How important is client motivation in cognitive behavioural therapy (CBT) for generalized anxiety disorder (GAD)? As many practitioners know, delivering CBT to clients who are not quite ready to change can be a challenge. For example, client completion of homework between sessions is an important component of CBT, and when a client isn’t motivated to do so, progressing with CBT can become difficult. In fact, 67% of therapists identify low motivation early in therapy to limit the success of CBT, yet previous research finds that motivation is not consistently related to CBT outcomes. Why is there such a discrepancy between therapist sense and the literature?
In most research examining motivation early in therapy, motivation is assessed using self-report measures. This can lead to a number of issues—for example, clients wanting to put their best foot forward by not revealing to their therapist that they aren’t fully motivated (response bias). Another issue is that GAD is a multi-faceted disorder with a number of problem areas. Clients may be motivated to change some parts of their GAD (ex. worry that hinders their performance at work), but not other parts (ex. overpreparing). This is difficult to assess in self-report questionnaires which ask about motivation overall.
This study examined motivation using an observational measure called the MISC, which has recently shown success in measuring motivation in GAD and has successfully linked motivation to client outcome. The MISC overcomes problems associated with self report because it measures motivation by examining client statements for or against change that spontaneously occur in a therapy session. Thus, it is less prone to response bias, and it can capture motivation about any GAD symptom that is discussed. In this study, the predictive ability of the MISC was directly compared to commonly used self-report measures of motivation. We also looked at how motivation varied between two treatment groups: clients receiving CBT, and clients receiving CBT integrated with motivational interviewing (MI-CBT). Motivational interviewing is a technique that aims to enhance motivation in clients, and therefore we expected that clients in the MI-CBT group would speak more favourably about change.
Results of this study revealed that the MISC was much more predictive of outcome than the self-report measures. Furthermore, clients in the MI-CBT treatment group had less statements that were arguing against change, and thus the therapeutic relationship was more harmonious.
These results indicate that motivation may be more important in therapy than previous research has suggested, aligning with therapist sense that it is a crucial component. They also identify the MISC as a more precise measure of motivation that could be used in future research and therapist practice. These results also identify a possible solution to the common problem of low client motivation at treatment outset. If CBT therapists identify that their clients have a lot of statements arguing against change, they may consider integrating motivational interviewing into their therapy to decrease client opposition to change.
Read the full paper:
(2018) The predictive capacity of self-reported motivation vs. early observed motivational language in cognitive behavioural therapy for generalized anxiety disorder, Cognitive Behaviour Therapy,