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Cognitive and Behavioral Practice 18 (2011) 46–54
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Setting the Stage for the Integration of Motivational Interviewing With
Cognitive Behavioral Therapy in the Treatment of Depression
Heather A. Flynn, University of Michigan
Unipolar depression is one of the most disabling and costly medical illnesses in the world (Lancet Global Mental Health Group et al.,
2007; Moussavi et al., 2007). Cognitive behavioral therapy (CBT), a widely studied and taught psychotherapeutic treatment for
depression, is among the recommended evidence-based treatments. Although CBT and other treatments are largely effective, many
depressed individuals do not fully respond to treatment, leaving them vulnerable for relapse and poor outcomes over the lifespan. This
article explores the integration of Motivational Interviewing (MI) as one possible strategy of enhancing CBT outcomes. MI provides an
evidence-based approach to addressing motivation for treatment and emphasizing key therapist-client interactional factors that have been
linked to clinical outcomes. As such, it may be synergistic with specific aspects of CBT, such as enhancing therapeutic alliance, motivation,
and specifically addressing ambivalence/resistance affecting treatment engagement, retention and adherence to various aspects of the
treatment (such as homework). For clinicians learning CBT, MI may also provide a specified model for learning basic psychotherapeutic
skills such as empathy, collaboration, and client-centered active listening. Given the urgency of improving the potency of depression
treatments, the extent to which the blending of a MI with CBT will improve the overall effectiveness is worthy of clinical research.
O
the past several decades, much has been learned
about the nature and treatment of depression. Two
large-scale World Health Organization reports now
document the worldwide medical disability associated
with depression, making improved detection and treatment a global public health priority (Lancet Global
Mental Health Group et al., 2007; Moussavi et al., 2007).
Progress has also been made in development and study of
treatments that are largely effective for unipolar depression. Persons appropriately treated for depression have
shorter periods of illness, are less likely to relapse, and
have longer periods of inter-depression wellness than
those who are not treated, or who are undertreated
(Frank et al., 1990, Segal, Williams, & Teasdale, 2002).
Both psychotherapy and medication treatment for
unipolar depression have received empirical support
and have been adopted as part of best practice guideline
care (American Psychiatric Association [APA], 2000; see
also Hollon, Thase, & Markowitz, 2002, for a review).
Cognitive behavioral therapy (CBT) is one of the most
widely studied, disseminated, and taught manualized
psychotherapies for depression. Despite its documented
efficacy in producing depression remission, large numbers of persons treated with CBT do not engage in, commit
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to, and/or fully respond to treatment (APA, 2000;
DeRubeis et al., 2005; Miranda et al., 2003).
This article explores the potential usefulness of one
strategy that may enhance CBT outcomes for depression in
order to stimulate clinical research and enhancement of
psychotherapist training models. Specifically, Motivational
Interviewing (MI), an evidence-based approach to improving client engagement and adherence, decreasing resistance, enhancing motivation, and improving specific
behavior change targets will be presented as potentially
synergistic with CBT in improving overall depression
outcomes. Here, synergy is conceptualized as “cooperative
action” between two treatments. In their recent chapter,
Arkowitz and Burke (2008) outlined MI as an integrative
framework that may be used throughout the course of CBT
for depression. Specifically, MI can be synergistically
blended throughout CBT to enhance motivation, reduce
resistance and resolve ambivalence about any aspect of the
treatment (such as engagement, adherence, and/or any
behavior change associated with depression recovery;
Arkowitz & Burke; Arkowitz & Westra, 2004). This conceptualization is similar to that used in the COMBINE study
(Miller, 2004), in which the Combined Behavioral Intervention (CBI) integrated several evidence-based elements
for the treatment of alcohol use disorders, including MI
and cognitive-behavioral skill training (as well as family
and social/community involvement, self-help groups, and
individualized treatment approach). In that study, treatment integration was also conceptualized as use of an MI
Integrating MI and CBT for Depression
therapeutic style throughout all phases of the CBI.
Psychotherapy integration has been broadly defined
elsewhere as “various attempts to look beyond the confines
of single-school approaches in order to see what can be
learned from other perspectives…characterized by an
openness to various ways of integrating diverse theories
and techniques” (Arkowitz, 1997, p. 228). Integration of MI
with CBT implies that CBT therapists will blend fundamental skills of MI (such as addressing motivation and
ambivalence, rolling with resistance, expressing empathy,
collaboration, and supporting autonomy) throughout the
therapy (Arkowitz & Burke; Arkowitz & Westra).
Although many forms of depression psychotherapy
address behavior change (e.g., behavior activation,
communication behaviors) with varying degrees of
emphasis, the extent to which the merging of evidencebased interventions that specifically target health behaviors (such as MI) will improve depression treatment
effectiveness has not been sufficiently investigated. At the
same time, research on understanding how to address
depression with MI is at an early stage (Arkowitz, Westra,
Miller, & Rollnick, 2008). CBT provides a well-developed
and -studied depression-specific treatment that may be
integrated with MI in order to broaden the applicability of
MI for depression treatment, pointing to the potential for
true synergy between the two interventions.
Brief Overview of MI and CBT
MI
MI has been defined most prominently by Miller and
Rollnick (2002) as a “client centered, directive method
for enhancing intrinsic motivation to change by exploring
and resolving ambivalence” (p. 25). Not intended to be a
distinct form of psychotherapy per se, MI may be best
understood as a “way of being with people” that was
originally developed to help people to change a particular
target behavior, and to be integrated with other treatment
and intervention approaches. The four key principles of
MI are (a) express empathy, (b) develop discrepancy, (c)
roll with resistance, and (d) support self-efficacy (Miller &
Rollnick, 2002). Recent research suggests that the
mechanisms of action of MI include therapist skill on
both the relational component (empathy and “MI
Spirit”—defined as Collaboration, Evocation, and Respect for Autonomy) and the technical component of MI
(evoking high levels of client articulation of commitment
to change, known as “change talk”; Moyers & Martin,
2006; Moyers, Miller, & Hendrickson, 2005).
MI has been studied extensively and has been found to
be efficacious in improving adherence to and effectiveness of subsequent forms of treatment (Burke, Arkowitz,
& Menchola, 2003). There has been considerable
research on the efficacy of MI as a treatment-engagement
intervention for substance abuse and other behavioral
and health issues (see reviews by Burke et al.; Hettema,
Steele & Miller, 2005; Noonan & Moyers, 1997).
Importantly, however, MI requires less time and resources
than other treatments, suggesting it has specific practical
utility as an exportable intervention, amenable to
integration. MI has similarly been shown to be efficacious
as a stand-alone intervention for a number of health
behavior domains, including substance use, HIV risk
behaviors, obesity, smoking, probation and parole behaviors, treatment and medication compliance, and nutritional behaviors (Hettema et al.). Based on available
research and clinical observation to date, it appears that
MI is particularly effective for individuals who are
ambivalent or resistant to a specific behavior change,
and may be less effective for individuals who are clearly
committed to behavior change (Hettema et al.). More
recently, clinicians and researchers have become interested in adaptation and integration of MI for the
treatment of psychiatric disorders such as depression
and anxiety (Arkowitz et al., 2008).
CBT
A cognitive conceptualization of emotional disorders
was first described by Aaron T. beck in the 1960s and
resulted in the formulation of cognitive therapy (CT; Beck,
Rush, & Shaw, 1979). In its original and basic form, CT
focused on changing negative views and related behavior
regarding the self, the world, and the future. CT has since
been broadened, emphasizing behavioral theoretical and
intervention components, to become more widely known
as CBT. Based on a 2000 review, CBT has been shown to be
effective in improving outcomes in close to 300 clinical
research studies for a variety of disorders, including
depression (Butler & Beck, 2000). Although the practice
of CBT may be quite varied in content, the basic CBT
model emphasizes the interplay between events, thoughts,
behavior, and mood. Key methods of CBT have been
summarized in a recent learning guide by Wright, Basco,
and Thase (2006) and include: a problem oriented focus,
individualized case conceptualizations, collaborative empiricism, Socratic questioning, use of structuring, psychoeducation and rehearsal of skills, identifying and modifying
automatic thoughts and schemas, behavioral methods to
reduce depression generating and maintaining behaviors
(behavioral activation), and practice of CBT skills to
prevent relapse. Overall, CBT is one of the most widely
used and studied psychotherapeutic treatments for unipolar depression.
Key Similarities and Differences Between MI and CBT
Clearly, MI and CBT, as currently conceptualized, are
not entirely distinct. Indeed, both approaches share
several components that are considered to be integral to
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expert use of the approach. Foremost, both approaches
emphasize a collaborative approach in working with
clients. For example, goals and session agendas in CBT
work are intended to be collaboratively negotiated with
clients. CBT practice involves “checking in” with clients
regarding therapeutic goals. Termed “collaborative empiricism,” CBT emphasizes work with the client to formulate
and test hypotheses about the links between mood, events,
thoughts, and behavior. Likewise, client collaboration is
one of the primary domains on which clinicians are rated
for adherence to MI. Both approaches are also understood
to be most effective when focused on specific problems or
behaviors. Supporting self-efficacy, one of the four
principles of MI has also been emphasized in most
conceptualizations of CBT (O'Leary & Wilson, 1987).
Despite a common emphasis on collaboration, one
basic difference is that CBT emphasizes an expert model,
where the therapist is assumed to be the key change
agent. In MI, the client is explicitly viewed as the expert
and key change agent. MI also deemphasizes the use of
labels; therefore, an MI clinician would not conceptualize
client cognitions as “irrational” or “distorted.” In describing a truly collaborative approach to CBT, Miller (1988)
commented that it is “feasible to guide cognitive-behavior
therapy towards ends derived from the client's own core
values, rather than towards a single, preconceived notion
of which beliefs are ‘rational’ and which ‘irrational’ (p.
54). Enhancement of collaboration, therefore, is another
key example of possible synergy between MI and CBT.
Rationale for Integrating MI with CBT
Given the widespread use and demonstrated effectiveness of CBT, why might consideration of integration with
MI be warranted? Arkowitz and Burke (2008) have
enumerated several key reasons why MI integration with
CBT is justifiable from the standpoint of enhancing the
treatment overall. First, although it is clear that CBT has
benefited large numbers of depressed patients, examination of overall response and remission rates in clinical
trials clearly reveals room for improvement. A metaanalysis of four types of psychotherapy (interpersonal
psychotherapy [IPT], CBT, and psychodynamic psychotherapy) as compared to medication treatment and pill
placebo showed overall response rates of CBT to be
approximately 50% (Hollon et al., 2002), comparable to
IPT and antidepressant medications, all of which outperformed psychodynamic therapy and placebo. Despite
overall statistically significant improvements compared to
control conditions based on aggregated data, large
numbers of depressed patients treated with CBT (or
with any known treatment) remain symptomatic (APA,
2000). Incomplete symptom remission has been shown to
increase risk of relapse, resulting in greater disability
attributable to depression over the lifespan (Kupfer,
1991). Given that chronic depression has been estimated
to account for among the greatest functional disability
worldwide (Lancet Global Mental Health Group et al.,
2007), it is critical for clinical researchers to pursue
strategies that improve depression treatment outcomes
beyond the 50% to 60% remission rate commonly
achieved in clinical trials.
Arkowitz and Burke (2008) also highlight the fact the
MI “fits the symptoms” of depression. Symptoms and
features of depression such as motivational deficits and
ambivalence about change are specific MI foci. Recent
studies have shown evidence that patients with more
severe depression who were nonresponsive to CBT
showed greater improvement with behavior activation
than with cognitive foci or with antidepressant medications (Coffman, Martell, Dimidjian, Gallop, & Hollon,
2007; Dimidjian et al., 2006), illustrating a promising role
for embedding strategies to improve adherence with
specific health behavior changes (Arkowitz & Burke,
2008). Importantly, MI has been designed and tested in
relatively brief formats to be used as adjunctive to other
treatments. In addition to sharing an emphasis on
behavior change and collaboration, both CBT and MI
explicitly emphasize beliefs/client perspectives and behaviors as intervention targets, providing logical points of
blending between the two approaches.
As outlined by Taylor and Asmundson (2004), people
come to treatment for a variety of reasons and with
varying levels of motivation. Overall, MI can be integrated
throughout CBT whenever motivational issues arise. In an
earlier article describing integration of CBT and MI for
anxiety and depressive disorders, Arkowitz and Westra
(2004) highlighted the fact that CBT does not formally
address ambivalence about treatment or change; rather, it
focuses on assisting clients with specific changes and skills.
In that sense, MI adds a specific and strategic focus on
building motivation for change. MI may be blended to
enhance motivation for initial treatment engagement
(Zuckoff, Swartz, & Grote, 2008), treatment retention,
and with adherence to various aspects of the treatment
(such as homework behavior-activation strategies). Therefore, fundamental MI skills can synergize with CBT by
enhancing treatment adherence and outcomes (Arkowitz
& Burke, 2008).
Another rationale for integration is that MI directly
and strategically addresses key predictors of CBT outcomes found in several studies (Arkowitz & Burke, 2008).
Empathy, a fundamental MI skill, has been linked to CBT
outcome in treatment studies (Burns & Nolen-Hoeksema,
1991, 1992; Miller, Taylor, & West, 1980). In a study
investigating the process of CT in 64 depressed outpatients (Castonguay, Goldfried, Wiser, Raue & Hayes,
1996), emotional experiencing, defined as the client’s
ability to focus on and accept their affective reactions, was
Integrating MI and CBT for Depression
found to predict improved depression outcomes. Conversely, maintaining a clinical focus on the link between
distorted thoughts and negative emotions predicted
poorer depression outcomes. Analyses from that study
also revealed that therapist persistence in imparting the
CBT model, especially in the presence of alliance
problems, may lead to poorer depression outcomes than
incorporating reflection and acceptance of affect with the
goal of facilitation of behavior change (Castonguay et al.,
1996). One implication of this research is that integration
of fundamental MI skills, such as reflective listening and
elicitation of client perspectives and motivation, may
enhance CBT outcomes.
Related to therapist interactional factors, a further
justification for exploring MI-CBT integration involves
criticism of training in manualized therapies, such as CBT,
particularly in clinical psychology, psychiatry residency,
and social work graduate programs. The heart of the
concern seems to be that training may be overemphasizing
the “mechanics” of a particular therapy model, while
underemphasizing therapist style and skills (described
above) that may enhance clinical outcomes. This is
important because these therapeutic interactional factors
have shown a strong effect on psychotherapy outcome, as
compared to any particular technique, over a number of
studies (for example, Beutler & Clarkin, 1990; Burns &
Nolen-Hoeksema, 1992; Lafferty, Beutler, & Crago, 1989).
Referred to as the “relationship stance” (Arkowitz &
Westra, 2004) and the “healing relationship” (Arkowitz &
Burke, 2008), integration of MI with CBT training may be
a logical approach to attending to therapist skills of
empathy, collaboration, evocation of client perspectives,
motivation, respect for individuals' autonomy (i.e., “MI
Spirit”), and addressing and resolving ambivalence
(Arkowitz & Burke). These are core MI skills that can be
taught and assessed using validated MI adherence and
competence rating scales (Moyers, Martin, Manuel,
Hendrickson, & Miller, 2005). Improvement in therapist
ratings of empathy and MI spirit have been shown in
clinical trials to be achievable with MI supervision (Miller,
Yahne, Moyers, Martinez, & Pirritano, 2004), and may
provide guidance for psychotherapy training models.
Finally, Arkowitz and Burke (2008) described the
utility of integrating MI with the aim of determining,
honing, and maintaining the therapeutic focus in CBT.
MI strategically maintains focus by eliciting, reflecting,
and strengthening “change talk” that is consistent with
the client’s values and goals. Arkowitz and Burke (2008)
outlined several levels of focus that may be strategically
guided and maintained by integrating MI. These levels
include ameliorating symptoms of depression overall,
identifying problems that contribute to mood symptoms,
actively changing thoughts and behaviors that contribute
to depression, and addressing ambivalence about antide-
pressant medications. Consistent with MI, foci are
presented, commonly as a “menu” in a collaborative
style using reflections of the client’s values. The client’s
motivation to focus on a specific goal (such as behavior
activation) is elicited rather than prescribed or imparted,
and permission to maintain that focus is obtained from
the client.
Clinical Applications of CBT and MI
The therapeutic alliance and therapist responsiveness
to client needs may have a strong influence on
successful behavior change outcomes. Engagement in
treatment and change in specific depression-related
behaviors can be challenging for therapists and patients
because they are often met with ambivalence or
resistance. Furthermore, it has become increasingly
clear that recovery from depression may involve a
number of specific behavioral change targets including
treatment adherence, increase in reinforcing activity, as
well as specific cognitive and interpersonal changes
(Hollon et al., 2002). These interactional factors and
behavioral change factors that influence treatment
outcome represent fundamental MI skills. Each of
these areas of CBT-MI synergy are considered below.
Specific areas of CBT-MI integration will be discussed,
along with clinical vignettes.
Client-Therapist Relational Factors
Research on behavior change across a number of
domains has provided evidence that intervention strategies must overlap with patient personal processes, such as
motivation and self-efficacy (DiClemente, 2007). It is clear
that CBT was originally conceptualized and is commonly
defined in treatment manuals (Beck, 1995) as a framework, within which psychotherapists should employ
clinical judgment in collaboratively tailoring the treatment to individual patients. As discussed above, skilled
CBT therapists are empathic (Burns & Nolen-Hoeksema,
1991; Miller et al., 1980), responsive to client needs,
collaborative, and respectful of client autonomy to make
decisions. Other CBT therapists, however, may lack
adequate training, supervision, and experience in skillfully employing the treatment. MI offers an operationally
defined, specified method for guiding therapist responsiveness to patients that may be integrated within CBT
(Arkowitz & Burke, 2008). Miller (2008) has offered four
broad perspectives that may be used to guide MI
integration with psychotherapy: (a) a belief in human
potential for growth and change, (b) emphasis on the
central role of volition (choice and decision-making), (c)
understanding and acceptance of ambivalence, and (d)
close attention to client and clinician language. MI,
therefore, may provide an organized framework for
training psychotherapists to deliver CBT in a way that is
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strategically responsive and flexible, collaborative, and
empathic. Empathy is explicitly emphasized in MI
training and supervision and supervision tools have
been developed to improve therapist empathy (Arkowitz
& Burke, 2008). These training and supervision
approaches on the relational components of empathy,
collaboration, evocation of patient perspectives, and
respect for client autonomy may be strategically integrated with CBT.
Depression psychotherapy research has shown that
much of the variance in depression outcomes is attributable to patient factors (Beutler, Crago, & Arizmendi,
1986), such as the patient’s contribution to the alliance
(Krupnick et al., 1996) and feeling understood, and clear
and organized in self-expression (Ablon & Jones, 1999).
This and other research implies that, in many clinical
instances, effective therapeutic approaches (such as MI)
emphasize evoking therapeutic elements from patients
rather than imparting expert information. This is in
contrast to the commonly used notion and resulting
language implying that psychotherapists “deliver” treatment. Instead, expert psychotherapists move between
imparting useful knowledge, direction, guidance, and
evoking client perspectives, skills, resources and strengths.
As such, both CBT and MI offer empirically based
elements that may be integrated.
Initial Treatment Engagement
Most people with depression do not present for
specialty care and therefore must be identified and either
treated or referred in settings such as primary care and
other medical and community settings (Young, Klap,
Sherbourne, & Wells, 2001). Studies of implementation of
CBT in nonspecialty settings and with special populations
have shown relatively poor treatment adherence (Miranda et al., 2003). For example, studies of CBT for
depression in low-income women found high rates of
attrition (up to 60%) from treatment (Appleby, Warner,
Whitton, & Faragher, 1997; Meager & Milgrom, 1996;
Prendergast & Austin, 2001), even with extensive outreach to encourage session attendance (Miranda et al.).
Over the past few decades, MI has been found to be
particularly effective in improving follow- through and
adherence to other forms of treatment and therefore is
promising as an addition to CBT. In a recent chapter,
Zuckoff et al. (2008) described a promising approach to
assign MI as a pretreatment engagement session for
improving adherence to IPT for depression. In addition
to substance abuse and depression, studies have also
used MI as a treatment engagement strategy for anxiety
disorders (Westra & Dozois, 2006) and interpersonal
violence treatments (Musser, Semiatin, Taft, & Murphy,
2008). These studies have all shown increased adherence
to treatment, and, in most cases, with improved outcomes in response to the other treatment. For example,
Westra and Dozois reported that three MI sessions prior
to group CBT for patients with panic disorder, generalized anxiety disorder, or social phobia resulted in
significantly higher expectancy of anxiety change,
homework compliance, and treatment response, compared with group CBT alone. Swartz and colleagues
(2006) found that one MI treatment engagement session
led to high rates (85%) of engagement in IPT and
improved depression and functioning outcomes in
depressed mothers. In a recent study, 74 patients with
cocaine use disorders were randomly assigned to either
CBT or CBT plus an initial MI engagement session.
Patients who received the MI session attended more drug
treatment sessions and reported significantly greater
desire for abstinence and expectation of success (McKee
et al., 2007). The results of these studies show promise
for continued development of MI as a prelude to CBT
treatment for depression. This strategy may be conceptualized as a combination as opposed to integration, but
is nonetheless a promising line of clinical research with
MI and CBT. Arkowitz and colleagues (2008) have
outlined the evidence base and applications of MI as an
effective and promising prelude to formal treatments for
anxiety and affective disorders in their recent volume
Motivational Interviewing in the Treatment of Psychological
Problems. A treatment engagement vignette is the first of
three clinical examples presented below to illustrate MI
skills that may be blended into specific CBT clinical
interactions.
Engagement Vignette (MI Skills Presented in Italics)
T: I see that your primary care physician has
referred you for depression psychotherapy. How do
you feel about that? (eliciting ambivalence; open-ended
question)
C: I'm not really sure what she thought I'd get out
of this… I've been feeling this way for years.
T: You're not sure this can help you (rolling with
resistance; reflection)
C: Yes, I've tried a few things myself, which helps a
little, but I don't know how talking to someone will
change anything.
T: You've been interested in trying to make this
better (reflecting change talk). What kinds of things
seem to help a little? (elicitation of additional change
talk; open-ended question)
C: Well, when I force myself to walk the dog, I do
feel a little better. Also when I get invited out with
friends, I can enjoy myself a bit, but I really don't
have the energy do those things that often.
Integrating MI and CBT for Depression
T: It makes a lot of sense that being physically and
socially active helps your mood, and understandable that depression can get in the way of doing
those things. Would it be okay with you if I talked a
little bit about how therapy can fit with that?
(reflecting ambivalence; eliciting permission)
C: Sure.
T: There is a kind of therapy that specifically helps
people do more of the things that make them feel
better and to build on the link between mood,
energy, activity, and thinking that you have noticed
and worked on already (reflective summary with
psychoeducation about aspects of CBT linked to the
client’s own ideas about change). How would that fit or
not fit for you? (elicitation of both ambivalence and
change talk about treatment engagement)
C: I would like to have more energy to do things
with people, so that makes sense, but I'm still not
sure talking about it will help.
T: You're still a bit mixed on whether focusing on
these things in therapy will help and at the same
time you want to do what you can to get better
(rolling with resistance, reflecting ambivalence). What
do you think you want to do? (elicitation of change
talk; respect for autonomy)
C: I suppose I could give it a try, I am tired of
feeling this way.
Behavior Activation
Behavior activation is a cornerstone of CBT and is
receiving growing research support as a key mechanism of
action, especially for more severe depression (Coffman et
al., 2007; Dimidjian et al., 2006). As mentioned previously,
MI works best and was developed specifically for targeting
behavior change. There are a number of specific
behaviors that are commonly targeted in behavior
activation, such as activity scheduling, exercise, increasing
or otherwise changing interpersonal behaviors, and
reduction of avoidance behaviors and rumination. Each
of these behavior change goals may be met with client
ambivalence and resistance.
MI therapists are specifically and strategically trained
in recognizing resistance/ambivalence, “rolling” with
resistance (i.e., avoiding argumentation), and eliciting
and enhancing client language in the direction of change
(change talk). Client change talk can be operationalized
as client language that articulates motivation for behavior
change, particularly articulation of one’s commitment to
make a change. Change talk has been found in studies
using linguistic coding to be particularly potent in
affecting behavior change outcomes. Client defense of
the status quo, known as counter-change talk, has been
inversely related to behavior change (Moyers & Martin,
2006; Moyers et al., 2005).
Client ambivalence about follow-through with behavior activation tasks may be directly addressed by integration of MI at the point at which resistance is detected by
the therapist. Well-trained MI therapists are skilled at
using a variety of techniques to elicit and encourage
change talk about a specific change while simultaneously
rolling with resistance and addressing ambivalence.
Therefore, it is important to investigate whether adding
MI to the training and overall clinical repertoire of CBT
therapists will improve their skill in helping clients with
specific depression-related behavior change.
The following clinical vignette illustrates a common
contributor to worsening mood (avoidance) that would
be a focus of CBT work and how the therapist, upon
detection of ambivalence about a specific target behavior
change (interpersonal activation), blends an MI style in
order to understand and help resolve ambivalence.
Behavior Activation Vignette
T: (Looking together at mood and behavior log)
How has your mood been this week? (open-ended
question)
C: Thinking back and looking at this, the weekend
was really low. By Sunday I was feeling miserable
and thinking about ways to escape. As you can see, I
started feeling more depressed Friday after work,
but it wasn’t too bad at that point. I didn't feel like
meeting my friends for dinner, so I stayed home
alone. Looks like it went downhill from there.
T: How would you have felt if you went with your
friends? (evoking mood-related change talk vs
imparting suggestion; open-ended question)
C: Probably a little better, but I’m sure they are
tired of dealing with me and I don't want to go out
when I am feeling that way.
T: Going out despite not feeling like it would have
helped your mood, and you are concerned that
feeling a little down would have bothered your
friends. (rolling with resistance by reflecting ambivalence)
C: Well, they haven't come out and said that, but I
suspect it's true, in which case I'd rather be alone.
T: Being alone seems better than bothering your
friends, although they haven't said anything. Your
suspicion of their frustration sometimes overrides
doing what would help you feel better (reflection:
rolling with resistance). How important is it in those
cases to boost your mood a bit by going out, from 0
to 10, with 10 being extremely important?
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C: I'd say an 8.
T: And why an 8 and not zero? (eliciting change talk)
C: I find, with the use of these logs, that if I can do
something about it when I begin to feel down, it
does help a bit. Then, I seem to have a little more
energy to do things. I can't keep losing whole
weekends like this. That is my only time with my
kids.
T: Feeling better for yourself and your kids is very
important to you (affirmation; reflection of change
talk). What do you think will help you next time you
are feeling down, but also concerned about the
effect on others? (evoking client strategies)
C: I think I will try to force myself to go out anyway,
and once I am there, at least try to interact with my
friends. It is a good distraction, after all.
T: That makes sense to me. It's important for you to
remain committed to this hard work. (affirmation;
reflection of behavior change plan)
This vignette represents one example of synergy
between CBT and MI. As can be seen, the focus on
behavioral avoidance and activation is consistent with
CBT. The style of addressing ambivalence, rolling with
resistance, boosting motivation, and evoking client
change talk about a specific behavior is MI-consistent.
This is an example of how a therapist, trained in both CBT
and MI, can integrate MI into the treatment at logical
points in the therapy (e.g., when specific behavioral
change resistance is encountered).
Homework Compliance
Although some inconsistencies in the literature exist,
there is substantial evidence that homework compliance
in CBT is an important mediator of outcome (Burns &
Nolen-Hoeksema, 1991; Burns & Spangler, 2000; Detweiler & Whisman, 1999; Rees, McEvoy, & Nathan,
2005). One of the key principles of MI is that
ambivalence influencing lack of follow-through with a
clinical recommendation is normal, and it provides
specific strategies and techniques to address ambivalence
and resistance. As such, MI provides a clear, specified
framework for CBT clinicians to use whenever difficulties
with homework completion arise. CBT therapist trained
in MI could use lack of homework completion as a signal
(resistance) for ambivalence, which would be met with
exploration and reflection of the ambivalence. Client
language in the direction of change would be targeted
and enhanced. The MI skills of exploring ambivalence
and evoking client change talk regarding CBT homework is presented below.
Homework Vignette
T: We can take a look at the thought-mood sheet
we discussed last week, or we can start with
whatever you wish today. What would be most
helpful for you? (collaborating on agenda)
C: To be honest, I never got to the thought-mood
sheet… I was too busy.
T: You had a lot going on this week (rolling with
resistance using reflection). What's it like for you to
think about working on this? (eliciting ambivalence;
open-ended question)
C: I don't know, I'm not sure how helpful it will be,
and you telling me I can change my thoughts seems
impossible.
T: Changing your thinking seems like a bit out of
reach right now and you want to make sure you are
spending your time on things that will help you
(rolling with resistance; using reflection). You are the
best expert on you… From your perspective, what is
something you can do that is likely to help your
mood? (collaboration on goals, emphasizing client
autonomy)
C: Well, it has been helpful to tune into what I am
doing and thinking when I'm feeling a little better
but the sheet you gave me is confusing. I'd rather
jot this down on my computer in a different way.
T: It will be helpful to you to track your mood in a
way that makes the most sense and is easiest for you
(reflection; supporting autonomy). What do you think
you'll do that will work for you? (respecting autonomy;
elicitation of strategies)
Conclusions and Future Directions
Clinical research on the efficacy of CBT for the
treatment of depression as well as for depression relapse
prevention has resulted in clinically meaningful outcomes overall, rendering CBT one of the most widely
adopted evidence-based treatments for depression.
Depression is associated with tremendous impairment,
and the risk of recurrence in the face of incomplete
remission is common and evident. Therefore, it is
critical to continue to explore strategies to enhance
existing depression treatments. MI is an evidence-based
strategy for improving retention and outcomes with
other formal treatments, for improving specific behavioral change outcomes, and has a primary emphasis on
evidence-based clinician interactional factors such as
empathy and collaboration. These client-centered factors are known to be contributors to depression psychotherapy outcome.
Integrating MI and CBT for Depression
Future studies are needed in order to determine
whether MI integration with CBT will lead to enhanced
depression outcomes. First, studies may examine the
effect of pre-CBT MI on CBT retention, engagement,
alliance, and outcomes (i.e., an additive effect). Second,
the synergistic effect of MI on CBT may be studied in
randomized, controlled trials in which groups of depressed patients are assigned either to CBT provided by
therapists not trained in MI (i.e., therapists rated low in
MI adherence and competence) compared to CBT
therapists rated high in MI adherence and competence.
Key outcomes may include treatment adherence, depression, and functioning outcomes. Ideally, this research
would pursue mediators and moderators of outcome. For
example, patients high or low on preference/need for
directiveness (moderation) may have differential outcomes to CBT with or without MI integration. There is
some indication in the literature that patients overall who
are high in levels of resistance respond better to MI than
to CBT-based approaches (Hettema et al., 2005). Mediators to be explored may include specific depression
symptom clusters and the severity of the depression
overall. For example, the extent to which an exclusively
eliciting interpersonal stance (consistent with MI) would
improve therapeutic outcomes with someone with moderate to severe neurovegetative symptoms is unknown.
Overall, it has become increasingly clear that recovery
from depression must involve a number of behavior
changes, including treatment adherence, increase in
reinforcing activity such as exercise, and cognitive and
interpersonal change (Hollon et al., 2002). MI has been at
the forefront of health behavior change research. The
extent to which the merging of a well-developed, specific
behavior change intervention, such as MI, with an existing
psychotherapeutic treatment for depression, such as CBT,
will improve the overall effectiveness of depression
treatment is certainly worthy of investigation.
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Address correspondence to Heather A. Flynn, Ph.D., Assistant
Professor, Director, Adult Psychotherapy Services, Department of
Psychiatry and Depression Center, University of Michigan Medical
School, Rachel Upjohn Building, 4250 Plymouth Road, Ann Arbor, MI
48109; e-mail: [email protected].
Received: January 13, 2009
Accepted: September 4, 2009
Available online 13 April 2010