CBT Plus Motivational Interviewing: A Superior Anxiety Treatment?

Cognitive Behavioral Therapy
Cognitive Behavioral Therapy
Recent studies have explored various adaptations to CBT with the aim of improving response rates in treating anxiety.

Combining motivational interviewing (MI) with cognitive behavioral therapy (CBT) may lead to greater improvement in long-term treatment outcomes for patients with generalized anxiety disorder (GAD) compared with CBT alone, according to research published in the Journal of Consulting and Clinical Psychology.

Although CBT has shown efficacy in treating anxiety disorders, a review of 25 studies found that only 46% of patients with GAD demonstrated significant improvement after CBT.

Recent studies have explored various adaptations to CBT with the aim of improving response rates. “A complementary and alternative way of adapting traditional CBT for GAD stems from considerations that client ambivalence about change may limit response rates to established CBT approaches,” wrote Henny A. Westra, PhD, from the Department of Psychology at York University in Toronto and colleagues. Findings from previous research “underscore the need for flexible intervention in response to readiness for change.”

While preliminary findings on the combination of CBT and MI for anxiety have been promising, well-controlled trials are lacking. To help fill the gap, researchers at Ryerson University and York University in Canada and the University of Massachusetts Amherst conducted a randomized controlled trial comparing the efficacy of CBT alone with a combination of motivational interviewing and CBT for GAD in adults with high-severity worry. Ambivalence about change is the central focus in MI, and therapists help patients become their own change advocates rather than filling that role for them.

A group of 43 patients underwent 15 weekly sessions of CBT, while another group of 42 patients underwent 4 sessions of MI followed by 11 sessions of CBT combined with MI to address resistance or ambivalence. Most of the participants were white women who had high rates of comorbidity. In the 4 initial MI sessions, therapists did not push for change but explored participants’ feelings and any ambivalence they might have about reducing their worry. During the MI-CBT phase, therapists supported patients in exploring ambivalence and resistance as these topics arose in session.

While the results show no differences between groups in terms of pre- and post-treatment outcomes, between-group differences were observed at the 6-month and 12-month follow-up points. The MI-CBT group reported greater reductions in worry and general distress compared with the CBT-only group. The MI-CBT group was also 5 times as likely to no longer meet diagnostic criteria for GAD compared with the CBT-only group, and twice as many CBT-only participants dropped out of treatment compared with MI-CBT participants (23% vs 10%).

Although “CBT-alone clients generally retained their gains, MI-CBT clients continued to improve after treatment ended,” the researchers reported. These results align with previous findings regarding long-term effects of MI.

While further trials could help identify the treatment components of MI that are linked with ongoing improvement, “it may be that having the opportunity to openly explore and resolve one’s ambivalence about change as it arises during treatment may confer greater resilience to relapse after treatment ends,” the researchers wrote. Additionally, the “MI spirit” that advocates an empathetic, collaborative, “client-as-expert” approach may be particularly beneficial post-treatment by helping patients develop autonomy and self-trust to encourage maintenance of their treatment gains.


Westra HA, Constantino MJ, Antony MM. Integrating motivational interviewing with cognitive-behavioral therapy for severe generalized anxiety disorder: an allegiance-controlled randomized clinical trial. J Consult Clin Psychol. 2016; Mar 17. doi.org/10.1037/ccp0000098.