Abstract
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.
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References
Amodei, N., & Lamb, R. (2004). Convergent and concurrent validity of the contemplation ladder and URICA scales. Drug and Alcohol Dependence, 73, 301–306. https://doi.org/10.1016/j.drugalcdep.2003.11.005.
Amrhein, P. C., Miller, W. R., Yahne, C. E., Palmer, M., & Fulcher, L. (2003). Client commitment language during motivational interviewing predicts drug use outcomes. Journal of Consulting and Clinical Psychology, 71, 862–878. https://doi.org/10.1037/0022-006X.71.5.862.
Anderson, R. A., & Rees, C. S. (2007). Group versus individual cognitive-behavioural treatment for obsessive-compulsive disorder: A controlled trial. Behaviour Research and Therapy, 45(1), 123–137. https://doi.org/10.1016/j.brat.2006.01.016.
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.
Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & May, J. T. E. (2010). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. USA: Oxford University Press.
Bieling, P. J., McCabe, R. E., & Antony, M. M. (2009). Group process in CBT. Cognitive-behavioral therapy in groups. New York: Gillford Press.
Bonsaksen, T., Lerdal, A., Borge, F.-M., Sexton, H., & Hoffart, A. (2011). Group climate development in cognitive and interpersonal group therapy for social phobia. Group Dynamics: Theory, Research, and Practice, 15(1), 32–48. https://doi.org/10.1037/a0020257.
Brogan, M. M., Prochaska, J. O., & Prochaska, J. M. (1999). Predicting termination and continuation status in psychotherapy using the transtheoretical model. Psychotherapy: Theory, Research, Practice, Training, 36, 105–113. https://doi.org/10.1037/h0087773.
Brown, T. A., Di Nardo, P. A., & Barlow, D. H. (1994). Anxiety disorders interview schedule for DSM-IV (adult version). Albany: Graywind.
Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety and mood disorders: Implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110, 49–58. https://doi.org/10.1037//0021-843X.110.1.49.
Campbell, S. D., Adamson, S. J., & Carter, J. D. (2010). Client language during motivational enhancement therapy and alcohol use outcome. Behavioural and Cognitive Psychotherapy, 38, 399–415. https://doi.org/10.1017/S1352465810000263.
Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6, 284–290. https://doi.org/10.1037/1040-3590.6.4.284.
Deutsch, M., & Gerard, H. (1955). A study of normative and informatio- nal social influences upon individual judgment. Journal of Abnormal and Social Psychology, 51, 629–636. https://doi.org/10.1037/h0046408.
DiClemente, C. C., Schlundt, D., & Gemmell, L. (2004). Readiness and stages of change in addiction treatment. The American Journal on Addictions, 13, 103–119. https://doi.org/10.1080/10550490490435777.
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.
Drieschner, K. H., Lammers, S. M., & van der Staak, C. P. (2004). Treatment motivation: An attempt for clarification of an ambiguous concept. Clinical Psychology Review, 23(8), 1115–1137. https://doi.org/10.1016/j.cpr.2003.09.003.
Dugas, M. J., Ladouceur, R., Léger, E., Freeston, M., Langlois, F., Provencher, M. D., et al. (2003). Group cognitive-behavioral therapy for generalized anxiety disorder: Treatment outcome and long-term follow-up. Journal of Consulting and Clinical Psychology, 71, 821–825.
Erickson, D. H., Janeck, A. S., & Tallman, K. (2009). Transdiagnostic group CBT for anxiety: Clinical experience and practical advice. Journal of Cognitive Psychotherapy, 23(1), 34. https://doi.org/10.1891/0889-8391.23.1.34.
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.
Glynn, L. H., & Moyers, T. B. (2010). Chasing change talk: The clinician’s role in evoking client language about change. Journal of Substance Abuse Treatment, 39, 65–70. https://doi.org/10.1016/j.jsat.2010.03.012.
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.
Hallgren, K. A., & Moyers, T. B. (2011). Does readiness to change predict in-session motivational language? Correspondence between two conceptualizations of client motivation. Addiction, 106, 1261–1269. https://doi.org/10.1111/j.1360-0443.2011.03421.x.
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.
Hill, R. J., Fishbein, M., & Ajzen, I. (1977). Belief, attitude, intention and behavior: An introduction to theory and research. Contemporary Sociology, 6(2), 244. https://doi.org/10.2307/2065853.
Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36, 427–440. https://doi.org/10.1007/s10608-012-9476-1.
Hornsey, M. J., Dwyer, L., Oei, T. P. S., & Dingle, G. A. (2009). Group processes and outcomes in group psychotherapy: Is it time to let go of “cohesiveness”? International Journal of Group Psychotherapy, 59(2), 267–278. https://doi.org/10.1521/ijgp.2009.59.2.267.
Hunter, J. A., Button, M. L., & Westra, H. A. (2014). Ambivalence and alliance ruptures in cognitive behavioral therapy for generalized anxiety. Cognitive Behaviour Therapy, 43, 201–208. https://doi.org/10.1080/16506073.2014.899617.
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.
Issakidis, C., & Andrews, G. (2004). Pretreatment attrition and dropout in an outpatient clinic for anxiety disorders. Acta Psychiatrica Scandinavica, 109(6), 426–433. https://doi.org/10.1111/j.1600-0047.2004.00264.x.
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.
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.
Keeley, M. L., Storch, E. A., Merlo, L. J., & Geffken, G. R. (2008). Clinical predictors of response to cognitive-behavioral therapy for obsessive–compulsive disorder. Clinical Psychology Review, 28(1), 118–130.
Keijsers, G. P., Kampman, M., & Hoogduin, C. A. (2001). Dropout prediction in cognitive behavior therapy for panic disorder. Behavior Therapy, 32(4), 739–749.
Krishnamurthy, P., Khare, A., Klenck, S. C., & Norton, P. J. (2015). Survival modeling of discontinuation from psychotherapy: A consumer decision-making perspective. Journal of Clinical Psychology, 71(3), 199–207. https://doi.org/10.1002/jclp.22122.
Lombardi, D. R., Button, M. L., & Westra, H. A. (2014). Measuring motivation: Change talk and counter-change talk in cognitive behavioral therapy for generalized anxiety. Cognitive Behaviour Therapy, 43, 12–21. https://doi.org/10.1080/16506073.2013.846400.
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.
Marker, I., & Norton, P. J. (2018). The efficacy of incorporating motivational interviewing to cognitive behavior therapy for anxiety disorders: A review and meta-analysis. Clinical Psychology Review, 62, 1–10. https://doi.org/10.1016/j.cpr.2018.04.004.
McConnaughy, E. A., DiClemente, C. C., Prochaska, J. O., & Velicer, W. F. (1989). Stages of change in psychotherapy: A follow-up report. Psychotherapy: Theory, Research, Practice, Training, 26(4), 494. https://doi.org/10.1037/h0085468.
McConnaughy, E. A., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research, and Practice, 20, 368–375. https://doi.org/10.1037/h0090198.
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.
Miller, W. R. (1985). Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin, 98(1), 84.
Miller, W. R. (2000). Motivational interviewing skill code (MISC): Coder’s manual. Albuquerque: University of New Mexico.
Miller, W. R., & Johnson, W. R. (2008). A natural language screening measure for motivation to change. Addictive Behaviors, 33, 1177–1182. https://doi.org/10.1016/j.addbeh.2008.04.018.
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.
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.
Muthén, B. O., & Satorra, A. (1995). Complex sample data in structural equation modeling. Sociological Methodology, 25(1), 267–316.
Muthén, L. K., & Muthén, B. (2014). Mplus user’s guide (Version 7.1). Los Angeles, CA: Muthén & Muthén.
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.
Norton, P. J. (2008). An open trial of a transdiagnostic cognitive-behavioral group therapy for anxiety disorder. Behavior Therapy, 39, 242–250. https://doi.org/10.1016/j.beth.2007.08.002.
Norton, P. J. (2012a). Group cognitive-behavioral therapy of anxiety: A transdiagnostic treatment manual. New York: Guilford.
Norton, P. J. (2012b). A randomized clinical trial of transdiagnostic cognitve-behavioral treatments for anxiety disorder by comparison to relaxation training. Behavior Therapy, 43, 506–517. https://doi.org/10.1016/j.beth.2010.08.011.
Norton, P. J., & Barrera, T. L. (2012). Transdiagnostic versus diagnosis-specific CBT for anxiety disorders: A preliminary randomized controlled noninferiority trial. Depression and Anxiety, 29, 874–882. https://doi.org/10.1002/da.21974.
Norton, P. J., & Kazantzis, N. (2016). Dynamic relationships of therapist alliance and group cohesion in transdiagnostic group CBT for anxiety disorders. Journal of Consulting and Clinical Psychology, 84, 146–155. https://doi.org/10.1037/ccp0000062.
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.
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.
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.
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.
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.
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.
Ryan, R. M., Plant, R. W., & O’Malley, S. (1995). Initial motivations for alcohol treatment: Relations with patient characteristics, treatment involvement, and dropout. Addictive Behaviors, 20(3), 279–297.
Sanderson, W. C., & Bruce, T. J. (2007). Causes and management of treatment-resistant panic disorder and agoraphobia: A survey of expert therapists. Cognitive and Behavioral Practice, 14, 26–35. https://doi.org/10.1016/j.cbpra.2006.04.020.
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.
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.
Sijercic, I., Button, M. L., Westra, H. A., & Hara, K. M. (2016). The interpersonal context of client motivational language in cognitive-behavioral therapy. Psychotherapy, 53, 13–21. https://doi.org/10.1037/pst0000017.
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.
Simpson, H. B., & Zuckoff, A. (2011). Using motivational interviewing to enhance treatment outcome in people with obsessive-compulsive disorder. Cognitive and behavioral practice, 18(1), 28–37.
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.
Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80, 547–559. https://doi.org/10.1037/a0028226.
Swift, J. K., & Greenberg, R. P. (2014). A treatment by disorder meta-analysis of dropout from psychotherapy. Journal of Psychotherapy Integration, 24, 193–207. https://doi.org/10.1037/a0037512.
Taylor, S., Abramowitz, J. S., & McKay, D. (2012). Non-adherence and non-response in the treatment of anxiety disorders. Journal of Anxiety Disorders, 26, 583–589. https://doi.org/10.1016/j.janxdis.2012.02.010.
Tucker, M., & Oei, T. P. S. (2007). Is group more cost effective than individual cognitive behaviour therapy? the evidence is not solid yet. Behavioural and Cognitive Psychotherapy, 35(01), 77. https://doi.org/10.1017/s1352465806003134.
Vallerand, R. J., & Thill, E. E. (1993). Introduction au concept de motivation. Introduction à la psychologie de la motivation. Paris: Ed. Etudes vivantes
Vogel, P. A., Hansen, B., Stiles, T. C., & Götestam, K. G. (2006). Treatment motivation, treatment expectancy, and helping alliance as predictors of outcome in cognitive behavioral treatment of OCD. Journal of Behavior Therapy and Experimental Psychiatry, 37(3), 247–255.
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.
Westra, H. A. (2011). Comparing the predictive capacity of observed in-session resistance to self-reported motivation in cognitive behavioral therapy. Behaviour Research and Therapy, 49(2), 106–113. https://doi.org/10.1016/j.brat.2010.11.007.
Westra, H. A. (2012). Motivational interviewing in the treatment of anxiety. USA: Guilford Press.
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.
Westra, H. A., Dozois, D. J., & Marcus, M. (2007). Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety. Journal of Consulting and Clinical Psychology, 75(3), 363. https://doi.org/10.1037/0022-006x.75.3.363.
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Marker, I., Salvaris, C.A., Thompson, E.M. et al. Client Motivation and Engagement in Transdiagnostic Group Cognitive Behavioral Therapy for Anxiety Disorders: Predictors and Outcomes. Cogn Ther Res 43, 819–833 (2019). https://doi.org/10.1007/s10608-019-10014-1
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DOI: https://doi.org/10.1007/s10608-019-10014-1