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

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.

Keywords::

• client resistance
• therapist awareness
• CBT
• generalized anxiety

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 (American Psychiatric Association, 2013), which was under development at the time of this study.

^2. 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.