Journal of Anxiety Disorders 75 (2020) 102276

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Journal of Anxiety Disorders

journal homepage: www.elsevier.com/locate/janxdis

Intermittent Motivational Interviewing and Transdiagnostic CBT for T

Anxiety: A Randomized Controlled Trial
Isabella Marker, Bronte E. Corbett, Sean P.A. Drummond, Peter J. Norton*
Monash University, Australia

A R T I C LE I N FO A B S T R A C T

Keywords: Recent meta-analytic findings suggest that Motivational Interviewing (MI) used as an adjunct to Cognitive
Motivational Interviewing Behavior Therapy (CBT) for anxiety disorders improves overall treatment outcomes (Marker & Norton, 2018).
CBT However, when used as a prelude to CBT, MI significantly increases the length of treatment and numerous
transdiagnostic studies note that the effectiveness of pre-treatment MI subsides over time. The current study adapted an already
anxiety disorders
established 12-session transdiagnostic CBT protocol (tCBT, Norton, 2012) to include one hour of MI spread
across four sessions of tCBT (sessions 1, 3, 8, and 10) at 15 minutes each, with the option of including additional
MI if resistance arose in therapy. Thirty-six treatment seeking adults with principal anxiety disorder diagnosis
were randomly assigned to receive intermittent MI and tCBT (iMI + tCBT) or tCBT and psychoeducation. Results
indicated that the iMI + tCBT condition significantly outperformed the tCBT condition on several primary
outcome variables. While no significant difference was found between the two groups on clinician rated scores of
participant principal anxiety disorder, differences were found on a composite index of participants’ self-report
measures of symptom improvement, and on clinician rated scores of global psychiatric functioning. These effects
were not moderated by baseline motivation or baseline ambivalence. The study also found that the iMI + tCBT
condition showed significantly greater improvement to comorbid conditions and greater reduction in self-report
depressive symptoms. The inclusion of MI did not impact participant drop out. This study provides further
support for integrating MI and tCBT and highlights that even small doses of MI can improve treatment outcomes,
without increasing length of usual therapy. Limitations and future research options are also discussed.

1. Introduction numerous transdiagnostic and diagnosis-specific CBT manuals exist, at

Recent meta-analytic findings suggest that Motivational
Interviewing (MI) used as an adjunct to Cognitive Behavior Therapy
(CBT) for anxiety disorders improves overall treatment outcomes
(Marker & Norton, 2018). The meta-analysis combined data of 12 trials
examining the efficacy of MI in combination with CBT (MI + CBT) and
CBT alone for a range of anxiety disorders including generalised anxiety
disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic
stress disorder (PTSD), social anxiety disorder, and panic disorder (PD).
Results indicated that combined MI and CBT approaches showed
greater symptom improvement at post-treatment than CBT alone, and
that this effect was not moderated by specific diagnoses. This finding
suggests that integrating MI strategies into CBT treatments for anxiety
disorders may improve treatment outcomes.
MI, a therapy initially developed for alcohol use disorders, aims to
explore and resolve ambivalence about change and fosters self-efficacy
to promote change behavior (Miller & Rollnick, 2002). Although
its core CBT is a proactive therapy, requiring the individual to challenge
cognitive and change avoidant behavioral patterns. Thus, motivation is
thought to play a large role in treatment response. Past research con-
firms the impact of early treatment motivation on symptom reduction
(Lombardi, Button, & Westra, 2014; Marker, Salvaris, Thompson,
Tolliday, & Norton, 2019) and improving other key process factors
known to impact treatment response such as therapeutic alliance
(Hunter, Button, & Westra, 2014) and treatment adherence (Simpson &
Zuckoff, 2011).
Beyond the practical inconveniences of treatment (e.g. time, cost)
and the challenges associated with completing components of treat-
ment, additional factors influence treatment ambivalence. Treatment
ambivalence has been defined as movements towards and away from
change and includes both ambivalence towards change and ambiva-
lence towards the means of facilitating change (Engle & Arkowitz,
2006). Characteristics contributing to anxiety pathology such as per-
fectionism (Kawamura, Hunt, Frost, & DiBartolo, 2001), worry (Hong,

⁎
Corresponding author at: School of Psychological Sciences, Level 4, Bldg 18 Innovation Walk, Clayton, 3800, Victoria, Australia.
E-mail address: Peter.Norton@monash.edu (P.J. Norton).

https://doi.org/10.1016/j.janxdis.2020.102276
Received 14 April 2019; Received in revised form 15 June 2020; Accepted 27 July 2020
Available online 31 July 2020
0887-6185/ © 2020 Elsevier Ltd. All rights reserved.
I. Marker, et al.
2007), and risk aversion (Lorian, Mahoney, & Grisham, 2012) are
perceived by clients to have both positive and negative implications.
For example, while worrying is often distressing for individuals with
GAD, positive beliefs about worry, such as believing that worrying
mentally prepares one for future hardships, are also common (Westra,
2012). Similarly, treatment ambivalence in PTSD has been described as
the dialectic of wanting support, while also wanting to evade difficul-
ties related to shame, trust, and trauma-related fear, and avoidance of
trauma stimuli (Resick, Monson, & Rizvi, 2008). Treatment ambiva-
lence has been found to be particularly common in both OCD and PTSD,
as CBT treatment requires individuals to withstand considerable levels
of anxiety in the face of feared stimuli without engaging in safety be-
haviors or avoidance (Resick et al., 2008; Simpson & Zuckoff, 2011).
Many treatment seekers even worry that exposure-based treatments
could exacerbate anxiety symptoms (Purdon, Rowa, & Antony, 2004;
Westra, 2012). Therefore, the utility of including MI alongside standard
CBT appears fruitful, as it may provide the opportunity for clients to
voice and resolve ambivalence as well as collaborate with their thera-
pist to find individualized and meaningful reasons to engage in a
treatment.
In most research settings, the two treatments have been combined
by including MI as a prelude to CBT, adding between one to four ses-
sions of MI, prior to commencing CBT (Marker & Norton, 2018). This
method allows clients to voice pre-treatment ambivalence and provides
opportunity to increase initial motivation by linking CBT goals to per-
sonal circumstances. Including MI in this manner is a valuable addition,
as clients entering treatment are often at varying levels of motivation
(Taylor & Asmundson, 2004). However, this method can substantially
increase the length of therapy, which in clinical settings may provide
further hindrance to accessing treatment due to increased cost and
time. Furthermore, this approach assumes that once individuals have
been sufficiently motivated, their levels of motivation remain constant.
This assumption both theoretically and empirically contradicts our
current understanding of motivation as a fluctuating state, and one that
changes over the course of therapy (Marker et al., 2019; Miller, 1985).
In research settings this explains why some studies that have tracked
client change scores over time found the initial symptom improvements
associated with MI to diminish over time (Barrera, Smith, & Norton,
2015; Yang & Strodl, 2011).
For these reasons it has been suggested to move towards a more
fully integrated approach of combining MI and CBT (Westra, 2012;
Naar & Safran, 2017). Three approaches have been trialled in the
context of anxiety disorders, all of which retain at least one session of
MI prior to CBT. The only known randomized controlled trail (RCT) to
attempt a fully integrated approach was published by Westra,
Constantino, and Antony (2016)). Using a sample of participants with
GAD, the study included up to four initial sessions of MI prior to the
commencement of CBT (11 sessions). During the CBT components of
treatment elements and techniques of MI were maintained. During the
trial, MI was encouraged as the therapeutic approach when resistance,
non-compliance, or ambivalence arose in sessions. Additionally, the
“spirit of MI,” a fundamental understanding that the therapeutic pro-
cess is grounded in collaboration and partnership and that the role of
therapist is to communicate compassion, acceptance, respect, and client
autonomy (Miller & Rollnick, 2012), was held throughout CBT. No
significant differences were found between the integrated MI and CBT
condition and the CBT alone condition at post-treatment, however
differences were found at follow-up favouring the integrated MI and
CBT approach.
The second approach of integrating MI and CBT again retains MI in
the initial sessions before commencing CBT. CBT is then maintained as
the therapeutic approach throughout, but MI techniques are en-
couraged to manage resistance as it becomes apparent to therapists.
This is consistent with prior CBT research showing that therapist use of
MI-consistent behaviour during times of resistance has positive effects
on treatment outcome (Aviram, Westra, Constantino, & Antony, 2016).
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Journal of Anxiety Disorders 75 (2020) 102276
The two trials that have used this approach in a PTSD (Blain, 2013) and
OCD sample (Simpson et al., 2010), included three initial MI sessions
prior to commencing CBT. Both trials utilized additional “MI modules,”
when therapists recognised resistance in session. No significant differ-
ences between the integrated MI and CBT and CBT alone condition
were found at post-treatment. While only Blain (2013) completed
follow-up assessments, these also found no differences between the
combined MI and CBT and CBT alone condition. Unfortunately, neither
trial documented how often nor with whom these additional MI mod-
ules were used, thereby reducing confidence in the extent MI and CBT
were integrated. A further explanation for the non-significant findings
may be that although therapists could deliver additional MI as re-
sistance arose during CBT, past research indicates that therapists have
trouble identifying resistance in session (Hara et al., 2015). Indeed, the
study by Westra and colleagues (2016) documented extensive training
of therapists including practice cases, video feedback and weekly su-
pervision by an expert in MI and CBT.
Although theoretically sound, these studies provide equivocal evi-
dence as to the effectiveness of the integrated MI and CBT approach.
Furthermore, the three trials all included large doses of MI (between 3
and 4 sessions) prior to commencing integrated MI and CBT, with a
combined treatment length of 15 (Blain, 2013; Westra et al., 2016) to
18 sessions (Simpson et al., 2010). Extending therapy to such a large
number of sessions is not always practical in clinical settings, and re-
moves the advantages offered by time-limited therapies such as CBT.
The final approach of integrating MI and CBT is to utilize MI at pre-
specified time points to provide opportunities to discuss ambivalence,
motivation, and self-efficacy intermittently throughout treatment. From
a theoretical perspective, this approach is unlikely to outperform fully
integrated or responsive-MI. However, it reduces both therapy time and
may be particularly useful to novice MI therapists who have difficulty
recognising and responding to resistance in session. Only one RCT has
been completed using the intermittent MI and CBT approach. Merlo
et al. (2010) included 20-30 minute sessions of MI prior to sessions 1, 4
and 8 of CBT in an adolescent OCD sample (n = 16). Participants were
said to have completed treatment at session 9, however were allotted up
to 14 sessions if symptom improvement was not yet adequate. The
study found that at the halfway point (session 5), the intermittent MI
and CBT group had a greater reduction in OCD symptoms, compared to
the CBT and psychoeducation condition. Although these differences
were not observed at post-treatment (session 14), the study found that
the intermittent MI group completed treatment on average three ses-
sions earlier than the CBT condition. This provides some preliminary
evidence that intermittent MI at fixed timepoints may be effective in
both reducing anxiety symptoms and length of treatment.
To date the intermittent MI and CBT approach has not been em-
pirically supported in adult anxiety populations. Considering the ben-
efits of this approach, the current authors conducted a series of case
studies examining an intermittent MI and transdiagnostic-CBT protocol
(iMI + tCBT; Marker & Norton, 2019). The iMI + tCBT protocol was
adapted from an already established 12-session transdiagnostic-CBT
protocol (tCBT; Norton, 2012) to include 15 minutes of MI spread
across four sessions (sessions 1, 3, 8, and 10), totalling one hour of MI.
Therapists were also encouraged to use MI techniques if they re-
cognised resistance in therapy. The protocol thus ensures that MI is
used at specific time points throughout therapy, without relying on the
therapist to recognise resistance. This bridges the gap between a fully
integrated and intermittent approach and does not require an extension
of therapy time. Three participants with principal anxiety disorder di-
agnoses completed the iMI + tCBT protocol. Results indicated a sub-
stantial decrease in both anxiety and depressive symptoms on all self-
report and clinician rated measures at post-treatment and three-month
follow-up, providing preliminary evidence for protocol feasibility.
However, given CBT is an already established evidence-based treatment
further analysis was required to ascertain whether intermittent MI was
adding benefit beyond that of CBT. Furthermore, in the addictive
I. Marker, et al. Journal of Anxiety Disorders 75 (2020) 102276

disorders realm, some researchers have argued that using MI when an
individual is already sufficiently motivated may be detrimental to the
therapeutic process (Hettema, Steele, & Miller, 2005).
As such, the primary aim of the current study to (1) examine the
effectiveness of the iMI + tCBT protocol using a small scale RCT, using
a tCBT and psychoeducation control group, and the secondary aims
were to (2) examine the impact of MI + tCBT on participant motiva-
tion, ambivalence, and dropout. Specifically for Aim 1, it was hy-
pothesised that iMI + tCBT would outperform the tCBT control condi-
tion on several outcome measures including clinician rated (primary
outcome) and self-report measures (secondary outcomes) at post-
treatment. For Aim 2, it was hypothesized that a) participant drop out
from treatment would be lower for the iMI + tCBT condition in com-
parison to the tCBT control condition; and b) baseline ambivalence and
motivation would moderate the relationship between baseline and post-
treatment outcomes for participants in the iMI + tCBT condition.
participant flow.
Participants were recruited through local newspaper and Facebook
advertisements, direct referral from local medical and mental health
professionals in the greater Melbourne area (Australia), and flyers
posted at a University campus, local shopping, and community centres.
Exclusion criteria for this study included (a) presence of cognitive im-
pairment, (b) inability to read and communicate in English efficiently,
(c) acute suicidality, or (d) psychosis or serious substance abuse, and
personality disorder diagnosis. Other than the exclusion of individuals
with diagnoses of psychosis, serious substance abuse, or personality
disorders, other comorbid psychiatric diagnoses were welcomed.
Thirteen participants were excluded from this study after assessment, as
they presented with a principal diagnosis other than anxiety, OCD, or
PTSD (predominantly depression). These individuals were enrolled in a
concurrent emotional disorders research trial.
2.2. Measures

2. Method This study used a battery of assessment measures including self-

report questionnaires and clinician rated assessments administered at
2.1. Participants pre and post-treatment. A 3-month follow-up assessment was in-
corporated into the trial design, but follow-up assessment attendance
Thirty-six treatment-seeking adults who met DSM-5 criteria for a was poor and differential across treatment condition, and the majority
principal anxiety disorder, OCD and/or PTSD diagnosis were rando- of participants failed to return 3-month follow-up self-report measures.
mized to receive intermittent MI and tCBT (iMI + tCBT; n = 18) or As such, only pre to post-treatment results are presented here.
tCBT alone (n = 18). Participant enrolment occurred between August,
2016, and May, 2018, with final follow-up data collected by December, 2.2.1. Anxiety and Related Disorders Interview Schedule for DSM-5
2018. A priori power analysis, setting 1-β at .80, α at .05, and using an The ADIS-5 (Brown & Barlow, 2014) was used during the assess-
estimated effect size of g = 0.59 based on the meta-analysis of Marker ment phase as a screening tool to ascertain the presence and severity of
and Norton (2018), indicated that a sample size of 32 would achieve anxiety, mood, and other related psychiatric diagnoses. The ADIS-5 is a
expected power. Another staff member of the clinic completed block semi-structured interview, which assesses current and past anxiety and
randomisation in groups of 4 to ensure balanced groups. See Table 1 for mood disorders based on the diagnostic criteria found in the Diagnostic
demographic and clinical characteristics of sample and Fig. 1 for and Statistical Manual of Mental Disorders (DSM-5). It also provides
screening questions for other psychiatric disorders such as alcohol and
Table 1 substance use disorders. Although the current version of the ADIS-5
Participant demographic and clinical characteristics does not have reliability data, its predecessor, the ADIS-IV (based on
Characteristic Total iMI + tCBT tCBT F p DSM-IV) has shown good to excellent inter-rater reliability (Brown, Di
Nardo, Lehman, & Campbell, 2001). Clinician Severity Ratings (CSR), a
Gender (female) 58.3% 61.1% 55.6% .39 .74
component of the ADIS-5, was used to quantify symptom severity and
Age (years) 41.08 (15.22) 41.56 (12.89) 40.61 .89 .86
(17.61) degree of impairment for each diagnosis. Scores range from 0 (not se-
Highest education: Frequency: vere at all) to 8 (very severe/distressing); a score of 4 (moderate im-
Less than H.S. 3 2 1 pairment) is deemed clinically significant and indicative of an anxiety
H.S. 16 7 9 disorder diagnosis (Barlow, 2014). ADIS-5 CSR scores were the primary
Undergraduate degree 14 8 6
Graduate degree 3 1 2
outcomes.
Marital status: Frequency: The ADIS-5 was administered pre and post treatment by clinical
Single 11 5 6 psychology doctoral students, blinded to the condition. Prior to the
Cohabitating 8 4 4 study doctoral students received training in the ADIS-5 by a clinical
Married 15 8 7
psychologist with extensive experience in conducting ADIS-5 inter-
Divorced/Separated 2 1 1
Race/ethnicity: Frequency: views. Training to reliability involved watching video recordings of
Caucasian 30 15 15 prior ADIS-5 assessments and rating a minimum of three ADIS-5 with
Asian 1 0 1 adequate diagnostic reliability (within one point divergence on CSR and
Indigenous Australian 1 1 0 Clinical Global Impressions). Via video recordings of assessments, 25%
Other 4 2 2
DSM-5 diagnosis: Frequency:
of ADIS-5 assessments (n = 9) were also selected at random and double
GAD 15 9 6 coded. Inter-rater reliability for principal anxiety disorder diagnosis
Social Phobia 11 6 5 showed 100% agreement (ICC = 1.0), and CSR severity ratings showed
Agoraphobia 2 0 2 good reliability (ICC = .79).
Panic Disorder 1 0 1
Specific Phobia 3 1 2
PTSD 1 1 0 2.2.2. Clinical Global Impressions (CGI)
Illness Anxiety 1 1 0 Two CGI (Guy, 1976) subscales were utilized in this study: the
ADNOS 2 0 2 Clinical Global Impression – Severity scale (CGI-S) and the Clinical
# anxiety diagnoses 1.92 (.91) 2.00 (.91) 1.83 (.92) .16 .59 Global Impression – Improvement scale (CGI-I), measuring symptom
Comorbid depression 38.9% 38.9% 38.9% .00 1.0
severity and treatment response respectively. The CGI-S ranges in
Note: Chi-squares for education, marital status, ethnicity, and DSM-5 diagnosis scores from 1 (normal, not at all ill) to 7 (among the most extremely ill
were not calculated due to small cell sizes. GAD = generalized anxiety disorder; patients). The CGI-I measures clinical improvement post treatment and
PTSD = post-traumatic stress disorder; ADNOS = anxiety disorder not other- ranges in scores from 1 (very much improved) to 7 (very much worse).
wise specified. Treatment response was considered for participants scoring 1 (very

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I. Marker, et al. Journal of Anxiety Disorders 75 (2020) 102276

Assessment
(ADIS-5; CGI)
n = 50

Excluded participants (n = 14):

n = 9; other principal psychiatric diagnosis
n = 2; unable to contact post-assessment
n = 2 acute suicidaility/risk concerns
n = 1; substance dependence requiring
attention

Randomized Randomized
tCBT iMI+tCBT
n = 18 n = 18

Feedback: ADIS-5 Feedback: ADIS-5

diagnoses; tCBT
overview; and psycho-
education (anxiety)
Measures: diagnosis
specific questionnaires
diagnoses; tCBT
overview; and psycho-
education (motivation)
Measures: diagnosis
specific questionnaires

Treatment: Treatment:
S1: Psycho-education S1: MI and psycho-
S2: Cognitive education
restructuring S2: Cognitive
S3: Cognitive restructuring
Drop out (n): restructuring S3: MI and cognitive Drop out (n):
S5 = 1 S4 = 1
S4-S9: Exposure restructuring
S8 = 1 = 3 S5 = 1 = 3
S10-S11: Core beliefs S4-S9: Exposure
S9 = 1 S8 = 1
S12: Relapse prevention (S8 includes MI)
Measures: ADDQ; BDI- S10: MI and core
II; CQ beliefs
S11: Core beliefs
S12: Relapse prevention
Measures: ADDQ; BDI-
II; CQ

3-Post-Treatment assessmentn
(ADIS-5; CGI)
n ==27; t BT ==13, iMI+ CBT== 14
Fig. 1. Participant Flow.

much improved) or 2 (much improved). Inter-rater reliability for CGI-S
and CGI-I showed good reliability (ICC = .79 and .79, respectively).
CGI-S and CGI-I scores were secondary outcomes for Aim 1.
2.2.3. Diagnosis specific self-report questionnaires
As the current study utilized a transdiagnostic anxiety protocol,
participants meeting any anxiety disorder diagnosis were invited to
complete this study. To obtain a self-report measure of symptom se-
verity participants were provided with a battery of diagnosis specific
self-report questionnaires completed at pre and post-treatment. These
questionnaires included 1) the 7-item Panic Disorder Severity Scale
(PDSS; Shear et al., 2001); 2) the 25-item Social Phobia Diagnostic
Questionnaire (SPDQ; Newman, Kachin, Zuellig, Constantino, &
Casham-McGrath, 2003); 3) the 9-item Generalized Anxiety Disorder
Questionnaire for DSM-5 (GADQ-5; Newman et al., 2002); 4) the 20-
item Dimensional Obsessive Compulsive Scale (DOCS; Abramowitz
et al., 2010); and 5) the 17-item Post-traumatic Stress Disorder
Checklist – Civilian Version (PCLC; Weathers, Huska, & Keane, 1991).
Each of these measures has shown acceptable psychometric character-
istics in outpatient anxiety disorder samples (Antony et al., 2001). All
measures showed good-excellent internal consistency at pre-treatment
(α = .78 to .94). Diagnosis-specific self-report questionnaires were
secondary outcomes for Aim 1.
2.2.4. Beck Depression Inventory – Second Edition (BDI-II)
The BDI-II was provided to participants at baseline and post-treat-
ment. The BDI-II is a 21-item self-report questionnaire commonly used
in clinical and research settings to assess symptoms of depression. The
BDI-II has shown high internal consistency and test-retest reliability
(Beck, Steer, Ball, & Ranieri, 1996; Beck, Steer, & Brown, 1996). The
BDI-II showed excellent reliability at pre-treatment (α = .91).
2.2.5. Change Questionnaire (CQ)
Motivation was measured using the Change Questionnaire at the
start of each session (CQ; Miller & Johnson, 2008). This is a 12-item
measure assessing client motivation to change. The questionnaire ex-
amines desire, ability, reasons, need, and commitment to change. This
measure has been shown to have good internal consistency and test-
retest reliability (Miller & Johnson, 2008) and found to predict treat-
ment outcome (Lombardi et al., 2014). The CQ showed excellent re-
liability at pre-treatment (α = .90).
2.2.6. Treatment Ambivalence Questionnaire (TAQ)
The TAQ (Rowa et al., 2014) was provided to participants at pre

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I. Marker, et al.
treatment and at the halfway point of treatment (session 6). This is a 26-
item measure assessing ambivalence about commencing exposure-
based treatments and includes questions assessing personal con-
sequences of treatment, adverse reactions to treatment, and incon-
venience of treatment. It has been found to have good internal con-
sistency (Rowa et al., 2014). The TAQ showed excellent reliability at
pre-treatment (α = .92).
2.2.7. Motivational Interviewing Treatment Integrity (MITI) Coding
Manual
The MITI (Version 4.2.1; Moyers et al., 2003) was used to measures
the quality of MI in both treatment groups. All MITI ratings were made
by research team members who were blind to condition and not in-
volved in treatment or assessment. Only the first 15 minutes of the
iMI + tCBT and tCBT alone sessions 1, 3, 8, and 10 were coded, to
ensure consistency across conditions. It includes four global dimensions
ranked on a 5-point Likert scale of 1 to 5, with 5 reflecting a high level
of proficiency (Moyers et al., 2014) as well as therapist behaviour
counts such as complex and simple reflections, and asking questions.
The four global dimensions are; (1) cultivating change talk; (2) soft-
ening sustain talk; (3) partnership; and (4) empathy. These create
technical and global components of MI. Summary scores are based on
the MITI’s ‘Clinician Basic Competence and Proficiency Thresholds’.
This includes a reflection-to-question ratio (the ratio of the number of
therapist reflections to questions), percent of complex reflections (the
ratio of complex reflections to total number of complex plus simple
reflections), relational global score (a composite average of the part-
nership and empathy ratings), and technical global score (a composite
average of cultivating change talk and softening sustain talk). The MITI
4.2 has good reliability and validity (Moyers, Martin, Catley, Harris,
and Ahluwalia 2003). All MI sessions, as well as the same corre-
sponding timepoints in the tCBT only condition, were rated using the
MITI. To assess inter-rater reliability, 15% of the recordings were ran-
domly selected and double coded by a second rater, and good to ex-
cellent ICC values (.73 to .99) were observed.
2.3. Procedure
The current study, including all methods and procedures, was
evaluated and approved by Monash University Human Rights Ethics
Committee. The trial was registered with the Australian New Zealand
Clinical Trials Registry (ANZCTR; Reference
Number = ACTRN12619001403123), and is reported here consistent
with the registered protocol.
Fifty participants were assessed using the ADIS-5 and CGI during a
1.5 -h assessment session. Participants meeting inclusion criteria
(n = 36) were randomly allocated to receive either iMI + tCBT
(n = 18) or tCBT alone (n = 18). All participants were required to
complete initial baseline measures of anxiety (diagnosis specific self-
report questionnaires), as well as indicators of ambivalence and moti-
vation for therapy (TAQ and CQ). A CONSORT diagram outlining pa-
tient flow and procedures is displayed in Fig. 1.
Clinical psychology doctoral students, who were blind to treatment
condition, completed all clinician rated assessments (pre and post-
treatment). Participants were contacted three times by phone and once
by mail at post-treatment. Self-report questionnaires and pre-paid en-
velopes were also mailed to all participants at post-treatment. No
monetary incentive was provided to participants for attending assess-
ments. At the end of each assessment participants were asked to return
mailed self-report questionnaires. If these had not been completed, time
was provided to complete questionnaires or new questionnaire packs
were provided with pre-paid envelopes for participants to complete at
home.
2.3.1. Transdiagnostic Cognitive Behavior Therapy (tCBT)
The tCBT protocol utilized in this study is based on Norton’s group
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Journal of Anxiety Disorders 75 (2020) 102276
tCBT manual (Norton, 2012), modified for an individual format.
Therapy consisted of 12 weekly one-hour tCBT sessions. Sessions one to
three focus on psychoeducation about anxiety and an introduction to
cognitive restructuring. Sessions four to nine are exposure-based ses-
sions. Sessions ten and eleven focus more broadly on cognitive re-
structuring techniques and how these extend to global patterns of ne-
gative automatic thinking (core beliefs). The final session is relapse
prevention. At sessions 1, 3, 8, and 10, the tCBT protocol included
15 minutes of psychoeducation at the beginning of the session to match
for time allocated to tCBT with the 15-minutes of MI incorporated in
the iMI + tCBT treatment (see below).
2.3.2. Intermittent Motivational Interviewing + tCBT
The iMI + tCBT protocol is identical to the tCBT protocol described
in text with the exception of additional MI components integrated at
intermittent time points. Fifteen minutes of MI (minimum 10 minutes;
maximum 20 minutes) were included at the beginning of standard tCBT
at sessions 1, 3, 8 and 10. Therapists used the Motivational Interviewing
Adapted for Anxiety (Westra & Dozois, 2003) manual for MI compo-
nents. This manual is based on the book by Miller and Rollnick, Moti-
vational Interviewing: Preparing People for Change (2002) but adapted for
anxiety populations as an accompanying treatment to CBT. The adapted
MI manual adheres to the four MI processes (engaging, focusing,
evoking, and planning) described by Miller and Rollnick (2012), with
an emphasis on ambivalence and motivation to change within an an-
xiety disorder framework. As advised by Westra and Dozois (2003), the
MI components include techniques and activities specific to the parti-
cipant’s individual stage of motivation.
In the iMI + tCBT protocol participants are first provided with
psychoeducation about motivation during the feedback session (5-
10 minutes). The purpose of psychoeducation is to provide a brief in-
troduction and rationale for MI. Included during psychoeducation is the
understanding that change is a process, that lapse and relapse are
common, that ambivalence about change is normal, and that
throughout this treatment there will be opportunity for clients to reflect
on their motivation, progress and ambivalence about change and
treatment. Fifteen minutes of MI were then included at sessions 1, 3, 8,
and 10. All participants completed the same activity in Session 1: a
Decisional Balance or Cost-Benefit Analysis (CBA), however for sessions
3, 8 and 10 the therapist chose techniques or activities based on the
client’s readiness for change. Readiness for change was categorised as
either Phase 1 (Exploring and Resolving Ambivalence About Change) or
Phase 2 (Preparing People for Change / Building Self-Efficacy for
Change). Protocol flexibility was advised, and therapists were en-
couraged to use MI strategies in the session if ambivalence arose, such
as if a client was reluctant or ambivalent about engaging in exposure
tasks.
2.3.3. Training and Therapists
Seven clinical psychology doctoral students provided treatment,
under the supervision of a registered clinical psychologist. These stu-
dents underwent extensive training in tCBT including attending a one-
day workshop, watching video recordings of treatment, and reading
relevant material (Norton, 2012). Students also received training in MI
including a one-day workshop and relevant reading material (Miller &
Rollnick, 2012; Westra & Dozois, 2003). Students were required to at-
tend weekly supervision and received feedback via video recordings of
sessions from a clinical psychologist with extensive experience in tCBT.
Therapist-level effects on outcomes were negligible (ICCs ≈ .01) and
were thus not modelled in the analyses.
2.4. Statistical Analyses
The primary aim of this study was to examine whether iMI + tCBT
would provide better outcomes at post treatment in comparison to tCBT
alone. This was assessed using both clinician-rated and self-report
I. Marker, et al.
measures of symptom severity at post treatment. The clinician-rated
measures used in this study were the CSR and CGI ratings providing
both a diagnosis specific and overall rating of symptom improvement.
The diagnosis-specific self-report questionnaires included the PDSS, the
SPDQ, the GADQ-5, the DOCS, and the PCLC.
A hierarchical linear modelling (HLM) framework was employed to
explore group differences in CSR (principal anxiety disorder severity
ratings) and CGI-S (overall psychiatric functioning) using intent-to-treat
(ITT) samples. HLM was chosen due to its ability to handle missing
data. A restricted maximum likelihood (REML) estimator and first-order
autoregressive covariance structure were employed, and the intercept
was set at post treatment such that positive β values indicate higher
scores at pre-treatment. Condition was coded such that positive inter-
action β values indicate greater improvement for tCBT-only condition
and negative values indicate greater improvement for the iMI + tCBT
condition. The analyses were then re-computed with all variables
standardized (M = 0; SD = 1) to compute fully standardized (STDxy)
coefficients as an estimate of the effect size (Snijders & Bosker, 2012).
Post-treatment CSR and CGI scores were available for 27 of the 36
participants (iMI + tCBT = 14). CGI-I ratings were used to assess
treatment response with ratings of 1 (very much improved) and 2
(much improved) indicative of clinically significant change. Chi square
analyses were performed to assess group difference in treatment re-
sponse using an ITT sample; participants who dropped out of treatment
were classified as non-responders.
Thirty-five participants returned baseline self-report questionnaires,
and 30 participants returned post-treatment questionnaires. In order to
compare self-reported symptom improvement from pre to post treat-
ment standard scores were calculated using the five diagnosis specific
questionnaires. Participants completed all five questionnaires at pre,
post and three-month follow-up and improvement scores were con-
verted to z scores using the following formula: standard score
X − mean
z= standard deviation , where X = symptom improvement score (i.e. raw pre
score – raw post score). Standard scores were used to obtain a diagnosis
specific self-report standard score for each participant, based on parti-
cipants’ presenting principal anxiety diagnosis i.e. if a participant met
criteria for GAD, their standard improvement score of the GADQ-5 was
used. Group differences between iMI + tCBT and tCBT alone were then
explored using HLM analyses using an ITT approach under the same
conditions as described above.
Secondary outcomes explored in this study included changes to
comorbidity and treatment attrition. Comorbidity was assessed by
clinicians during assessment using the ADIS-5 and was defined as a
binary variable. Due to treatment attrition, missing data was observed
at post treatment (iMI + tCBT = 4, tCBT = 5). Group differences were
examined using chi-square comparisons of completer samples.
Treatment attrition was also explored using chi-square tests, and a
participant was identified as drop out if they failed to attend the final
three sessions. Additionally, the study sought to examine whether
baseline ambivalence and motivation would moderate the relationship
between baseline and post-treatment outcomes for participants in the
iMI + tCBT condition. This was examined using HLM approach under
the same conditions as described above.
3. Results
3.1. Baseline Group Differences
No significant differences were found between iMI + tCBT and tCBT
on baseline demographic or clinical characteristics (see Table 1). Mo-
tivation for treatment at baseline, as measured by the CQ, was also
found to be equivalent between groups, t(34) = .39, p = .70, d = 0.13,
with both the iMI + tCBT (M = 104.28, SD = 12.50) and the tCBT
condition (M = 105.80, SD = 10.76) reporting high motivation for
treatment. No statistically significant difference was found between
initial treatment ambivalence between the iMI + tCBT (M = 57.55,
6
Journal of Anxiety Disorders 75 (2020) 102276
SD = 24.16) and tCBT condition (M = 61.22, SD = 23.74), t(34) = .46,
p = .65, d = 0.15, and mean scores are similar to reported norms in
anxiety samples (Rowa et al., 2014). Finally, there were no significant
differences in completion of post-treatment or 3-month follow-up as-
sessment between those assigned to iMI + tCBT and tCBT alone (post:
χ2 (df = 1) = 0.15, p = 0.70; 3-month: χ2 (df = 1) = 1.03, p = 0.31.
3.2. Treatment Fidelity
Supporting the fidelity of the iMI + tCBT condition, the Relational
Global and Technical Global both met MITI criteria for Fair quality,
Percent Complex Reflections was categorized as Good quality, while the
Reflection-to-Question Ratio dimension was categorised as Poor, mar-
ginally below the threshold of 1:1 at 0:96 to meet the Fair category.
Supporting the lack of contamination in the tCBT condition, Relational
Global, Technical Global, and Reflection-to-Question Ratio were rated
as Poor quality, although Percent Complex Reflections were categorised
as Good. Using dimension scores, one-way independent measures
ANOVAs showed statistically significant difference between iMI + tCBT
and tCBT-only treatment conditions for the Relational Global, F
(1,29) = 10.89, p = .003, d = 1.21, and Technical Global dimensions,
F(1,29) = 12.68, p = .001, d = 1.31. There were no significant dif-
ference for Percent Complex Reflections, F(1,29) = 0.52, p = .48, d =
0.22, or Reflection-to-Question Ratio F(1,29) = 0.36, p = .55, d =
0.33, between conditions.
3.3. Effects of Treatment and Condition on Primary Outcomes
3.3.1. Clinician Rated
HLM was used to examine the effectiveness of iMI + tCBT over tCBT
alone using pre and post treatment CSR-principal and CGI-S scores. In
the HLM model predicting principal anxiety disorder clinician severity
rating from the ADIS-5 (CSR-principal), the linear effect of time on
severity rating was significant (ß = 2.94, STDxy = 1.69, SEß = .31,
p < .001), indicating a reduction in clinician rated severity of parti-
cipants principal anxiety disorder diagnosis from baseline to post
treatment. However, no significant interaction between treatment
condition and the linear effect of time (ß = -.34, STDxy = -0.19,
SEß = .44, p = .45) was found. Global psychiatric severity scores (CGI-
S) showed a main effect of time (ß = 2.36, STDxy = 1.77, SEß = .29,
p < .001) and a significant interaction between treatment condition
and time (ß = -.89, STDxy = -0.66, SEß = .41, p = .039). This in-
dicates that the iMI+tCBT group showed greater reduction in symp-
tomatology across principal and comorbid diagnoses. CGI-I scores in-
dicated that 66.7% of participants in the iMI+tCBT condition showed
clinically significant improvement, in comparison to 44.4% in the tCBT
condition, however this difference was not statistically significant χ2
(df = 1) = 1.80, p = 0.18, d = 0.46 (Table 2).
3.3.2. Self-report
HLM using participants’ standard scores of diagnosis specific ques-
tionnaires examined changes to self-reported treatment outcomes. A
significant interaction between time and treatment condition (ß = -.73,
STDxy = -0.78, SE ß = .34, p = .038) indicated that participants in the
iMI+tCBT condition showed greater improvement in self-report rated
outcomes from baseline to post-treatment.
3.4. Effects of Treatment and Condition on Secondary Outcomes
3.4.1. Treatment Attrition
Thirty of thirty-six participants (83.33%) completed all 12 sessions
of treatment. Contrary to the hypothesis, no significant differences in
drop out were found between the iMI + tCBT condition (n = 3) and the
tCBT (n = 3) condition, χ2 (df = 1) = 0.00, p = 1.00, d = 0.00.
I. Marker, et al.
Table 2
Means (SD) of primary and secondary outcomes at pre- and post-treatment
iMI + tCBT tCBT
ADIS-5 Primary CSR pre 5.50 (0.86) 5.06 (1.05)
ADIS-5 Primary CSR post 2.43 (1.28) 2.85 (1.28)
CGI-S pre 4.64 (0.63) 4.54 (0.66)
CGI-S post 2.21 (1.05) 3.08(1.32)
CGI-I post 1.21 (0.74) 2.15 (0.80)
BDI pre 21.67 (13.73) 16.85 (11.89)
BDI post 7.77 (6.73) 10.70 (11.51)
Note: ADIS-5 = Anxiety and Related Disorders Interview Schedule for DSM-5;
CSR = clinician severity ratings; CGI-S = Clinical Global Impressions – Severity
rating; CGI-I = Clinical Global Impressions – Improvement rating; BDI = Beck
Depression Inventory-II.
3.4.2. Comorbid Diagnoses
Twenty-eight participants (iMI + tCBT = 15; tCBT = 13) met cri-
teria for a comorbid anxiety or mood disorder at pre-treatment. At post
treatment, 53.57% no longer met criteria for a clinically significant
comorbid diagnosis. In the iMI + tCBT condition 73.3% no longer met
criteria for comorbidity, as opposed to 30.8% in the tCBT condition;
this difference was statistically significant, X 2 (1, N = 28) = 5.07, p =
0.02, d = 0.94.
3.4.3. Depression comorbidity
Finally, to examine the impact of treatment condition on depressive
symptoms, an HLM using participants’ scores on the BDI at pre- and
post-treatment was computed. A main effect of time was observed
(ß = 13.90, STDxy = 1.13, SE ß = .2.56, p < .001), suggesting
overall improvement in BDI scores during treatment. This was mod-
ified, however, by a significant interaction of treatment condition by
time (ß = -7.76, STDxy = -0.63, SE ß = 3.63, p = .040) such that
greater improvement was observed among participants in the iMI
+tCBT condition that for those in the tCBT condition.
3.4.4. Moderator Analyses
In order to test the hypothesis that baseline motivation and am-
bivalence moderated the relationship between baseline and post-treat-
ment symptom severity for participants in the iMI + tCBT condition, a
series of HLMs were run to examine the moderating role of motivation
(CQ) and ambivalence (TAQ) on outcomes. Contrary to the hypothesis,
baseline motivation, as assessed by CQ, did not moderate the re-
lationship between clinician rated pre- and post-treatment primary
anxiety disorder symptom severity, (ß = .02, STDxy = 0.15, SEß = .02,
p = .23), CGI-S scores, (ß = .01, STDxy = 0.06, SEß = .02, p = .74),
or diagnosis-specific self-report questionnaires, (ß = -.02, STDxy =
-0.23, SEß = .01, p = .24). Similarly, baseline ambivalence did not act
as a moderator between clinician rated pre and post treatment primary
anxiety disorder symptom severity, (ß < -.01, STDxy < -0.01,
SEß = .01, p = .99), CGI-S scores, (ß = -.01, STDxy = -0.17,
SEß = .01, p = .31) or diagnosis-specific self-report questionnaires, (ß
= .01, STDxy = 0.28, SEß = .01, p = .17).
4. Discussion
The aim of the current study was to ascertain the effectiveness of
incorporating MI at intermittent time points during the course of tCBT
for anxiety disorders by comparing the iMI + tCBT protocol with an
already established tCBT protocol. Findings of the current study in-
dicated that differences between the two groups were evident for sev-
eral primary outcome measures of symptom improvement. Specifically,
participant self-report measures of symptom severity and clinician im-
pressions of psychiatric functioning showed greater improvement in the
7
Journal of Anxiety Disorders 75 (2020) 102276
iMI + tCBT condition than the tCBT alone condition. These findings
indicate that participants reported a greater sense of subjective im-
provement in anxiety symptoms corresponding to their principal an-
xiety disorder diagnosis. Clinicians also rated a greater change in par-
ticipants’ overall psychiatric functioning (CGI-S) which takes into
account both principal and comorbid diagnoses. This corresponds with
previous research supporting the application of MI as an accompanying
treatment of CBT for anxiety disorders (Marker & Norton, 2019).
Conversely, clinician rated severity scores of principal anxiety disorder
diagnosis (CSR) were equivocal between groups. Furthermore, no sig-
nificant difference was observed in clinicians’ impressions of psychia-
tric improvement (CGI-I).
The reasons for the discrepancy in results across analyses is unclear.
A possible explanation for the difference between clinician-rated and
self-report measures may reflect the greater range available for self-
report measures, whereas clinician-rated scores fall within a small
range (CSR range = 0-8, CGI ranges = 0-7). Thus, subtle nuances in
anxiety symptom change may not be evident. Two previous studies led
by Westra (Westra & Dozois, 2006; Westra, Arkowitz, & Dozois, 2009)
also found significant improvements in self-report measures, and only
trends towards significance in clinician rated scores. This explanation,
however, would not explain the differences in statistical conclusions
within clinician-rated measures. To our knowledge, no studies have
compared the overall validity or treatment sensitivity of the CGI and
CSR. Overall our study also found that 70% of participants no longer
met clinical severity (CSR < 4) for their primary anxiety disorder di-
agnosis post-treatment, meaning that due to the substantial effect of
CBT, the effect of MI may not be as palpable.
Clinically, this study has several implications, the first being that MI
can be structured into CBT at particular time points, which may be
particularly useful to novice therapists with limited expertise in MI. MI
is often considered a responsive therapy; to be used flexibly as am-
bivalence or resistance arises in therapy. Research suggests that in-
creased rigidity may be detrimental to the therapeutic process (Zuckoff,
Swartz, & Grote, 2008) and in the realm of addictive disorders using MI
when a person is sufficiently motivated has been found to be counter-
productive (Hettema et al., 2005). Our findings indicated that baseline
motivation and ambivalence did not act as a moderator for those in the
iMI + tCBT condition, which indicates that even motivated individuals
may benefit from MI techniques, particularly those geared towards in-
creasing self-efficacy. While we do not advocate for rigidly persisting
with MI for an allocated period of time when a person is clearly ready
and motivated to move towards CBT techniques, the current study does
suggest that regularly providing opportunities for a client to voice
ambivalence and discuss motivation and self-efficacy, in absence of
resistance may be beneficial. An advantage of this intermittent ap-
proach is that it requires less expertise in MI on part of the therapist.
Research suggests that adequate responses to client change language
require extensive training, beyond what is obtained through the use of
workshops and readings (Hettema et al., 2005). Therapists often have
immense difficulty detecting resistance and non-collaboration as it
arises in session (Hara et al., 2015). Therefore, planning to regularly
discuss ambivalence and motivation during the course of CBT identifies
clients who may not display observable signs of resistance and provides
further opportunity to advance client confidence in using CBT skills. An
intermittent approach also provides numerous opportunities for thera-
pists to practice MI skills throughout CBT and novice therapists may
choose to use this approach until greater expertise is gathered and a
more fully integrated and responsive approach is possible. Our protocol
allowed the flexibility of delivering additional MI, but did not rely so-
lely on the therapist to recognise resistance in therapy.
Furthermore, the study highlights that even small doses of MI (one
hour spread across four different time points) can yield to positive ef-
fects, which reduces overall therapy time by not including an additional
session. Interestingly the tCBT protocol used in this study has pre-
viously been adapted to include one hour of prelude MI (Barrera et al.,
I. Marker, et al.
2015). As a prelude, one hour of MI did not produce statistically sig-
nificant differences in post-treatment outcomes in comparison to a tCBT
only condition. Barrera et al. (2015) found that while anxiety symptoms
improved in the MI + tCBT condition, and initially outperformed the
tCBT only condition, the effectiveness of MI appeared to subside, with
both groups showing equivalent improvement by the end of treatment.
The current study, which also used one hour of MI but dispersed across
four time points, found significant differences at post treatment. This
provides some evidence for the utility of more integrated MI and CBT
approaches. However, our study allowed for additional MI to be used by
therapists if they recognised resistance, thus studies are not strictly time
matched. Further research comparing approaches would need to be
conducted to ascertain superiority of approach.
This study has several limitations, the principal being that partici-
pants entering the study all did so via self-referral and showed high
levels of motivation and low levels of ambivalence at baseline. Clients
with high levels of ambivalence likely require larger doses of MI, par-
ticularly in early sessions, and this protocol may not be suitable for such
populations. Participants were also primarily of European descent and
highly educated making it difficult to generalize the findings. Third, the
Motivational Interviewing Adapted for Anxiety (Westra & Dozois, 2003)
manual was used in the iMI + tCBT condition. This manual is based on
the first edition of Miller & Rollnick’s MI manual (2002) not the more
recent version (Miller & Rollnick, 2012). Therapists read Westra’s Mo-
tivational Interviewing in the Treatment of Anxiety Disorders (2016), which
uses the later versions of MI, to facilitate their learning. However, the
manual used in the study relied on the initial version, as no updated
manual is readily available. Additionally, although MI adherence in
iMI + tCBT and non-use in tCBT-only was assessed using the MITI
coding system, no tCBT fidelity assessments were conducted. Although
the sessions were supervised by the tCBT protocol developer (PJN),
future studies should assess both MI and tCBT fidelity to ensure that the
integration of the two components does not negatively impact the de-
livery of either component. Finally, although follow-up was attempted,
numerous participants were unable to be contacted at the three-month
mark. Therefore, it is unknown whether differences between conditions
were maintained at follow-up, or if they became more pronounced, as
shown by Westra et al. (2016). In addition to lack of follow-up data,
understanding of outcomes may have been improved by using repeated
measures data, rather than pre and post data. Within these limitations,
the current study adds to the building body of research suggesting the
utility of MI as an adjunct to CBT. It furthermore highlights that even
low doses of MI interspersed at different time points of treatment can
lead to positive therapy outcomes.
Funding
This material is the result of work supported with resources and the
use of facilities at Monash University, Clayton, Victoria, Australia. The
views expressed in this article are those of the authors and do not ne-
cessarily reflect the position or policy of Monash University.
References
Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo,
D., ... Hale, L. R. (2010). Assessment of obsessive-compulsive symptom dimensions:
Development and evaluation of the Dimensional Obsessive-Compulsive Scale.
Psychological Assessment, 22(1), 180–198. https://doi.org/10.1037/a0018260.
Antony, M. M., Orsillo, S. M., & Roemer, L. (Eds.). (2001). Practitioner's guide to empirically
based measures of anxiety. New York: Kluwer Academic Publishers.
Aviram, A., Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Responsive
management of early resistance in cognitive–behavioral therapy for generalized an-
xiety disorder. Journal of Consulting and Clinical Psychology, 84(9), 783–794. https://
doi.org/10.1037/ccp0000100.
Barlow, D. H. (Ed.). (2014). Clinical handbook of psychological disorders: A step-by-step
treatment manual(5th ed.). NY, USA: Guilford Press.
Barrera, T. L., Smith, A. H., & Norton, P. J. (2015). Motivational Interviewing as an
Adjunct to Cognitive Behavioral Therapy for Anxiety. Journal of Clinical Psychology,
72(1), 5–14. https://doi.org/10.1002/jclp.22239.
8
Journal of Anxiety Disorders 75 (2020) 102276
Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. F. (1996). ). Comparison of Beck
Depression Inventories-IA and -II in psychiatric outpatients. Journal of Personality
Assessment, 67(3), 588–597.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the beck depression
inventory—II. San Antonio, TX: The Psychological Corporation.
Blain, L. M. (2013). Motivational Interviewing as an Augmentation to Increase Effectiveness in
Cognitive Processing Therapy for PTSD: An Initial Trial (Dissertation) 295. Retrieved
from http://irl.umsl.edu/dissertation/295.
Brown, T. A., & Barlow, D. H. (2014). Anxiety and related disorders interview schedule for
DSM-5 (ADIS-5): Adult version - Client interview schedule. New York, NY: Oxford.
Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-
IV anxiety and mood disorders: Implications for the classification of emotional dis-
orders. Journal of Abnormal Psychology, 110(1), 49–58.
Engle, D. E., & Arkowitz, H. (2006). Ambivalence in psychotherapy: Facilitating readiness to
change. New York, NY: Guilford Press.
Guy, W. (Ed.). (1976). ECDEU assessment manual for psychopharmacology(Revised ed.).
Rockville, MD, USA: Department of Health, Education and Welfare.
Hara, K. M., Westra, H. A., Aviram, A., Button, M. L., Constantino, M. J., & Antony, M. M.
(2015). Therapist awareness of client resistance in cognitive-behavioral therapy for
generalized anxiety disorder. Cognitive Behaviour Therapy, 44, 162–174. https://doi.
org/10.1080/16506073.2014.998705.
Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational Interviewing. Annual Review
of Clinical Psychology, 1(1), 91–111. https://doi.org/10.1146/annurev.clinpsy.1.
102803.143833.
Hong, R. Y. (2007). Worry and rumination: Differential associations with anxious and
depressive symptoms and coping behavior. Behaviour Research and Therapy, 45(2),
277–290. https://doi.org/10.1016/j.brat.2006.03.006.
Hunter, J. A., Button, M. L., & Westra, H. A. (2014). Ambivalence and Alliance Ruptures
in Cognitive Behavioral Therapy for Generalized Anxiety. Cognitive Behaviour
Therapy, 43(3), 201–208. https://doi.org/10.1080/16506073.2014.899617.
Kawamura, K. Y., Hunt, S. L., Frost, R. O., & DiBartolo, P. M. (2001). Perfectionism,
anxiety, and depression: Are the relationships independent? Cognitive Therapy and
Research, 25(3), 291–301. https://doi.org/10.1023/A:1010736529013.
Lorian, C. N., Mahoney, A., & Grisham, J. R. (2012). Playing it safe: An examination of
risk-avoidance in an anxious treatment-seeking sample. Journal of affective disorders,
141(1), 63–71. https://doi.org/10.1016/j.jad.2012.02.021.
Lombardi, D. R., Button, M. L., & Westra, H. A. (2014). Measuring motivation: Change
talk and counter-change talk in cognitive behavioral therapy for generalized anxiety.
Cognitive Behaviour Therapy, 43, 12–21. https://doi.org/10.1080/16506073.2013.
846400.
Marker, I., & Norton, P. J. (2018). The efficacy of incorporating motivational interviewing
to cognitive behavior therapy for anxiety disorders: A review and meta-analysis.
Clinical Psychology Review, 62, 1–10. https://doi.org/10.1016/j.cpr.2018.04.004.
Marker, I., & Norton, P. J. (2019). Intermittent Motivational Interviewing and
Transdiagnostic CBT for Anxiety: A Case Study. Clinical Case Studies, 18(4), 300–318.
https://doi.org/10.1177/1534650119849104.
Marker, I., Salvaris, C. A., Thompson, E. M., Tolliday, T., & Norton, P. J. (2019). Client
Motivation and Engagement in Transdiagnostic Group Cognitive Behavioral Therapy
for Anxiety Disorders: Predictors and Outcomes. Cognitive Therapy and Research,
43(5), 819–833. https://doi.org/10.1007/s10608-019-10014-1.
Merlo, L. J., Storch, E. A., Lehmkuhl, H. D., Jacob, M. L., Murphy, T. K., Goodman, W. K.,
... Geffken, G. R. (2010). Cognitive Behavioral Therapy Plus Motivational
Interviewing Improves Outcome for Pediatric Obsessive–Compulsive Disorder: A
Preliminary Study. Cognitive Behaviour Therapy, 39(1), 24–27. https://doi.org/10.
1080/16506070902831773.
Moyers, T. B., Manuel, J. K., & Ernst, D. (2014). Motivational Interviewing Treatment
Integrity Coding Manual 4 .1. Unpublished manual. 4 Unpublished.
Miller, W. R. (1985). Motivation for treatment: A review with special emphasis on al-
coholism. Psychological Bulletin, 98(1), 84–107. https://doi.org/10.1037/0033-2909.
98.1.84.
Miller, W. R., & Johnson, W. R. (2008). A natural language screening measure for mo-
tivation to change. Addictive Behaviors, 33, 1177–1182. https://doi.org/10.1016/j.
addbeh.2008.04.018.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change.
New York: Guilford Press.
Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. New
York, NY: Guilford press.
Moyers, T., Martin, T., Catley, D., Harris, K. J., & Ahluwalia, J. S., (2003). Assessing the
integrity of motivational interviewing interventions: Reliability of the motivational
interviewing skills code. Behavioural and Cognitive Psychotherapy, 31, 177 184.
https://doi.org/10.1017/S1352465803002054.
Naar, S., & Safran, S. A. (2017). Motivational Interviewing and CBT. NY: Guilford Press.
Newman, M. G., Kachin, K. E., Zuellig, A. R., Constantino, M. J., & Casham-McGrath, L.
(2003). The Social Phobia Diagnostic Questionnaire: preliminary validation of a new
self-report diagnostic measure of social phobia. Psychological Medicine, 33(4),
623–635. https://doi.org/10.1017/s0033291703007669.
Newman, M. G., Zuellig, A. R., Kachin, K. E., Constantino, M. J., Przeworski, A., Erickson,
T., ... Cashman-McGrath, L. (2002). Preliminary reliability and validity of the
Generalized Anxiety Disorder Questionnaire-IV: A revised self-report diagnostic
measure of generalized anxiety disorder. Behavior Therapy, 33(2), 215–233. https://
doi.org/10.1016/s0005-7894(02)80026-0.
Norton, P. J. (2012). Group cognitive-behavioral therapy of anxiety: A transdiagnostic treat-
ment manual. New York, NY: Guilford.
Purdon, C., Rowa, K., & Antony, M. M. (2004). Treatment fears in individuals awaiting
treatment of OCD. Paper presented at the meeting of the Association for Advancement of
Behavior Therapy.
I. Marker, et al.
Resick, P. A., Monson, C. M., & Rizvi, S. L. (2008). Posttraumatic stress disorder. In D. H.
Barlow (Ed.). Clinical handbook of psychological disorders: A step-by-step treatment
manual(4th ed.). New York, NY: The Guilford Press.
Rowa, K., Gifford, S., McCabe, R., Milosevic, I., Antony, M. M., & Purdon, C. (2014).
Treatment fears in anxiety disorders: Development and validation of the Treatment
Ambivalence Questionnaire. Journal of Clinical Psychology, 70, 979–993. https://doi.
org/10.1002/jclp.22096.
Shear, M. K., Rucci, P., Williams, J., Frank, E., Grochocinski, V., Vander Bilt, J., ... Wang,
T. (2001). Reliability and validity of the Panic Disorder Severity Scale: replication
and extension. Journal of Psychiatric Research, 35(5), 293–296. https://doi.org/10.
1016/s0022-3956(01)00028-0.
Simpson, H. B., Zuckoff, A. M., Maher, M. J., Page, J. R., Franklin, M. E., Foa, E. B., ...
Wang, Y. (2010). Challenges using motivational interviewing as an adjunct to ex-
posure therapy for obsessive-compulsive disorder. Behaviour Research and Therapy,
48(10), 941–948. https://doi.org/10.1016/j.brat.2010.05.026.
Simpson, H. B., & Zuckoff, A. (2011). Using Motivational Interviewing to Enhance
Treatment Outcome in People With Obsessive-Compulsive Disorder. Cognitive and
Behavioral Practice, 18(1), 28–37. https://doi.org/10.1016/j.cbpra.2009.06.009.
Snijders, T. A. B., & Bosker, R. J. (2012). Multilevel analysis: An introduction to basic and
advanced multilevel modeling. Thousand Oaks: Sage.
Taylor, S., & Asmundson, G. J. (2004). Treating health anxiety: A cognitive-behavioral ap-
proach. New York: Guilford Press.
Weathers, F. W., Huska, J. A., & Keane, T. M. (1991). PCL-C for DSM-IV. Boston: National
Center for PTSD-Behavioral Science Division.
Journal of Anxiety Disorders 75 (2020) 102276
Westra, H. A. (2012). Motivational interviewing in the treatment of anxiety. USA: Guilford
Press.
Westra, H. A., Arkowitz, H., & Dozois, D. J. A. (2009). Adding a motivational interviewing
pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A
preliminary randomized controlled trial. Journal of Anxiety Disorders, 23(8),
1106–1117. https://doi.org/10.1016/j.janxdis.2009.07.014.
Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Integrating motivational in-
terviewing with cognitive-behavioral therapy for severe generalized anxiety disorder:
An allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical
Psychology, 84(9), 768–782. https://doi.org/10.1037/ccp0000098.
Westra, H. A., & Dozois, D. J. A. (2003). Motivational interviewing adapted for anxiety.
Unpublished treatment manual.
Westra, H. A., & Dozois, D. J. A. (2006). Preparing Clients for Cognitive Behavioral
Therapy: A Randomized Pilot Study of Motivational Interviewing for Anxiety.
Cognitive Therapy and Research, 30(4), 481–498. https://doi.org/10.1007/s10608-
006-9016-y.
Yang, W., & Strodl, E. (2011). Motivational Interviewing changes the treatment trajectory
of group Cognitive-Behavioral Therapy for anxiety. In S. Boag, & N. Tiliopoulos
(Eds.). Personality and Individual Differences: Theory, Assessment, & Application (pp.
237–248). New York: Nova Science Publishers, Inc.
Zuckoff, A., Swartz, H. A., & Grote, N. K. (2008). Motivational interviewing as a prelude
to psychotherapy of depression. In H. Arkowitz, H. A. Westra, W. R. Miller, & S.
Rollnick (Eds.). Motivational interviewing in the treatment of psychological problems.
New York: Guilford Publications.