Patients’ resistance interferes with therapist adherence to CBT techniques
Monday, May 11, 2015
Posted by: Lorenzo Lorenzo-Luaces
Although it is an intuition of many clinicians that it is more difficult to do therapy with some patients than with others, this is a topic that has received little attention in research. In a recent study, Zickgraf and colleagues (2015) found that some patients’ interpersonal variables were related to the therapist deviating from their treatment manual more often. In these cases, therapists started using more techniques from other therapy orientations. The team of researchers from the University of Pennsylvania and Cornell University evaluated psychotherapy sessions for 38 patients who were treated by four therapists who followed a manual for panic control therapy (PCT), a highly structured session-by-session CBT protocol for the treatment of panic disorder. The authors focused on resistance, a construct that refers to behaviors that might interfere with the therapy, by disagreeing with or questioning the therapy agenda. In the study, psychotherapy sessions were rated in 30-second intervals on resistance by independent judges. Lead author Hana Zickgraf from the University of Pennsylvania commented that “observer coding is difficult and time consuming, but resistance is important for clinical practice and the validity of treatment research.” For example, she quoted a recent survey of cognitive-behavioral practitioners, in which 30-50% of responders reported interpersonal variables like resistance and personality disorders as impediments to the implementation of CBT.
The method employed in this study to measure resistance seems to have paid off as the authors were able to find a significant effect of patient resistance on therapist adherence. Specifically, when patients were resistant to therapy, therapists were less likely to use the standard CBT and more likely to use techniques from other therapies. The therapists were also less likely to adhere to the CBT session protocol for patients with personality disorders, and some of the therapists were also more likely to use non-CBT interventions for these patients. Interestingly, the severity of the patient’s panic did not seem to interfere with the delivery of the CBT interventions, suggesting that patient’s interpersonal style rather than other aspects of their clinical profile affected adherence. Zickgraf relates the issue of patient’s interpersonal styles “to understanding why adherence so often doesn't relate to treatment outcomes. What we found could hint at one answer...that when a patient makes it difficult to deliver the treatment as written, many clinicians use their clinical expertise to implement other strategies, some from outside the CBT model, to help the patient.” In balancing protecting the integrity of treatment studies while trying to keep patients involved in therapy, she suggests that “researchers could anticipate [resistance] by developing more modular interventions with specific, model-consistent interventions to address resistance and other events that can interfere with protocol adherence. This might help researchers improve the internal validity of their studies and help us to identify the specific ingredients that make CBT effective.” Future directions for this research include exploring the relationship between interpersonal variables like resistance, adherence to treatment, and outcomes.