managing resistance in cognitive behavioural therapy adi aviram a dissertation subm

235 Pages·2015·1.3 MB·English

TESTING THE CONTEXT RESPONSIVITY HYPOTHESIS: MANAGING RESISTANCE IN
COGNITIVE BEHAVIOURAL THERAPY

ADI AVIRAM

A DISSERTATION SUBMITTED TO
THE FACULTY OF GRADUATE STUDIES
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

GRADUATE PROGRAM IN PSYCHOLOGY
YORK UNIVERSITY
TORONTO, ONTARIO

August 2015

© Adi Aviram, 2015
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Abstract
Despite growing recognition of the importance of context-responsivity in psychotherapy, and
recommendations to develop context-responsive models through identification of clinical
markers to which therapists need to be responsive, the notion of context-responsivity in relation
to key markers such as resistance remains largely understudied. The current study sought to
examine therapist responsiveness during identified moments of resistance (i.e., client
disagreement with therapist direction) in the context of cognitive-behavioural therapy (CBT) for
generalized anxiety disorder (Westra et al., 2015). There were two ways in which context-
responsivity was investigated. The first was to examine whether differences in therapist style
(i.e., more supportive and less directive behaviour) in the presence of disagreement go on to
predict proximal (i.e., level of subsequent resistance in the session following therapist
management of resistance) and distal (i.e., pre-to-post worry reduction) therapy outcomes. To
this end, the present study utilized the Manual for Rating Interpersonal Resistance (Westra et
al., 2009) to identify moments of client disagreement with therapist direction. In turn, the
Motivational Interviewing Treatment Integrity (MITI; Moyers et al., 2010) was used to rate
therapist use of theoretically indicated motivational interviewing (MI) skills (e.g., level of
empathy, collaboration, evocation, and support of client autonomy) during identified moments
of disagreement. The second approach to investigating context-responsivity was through
comparing variations in therapist MI adherence in the presence of disagreement, with variations
in therapist general MI adherence during randomly selected moments in therapy, in order to
examine whether the timing of therapist use of MI principles differentially impacts treatment
outcomes. Results indicated that clients whose therapists displayed higher levels of MI
relational conditions in the context of disagreement had substantially lower levels of subsequent
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resistance and post-treatment worry. Furthermore, while variations in therapist MI adherence in
the context of disagreement were consistently and substantially related to CBT outcomes,
variations in therapist general MI adherence were not. These findings provide support for the
context-responsivity hypothesis, and serve to suggest that systematic incorporation of the client-
centered relational conditions advanced in MI to the responsive management of resistance in
CBT is a valuable clinical endeavor which should become a priority for clinical training.
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Dedication
To my sister who always believed in me and challenged me to aim higher than I thought I could
achieve. To my brother, whose kind and unfettered spirit does not cease to amaze me, and has
taught me much about human tenacity. To my father, who taught me independence of thought,
and who, with his humour, has helped me to stay grounded when I was tempted to take life too
seriously. And to my mother, whose finely tuned empathy, perceptive ability, and deep
compassion have shaped my interest in, and understanding of the subtleties of human experience.
v

Acknowledgements
There are no words profound and gratitude-infused enough to express my deep
appreciation to my graduate supervisor, and indeed my mentor, Dr. Henny Westra. Your
dedication, guidance, and unwavering support have challenged me to grow as a clinician and
academic. Your capacity for critical thought and courage to challenge conventional beliefs has
taught me to be creative, and to hold my ideas unapologetically – with passion and conviction. I
have deeply enjoyed our long and spirited conversations about therapy process and the human
experience. You have provided me a foundation in psychology that will inspire me for a lifetime,
and I can only hope our invigorating, co-constructive conversations will continue as I embark on
the next steps of my career.
I would like to sincerely thank my committee members, Dr. Lynne Angus and Dr. Karen
Fergus, for their guidance and invaluable feedback on my dissertation, which has significantly
strengthened this research. My sincere thanks also go to Dr. David Flora for providing such
detailed and constructive feedback on the statistical analyses of this project, and to Melissa
Button and Kimberley Hara for their assistance in coding the numerous hours of psychotherapy
sessions that made this study possible. My heartfelt gratitude also goes to Dr. Bill Stiles for
taking the time to be on my committee. I have long admired his body of work and it is truly an
honour to have him participate in this process.
I am grateful to the wonderful faculty at York University who have provided me with
excellent clinical training and taught me to deeply believe that the client‟s process must be
trusted and respected. I have been particularly moved by Dr. John Eastwood whose ferocious
intellect has challenged and motivated me to become a thoughtful researcher and clinician.
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To my parents to whom this work is dedicated; your precious qualities have played a
crucial role in shaping the person, therapist, and researcher I am today. My accomplishments are
a reflection of the values you have instilled in me. This is your success too.
Finally, to Eran, who never ceases to amaze me with his steadiness, humility, and ability
to stay positive regardless of life‟s burdens. You encourage me to do the same. Thank you for
accompanying me through it all, and, like my father, for reminding me to laugh.
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TABLE OF CONTENTS
Abstract ........................................................................................................................................... ii
Dedication ...................................................................................................................................... iv
Acknowledgements ......................................................................................................................... v
Table of Contents .......................................................................................................................... vii
List of Tables .................................................................................................................................. x
List of Figures ................................................................................................................................ xi

Introduction ..................................................................................................................................... 1
Key Moments in Psychotherapy ................................................................................................. 2
Resistance ................................................................................................................................... 4
Psychoanalytic ........................................................................................................................ 5
Psychodynamic ....................................................................................................................... 6
Cognitive and Behavioural ..................................................................................................... 7
Humanistic .............................................................................................................................. 9
Summary ............................................................................................................................... 10
Responsiveness in Psychotherapy............................................................................................. 11
Therapist Responsivity in the Context of Resistance ............................................................... 18
Therapist Behaviours Influencing Client Resistance ............................................................ 19
The Need for Moment-to-Moment Studies on Therapist Responsiveness in the Context of
Resistance ............................................................................................................................. 24
The Motivational Interviewing Treatment Integrity (MITI) Coding System ....................... 27
Resistance and Noncompliance in CBT ................................................................................... 31
Management of Resistance in CBT ...................................................................................... 33
Aims of the Present Study......................................................................................................... 36

Method .......................................................................................................................................... 43
Participants and Selection ......................................................................................................... 43
Therapists and Therapist Training ........................................................................................ 45
Treatment .............................................................................................................................. 47
Self- and Clinician-Report Measures ........................................................................................ 48
Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990). ... 48
Therapist Ratings of Resistance. ........................................................................................... 48
Credibility and Expectancy Questionnaire (CEQ; Devilly & Borkovec, 2000). .................. 49
Process Measures and Method .................................................................................................. 49
Sample Selection ................................................................................................................... 50
Resistance Coding ................................................................................................................. 51
Disagreement Episode Identification .................................................................................... 51
MITI Coding for Disagreement Episodes ............................................................................. 52
Subsequent Resistance Coding ............................................................................................. 52
General MI Adherence Coding ............................................................................................. 52
Process Coding Measures ......................................................................................................... 53
Manual for Rating Interpersonal Resistance (Westra, Aviram, Kertes, Ahmed, & Connors,
2009). .................................................................................................................................... 53
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Motivational Interviewing Treatment Integrity (MITI 3.1.1; Moyers, Martin, Manuel,
Miller, & Ernst, 2010) ........................................................................................................... 56
Training and Reliability ............................................................................................................ 60
Resistance Coding ................................................................................................................. 60
MITI Coding ......................................................................................................................... 61

Results ........................................................................................................................................... 62
Sample Characteristics .............................................................................................................. 62
Preliminary Analyses ................................................................................................................ 62
Range of MI Adherence ........................................................................................................ 63
Consistency of Disagreement Management .......................................................................... 63
Intercorrelations of Measures ................................................................................................... 63
Behavioural Count Summary Scores during Disagreement and Study Outcome Measures 63
Behavioural Count Summary Scores during Randomly Selected 20-Minute Therapy
Segments and Study Outcome Measures .............................................................................. 64
Global Measures of MI Adherence and Study Outcome Measures ...................................... 65
Regression Analyses ................................................................................................................. 66
Hypothesis 1: Higher Ratings of CBT Therapist MI Adherence in the Context of Client
Disagreement will be Associated with Significantly Lower Ratings of Post-Treatment
Worry .................................................................................................................................... 66
Hypothesis 2: Higher Ratings of CBT Therapist MI Adherence in the Context of Client
Disagreement will be associated with Significantly Lower Levels of Subsequent Resistance
............................................................................................................................................... 67
Hypothesis 3: Higher Levels of CBT Therapist Context-Specific MI Adherence (i.e., During
Disagreement Episodes) will Result in Significantly Lower Ratings of Post-Treatment
Worry and Subsequent Resistance, when compared to CBT Therapist General MI
Adherence (i.e., During Randomly Selected Moments in Therapy) ..................................... 68
General MI Adherence in the Prediction of Post-Treatment Worry ................................. 69
General MI Adherence in the Prediction of Subsequent Resistance ................................ 69

Discussion ..................................................................................................................................... 70
Context Responsivity in CBT: What you do in the Presence of Resistance Matters ............... 72
Deviation of Effective Resistance Management from Existing CBT Recommendations .... 76
A Little Good Process Goes a Long Way? ........................................................................... 80
Context Responsivity in CBT: When you become More MI-Like Matters .............................. 83
Resistance is an Important Clinical Marker in Psychotherapy ............................................. 86
Why Might it be Important to be More „MI-Like‟ Especially at Moments of Client
Opposition? ........................................................................................................................... 89
Support for the „Responsiveness Critique‟ ......................................................................... 104
Could Management of Disagreement be a Key CBT Therapist Effect? ............................. 107
Clinical and Training Implications ......................................................................................... 111
Strengths, Limitations, and Future Directions ........................................................................ 119

References ................................................................................................................................... 126

Appendices .................................................................................................................................. 166
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Appendix A: Manual for Rating Interpersonal Resistance ..................................................... 166
Appendix B: Examples Illustrating the Beginning of Disagreement Episodes ...................... 184
Appendix C: Summary of MITI Global Scores on a Dimension from High (5) to Low (1) .. 186
Appendix D: Summary of MITI Behavioural Counts and Coding Considerations ................ 188
Appendix E: Example Illustrating High MI Adherence during Disagreement ....................... 193
Appendix F: Example Illustrating Low MI Adherence during Disagreement ....................... 202
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LIST OF TABLES

Table 1: Therapist Characteristics .............................................................................................. 216
Table 2: Sample Characteristics .................................................................................................. 217
Table 3: Means and Standard Deviations for Study Variables ................................................... 218
Table 4: Intercorrelations among Behavioural Count Summary Scores during Disagreement
Episodes ...................................................................................................................................... 219
Table 5: Intercorrelations among Behavioural Count Summary Scores during Randomly
Selected Therapy Segments ........................................................................................................ 220
Table 6: Intercorrelations among Primary Study Variables ....................................................... 221
Table 7: Random-Intercepts Models Examining Disagreement MI Adherence and General
MI Adherence in the Prediction of Worry Reduction ................................................................. 222
Table 8: Regression Analyses Examining Disagreement MI Adherence and General MI
Adherence in the Prediction of Subsequent Resistance .............................................................. 223