Comparing Therapist Responsivity to Resistance Markers in Cognitive-Behavioural Therapy and Motivational Interviewing Integrated with Cognitive-Behavioural Therapy for Generalized Anxiety

While therapist supportive, rather than directive, strategies have been particularly indicated during client resistance, little systematic research has examined how therapists responsively navigate resistance (Aviram et al., 2016; Westra & Norouzian, 2018). In the context of Cognitive-Behavioural Therapy (CBT) for Generalized Anxiety Disorder (GAD; Westra et al., 2016), the present study examined (1) the degree to which therapist management of resistance differs 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 behaviours differentiating therapy groups during resistance on client worry outcomes immediately posttreatment and 1-year posttreatment. An adapted version of the Client Resistance Code (Chamberlain et al., 1984; Westra et al., 2009) was used to identify episodes of client resistance to therapist direction, and specific moments of disagreement were rated for therapist behaviour (i.e., degree of interpersonal affiliation, control and hostility) using the Structural Analysis of Social Behavior (Benjamin, 1974). Therapists trained in MI integrated with CBT were found to exhibit significantly more affiliative and fewer hostile behaviours during disagreement episodes compared to those trained in CBT-alone. Increased therapist affiliation during disagreement episodes was also found to mediate client 1-year posttreatment outcomes, such that increased therapist affiliation as facilitated by MI-CBT vs. CBT-alone was associated with improved outcomes. Increased therapist hostility also mediated 1-year outcomes, demonstrating increased therapist hostility as facilitated by CBT-alone vs. MI-CBT was associated with poorer outcomes at 1-year posttreatment. This study highlights the value of training therapists in the responsive detection and management of client resistance, as well as the systematic integration of relational models, such as MI, with more action-oriented treatment approaches. Findings have significant capacity to improve clinical decision-making and therapist effectiveness, thereby improving the efficacy of CBT for GAD.