individual-CBT has proven somewhat difficult with many self-report measures providing weak and inconsistent results. For this reason observational measures of motivation, such as rating client change (CT) language during CBT, have been trialled with some success. The current study aimed to measure motivation using an observational coding system of CT and counter change talk (CCT) during two components of group CBT: cognitive restructuring and exposure sessions. The study explored the predictive capacity of CT and CCT in determining treatment outcomes, and baseline characteristics that predicted in session CT and CCT. Results indicated that CT and CCT predicted different treatment outcomes depending on the stage of therapy. CT and CCT predicted symptom severity at post-treatment and slope of improvement in cognitive restructuring sessions. During exposure sessions only CCT was predictive of poorer treatment outcomes but CT determined client attendance and treatment drop out. Furthermore, baseline characteristics including symptom severity, education, and age were predictive of CT and CCT throughout treatment. These findings are discussed and comparisons are drawn to the role of motivation in individual-CBT. Limitations and implications of this research are explored, specifically the utility of coding motivational language using observational methods in group settings.
KeywordsAnxiety Cognitive behavioural therapy Group therapy Motivation Change talk
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.
Compliance with Ethical Standards
Conflict of interest
Isabella Marker, Chloe A. Salvaris, Emma M. Thompson, Thomas Tolliday and Peter J. Norton declare no potential conflicts of interest pertaining to this submission to Cognitive Therapy and Research.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
This article does not contain any studies with animals performed by any of the authors.
- Arch, J. J., & Ayers, C. R. (2013). Which treatment worked better for whom? Moderators of group cognitive behavioral therapy versus adapted mindfulness based stress reduction for anxiety disorders. Behaviour Research and Therapy, 51(8), 434–442. https://doi.org/10.1016/j.brat.2013.04.004.CrossRefPubMedGoogle Scholar
- Bieling, P. J., McCabe, R. E., & Antony, M. M. (2009). Group process in CBT. Cognitive-behavioral therapy in groups. New York: Gillford Press.Google Scholar
- Brown, T. A., Di Nardo, P. A., & Barlow, D. H. (1994). Anxiety disorders interview schedule for DSM-IV (adult version). Albany: Graywind.Google Scholar
- Dozois, D. J., Westra, H. A., Collins, K. A., Fung, T. S., & Garry, J. K. (2004). Stages of change in anxiety: Psychometric properties of the University of Rhode Island Change Assessment (URICA) scale. Behaviour Research and Therapy, 42, 711–729. https://doi.org/10.1016/S0005-7967(03)00193-1.CrossRefPubMedGoogle Scholar
- Glenn, D., Golinelli, D., Rose, R. D., Roy-Byrne, P., Stein, M. B., Sullivan, G., … Craske, M. G. (2013). Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement. Journal of Consulting and Clinical Psychology, 81(4), 639. https://doi.org/10.1037/a0033403.CrossRefPubMedPubMedCentralGoogle Scholar
- Glynn, L. H., & Moyers, T. B. (2012). Manual for the Client Language EAsy Rating (CLEAR) coding system: Formerly “Motivational Interviewing Skill Code (MISC) 1.1”. Retrieved from http://casaa.unm.edu/codinginst.html.
- Hara, K. M., Westra, H. A., Aviram, A., Button, M. L., Constantino, M. J., & Antony, M. M. (2015). Therapist awareness of client resistance in cognitive-behavioral therapy for generalized anxiety disorder. Cognitive Behaviour Therapy, 44, 162–174. https://doi.org/10.1080/16506073.2014.998705.CrossRefPubMedGoogle Scholar
- Huppert, J. D., Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2006). The interaction of motivation and therapist adherence predicts outcome in cognitive behavioral therapy for panic disorder: Preliminary findings. Cognitive and Behavioral Practice, 13, 198–204. https://doi.org/10.1016/j.cbpra.2005.10.001.CrossRefGoogle Scholar
- Jaurrieta, N., Jimenez-Murcia, S., Menchón, J. M., Alonso, M. D. P., Segalas, C., ÁLvarez-Moya, E. M., … Vallejo, J. (2008). Individual versus group cognitive–behavioral treatment for obsessive–compulsive disorder: A controlled pilot study. Psychotherapy Research, 18(5), 604–614. https://doi.org/10.1080/10503300802192141.CrossRefPubMedGoogle Scholar
- Jónsson, H., Hougaard, E., & Bennedsen, B. E. (2010). Randomized comparative study of group versus individual cognitive behavioural therapy for obsessive compulsive disorder. Acta Psychiatrica Scandinavica, 123(5), 387–397. https://doi.org/10.1111/j.1600-0447.2010.01613.x.CrossRefPubMedGoogle Scholar
- Maher, M. J., Wang, Y., Zuckoff, A., Wall, M. M., Franklin, M., Foa, E. B., & Simpson, H. B. (2012). Predictors of patient adherence to cognitive-behavioral therapy for obsessive-compulsive disorder. Psychotherapy and Psychosomatics, 81, 124–126. https://doi.org/10.1159/000330214.CrossRefPubMedPubMedCentralGoogle Scholar
- McEvoy, P. M., Burgess, M. M., & Nathan, P. (2014). The relationship between interpersonal problems, therapeutic alliance, and outcomes following group and individual cognitive behaviour therapy. Journal of Affective Disorders, 157, 25–32. https://doi.org/10.1016/j.jad.2013.12.038.CrossRefPubMedGoogle Scholar
- Miller, W. R. (2000). Motivational interviewing skill code (MISC): Coder’s manual. Albuquerque: University of New Mexico.Google Scholar
- Montaño, D., & Kasprzyk, D. (2008). Theory of reasoned action, theory of planned behaviour, and the integrated behavioural model. In K. Glanz, B. K. Rimer & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (pp. 67–96). San Francisco: John Wiley & Sons.Google Scholar
- Moyers, T. B., Martin, T., Christopher, P. J., Houck, J. M., Tonigan, J. S., & Amrhein, P. C. (2007). Client language as a mediator of motivational interviewing efficacy: Where is the evidence? Alcoholism: Clinical and Experimental Research, 31(3), 40s–47s. https://doi.org/10.1111/j.1530-0277.2007.00492.x.CrossRefGoogle Scholar
- Muthén, L. K., & Muthén, B. (2014). Mplus user’s guide (Version 7.1). Los Angeles, CA: Muthén & Muthén.Google Scholar
- Napper, L. E., Wood, M. M., Jaffe, A., Fisher, D. G., Reynolds, G. L., & Klahn, J. A. (2008). Convergent and discriminant validity of three measures of stage of change. Psychology of Addictive Behaviors, 22, 362–371. https://doi.org/10.1037/0893-164X.22.3.362.CrossRefPubMedPubMedCentralGoogle Scholar
- Norton, P. J. (2012a). Group cognitive-behavioral therapy of anxiety: A transdiagnostic treatment manual. New York: Guilford.Google Scholar
- Norton, P. J., & Price, E. C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. The Journal of nervous and mental disease, 195(6), 521–531. https://doi.org/10.1097/01.nmd.0000253843.70149.9a.CrossRefPubMedGoogle Scholar
- Oei, T. P., & Browne, A. (2006). Components of group processes: Have they contributed to the outcome of mood and anxiety disorder patients in a group cognitive-behaviour therapy program? American Journal of Psychotherapy, 60(1), 53–70. https://doi.org/10.1176/appi.psychotherapy.2006.60.1.53.CrossRefPubMedGoogle Scholar
- Otto, M. W., Behar, E., Smits, J. A., & Hofmann, S. G. (2008). Combining pharmacological and cognitive behavioral therapy in the treatment of anxiety disorders. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 429–440). New York: Oxford University Press.Google Scholar
- Poulin, L. E. (2018). The Predictive Capacity of Self-Reported Motivation vs. Observed Motivational Language in Cognitive Behavioural Therapy for Generalized Anxiety Disorder (Master’s Thesis). Retrieved from: https://yorkspace.library.yorku.ca/xmlui/handle/10315/35525?show=full.
- Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (2013). Applying the stages of change. Psychotherapy in Australia, 19(2), 10.Google Scholar
- Purdon, C., Rowa, K., & Antony, M. M. (2004). Treatment fears in individuals awaiting treatment of OCD. Paper presented at the meeting of the Association for Advancement of Behavior Therapy, New Orleans, LA.Google Scholar
- Romano, M. (2016). An examination of the process of Motivational Interviewing in the anxiety disorders (Doctoral Thesis). Retrieved from: https://royalsoc.org.au/images/pdf/journal/150-1-Romano.pdf.
- Rowa, K., Gifford, S., McCabe, R., Milosevic, I., Antony, M. M., & Purdon, C. (2014). Treatment fears in anxiety disorders: Development and validation of the treatment ambivalence questionnaire. Journal of Clinical Psychology, 70, 979–993. https://doi.org/10.1002/jclp.22096.CrossRefPubMedGoogle Scholar
- Satterfield, J. M. (1994). Integrating group dynamics and cognitive-behavioral groups: A hybrid model. Clinical Psychology: Science and Practice, 1(2), 185–196. https://doi.org/10.1111/j.1468-2850.1994.tb00019.x.CrossRefGoogle Scholar
- Sharp, D. M., Power, K. G., & Swanson, V. (2004). A comparison of the efficacy and acceptability of group versus individual cognitive behaviour therapy in the treatment of panic disorder and agoraphobia in primary care. Clinical Psychology & Psychotherapy, 11(2), 73–82. https://doi.org/10.1002/cpp.393.CrossRefGoogle Scholar
- Simpson, H. B., Maher, M. J., Wang, Y., Bao, Y., Foa, E. B., & Franklin, M. (2011). Patient adherence predicts outcome from cognitive behavioral therapy in obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 79, 247–252. https://doi.org/10.1037/a0022659.CrossRefPubMedPubMedCentralGoogle Scholar
- Spielberger, C. D., Gorsuch, R. L., Luschene, R. E., Vagg, P. R., & Jacobs, G. A. (1993). State-trait anxiety inventory for adults. Palo Alto: Mind Garden.Google Scholar
- Vallerand, R. J., & Thill, E. E. (1993). Introduction au concept de motivation. Introduction à la psychologie de la motivation. Paris: Ed. Etudes vivantesGoogle Scholar
- Weck, F., Grikscheit, F., Jakob, M., Hofling, V., & Stangier, U. (2015). Treatment failure in cognitive-behavioural therapy: Therapeutic alliance as a precondition for an adherent and competent implementation of techniques. British Journal of Clinical Psychology, 54, 91–108. https://doi.org/10.1111/bjc.12063.CrossRefPubMedGoogle Scholar
- Westra, H. A. (2012). Motivational interviewing in the treatment of anxiety. USA: Guilford Press.Google Scholar
- Westra, H. A., Arkowitz, H., & Dozois, D. J. (2009). Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A preliminary randomized controlled trial. Journal of Anxiety Disorders, 23(8), 1106–1117. https://doi.org/10.1016/j.janxdis.2009.07.014.CrossRefPubMedPubMedCentralGoogle Scholar