Responsive Management of Early Resistance in Cognitive–Behavioral Therapy for Generalized Anxiety Disorder

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Objective: Client resistance limits the efficacy of cognitive–behavioral therapy (CBT), rendering it an important process marker for clinicians. Yet, little is known about how CBT therapists’ responsively navigate resistance. This study examined whether differences in therapists’ behavior during moments of early resistance in CBT predict distal (posttreatment worry) and proximal (subsequent resistance) therapy outcomes. We hypothesized that clinicians’ use of supportive, motivational interviewing (MI)-consistent strategies versus directive CBT methods during resistance episodes would relate to more favorable outcomes. Method: Clients (N = 30) with severe generalized anxiety disorder (GAD) were treated with CBT (without MI) in the context of a randomized controlled trial. An adapted version of the Client Resistance Code was used to identify moments of client disagreement with therapist direction, and these episodes were rated for therapist behavior using the Motivational Interviewing Treatment Integrity (MITI). Context-specific variations in therapists’ MITI ratings during disagreement were compared with variations in ratings during randomly selected moments to examine whether the timing of therapist use of theoretically indicated MI skills differentially impacted outcomes. Results: Clients whose therapists displayed greater MI-consistent responses during disagreement had lower levels of posttreatment worry, t = −2.84, p = .009, and subsequent resistance, t = −2.96, p = .013. Additionally, MI-consistent behavior during disagreement was substantially related to treatment outcomes, but MI-like behavior during randomly selected therapy segments was not (t = −.15, p = .886 for posttreatment worry, and t = −.09, p = .934 for subsequent resistance). Conclusions: Findings support the importance of context-responsivity to resistance markers, suggesting that systematic incorporation of MI for managing resistance holds promise for improving CBT for GAD.

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