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 Motivational Interviewing
in the Treatment of Anxiety
 Applications of Motivational Interviewing
Stephen Rollnick and William R. Miller, Series Editors

Since the publication of Miller and Rollnick’s classic Motivational Interviewing, MI

has become hugely popular as a tool for facilitating many different kinds of pos-
itive behavior change. This highly practical series demonstrates MI approaches
for a range of applied contexts and with a variety of populations. Each accessible
volume reviews the empirical evidence base and presents easy-to-implement
strategies, illuminating concrete examples, and clear-cut guidance on integrat-
ing MI with other interventions.

Motivational Interviewing in the Treatment of Psychological Problems

Hal Arkowitz, Henny A. Westra, William R. Miller, and Stephen Rollnick, Editors

Motivational Interviewing in Health Care:

Helping Patients Change Behavior
Stephen Rollnick, William R. Miller, and Christopher C. Butler

Building Motivational Interviewing Skills: A Practitioner Workbook

David B. Rosengren

Motivational Interviewing with Adolescents and Young Adults

Sylvie Naar-King and Mariann Suarez

Motivational Interviewing in Social Work Practice

Melinda Hohman

Motivational Interviewing in the Treatment of Anxiety

Henny A. Westra

Motivational Interviewing: Helping People Change, Third Edition

William R. Miller and Stephen Rollnick
Motivational
Interviewing
in the Treatment
of Anxiety

Henny A. Westra

The Guilford Press

New York  London
© 2012 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com

All rights reserved

No part of this book may be reproduced, translated, stored in

a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording,
or otherwise, without written permission from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

The author has checked with sources believed to be reliable in her efforts to provide informa-
tion that is complete and generally in accord with the standards of practice that are accepted
at the time of publication. However, in view of the possibility of human error or changes in
behavioral, mental health, or medical sciences, neither the author, nor the editors and publisher,
nor any other party who has been involved in the preparation or publication of this work war-
rants that the information contained herein is in every respect accurate or complete, and they
are not responsible for any errors or omissions or the results obtained from the use of such
information. Readers are encouraged to confirm the information contained in this book with
other sources.

Library of Congress Cataloging-in-Publication Data

Westra, Henny A.
Motivational interviewing in the treatment of anxiety / Henny A. Westra. — 1st ed.
p. cm. — (Applications of motivational interviewing)
Includes bibliographical references and index.
ISBN 978-1-4625-0481-7 (hardcover : alk. paper)
1. Anxiety. 2. Motivational interviewing. 3. Anxiety—Treatment. I. Title.
BF575.A6.W47 2012
158.3′9—dc23
2012001799
To Bill and Steve for their pioneering efforts

To my dear colleagues at York (and Mike)

who regularly inspire me

To Joanne, Clarence, Meisje, and Jenny

for their unconditional love

To my parents for their support

And to Carl Rogers,

the grandfather of motivational interviewing
 About the Author

Henny A. Westra, PhD, is Associate Professor of Psychology at York Uni-

versity in Toronto, Ontario, Canada. She has extensive clinical and research
experience and has worked as a front-line clinician, clinical director, pro-
fessor, and trainer. Dr. Westra’s research on motivation and interpersonal
process in psychotherapy has been funded by the National Institute of
Mental Health and the Canadian Institute of Health Research. She has
presented and published widely on the treatment of anxiety and depression.

vii
 Series Editors’ Note

T he field of motivational interviewing (MI) is moving fast. Rising

publication rates across diverse areas reflect the attentiveness not only of
researchers, but of clinicians too. This book combines both sensibilities, in
a new area of application.
The orientation of this text will serve the field well. MI emerged from
humanistic and behavioral psychotherapy, and in the face of so many efforts
to adapt it for use by practitioners outside of these fields, this book returns
you to its roots. Henny Westra pays very careful attention to the therapeu-
tic relationship and to what happens in a conversation about change. These
are the twin threads that run through any use of MI, and they are woven
together with considerable skill in this text. The book shines with clinical
experience.
The clients Westra writes about are mostly help-seeking, and they
often present with interrelated problems, whatever label is attached to
them. Westra breaks new ground in demonstrating how to discuss complex
problems without oversimplification, and with a clear sense of direction:
resolution that promotes growth and freedom from tension, distress, and
disability.
This book arrives at a time of transition in our own writing on MI,
shortly before the third edition of our text appears (Miller & Rollnick,
in press), yet the evidence of synergy with our work is striking. Westra’s
journey into what she calls the action stage is well matched by our own
thinking on what we call the planning process. Put simply, talk about plan-
ning involves skillful attention to the language of change, as does helping
someone resolve ambivalence and move toward decision making.
ix
x Series Editors’ Note

“MI makes good clinical sense,” one of Westra’s closing comments in

this book, is a phrase that captures much of what precedes it. This book
lays down a challenge to clinicians to be thoughtful and skillful, and to
researchers to study process in addition to client outcomes. We congratu-
late and thank her for making such considerable experience available to
others.

                        Stephen Rollnick

                        William R. M iller
 Preface

Scope and Overview of the Book

Since its inception, motivational interviewing (MI) has diffused rapidly. It

was originally developed within the area of problem drinking as an alter-
native to the confrontational style of interaction that often characterized
addictions counseling at the time. Since then, MI has become an estab-
lished, empirically supported treatment for substance abuse, has been
extended to health behaviors, and is more recently being applied to the
treatment of other major mental health problems such as anxiety disorders,
eating disorders, depression, problem gambling, and corrections.
This book describes the integration of MI with other therapies for
the treatment of anxiety and co-occurring problems such as depression.
I consider what treatment for these problems would look like if it were
informed by MI. A major aspect of MI is a specific attitude held by the
therapist—a particular way of thinking about the client, the process of
change, and the therapist’s role in it. This “MI spirit” draws heavily on
the client-centered therapy and principles outlined by Carl Rogers, and MI
principles and methods derive from this foundational attitude, with specific
MI techniques representing opportunities to communicate this attitude.
My objective in this book is not to identify what is lacking in other
major approaches to treating anxiety but rather to suggest (from my own
particular vantage point) how treatment might be enhanced if it were
informed by knowledge of MI. I suspect that many good therapists will
recognize themselves and what they do (perhaps intuitively) in these pages.
xi
xii Preface

This effort is an attempt to show how MI can make explicit some of what
may have previously been implicit or unspecified.

Who Should Read This Book?

This book is intended for any helping professional involved in providing

a formal course of treatment for those with anxiety and related problems.
This target group includes practitioners working within many other major
approaches to therapy, and this volume may be especially useful for those
working with more directive or action-oriented approaches for promot-
ing behavior change. It focuses on anxiety and the problems that go along
with it, most notably depression, since these are highly prevalent problems
in clinical practice and therefore provide an essential context for illustrat-
ing how MI can inform other treatments. Whether anxiety constitutes the
primary reason for treatment or accompanies other problems, this book
is intended to provide guidance on how infusing treatment with MI can
advance client engagement and treatment response. Practitioners of various
approaches will improve their skills at recognizing and effectively manag-
ing ambivalence and motivational impasses that often threaten the client’s
efforts to change.
Many of the clinical illustrations in the book will be most familiar to
individuals practicing cognitive-behavioral therapy (CBT). This is because
my background is in CBT, and my primary orientation in clinical practice
is the integration of MI with specific CBT methods and concepts. However,
since the MI-informed elements of therapy presented in this book are not
intended to be specific to any particular orientation, interventions derived
from other approaches can be substituted for the specific methods used for
illustration.

A Beginning Effort

This book is one of a number of attempts to describe how MI can inform the
process of treatment more broadly (with the COMBINE trial in the area of
substance abuse being another [COMBINE Study Research Group, 2003];
see also Arkowitz & Burke, 2008, on integrating MI into the treatment
of depression). Other approaches exist that outline how a client-centered
perspective can serve as an essential platform from which a variety of more
directive interventions and approaches can be practiced (emotion-focused
therapy: Greenberg, 2002; Greenberg, Rice, & Elliott, 1993; client as self-
healer: Bohart & Tallman, 1999). Accordingly, this book represents an
initial effort to integrate MI specifically with other more action-oriented
 Preface xiii

methods. I suppose I am in a unique position to make an initial attempt at

such an integration since I have a foot planted in several different worlds,
including CBT, MI, and client-centered principles,1 and thus can appreci-
ate the strengths and limits of each of these major models.
I hope this book encourages you to seek training in MI (or, if you
already know MI, enables you to extend the application of it to common
problems like anxiety); enhances your practice, whatever your approach;
and stimulates thinking and dialogue about how client engagement with
existing approaches can be improved.

1 With deep gratitude to my client-centered colleagues at York University, from whom I have
learned a great deal, especially Lynne Angus, John Eastwood, Leslie Greenberg, David Ren-
nie, and Shake Toukmanian.
 Contents

Part I. Integrating Motivational Interviewing

into the Treatment of Anxiety
and Related Problems
1. Where and Why Motivational Interviewing Fits 3

2. The Spirit of Motivational Interviewing 18

Part II. Assessing Readiness for Change

3. Observing Resistance 35

4. Asking about Readiness 50

Part III. Understanding Ambivalence

and Building Resolve
5. Introduction to Working with Ambivalence 67

6. Understanding and Reframing Resistance to Change 76

7. Evoking and Elaborating Change Talk 103

8. Developing Discrepancy 122

xv
xvi Contents

Part IV. Extending Motivational Interviewing

into the Action Phase

9. Evoking and Elaborating Client Expertise 139

10. Sharing Your Expertise 161

11. Listening Reflectively 177

12. Rolling with Resistance 192

Part V. Putting It All Together

13. Integrated Case Example 215

Epilogue. Training and Future Directions 243

Appendix. Resources and Recommended Readings 247

References 251

Index 265
 Part I
d
Integrating Motivational
Interviewing into the Treatment
of Anxiety and Related Problems
 1
d
Where and Why
Motivational Interviewing Fits

C onstant or overwhelming feelings of worry, fear, and dread can

create great suffering and misery for those who are repeatedly hijacked by
anxiety. When severe enough, it is common for anxiety (and the accompa-
nying search for safety) to eclipse critical priorities such as educational or
career advancement, forming satisfying relationships, and leisure pursuits,
or more generally feeling joy and contentment. It is also not uncommon to
see people limping along in their jobs, relationships, or activities but feeling
chronically distressed, unsatisfied, or even depressed. Such feelings often
prompt people to consider treatment.
While one might assume relief from these highly noxious feeling states
would be incentive enough to work toward overcoming them, people are
surprisingly conflicted about being less anxious or depressed and about
taking action to bring about these ends. Change is difficult and fraught
with ambivalence, including conflicting and often opposing motives and
feelings. Individuals with anxiety commonly wrestle with such ambiva-
lence. While they may be aware that anxiety is causing problems and have
a desire to be free from it, familiar patterns have a seductive quality, despite
the many problems they may create. Moreover, it is difficult and demand-
ing to face one’s fears, a necessary step in overcoming anxiety, and this is
typically not done without significant reluctance and reservations.
Although motivational interviewing (MI) was originally developed as
a method to help people work through conflicted feelings about drinking, it
is also highly relevant and adaptable to the treatment of anxiety and related
problems. Having the tools to help clients process their mixed feelings about
change, in an atmosphere of acceptance and understanding, enables a ther-
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