Anxiety disorders are among the most common mental illnesses in the United States, affecting 18% of the adult population ages 18 and older (see ADAA for facts and statistics). For the past several decades, cognitive behavior therapy (CBT) has been a staple in the treatment of anxiety disorders, with research demonstrating that it consistently outperforms wait list and placebo control conditions (Olatunji, Cisler, & Deacon, 2010). Despite this impressive evidence base for its efficacy, clinicians and researchers alike know that a sizeable minority of anxious patients have an incomplete response to CBT and/or fail to achieve high end-state functioning. Thus, the CBT community continues to challenge itself to hone its treatment approaches in order to maximize the likelihood of success with anxious patients.

Perhaps the two most central features of cognitive behavioral treatment of anxiety are cognitive restructuring and exposure, the latter of which is often framed as a behavioral experiment in which anxious patients test out their catastrophic predictions of what will happen if they have contact with a feared stimulus or situation. Both of these strategic interventions are action-oriented and have benefited countless patients with anxiety disorders. However, it is increasingly being recognized that many anxious patients do not present to treatment in the action stage of change. Indeed, change is threatening for many anxious patients, and they are daunted by the notion of confronting their worst fears. One recent innovation in the cognitive behavioral treatment of anxiety disorders is the use of a motivational interviewing intervention before delivering a standard course of CBT. Westra (2012), in her landmark text on the topic, summarized research suggesting that motivational interviewing + CBT is associated with greater symptom reduction than CBT alone and can improve attendance and compliance with treatment. Although I would argue that many core features of CBT mirror many core principles of motivational interviewing (e.g., collaboration), the research on this topic reminds us that careful and systematic attention to patients' readiness for change at the beginning of a course of CBT is beneficial. (To be continued...)