Disentangling the Impact of Resistance and Ambivalence on Therapy Outcomes in Cognitive Behavioural Therapy for Generalized Anxiety Disorder

Abstract

Resistance and ambivalence about change are increasingly recognized as important determinants of treatment outcomes. Moreover, resistance and ambivalence are thought to be theoretically related in that clients who are more ambivalent about change are more likely to demonstrate resistance to the process and tasks of treatment. In the context of cognitive behavioural therapy (CBT) for generalized anxiety disorder, the present study simultaneously examined early resistance and ambivalence using two observer-based coding systems in order to determine their inter-relationship and, importantly, to investigate their relative contributions to outcome. Resistance was also coded during mid-treatment in order to investigate possible mediation pathways. Early ambivalence (clients’ arguments against change or counter-change talk) was found to be no longer related to outcomes when early resistance was taken into account, suggesting that disharmony in the therapeutic relationship is more important to outcomes than ambivalence per se. Moreover, mid-treatment resistance partially mediated the relationship between early resistance and post-treatment worry severity. That is, higher early opposition to therapist direction is related to poorer outcomes, in part because it is associated with greater resistance during the working phase of CBT. The findings underscore the critical need for therapists to be sensitive to identifying resistance early and throughout treatment.

Keywords::

• ambivalence
• resistance
• motivation
• cognitive behavioural therapy
• anxiety

Acknowledgements

This work was supported by the Social Sciences and Humanities Research Council; Canadian Institute of Health Research; and National Institute of Mental Health [grant number R34-MH072615].Disclosure statement: The authors have declared that no conflict of interest exists.

Notes

^1. Note that there were no significant differences in CT and CCT ratings in tapes taken from the first versus the second sessions [CT: t(35) = − 1.80, p = .081; CCT: t(35) = .34, p = .735]. However, CT ratings from session 1 were marginally lower than CT ratings from session 2. When analyses were run using only session 1, the direction of the findings was the same.