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Therapist Awareness of Client Resistance in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder a

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Kimberley M. Hara , Henny A. Westra , Adi Aviram , Melissa L. a

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Button , Michael J. Constantino & Martin M. Antony a

Department of Psychology, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada b

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Department of Psychological and Brain Sciences, University of Massachusetts Amherst, 612 Tobin Hall-135 Hicks Way, Amherst, MA 01003-9271, USA c

Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3, Canada Published online: 22 Jan 2015.

To cite this article: Kimberley M. Hara, Henny A. Westra, Adi Aviram, Melissa L. Button, Michael J. Constantino & Martin M. Antony (2015): Therapist Awareness of Client Resistance in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder, Cognitive Behaviour Therapy, DOI: 10.1080/16506073.2014.998705 To link to this article: http://dx.doi.org/10.1080/16506073.2014.998705

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Cognitive Behaviour Therapy, 2015 http://dx.doi.org/10.1080/16506073.2014.998705

Therapist Awareness of Client Resistance in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder Kimberley M. Hara1, Henny A. Westra1, Adi Aviram1, Melissa L. Button1, Michael J. Constantino2 and Martin M. Antony3 1

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Department of Psychology, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada; 2Department of Psychological and Brain Sciences, University of Massachusetts Amherst, 612 Tobin Hall-135 Hicks Way, Amherst, MA 01003-9271, USA; 3Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3, Canada Abstract. Clients’ resistance relates negatively to their retention and outcomes in psychotherapy; thus, it has been increasingly identified as a key process marker in both research and practice. This study compared therapists’ postsession ratings of resistance with those of trained observers in the context of 40 therapist–client dyads receiving 15 sessions of cognitive-behavioral therapy for generalized anxiety disorder. Therapist and observer ratings were then examined as correlates of proximal (therapeutic alliance quality and homework compliance) and distal (posttreatment worry severity) outcomes. Although there was reasonable concordance between rater perspectives, observer ratings were highly and consistently related to both proximal and distal outcomes, while therapist ratings were not. These findings underscore the need to enhance therapists’ proficiency in identifying important and often covert in-session clinical phenomena such as the cues reflecting resistance and noncollaboration. Key words: client resistance; therapist awareness; CBT; generalized anxiety. Received 1 September 2014; Accepted 11 December 2014 Correspondence address: Kimberley M. Hara, Department of Psychology, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada. Tel: þ1 416-986-5096. Email: [email protected]

Clinicians have long considered client resistance, or opposition to the direction set by the therapist or therapy (Westra, Aviram, Kertes, Ahmed, & Connors, 2009), as a clinically important variable in psychotherapy. Examples of resistance include the therapist asking a question and the client ignoring it, the therapist making a suggestion and the client disagreeing, or the therapist making a reflection and the client interrupting. These experiences may be especially salient in action-oriented therapies, such as cognitivebehavioral therapy (CBT), where therapist guidance or demand might promote resistance among clients who are ambivalent about change (e.g., Leahy, 2001; Sanderson & Bruce, 2007; Westra, 2012). While CBT is widely regarded as an effective treatment for anxiety (e.g., Chambless et al., 1996), treatment nonresponse is a common q 2015 Swedish Association for Behaviour Therapy

occurrence, with approximately 60% of individuals with anxiety partially responding or not responding to treatment (Westen & Morrison, 2001). In the area of generalized anxiety disorder (GAD) specifically, up to half of clients are nonresponders to treatment (Hunot, Churchill, Teixeira, & Silva de Lima, 2007). Client ambivalence or “resistance to treatment” is considered a critical factor limiting treatment response to CBT (Leahy, 2001; Westra, 2004). Individuals with GAD have been found to be particularly ambivalent about change, often holding both positive (e.g., “worry prevents bad things from happening”) and negative (e.g., “worry interferes with my life”) beliefs about worry (Borkovec & Roemer, 1995; Westra, 2004). This ambivalence is often expressed indirectly when clients are required to comply with the requirements of effective CBT (e.g., in the form of homework

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noncompliance, debating with the therapist, and failure to take an active role in sessions) (Newman, 2002; Westra, 2004). Across a growing research base, client resistance, as opposed to collaboration or compliance with therapist direction, relates consistently and negatively to treatment processes and outcomes. For example, higher levels of resistance have been shown to consistently relate to poor outcomes and disengagement in therapy (Gomes-Schwartz, 1978; Jungbluth & Shirk, 2009; Miller & Rollnick, 1991), and with the early termination of treatment (Beutler, Harwood, Michelson, Song, & Holman, 2011; Piper et al., 1999; Strupp, 1980). In a review by Beutler, Rocco, Moleiro, and Talebi (2001) exploring the predictive capabilities of resistance, 82% of studies showed that client resistance negatively impacted treatment outcomes. In a more recent work examining the effectiveness of CBT for GAD, Aviram and Westra (2011) found that as early as the first session of therapy, higher levels of resistance strongly and reliably predicted poorer outcomes even up to 1 year posttreatment, reflecting a lack of collaboration between client and therapist. This study also demonstrated that the level of resistance predicted subsequent engagement in therapy sessions and homework completion (Aviram & Westra, 2011). Furthermore, in this context, early resistance has been found to account for over 30% of the variance in posttreatment outcomes (Westra, 2011). Thus, the empirical case for resistance as a key clinical marker is strong. Arguably, the first step for therapists to address client resistance effectively is to be able to identify it (Binder & Strupp, 1997; Miller & Rollnick, 2002; Westra, 2012). Yet, surprisingly little is known about therapist awareness of client resistance, and whether this awareness is associated with client outcomes. Although no previous study has examined such awareness directly, existing research suggests that therapists may have difficulty in identifying negative process and treatment failure (e.g., Castonguay, Boswell, Constantino, Goldfried, & Hill, 2010; Henry, Schacht, & Strupp, 1990; Hill, Thompson, & Corbett, 1992; Kendall, Kortlander, Chansky, & Brady, 1992), or otherwise tend to minimize it (Hunsley, Aubry, Verstervelt, & Vito, 1999). For example, studies concern-

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ing early therapy termination have found that therapists tend to maintain a protective self-serving bias, with clients’ negative perceptions of therapy often going unnoticed or unacknowledged (e.g., Pekarik & FinneyOwen, 1987; Todd, Deane, & Bragdon, 2003). Specifically, when comparing therapist and client reasons for terminating treatment, therapists were more likely than clients to endorse success as a determinant, while largely disregarding clients’ negative feelings that underlie termination, such as dissatisfaction with therapy. Notably, an emerging literature suggests that providing therapists with feedback regarding difficulties in treatment can enhance client outcomes (Lambert, Whipple, Smart, Vermeersch, & Nielsen, 2001; Miller, Duncan, Brown, Sorrell, & Chalk, 2006; Whipple et al., 2003). Given that resistance appears to be a critical therapy process variable, which may nevertheless go unnoticed or unacknowledged by therapists, this study sought to evaluate therapists’ awareness of client resistance directly. We did so in the context of CBT by comparing therapist postsession ratings of resistance with those of trained observers. We then examined therapist and observer ratings as correlates of both proximal (therapeutic alliance quality and homework compliance) and distal (posttreatment worry severity) outcomes. All data were collected in the context of a randomized controlled trial (RCT) of CBT for GAD (Westra, Constantino, & Antony, 2014). Given previous research that therapists may have difficulty in identifying negative processes (e.g., tensions or disharmony in the therapeutic relationship) in therapy, we expected that therapist and trained observer ratings of resistance would be discordant (with higher observer ratings reflecting more sensitivity to resistance moments) (e.g., Binder & Strupp, 1997; Castonguay et al., 2010; Henry et al., 1990; Hill et al., 1992; Kendall et al., 1992). In addition, based on previous research on resistance (Aviram & Westra, 2011), we expected that observer ratings of resistance would be strongly associated with both proximal and distal treatment outcomes. Moreover, we expected that observer ratings would uniquely predict variance in outcomes beyond therapist ratings. As a first test of therapist ratings,

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we made no prediction of their relation to treatment outcomes.

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Method Data for this study were derived from a larger RCT comparing an integrated treatment of motivational interviewing (MI) and CBT with CBT alone for severe GAD (Westra et al., 2014). Only dyads in the CBT alone group (N ¼ 40) were analyzed for this study. Likely due to the systematic training in the recognition and minimization of resistance in MI, levels of resistance have been found to be substantially lower in MI compared to CBT for GAD (Aviram & Westra, 2011). Given that levels of resistance have been shown to systematically differ between MI and CBT groups, there is no justification for collapsing the two treatment groups. Moreover, there would not be enough variability in the phenomena of interest, resistance, in this study in the MI–CBT group.

Participants Participants were recruited from community advertisements in the greater Toronto area. All participants had a principal GAD diagnosis based on the Structured Diagnostic Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1996).1 Criteria were also met for severe GAD, as defined by a Penn State Worry Questionnaire (PSWQ) score of 68 or higher (out of a possible 80) (Meyer, Miller, Metzger, & Borkovec, 1990). Clients agreed to refrain from engaging in any concurrent psychotherapy or from taking benzodiazepine medications. Clients who were concurrently using an antidepressant were required to be on a stable dose at study entry (i.e., for at least 3 months) and to remain on that dose throughout. Therapists. There were 13 CBT therapists (12 doctoral candidates in clinical psychology and 1 postdoctoral psychologist). All therapists were female. Each therapist saw between 1 and 7 cases, with a mean number of 4.3 clients per therapist. In the larger RCT, therapists were nested within treatment group in order to control for allegiance effects and to ensure that each therapist was not in a position of having to deliver treatment components in which they did not believe (or came to believe) were most effective (Westra et al., 2014). Thus, each CBT therapist

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delivered only CBT. Moreover, therapists self-selected into the treatment condition in the larger RCT (either CBT alone or MI – CBT). Training consisted of readings, as well as four daylong workshops including discussion and role-play. Therapists received case supervision for both practice and study cases, which consisted of videotape review and weekly individual meetings with one senior CBT psychologist and one postdoctoral fellow.

CBT treatment Treatment consisted of 15 weekly sessions of CBT. The treatment manual was constructed from a number of evidence-based protocols (e.g., Cote´ & Barlow, 1992; Craske & Barlow, 2006; Zinbarg, Craske, & Barlow, 2006) and included progressive muscle relaxation, cognitive restructuring (with a focus on probability overestimation and catastrophic thinking), and one or more additional behavioral strategies (e.g., behavioral experiments, reduction of worry behaviors, and imaginal exposure to feared outcomes). Therapists were instructed to implement treatment in a specific order (e.g., progressive muscle relaxation first, cognitive restructuring second, and behavioral strategies third), but the length of time spent on each component was left to the judgment of the therapist based on the needs and responsiveness of the client to each treatment element. Homework was routinely determined and common homework activities included self-monitoring, relaxation practice, thought records, and eliminating worry behaviors, among others.

Measures Penn State Worry Questionnaire (Meyer et al., 1990). The PSWQ is a widely used 16-item instrument assessing trait worry that was employed as the principal outcome measure. The PSWQ possesses high temporal stability and internal consistency, as reflected by a Cronbach’s a of .93 for all anxiety disorders, and .86 for GAD, as well as good convergent and discriminant validity (Brown, Antony, & Barlow, 1992; Meyer et al., 1990). It also differentiates individuals with GAD from those with other anxiety disorders (Brown et al., 1992). Scores range from 16 to 80, with higher scores indicating greater worry. The

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average Cronbach’s a for the PSWQ in this study was .80. Working Alliance Inventory—Short Form (Horvath & Greenberg, 1989; Tracey & Kokotovic, 1989). The Working Alliance Inventory—Short Form (WAI-S) is a widely used measure assessing the quality of the therapeutic relationship from both client and therapist perspectives. This pantheoretical instrument is composed of 12 items rated on a seven-point scale that assess Bordin’s (1979) proposed elements of the alliance: client and therapist bond, agreement on therapy goals, and agreement on therapy tasks. The WAI-S has demonstrated sound psychometric properties for both client and therapist versions (Horvath & Bedi, 2002). Internal consistency scores for the client version of this scale have been estimated at .93, and range from .85 to .88 for the subscales (Horvath & Greenberg, 1986, 1989). The WAI has also been shown to have high convergent validity with the Empathy Scale of the Barrett-Lennard Relationship Inventory (Barrett-Lennard, 1962) and is highly predictive of therapy outcomes (Horvath & Greenberg, 1986, 1989). Scores range from 12 to 84, with higher scores indicating higher perceived alliance quality. Only the client version of this instrument was utilized in the current study. The average Cronbach’s a for the WAI-S was .81 in the present study. The Homework Rating Scale II (Kazantzis, Deane, & Ronan, 2005). The Homework Rating Scale II (HRS-II) is a measure of client homework compliance consisting of 12 items rated on a five-point ordinal scale. The HRS-II measures various dimensions of homework compliance, including the quantity and quality of homework completed, engagement in homework, obstacles experienced when completing homework, beliefs in homework, and homework progress and mastery. The HRS-II consists of three subscales (i.e., Beliefs, Consequences, and Engagement), and a higher score on each subscale indicates superior performance in each domain. Both the client and therapist versions of the HRS-II have been found to possess good internal consistency (a ¼ .83 and .86 respectively) and high interrater reliability (overall intraclass correlation coefficientof .83) (Kazantzis et al., 2005; McDonald & Morgan, 2013). Moreover, clients’ positive beliefs and expectations

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about homework have been found to relate strongly to their engagement in homework tasks (McDonald & Morgan, 2013). The Cronbach’s a of the HRS-II in the present study was .80, and only clients completed this measure following each therapy session. Therapist ratings of resistance. Because there is no published measure of therapistrated resistance, we constructed one for this study. Namely, therapists responded to three items on a five-point Likert scale: (1) “In the session you just completed with your client, please approximate how often the client opposed or went against the direction you were setting/wanting to go in” (“Not at all” to “A whole lot”), (2) “How cooperative was the client in this session?” (“Not at all cooperative” to “Extremely cooperative”), and (3) “How often did you feel that you and the client were at cross-purposes?” (“Not at all” to “A whole lot”). The average Cronbach’s a for these items over the first six sessions was .83, indicating good internal consistency. Therapists also completed three visual analog scales (VASs) where they rated clients on the dimensions of Passive – active, Defensive – receptive, and Rigid– flexible. Although the VAS items are not a direct measurement of resistance as the Likert items, in general, the dimensions assessed were considered germane to the construct of resistance. The average Cronbach’s a for these items over the first seven sessions was .79, indicating good internal consistency. A higher score on each dimension indicated more positive therapist ratings (i.e., less resistance). Adapted Client Resistance Code (Westra, Aviram, et al., 2009). In the Client Resistance Code (CRC; Chamberlain, Patterson, Reid, Kavanagh, & Forgatch, 1984), resistance is defined as any behavior that opposes, blocks, diverts, or impedes the direction set by the therapist. Resistance can be expressed either directly (i.e., verbal statements such as “I do the breathing and it helps but it doesn’t fix it,” or “I just hate writing things down”) or indirectly (i.e., in process, such as disagreeing, ignoring, and interrupting). Rather than being considered a characteristic of clients, resistance is inextricably embedded in the interpersonal process between client and therapist and is thus considered a measure of interpersonal process. In this sense, this measure reflects the degree of willing compliance in the therapy process.

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The CRC consists of 11 categories of resistant behavior (e.g., disagreeing, blaming, sidetracking, and ignoring) and has been shown to possess good construct and predictive validity (Chamberlain et al., 1984; Patterson & Forgatch, 1985), as well as face and content validity (Bischoff & Tracey, 1995).2 Resistance coding. The central definition of resistance was retained in the adapted version of the CRC, but the coding was altered in a number of ways to enhance reliability and validity (Westra, Aviram, et al., 2009). First, the 11 subcategories of resistance in the CRC were collapsed to form a single resistance code. This was done given that the presence or absence of resistance was of primary interest, rather than the particular content forms of resistance as defined by the CRC. Moreover, using a global definition of resistance greatly aids in achieving reliability among coders in identifying complex processes such as resistance because reliability on a single score rather than multiple codes is more readily achievable. Second, rather than using transcripts and segmenting sessions into turns of talk or thought units, videotapes of sessions were segmented into 30-s time bins, and each time bin was coded. Using time bins has a number of advantages in that talk turns do not need to be identified and coding can be done directly from the videotape. This allows coders to focus on identifying the gestalt construct through the use of both verbal and nonverbal cues. In our experience, this is particularly important in coding resistance, given that intonations and inflections (rather than particular words) can often denote the presence and intensity of client opposition. We chose the specific length of the time bins given that we deemed it long enough to capture the construct of interest (i.e., resistance), while still being short enough to ensure valid coding. Following segmentation, each time bin is rated for the presence of resistance on a fourpoint scale ranging from 0 to 3. Namely, 0 reflects the absence of resistance (i.e., client is cooperative). A code of 1 reflects minimal or qualified resistance, either in process (e.g., “polite” or gentle responses where the client is not sending a unilateral message that he/she is going against the therapist) or in content (e.g., “I do the breathing and it helps, but it doesn’t fix it”). A code of 2 reflects clear and unequivocal resistance in process (e.g., ignor-

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ing, not responding, and talking over the therapist in order to oppose) or in content (e.g., clearly and unequivocally expressed doubts or disagreements; “Thought records don’t work for me”). Finally, a code of 3 represents hostile or confrontational resistance, which typically occurs in process (e.g., responses that are clearly overly firm and emphatic), but may also occur in content (e.g., “You’ve got your work cut out for you with me!”). The team of resistance coders consisted of three graduate students in clinical psychology (2 doctoral and 1 master’s level) and one Ph.D. psychologist. Two of the coders were involved in adapting the CRC for use with CBT for GAD. The remaining two coders were trained to the criterion over a period of 10 months. After reading the Manual for Rating Interpersonal Resistance (Westra, Aviram, et al., 2009), coders participated in a 2-day workshop and coded samples of publicly available therapy sessions, followed by therapy session videotapes from a previous RCT of CBT for GAD (Westra, Arkowitz, & Dozois, 2009). Next, the coders independently rated new practice sessions, meeting weekly to review discrepancies, until they achieved proficiency as assessed by 85% observed agreement. Coders were unaware of clients’ outcome status throughout the coding process. Interrater reliability was calculated throughout the coding process to reduce the possibility of coder drift and was calculated by double-coding 20% of all recordings. Weighted kappa coefficients were calculated for each pair of raters and ranged from .70 to .98, with a mean of .85, indicating good to excellent agreement (Fleiss, 1981).

Procedure Therapists completed resistance ratings immediately following each session. Trained observers coded observed resistance for each 30-s time bin in one randomly selected session in the early course of treatment (sessions 2– 7). Only one session was sampled because coding is highly labor-intensive and time-consuming. Moreover, previous research has consistently demonstrated that the coding of one early treatment session provides adequate information on which to base outcome predictions (Aviram & Westra, 2011). Finally, resistance levels tend to be highly correlated over time in

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therapy (e.g., early resistance with midtreatment resistance; Button, Westra, Hara, & Aviram, 2014). Given previous research indicating that clear, unequivocal resistance (a code of 2) was the most common code accounting for the highest outcome variance in the prediction of treatment outcomes (Aviram, Westra, & Eastwood, 2011), the present study only considered the frequency of clear resistance in observer coder ratings. That is, each time bin could receive a code of 1, 2, or 3, and only those time bins receiving a code of 2 (clear resistance) were considered in the present study. The frequency of clear resistance was calculated by dividing the number of 30-s time bins containing a code of 2 by the total number of time bins in the session. Clients completed the PSWQ at baseline and posttreatment. The WAI-S was completed after each session, and HRS-II ratings were completed after every other session beginning with session 2. HRS-II ratings for the present study were drawn from the session selected for coding when these coincided (i.e., even numbered sessions); when they did not coincide, the HRS-II score for the following session was analyzed.

Results Client demographics, including means and standard deviations for all study measures, are presented in Table 1. The study sample was mainly female and Caucasian, with a mean age of 34 years, a high rate of comorbidity, and some postsecondary education. Correlations between the various measures used in the present study are presented in Table 2. Of note, observer-rated resistance was found to be consistently related to posttreatment worry, homework compliance, and working alliance during treatment. In contrast, therapist-rated resistance was far less consistently related to the same indices. All variables were normally distributed.

Concordance between therapist and observer ratings of resistance The correlations between individual therapists’ and trained observers’ ratings of resistance are presented in Table 3. In general, there was fairly high correspondence between therapist observations and

Table 1. Sample characteristics Measure

CBT (N ¼ 40)

Penn State Worry Questionnaire Baseline M ¼ 75.36, SD ¼ 3.43 Post CBT M ¼ 41.55, SD ¼ 16.38 Observed resistance M ¼ 0.19, SD ¼ 0.15 Therapist-rated resistance Average of M ¼ 1.87, SD ¼ 0.94 Likert items Average of M ¼ 65.52, SD ¼ 18.55 VAS items Homework compliance M ¼ 31.10, SD ¼ 7.90 (HRS-II) Working Alliance M ¼ 71.53, SD ¼ 9.81 Inventory (WAI-S) Gender 36 female, 4 male Age M ¼ 34.57, SD ¼ 12.09 Ethnicity 30 Caucasian 5 Asian 3 Hispanic 2 African Canadian Marital status 18 Married/cohabitating 13 Never married 9 Divorced/widowed/ separated Employment status 10 Unemployed/ not in school 30 Employed/in school Highest level of 12 High school education 21 Postsecondary 7 Graduate school Worry chronicity M ¼ 13.82 years (range 1 – 45) Comorbidity 30 (75%) Anxiety disorder 16 (41%) Major depressive disorder/dysthymic disorder

trained observer ratings. Most correlations ranged from – .46 to –.61 and from .44 to .46. In particular, higher levels of observed resistance were significantly associated with therapist ratings of client opposition and lower cooperativeness, a greater sense of working at cross-purposes, and rating the client as more defensive and rigid.

Predicting homework compliance Table 4 presents the results of a series of hierarchical linear regressions examining the various proximal and distal outcome measures included in the present study. To conserve

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Table 2. Correlations among all measures Measure

1

2

3

4

5

6

7

1. Observed resistance



.52** p , .001 –

2 .40* p ¼ .010 .79** p , .001 –

.08 p ¼ .614 .18 p ¼ .261 2.24 p ¼ .132 –

.52** p , .001 .09 p ¼ .578 2.13 p ¼ .420 2.02 p ¼ .915 –

2.50** p , .001 2 .32* p ¼ .046 .25 p ¼ .117 .01 p ¼ .945 2 .38* p ¼ .016 –

2.51** p , .001 2.23 p ¼ .147 .35* p ¼ .027 .19 p ¼ .247 2.49** p , .001 .50** p , .001 –

2. Therapist resistance Likert 3. Therapist resistance VAS 4. PSWQ pre 5. PSWQ post 6. Client HW

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7. WAI

Note. For the purposes of this table, therapist responses to the Likert resistance items were averaged, as were their responses to the VAS resistance items; 1: observed resistance, 2: therapist-rated resistance, average of Likert items, 3: therapist-rated resistance, average of VAS items, note that higher scores equal greater client receptivity, 4: Penn State Worry Questionnaire (PSWQ) pretreatment, 5: PSWQ posttreatment, 6: client-rated homework, 7: working alliance inventory. *p , .05; **p , .001.

Table 3. Correlations between therapist and observer ratings of resistance Measure Therapist ratings of resistance Likert items Client opposition to therapist direction Cooperativeness of client Working at cross-purposes Visual analog scale items Passive –active Defensive – receptive Rigid – flexible

Observed resistance

associated with client-rated homework compliance. In contrast, observer ratings of resistance were highly significantly related to homework compliance. Namely, higher levels of observed resistance were associated with lower ratings of subsequent homework compliance.

r ¼ .44 ( p ¼ .004)** r ¼ 2 .61 ( p , .001)*** r ¼ .46 ( p ¼ .003)** r ¼ .04 r ¼ 2 .54 ( p , .001)*** r ¼ 2 .46 ( p ¼ .003)**

Note. **p , .01; ***p , .001.

power for the analyses, therapist responses to the Likert items for rating resistance were averaged, as were their responses to the VAS items. In the prediction of client-rated homework compliance, baseline PSWQ scores were entered into the equation in block 1 to control for initial symptom severity. Therapist ratings were then entered into the equation at block 2, along with observer-rated resistance. Neither therapist responses to the Likert resistance items nor their VAS ratings of resistance were

Predicting working alliance Hierarchical linear regression was also used to examine the relation between therapist and observer ratings of resistance and client-rated alliance immediately after the session (see Table 4). Again, baseline PSWQ scores were entered into the equation in block 1 in order to control for initial symptom severity. Therapist ratings were then entered into the equation at block 2, together with observer-rated resistance. While therapist responses to the Likert resistance items were not related to alliance ratings, their VAS ratings of resistance were significantly associated with client WAI ratings. That is, lower levels of therapist-rated resistance were associated with higher client ratings of the alliance. Similarly, observer ratings of resistance were found to be highly significantly associated with client-rated alliance. Again, higher levels of observed resistance were associated with significantly lower alliance.

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Table 4. Regression analyses examining therapist and observer ratings of resistance in the prediction of proximal and distal outcomes

DV: Client-rated homework compliance Block 1: R 2 change ¼ .00; F (1, 39) ¼ 0.01, p ¼ .927 Baseline PSWQ Block 2: R 2 change ¼ .32; F (4, 39) ¼ 4.03, p ¼ .009 Therapist-rated resistance: Likert items Therapist-rated resistance: VAS items Observer-rated resistance DV: Working Alliance Inventory Block 1: R 2 change ¼ .03; F (1, 39) ¼ 1.10, p ¼ .302 Baseline PSWQ Block 2: R 2 change ¼ .40; F (4, 39) ¼ 6.54, p , .001 Therapist-rated resistance: Likert items Therapist-rated resistance: VAS items Observer-rated resistance DV: Posttreatment Penn State Worry Questionnaire Block 1: R 2 change ¼ .00; F (1, 39) ¼ 0.01, p ¼ .915 Baseline PSWQ Block 2: R 2 change ¼ .30; F (4, 39) ¼ 3.69, p ¼ .013 Therapist-rated resistance: Likert items Therapist-rated resistance: VAS items Observer-rated resistance

b

t

.02

0.09

2.22 2.11 2.49

20.93 20.47 23.15

.17

1.05

2.05 .62 2.51

20.45 2.89 23.58

2.02

0.11

2.25 .00 .61

21.01 20.17 3.82

p

.927 .359 .643 .003** .302 .630 .006** ,.001*** .915 .322 .986 ,.001***

Note. PSWQ, Penn State Worry Questionnaire; DV, dependent variable; VAS, visual analog scale. **p , .01; ***p , .001.

Predicting treatment outcome Hierarchical linear regression was also utilized to examine the predictive capacity of therapist and observer ratings of resistance in relation to treatment (worry) outcomes (see Table 4). Here, baseline PSWQ scores were entered into the equation in block 1 to control for symptom severity. Therapist ratings and observer-rated resistance were then entered into the equation at block 2. Neither therapist responses to the Likert resistance items nor their VAS ratings of resistance were predictive of posttreatment PSWQ scores. In contrast, observer ratings of resistance were found to be highly significant predictors. That is, higher levels of observed resistance were associated with significantly greater posttreatment worry.

Discussion Unexpectedly, the present study revealed moderate agreement between CBT therapists’ ratings of resistance and those of trained observers in the context of CBT for GAD. This suggests that CBT therapists and observers are picking up on some similar

cues of opposition, defensiveness, and lack of collaboration between the client and the therapist. Nevertheless, despite some agreement on the presence of this problematic phenomenon, there was discrepancy in how the therapist and observer ratings correlated with the outcomes of interest. Specifically, trained observer ratings were consistently and substantively predictive of both proximal (postsession alliance and homework compliance) and distal (posttreatment worry) outcomes. In contrast, therapist ratings were less consistently related to outcomes, correlating with postsession alliance. One explanation for these findings may be that while therapists did in fact notice some similar cues of opposition to trained observers, therapists may have been more likely to identify the obvious or overt signals of resistance (e.g., disagreeing and arguing) while overlooking the more subtle or nuanced cues of opposition (e.g., withdrawing, passivity, and sidetracking), which observers were trained to identify. Signals of disharmony or noncollaboration are often far from obvious and can be quite covert, with complex and subtle interpersonal cues (tone, inflection,

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pauses, posture, gestures, etc.) reflecting opposition (Watson & Greenberg, 2000; Westra, 2012). Moreover, difficulties in identifying opposition are further magnified because clients do not freely and openly express their concerns about therapy (Rennie, 1993; Rhodes, Hill, Thompson, & Elliott, 1994), and therapists have difficulty in identifying negative processes in which they are recipients or participants (Binder & Strupp, 1997). Previous research also suggests that therapists often hold self-serving biases, further compounding difficulties in acknowledging negative processes or treatment failure (e.g., Hill et al., 1992; Hunsley et al., 1999; Todd et al., 2003). This interpretation of the findings fits with our own experience in training resistance coders. Training is often a difficult process because resistance is typically expressed indirectly and in a complex manner (e.g., contradictory cues in which nonverbal cues undermine seemingly cooperative verbal statements), and one must learn to notice and decipher the nonverbal and often very subtle cues signaling opposition. These cues also tend to build up gradually over the course of the session, and may be particularly difficult to notice when one is an active participant in the session (with many other things to attend to), and lacks specific observational training. Importantly, these findings strongly suggest that therapist observation of key process phenomena such as resistance is not automatic and cannot be assumed. Rather, specific training in the identification of in-session cues of opposition and noncollaboration is needed to detect phenomena that have been demonstrated to be empirically and critically related to outcomes, such as the phenomena informing the ratings of trained observers. Moreover, resistance is relatively rare when compared to moments of cooperation, and on an absolute level occurred in only 20% of all 30-s time bins in a session. That is, not all moments are equally significant and even though they may be rare, the ability to detect such key moments becomes particularly important for effective intervention. Interestingly, there is also evidence to support that enhancing therapist awareness of negative process can improve client outcomes. For example, Lambert et al. (2001) and Whipple et al. (2003) found that making therapists aware of difficulties in treatment (e.g., by

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giving therapists feedback when cases are failing) improves client outcomes. In addition, the fact that observers are able to pick out signals of resistance that relate powerfully to proximal and distal outcomes suggests that this awareness is a trainable skill. Moreover, models of effectively responding to resistance are emerging. For example, MI (Miller & Rollnick, 2002) is centered on the effective management of resistance, emphasizing the critical importance of therapist responsivity (Stiles, Honos-Webb, & Surko, 1998) to moment-to-moment motivational markers in treatment (e.g., Constantino, Boswell, Bernecker, & Castonguay, 2013; Miller & Rollnick, 2013; Westra, 2012). Increasing therapists’ awareness of signals of client resistance may improve therapist performance at key moments, and ultimately, enhance therapy outcomes. Similarly, Binder and Strupp (1997) stated that observational training of negative process should be a standard part of psychotherapy training, given their findings that negative process is enormously destructive and extremely difficult for therapists to identify and manage. In particular, they noted that, We have observed that senior and junior clinicians (and students) who spend a good deal of time reviewing therapy sessions, often for the purpose of doing process ratings for research, incur the fortuitous benefit of enhancing their capacity to detect subtle nuances of interpersonal interactions. Early exposure of novice therapists to a course in which they are coached in systematically analyzing the interpersonal process illustrated in videotaped therapy sessions—perhaps even doing process ratings with available research instruments—would be a useful addition to psychotherapy training curricula. (Binder & Strupp, 1997, p. 135).

Based on the findings of the present study, indicating that such observational skills cannot be assumed with standard training in a given modality (CBT in this case), we strongly echo this recommendation. Moreover, observation via video recording, in our experience, also has the unique advantage of facilitating skill development for effectively responding to resistance. Specifically, observation via video recording removes the pressure to immediately react, thus affording the luxury of time to brainstorm possible

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responses to often very provocative or therapeutically challenging client responses and/or behaviors. Moreover, such training also allows one to disconnect from interactions, which can be highly charged, thus allowing the distance necessary for more helpful responses to emerge. In terms of limitations, this study exclusively examined those with GAD in CBT. It would be important to examine whether these findings would extend to other treatment approaches beyond CBT and to other clinical populations beyond individuals with GAD. In addition, the use of a nonvalidated measure of therapist ratings of resistance is an important limitation. Moreover, observers and therapists completed two different measures of resistance, contributing to measurement error. While this was done out of necessity, it is possible that the therapist measure did not adequately capture therapist approximation of client resistance. Nevertheless, the finding of some significant convergence with trained observer coding is promising for the scale’s validity in capturing client resistance. Future studies should use validated measures of therapist assessment of resistance and, if possible, have observers and clients complete at least one of the same measures. It may also be useful for future studies to attempt to disentangle whether therapists are indeed picking up explicit cues and missing more covert forms of resistance. Finally with respect to study limitations, the sample size was relatively small and the study was correlational in nature. To our knowledge, this is the first study to examine therapist awareness of client resistance by comparing therapists’ and observers’ ratings of resistance. It serves as an initial test of the hypothesized importance of identifying client resistance and highlights the need for enhanced observational training of resistance for therapists. The results indicate that, although there was moderate correspondence between therapist and trained observer ratings of resistance, trained observer ratings were related significantly to both proximal and distal outcomes, while therapist ratings generally were not. With the foregoing in mind, this study replicates the usefulness and predictive capacity of observational measures of resistance, and suggests that there is a critical need to enhance therapist awareness of

this important phenomenon in psychotherapy training.

Acknowledgements The authors gratefully acknowledge financial support for this project from a Social Sciences and Humanities Research Council Award to Kimberley M. Hara and a Canadian Institute of Health Research Operating Grant (114909) awarded to Henny A. Westra, Michael J. Constantino, and Martin M. Antony.

Disclosure statement The authors have declared that no conflict of interests exists.

Notes 1. All clients also met provisional criteria for DSM-5 2.

(American Psychiatric Association, 2013), which was under development at the time of this study. In the context of CBT, it is important to note that homework noncompliance is not automatically considered resistance in the Adapted CRC. Resistance codes are not based on the content of discussions but rather on the disharmony in the underlying interpersonal process between the client and the therapist. It is very possible to have noncontentious discussions of homework problems and noncompliance in CBT, which would not be coded as resistance.

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