Motivational Enhancement Therapy Reduces Anxiety Sensitivity

Abstract

Anxiety sensitivity (AS), the fear of the consequences of anxiety, is known to be a risk factor in the
development and maintenance of anxiety psychopathology. In recent years, AS has been shown to be responsive to a variety of interventions aimed at reducing this malleable risk factor. Motivational interviewing (MI) and motivation enhancement treatment (MET) have been shown to be effective in enhancing the treatment of anxiety disorders. Thus, it was hypothesized that motivational interventions may also be effective in those with elevated AS. The aim of the present study was to examine whether the use of MI/
MET would be effective in reducing AS. Participants (N = 80) with elevated AS were randomized into an MET
or health-focused psychoeducation control group. Results revealed that the MET condition showed a significant reduction in AS in comparison to the control group. These findings are comparable to reductions in AS observed in other AS interventions. Further, changes in motivation mediated the association between experimental group and post-intervention AS. This study is the first to demonstrate the efficacy of MI/MET strategies in the reduction of AS. Implications of the findings and directions for future research are discussed

Full text

ORIGINAL ARTICLE
Motivational Enhancement Therapy Reduces Anxiety Sensitivity
Kristina J. Korte •Norman B. Schmidt
Published online: 7 June 2013
ÓSpringer Science+Business Media New York 2013
Abstract Anxiety sensitivity (AS), the fear of the con-
sequences of anxiety, is known to be a risk factor in the
development and maintenance of anxiety psychopathology.
In recent years, AS has been shown to be responsive to a
variety of interventions aimed at reducing this malleable
risk factor. Motivational interviewing (MI) and motivation
enhancement treatment (MET) have been shown to be
effective in enhancing the treatment of anxiety disorders.
Thus, it was hypothesized that motivational interventions
may also be effective in those with elevated AS. The aim of
the present study was to examine whether the use of MI/
MET would be effective in reducing AS. Participants
(N=80) with elevated AS were randomized into an MET
or health-focused psychoeducation control group. Results
revealed that the MET condition showed a significant
reduction in AS in comparison to the control group. These
findings are comparable to reductions in AS observed in
other AS interventions. Further, changes in motivation
mediated the association between experimental group and
post-intervention AS. This study is the first to demonstrate
the efficacy of MI/MET strategies in the reduction of AS.
Implications of the findings and directions for future
research are discussed.
Keywords Anxiety sensitivity Anxiety Motivation 
Motivational interviewing Motivation enhancement
therapy Risk factor Intervention
Introduction
Anxiety disorders are among the most prevalent and disabling
forms of mental health conditions. The annual cost and eco-
nomic burden of anxiety disorders is staggering (DuPont et al.
1996; Kessler et al. 2005), making the prevention of these
disorders a priority. Approaches aimed at the prevention of
anxiety disorders are being investigated and have been shown
to be effective in reducing vulnerability factors associated
with anxiety disorders (Keough and Schmidt 2012;Schmidt
et al. 2007). However, this area of work is still in the nascent
stage. As such, increased efforts examining the prevention of
anxiety disorders are crucial to reducing the prevalence and
economic burden associated with these disorders.
One risk factor, anxiety sensitivity (AS; Reiss et al.
1986), has received considerable attention in the prevention
literature. AS can be defined as the fear of anxiety and the
potential physical, social, or cognitive consequences of
anxiety. AS is known to be a risk factor in the development
(Schmidt et al. 1997; Schmidt et al. 2006) and maintenance
of anxiety psychopathology (Olatunji and Wolitzky-Taylor
2009). It has also been shown to prospectively predict the
development of anxiety psychopathology, such as sponta-
neous panic attacks (Schmidt et al. 1997,1999) and panic
disorder (Schmidt et al. 2006), and also mediates the
reduction of anxiety and depressive symptoms in treatment
outcome studies (Otto and Reilly-Harrington 1999; Smits
et al. 2004; Telch et al. 1993).
Considerable evidence indicates that AS is a malleable
risk factor, thereby making it an excellent candidate for
prevention studies (Kraemer et al. 2001). Prior preventive
interventions suggest that AS can be reduced using a variety
of cognitive-behavioral approaches (Feldner et al. 2008;
Keough and Schmidt 2012; Schmidt et al. 2007) as well as
exercise interventions (Broman-Fulks and Storey 2008;
K. J. Korte (&)N. B. Schmidt
Department of Psychology, Florida State University,
1107 W. Call St., Tallahassee, FL 32306, USA
e-mail: korte@psy.fsu.edu
123
Cogn Ther Res (2013) 37:1140–1150
DOI 10.1007/s10608-013-9550-3

Smits et al. 2008a). Specifically, Schmidt et al. (2007)
showed that a brief, computerized cognitive-behavioral
intervention modeled after educational and behavioral pro-
cedures typically used to treat anxiety disorders (e.g., dis-
cussing the benign nature of stress on the body, providing
corrective feedback, discussing exposure procedures) was
effective at reducing AS at post-intervention by approxi-
mately 30 % relative to a 17 % reduction in the health
focused control condition. The active group was also asso-
ciated with lower rates of Axis I disorders at a one-year
follow-up. Recently, Keough and Schmidt (2012) performed
an extension of this study by adding an interoceptive expo-
sure homework component. Those in the active condition
showed a 58 % reduction in AS at a one-month follow-up.
Smits et al. (2008b) conducted a meta-analysis of cognitive-
behavioral interventions utilizing exposure and cognitive
therapy techniques in the reduction of AS. For the eight
studies using ‘‘at-risk’’ samples (i.e., individuals with ele-
vated AS), there was an average 29 % reduction in AS in the
active conditions and an 18 % reduction in the control con-
ditions (Hedges’ g=.74) thereby demonstrating the effi-
cacy of these interventions in reducing AS.
Motivational interviewing (MI; Miller and Rollnick
2002) and motivation enhancement therapy (MET; Miller
et al. 1992) are approaches that may also be effective in
reducing elevated AS. MI is a therapeutic approach
focusing on the enhancement of intrinsic motivation to
resolve ambivalence to change a problematic behavior. MI
was originally developed to address the underlying treat-
ment ambivalence and resistance often observed in prob-
lematic behaviors associated with substance use disorders.
MET is similar to MI and utilizes many of the techniques
used in MI; however, MET is different from MI in that it
also includes the provision of diagnostic feedback (e.g.,
discussion of diagnosis or problem behavior and the
potential treatment options available; Miller et al. 1992).
Because individuals with high AS may be unaware of their
elevated risk, the use of interventions aimed at increasing
awareness and motivation to change risk status may be
beneficial for this population.
One premise of MI/MET is that despite the recognition
of problematic behaviors, some people may be ambivalent
or unmotivated to change these behaviors. For example, a
person with a substance use disorder may be aware of the
negative impact their addiction has on their life, such as
having difficulties with family or friends, but they may be
unmotivated to change their behavior due to the reinforcing
effects of their substance use. Likewise, a person high in
AS may be aware that their fear of anxiety related sensa-
tions limits their ability to engage in certain anxiety pro-
voking situations (e.g., avoiding exercise because the
physical sensations are similar to the experience of anxiety
sensations). However, they may be ambivalent about
changing their behavior due to the distress they experience
when confronting their AS-related situations.
The efficacy of MI/MET to increase motivation for
behavior change has been demonstrated across a range of
disorders (Buckner et al. 2008; Burke 2011; Miller et al.
1992; Maltby and Tolin 2005; Merlo et al. 2010). MI/MET
has been integrated with disorder specific treatments to
increase motivation for treatment throughout the course of
treatment (Riccardi et al. 2010; Buckner et al. 2008). MI/
MET and has also been used as a pretreatment in which an
individual receives MI/MET in their initial treatment session
to increase motivation for treatment before beginning a
disorder specific treatment (e.g., CBT for obsessive–com-
pulsive disorder). This approach is frequently used to
enhance motivation in those who may be ambivalent about
beginning treatment for their problematic behaviors (Westra
and Dozios 2006; Westra et al. 2009). Interestingly, the use
of MI/MET, prior to the initiation of CBT, has been shown to
produce symptom reduction during the motivation
enhancement stage of the treatment (Angus and Kagan 2009;
Buckner 2009; Westra et al. 2009). For example, Westra and
colleagues reported a significant reduction in worry in
patients with generalized anxiety disorder after receiving a
four session MI pretreatment compared to a no MI pre-
treatment control group. These findings demonstrate the
potency of MI/MET even when specific symptoms may not
been targeted with a traditional CBT protocol.
Although the mechanisms underlying this effect have
not been fully investigated, some have suggested that
symptom reduction may be due to a change in the client’s
commitment to change which leads to various behavioral
changes. It is also possible that the combination of having a
commitment to change and receiving psychoeducation or
feedback during MI/MET may be sufficient to produce
behavioral changes (Angus and Kagan 2009; Buckner
2009), which may in turn impact symptoms.
Although MI has been shown to be effective in the
treatment of diagnosed conditions, the use of MI/MET in
‘‘at-risk’’ populations has not been examined. As discussed
above, several studies have reported a reduction in symp-
toms after receiving pretreatment MI (Angus and Kagan;
Buckner 2009; Westra et al. 2009). Thus, it seems that
receiving information about the nature of a malleable risk
factor, such as AS, may also have a similar effect. That is,
it is possible that those with elevated AS may also show a
reduction in AS symptoms after receiving MI/MET. The
aim of the present study was to examine this issue. It was
hypothesized that individuals high in AS who received
MET would show a significant reduction in AS compared
to those in a control condition receiving general health
focused information. Further, we hypothesized that this
association would be mediated by changes in motivation to
change AS.
Cogn Ther Res (2013) 37:1140–1150 1141
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Methods
Participants
A total of 80 individuals completed the study. Participants
were undergraduate students enrolled in an introductory
psychology course at a large southern university with an
elevated level of AS (i.e., scores of 25 or higher on the
Anxiety Sensitivity Index (ASI), a self-report measure of
AS; Reiss et al. 1986). A majority of the participants were
female (75.0 % females, 25.0 % males), with a mean age
of 18.66 (SD =1.01). Sixty-nine percent of the partici-
pants were Caucasian, 14 % Hispanic, 9 % African
American, 5 % Asian, 1 % Pacific Islander and 3 % Other
(e.g., bi-racial). Nine participants (11.3 %) were diagnosed
with an anxiety disorder (2 panic disorder, 3 social anxiety
disorder, 3 generalized anxiety disorder, 1 post-traumatic
stress disorder). Participants received course credit as
compensation for completing the study.
Therapists
The MET protocol was developed and administered by the
first author, an advanced doctoral student in a clinical
psychology program. The protocol was developed based on
principles from motivational interviewing (MI; Miller and
Rollnick 2002) and from a prior investigation using MET
for anxiety disorders (Buckner and Schmidt 2009). During
the study, the first author was supervised by the second
author, a licensed psychologist, to ensure appropriate use
of MET.
Measures
Diagnostic Assessment
Structured Clinical Interview for the DSM-IV (SCID):
Anxiety Disorder Module The anxiety disorder module of
the SCID (First et al. 1995) was administered to assess for
the presence of current or past anxiety disorder diagnoses
in the sample. The SCID’s were administered by the first
author and presented and reviewed by the second author, a
licensed psychologist, to ensure accurate diagnoses. Nine
participants were diagnosed with an anxiety disorder (2
panic disorder, 3 social anxiety disorder, 3 generalized
anxiety disorder, 1 post-traumatic stress disorder).
Self-Report Measures
Demographics An experimenter developed form was
used to gather demographic information, mental health
history, and family history of mental health disorders.
Anxiety Sensitivity The ASI was used to assess for
symptoms of AS (Reiss et al. 1986). The ASI is a 16-item
scale measuring the potential harmful consequences of
anxiety related symptoms. The ASI consists of three sub-
scales corresponding to the three lower-order factors of the
hierarchical AS structure (see Zinbarg et al. 1997). The
subscales are: (1) physical concerns (e.g. ‘‘It scares me
when I feel shaky’’), (2) cognitive concerns (e.g., ‘‘When I
cannot keep my mind on a task, I worry that I might be
going crazy’’), and (3) social concerns (e.g., ‘‘It is impor-
tant for me not to appear nervous’’). Respondents are asked
to indicate the degree to which they agree or disagree with
the items on a 5-point Likert Scale (0 =very little,
4=very much). The ASI has sound psychometric prop-
erties demonstrating good construct validity (Taylor et al.
1991) and adequate internal consistency (Reiss et al. 1986).
The ASI was shown to have adequate internal consistency
in the present sample (pre-intervention a=.83; post-
intervention a=.84).
Negative Affect The Positive and Negative Affect Sche-
dule-Negative Affect subscale (PANAS-NA; Watson and
Clark 1999) is a negative emotion subscale measuring
symptoms of sadness, depression, anxiety, and fear. The
scale is comprised of the following 10 items: afraid,
scared,nervous,jittery,irritable, hostile, guilty, ashamed,
upset, and distressed. Respondents are asked to indicate the
extent to which they feel this way, in general, on a 5-point
Likert scale (1 =very slightly,not at all,3=moderately,
5=extremely). The PANAS-NA subscale has been shown
to be a reliable and valid measure of negative affect
(Watson 2000). The PANAS-NA subscale demonstrated
excellent internal consistency in the present sample
(a=.87). The PANAS-NA subscale was used to control
for negative affect in the analyses.
Trait Anxiety The State Trait Anxiety Inventory-Trait
(STAI-T); (Spielberger et al. 1983) was used to measure
trait anxiety. The STAI-Trait is a 20-item self-report
measure asking respondents to indicate the degree to which
each item reflects how they generally feel. Responses to the
items are made on a 4-point Likert scale (1 =not at all,
4=very much so). The STAI-T has been shown to be a
reliable and valid measure of trait anxiety (Spielberger
et al. 1983). The STAI-T demonstrated adequate internal
consistency in the present sample (a=.70). The STAI-T
was used to control for trait anxiety in the analyses.
Motivation Motivation to change AS was measured using
the Importance and Confidence to Change Form (ICCF).
The ICCF is an experimenter developed questionnaire,
adapted from Miller and Rollnick’s (2002) importance and
confidence rulers that are frequently used to assess for
1142 Cogn Ther Res (2013) 37:1140–1150
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change in intrinsic motivation in research utilizing MI and
MET strategies (Buckner and Schmidt 2009; Merlo et al.
2010). The ICCF was adapted from the Importance/Confi-
dence Form used by Buckner and Schmidt (2009), which
showed that the Importance/Confidence Form predicted
behavioral changes measured in the study (see Buckner and
Schmidt 2009). The ICCF asks respondents to indicate their
perceived importance to change their level of AS and their
confidence in their ability to change their level of AS. The
ICCF is comprised of the following two items: ‘‘How
important is it for you to change your level of AS?’’ (0 =not
important,5=moderately important,10=extremely
important) and ‘‘How confident are you in your ability to
change your level of AS?’’ (0 =not confident,5=moder-
ately confident,10=extremely confident). The ICCF was
administered before the intervention session (i.e., MET or
control session) and at post-intervention. The ICCF was
shown to have excellent internal consistency in the present
sample (pre-intervention a=.80; post-intervention
a=.85).
Procedure
Overview
The data used in the present study were collected for a
larger study examining the use of MET to enhance moti-
vation to receive a risk reduction intervention for those
with elevated AS. The aim of the primary study was to
examine the use of MET to increase motivation for an AS
intervention that was offered to participants after they
completed the study. Once participants arrived for the
study, they completed baseline questionnaires and were
randomized into the experimental conditions (i.e., MET
group, N=38; health focused control group N=42).
Because we thought that most participants would not know
the definition of AS, we thought it was necessary to provide
psychoeducation about AS (i.e., define AS, give brief
psychoeducation about risk related to elevated AS; see
high-risk feedback section) to all participants to ensure that
each participant had a basic understanding of AS before
beginning the experimental sessions (i.e., the MET session
or the health focused psychoeducation control session).
After receiving high-risk feedback, participants proceeded
to the experimental session in which they received the
MET or the health-focused psychoeducation. After the
experimental session, participants completed the post-
experiment questionnaires (see Fig. 1).
Pre-experiment
Participants were identified through an online screening
program in which participants completed a battery of
questionnaires to determine eligibility for ongoing studies.
Eligible participants were sent an email inviting them to
participate in a study titled ‘‘Anxiety Disorders Risk Fac-
tors Study’’. Participants were told that they would be
participating in a study about anxiety and its risk factors.
Upon arrival to the laboratory, eligible participants were
consented and randomized to either the experimental group
(MET), or the health focused control group. All partici-
pants completed a battery of baseline self-report ques-
tionnaires (including the ASI). After completing the
questionnaires, the participants met with a clinician and
were administered the SCID—Anxiety Disorder Module.
After completing the SCID, all participants received high-
risk feedback before receiving the MET for the active
group or the health focused psychoeducation control group.
Participants received the high-risk feedback to ensure they
were aware of their elevated risk status prior to the
experimental session.
High-Risk Feedback Upon completion of the SCID,
participants received the following high-risk feedback
about their level of AS (adapted from Buckner and Schmidt
2009; see Korte and Schmidt 2013):
Based on your responses to the online questionnaires,
it appears that you have a clinically significant level
of anxiety sensitivity. By clinically significant, we
mean that your level of anxiety sensitivity is higher
than that of the general population, which places you
at an increased risk for developing significant prob-
lems with anxiety. Anxiety sensitivity can be defined
as the fear of anxiety and anxiety related conse-
quences. For example, people with anxiety sensitivity
commonly report that they fear the experience of
anxiety related sensations (e.g., racing heart, shaking,
sweating) because they fear that something may be
wrong with them. Research has shown that being
high in anxiety sensitivity places you at an increased
risk for the future development of an anxiety disor-
der, like panic disorder. Just like the way smoking
increases the risk for developing cancer, and having
high cholesterol increases the risk of heart disease,
being high in anxiety sensitivity places you at an
increased risk for developing an anxiety disorder. The
good news is that there are effective interventions for
your vulnerability. Cognitive behavioral therapy, or
CBT, is an effective form of treatment for the anxiety
disorders. CBT is also effective in reducing levels of
anxiety sensitivity. In CBT, emotions are viewed as
linked with our thoughts (cognitions) and behaviors.
The clinician shows the participant a diagram illustrat-
ing that thoughts, feelings, and behaviors are linked. The
participants are then told:
Cogn Ther Res (2013) 37:1140–1150 1143
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As can be seen from this diagram, our thoughts can
influence our feelings and behaviors. One of the main
goals of CBT is to alter the maladaptive thoughts that
contribute to your feelings of anxiety. At the end of
this study, you will be given the option to return to
the laboratory at a later date to receive a brief form of
CBT designed to reduce levels of anxiety sensitivity.
Further detail on the high-risk feedback procedure can
be found in Korte and Schmidt (2013). High-risk feedback
took approximately 5 min to complete. After receiving it,
participants continued to the experimental session where
they received either: (1) MET for AS, or (2) health focused
psychoeducation.
Experimental Session
Motivation Enhancement Therapy (MET) Participants in
the MET condition received a manualized form of MET,
adapted from the first session in Buckner’s (2007) MET
treatment manual. The session of MET focused on
enhancing motivation to change AS through the use of the
Anxiety Sensitivity Amelioration Treatment (ASAT) pro-
tocol. ASAT is a brief AS intervention (see Schmidt et al.
2007), designed to reduce elevated levels of AS and to
potentially prevent the development of future anxiety dis-
orders. Throughout the MET session, ASAT was discussed
as an AS intervention available for them if they were
Mass Prescreening
N= 1,042
Consenting,
Random
Assignment
N=80
Health Focused
Control Condition
N= 42
MET Condition
N= 38
Baseline
Questionnaires,
SCID
—Anxiety
Baseline
Questionnaires,
SCID —Anxiety
High-risk
Feedback
High-risk
Feedback
Health Focused
Control
Session
MET Session
Post-experiment
Questionnaires,
Debriefing
Post-experiment
Questionnaires,
Debriefing
332 ASI > 25, sent
email for the study
N= 118 presented
for study
N= 65 eligible
N= 38 ineligible &
excluded
Fig. 1 Subject flow chart for
the experimental and control
groups
1144 Cogn Ther Res (2013) 37:1140–1150
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interested in completing it. The specific techniques used
during the MET session are enumerated below.
The MET session began by discussing the nature of AS,
including providing the participant with a handout that
provided examples of the social concerns, physical con-
cerns, and cognitive concerns related to AS (approximately
5–10 min in duration). Before proceeding, the experi-
menter asked the participants if they had any questions. If
they indicated that they did not have questions, the
experimenter queried the participant regarding their own
experiences that may be relevant to elevated AS (approx-
imately 5 min in duration). After this discussion, the
experimenter provided diagnostic feedback by comparing
the participant’s level of AS with the norm level in the
population. Specifically, the experimenter provided each
participant with an individualized graph showing their
level of AS in comparison to the clinical cutoff and the
norms of the general population. After viewing and
explaining the graph, the experimenter prompted for the
participant’s impression of this feedback (approximately
10 min in duration). Specifically, the experimenter asked:
‘‘What do you think of that’’ and ‘‘Does your level of AS
surprise you?’’ The participants were then provided with
information about the elevated risk for anxiety disorders in
those with high AS and discussed the ability for CBT-
based interventions to reduce AS and subsequent risk for
developing anxiety (approximately 5–10 min in duration).
In particular, the experimenter asked about the partici-
pant’s short and long-term goals and then asked them to
consider whether AS could interfere with those goals
(approximately 5–10 min in duration). Next, the experi-
menter explored the pros and cons of participating in an AS
intervention. Each participant completed an individualized
list of pros and cons of completing the AS intervention.
The participant discussed the pros and cons with the
experimenter and filled out the worksheet as each pro or
con was discussed (approximately 10 min in duration).
Finally, the session concluded with the creation of a change
plan (e.g., call clinic about ASAT intervention, return to
lab to complete the ASAT intervention offered at the end of
the study; approximately 2–5 min). The MET session las-
ted approximately 45–60 min depending on the respon-
siveness and the number of questions asked by the
participant.
Health Focused Control Participants in the control condi-
tion received psychoeducation focusing on health. The health
focused psychoeducation group was used to control for time
spent with the experimenter in the MET condition. The same
experimenter providing MET also provided the psychoedu-
cation to ensure that there were not group differences due to
differences in the experimenter. Psychoeducation focused on
nutrition, exercise, and general well being (i.e., stress
reduction, sleep habits). The health focused psychoeducation
control session lasted approximately 30–45 min depending on
the responsiveness and the number of questions asked by the
participant.
Post-experiment
Upon completion of the experimental session, participants
completed a post-experiment battery of questionnaires.
After this, participants met with a research assistant who
provided them with a handout briefly describing the free
computerized ASAT intervention (see Schmidt et al. 2007
for details about the intervention). The handout included
the number to the anxiety clinic and participants were
instructed to call and arrange a time to receive the free AS
intervention if they were interested. After reading the
handout, participants were debriefed and dismissed.
Results
A hierarchical linear regression equation was created to test
the hypothesis that experimental condition (i.e., MET or
health focused control) would be a significant predictor of
changes in AS. Post-intervention ASI score was used as the
criterion variable. Baseline ASI was entered in Block 1 to
control for baseline levels of AS. Experimental condition was
entered as the predictor in Block 2 to assess for the effect of
experimental condition on post-intervention AS symptoms.
The first step of the hierarchical regression model
accounted for 75.0 % of the variance (F(1, 78) =238.13,
p\.001). Unsurprisingly, baseline ASI was significantly
associated with the post-intervention ASI (b=.87,
p\.001), in the first step of the model. After the condition
variable was entered in the second step, the final model
accounted for 76.1 % of the variance (F(2, 77) =126.72,
p\.001). As expected, adding the condition variable in the
second step of the model, revealed condition to be a signif-
icant predictor of the ASI score at post-intervention, above
and beyond baseline ASI accounting for unique variance
(b=.12, p\.05) in the regression model, thereby provid-
ing evidence that the MET condition was a significant pre-
dictor in reduction of AS symptoms in comparison to the
health focused psychoeducation control group.
To ensure these effects were not confounded by the
presence of a small sample of individuals with an anxiety
disorder diagnosis, a second series of hierarchical regres-
sion analyses were preformed to evaluate the effect of
condition on changes in AS after dropping the data from
the 9 participants with anxiety disorder diagnoses. Results
followed the same pattern as the original set of analyses
with condition being a significant predictor of changes in
the ASI total score (b=.13, p\.05).
Cogn Ther Res (2013) 37:1140–1150 1145
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To provide a more stringent test of the findings, we also
examined whether the pattern of results would change after
adding negative affect and trait anxiety as covariates. The
PANAS-NA subscale was used to control for negative
affect and the STAI-T was used to control for trait anxiety.
The baseline ASI score, PANAS-NA score, and STAI-T
score were entered in Block 1 to control for these variables
in the analyses. Post-intervention ASI total score was
entered in Block 2. Once again, results followed the same
pattern as the original set of analyses. As expected, base-
line ASI total score and condition were significant pre-
dictors of post-intervention ASI total score (b=.85,
p\.001, b=.19, p\.01, respectively). Neither of the
covariates, PANAS-NA or STAI-T, were significant pre-
dictors (b=-.26, p=ns,b=.41, p=ns). Table 1
reports the full results of the regression model.
Percent Symptom Reduction
Overall, the MET condition showed a 24 % decrease in the
overall AS score (pre-intervention M=27.89, SD =9.09;
post-intervention M=21.24, SD =9.99), whereas the
control group showed a 14 % reduction (pre-intervention
M=30.32, SD =9.67; post-intervention M=26.05,
SD =10.62). After removing the 9 participants with anxiety
disorders from the analyses, the percent change increased.
Specifically, the MET condition showed 26 % reduction in
overall AS (pre-intervention M=27.79, SD =9.35; post-
intervention M=20.55, SD =10.10). In contrast, the
control group showed a 16 % reduction in overall AS scores
(pre-intervention M=28.71, SD =8.65; post-intervention
M=23.87, SD =23.87).
Mediation Analyses
To test the hypothesis that the association between exper-
imental group and post-experiment AS was mediated by
(1) confidence to change AS or (2) importance to change
AS we computed a series of mediation analyses. For the
mediation models, the predictor (X) was experimental
group (MET, control), the mediator (M) was either the
ICCF-Confidence to Change AS or the ICCF-Importance to
Change AS variables and the criterion (Y) was the post-
intervention ASI total score. Baseline ASI scores and either
the baseline ICCF-Importance or ICCF-Confidence vari-
ables were entered as covariates in the mediation models.
Mediation analyses were conducted using PROCESS, a
recently developed computational tool for SPSS and SAS to
test mediation, moderation, and conditional process mod-
eling (Hayes 2012). PROCESS is able to perform the spe-
cialized tasks for mediation analyses from classic mediation
approaches (Baron and Kenny 1986) and modern mediation
approaches such as SOBEL (Preacher and Hayes 2004),
PRODCLIN (MacKinnon et al. 2007), and RMEDIATION
(Tofighi and MacKinnon 2011). However, PROCESS is
able to produce many of the computations from earlier
mediation programs while expanding the number of medi-
ation and moderation analyses that can be conducted.
PROCESS also provides estimates of model coefficients
using ordinary least squares (OLS) regression, produces
direct and indirect effect estimates in mediation, and gen-
erates bias corrected and percentile based bootstrapped
confidence intervals for indirect effects in mediation mod-
els. Consistent with Hayes (2012), mediation was deemed
to be statistically significant if the 95 % bias-corrected
bootstrapped confidence intervals for the indirect effect did
not include zero.
Confidence to Change AS
To examine the prediction that confidence to change AS
mediates the association between experimental group and
post-intervention ASI score, a test of simple mediation was
computed. The total effect model was significant accounting
for 77 % of the variance (F(3, 76) =86.60, p\.001). The
direct effect of experimental group on post-intervention ASI
total score was significant (coefficient =3.05, SE =1.18,
p\.05). Consistent with predictions, confidence to change
AS mediated the association between experimental group
and post-intervention ASI total score (coefficient =-54,
SE =.36). The 95 % bias-corrected bootstrapped confi-
dence interval of the indirect effect did not include zero
(-1.58, -.03), indicating that there was a significant indirect
effect of the experimental condition (MET, control) on post-
intervention AS (ASI total score) that was mediated by
confidence to change AS (ICCF-Confidence; see Table 2for
the full mediation model results).
Importance to Change AS
We also computed mediation analyses to examine the
prediction that changes in the ICCF-Importance to Change
Table 1 Regression model for the post-intervention reduction in AS
Scale tbp
Dependent variable: post-experiment ASI
Variance explained: 75.0 %
Block 1
Baseline STAI 1.40 .11 .17
Baseline PANAS-NA -.15 -.01 .88
Baseline ASI 11.85 .84 .01
Variance explained: 76.1 %
Block 2
Condition 2.43 .14 .02
ASI Anxiety Sensitivity Index, N=80
1146 Cogn Ther Res (2013) 37:1140–1150
123

AS variable would mediate the association between
experimental condition and post-intervention ASI scores.
Contrary to predictions, the ICCF-Importance to Change
AS variable was not a significant mediator of the associa-
tion between experimental condition and post-intervention
ASI score. The indirect effect was not significant (coeffi-
cient =-.35, SE =.35) as the 95 % bias-corrected boot-
strapped confidence interval included zero (-1.38, .06),
although this effect did trend toward significance (see
Table 3for the change in the means and standard devia-
tions of the ICCF-Importance and ICCF-Confidence to
change variables from pre to post-intervention).
Discussion
Results of the present study show the use of a single session
of MET to be effective at reducing AS. The MET group
showed a 26 % reduction in AS symptoms, which is similar
to that reported in other AS intervention studies. For
instance, Schmidt et al. (2007) reported a 30 % reduction in
AS at post-intervention. Further, Smits et al. (2008a,b)
performed a meta-analysis of AS interventions and reported
a mean change of 6.92, (SD =2.54) on the ASI in active
condition and a 4.32 point change (SD =3.61) in the control
condition in ‘‘at-risk’’ samples. This change is comparable to
the change in AS (7.25 points for the MET group; 4.84 points
for the control group) in the present investigation. Thus, the
level of post-intervention reduction in AS after the MET
session in the present study is similar to the post-intervention
reduction when utilizing other CBT techniques.
These findings naturally raise the question of why would
we observe a significant reduction in AS after a single
session of MET designed with the goal of increasing
motivation to engage in effective CBT-based interventions?
As revealed in the present study, increases in motivation
mediated the association between experimental group and
post-intervention AS. Specifically, one commonly mea-
sured motivational construct—confidence to change –was
shown to mediate the association between experimental
condition and AS at post-intervention, whereas a second
motivational construct—importance to change, did not
mediate this association, although this effect did trend
toward significance. The finding that MET impacts symp-
toms by increasing motivation to change is theoretically
consistent with the principles of MI/MET approaches
(Miller and Rollnick 2002). These findings are also con-
sistent with prior work examining the use of MI/MET in
anxiety disorders (Buckner and Schmidt 2009; Merlo
et al. 2010), in which MI/MET was effective at increasing
motivation to change. However, it is interesting to note
that importance to change was not a significant mediator.
These findings suggest that MET may be more effective
at increasing confidence to change AS (i.e., perceived
ability to change AS), whereas MET may be less effective
at increasing importance to change AS (i.e., perceived
reasons to change AS). However, it should also be noted
that the actual level of change in the importance and
confidence to change variables were similar (see Table 3),
but there was more variability in importance to
change AS than confidence to change AS in the present
sample.
Table 2 Total effect mediation
model of experimental
condition on post-intervention
AS mediated by confidence to
change
ASI Anxiety Sensitivity Index,
ICCF Importance and
Confidence Form, CI 95 % bias
adjusted bootstrapped
confidence interval, N=80
Coefficient SE t p
Total model
Baseline ICCF-
Confidence
-1.78 .68 -2.33 .05
Baseline ASI .92 .06 14.86 .001
Post ICCF-Confidence 1.15 .64 1.81 .07
Condition 3.05 1.18 2.59 .01
Indirect effect Upper CI Lower CI
Post-intervention
ICCF-confidence
-0.54 .36 -1.58 -0.03
Table 3 Pre and post-
intervention change in ICCF
importance and confidence to
change AS by condition
ICCF-Importance and
Confidence to Change Form—
Anxiety Sensitivity, N=80
MET Control
Pre Post Pre Post
ICCF-
Importance
5.49 (1.88) 6.08 (2.36) 6.05 (2.08) 6.09 (1.97)
ICCF-
Confidence
6.57 (1.54) 6.97 (1.52) 6.56 (1.96) 6.53 (2.12)
Cogn Ther Res (2013) 37:1140–1150 1147
123

Although the present study showed that confidence to
change AS mediated the association between experimental
condition and AS, it is important to note that confidence to
change was a partial mediator in the association, thus it is
possible that there are other mechanisms impacting this
association. One possibility is that in addition to enhancing
motivation, the MET techniques may have also promoted
cognitive change about AS related cognitions. That is,
some of the MET techniques (e.g., psychoeducation about
AS, discussing how AS impacts daily life) may have
altered AS related cognitions, thereby resulting in a
reduction in AS. Unfortunately, the present study did not
directly measure change in cognitions from pre to post-
intervention, so we were unable to determine whether this
was in fact another mechanism involved in the reduction of
AS after MET.
As with any study, the current study should be consid-
ered in lieu of its limitations and directions for subsequent
research. First, because the sample was primarily com-
posed of Caucasian females, this could limit the general-
izability of these findings. Future research would benefit
from replicating these findings in a more demographically
diverse sample. However, because AS has been shown to
be higher in females (Stewart et al. 1997; Zvolensky et al.
2001), it is not unreasonable to use a sample with a
majority of female participants. Further, there was also a
minimal difference in the duration of the MET condition
and the psychoeducation control groups. Although both
conditions were designed to last approximately 45 min,
there was some fluctuation in the session duration as some
participants were more engaged in the session (i.e., MET
condition), whereas others were less engaged (i.e., control
condition), thereby reducing the session time. Additionally,
because the present study did not include a follow-up
period, it is also impossible to rule out whether the
observed change in AS reflects a transient change or if it is
maintained over time. As such, future work should include
a follow-up period to examine the longevity of the findings.
Furthermore, a key limitation in examining mediation in
intervention studies is the difficulty in establishing a
sequential timeline between the mediator and the outcome
variable (Kazdin 2007; Smits et al. 2012). As suggested by
Kazdin (2007), an optimal approach to establish mediation
in treatment studies is to assess for change in symptoms
and the proposed mediators at multiple time points, such as
before each treatment session. Whereas it is possible to
utilize this approach with multi-session designs, the ability
to perform multiple assessments in a one-session inter-
vention design is limited. Thus, given the one-session
design of the present study, we cannot conclude with cer-
tainty that change in the mediator (i.e., change in motiva-
tion) occurred before change in the outcome (i.e., change in
AS) as the data was collected using a pre and post-inter-
vention assessment procedure.
The results of the present study also provide several
avenues for future research. For example, it would be
interesting to examine whether augmenting AS interven-
tions with MI/MET enhances the potency of AS interven-
tions. Future research should examine this question by
examining whether adding an MI/MET session before
completion of an AS intervention results in further reduc-
tion of AS symptoms. It is also important to examine other
potential mediators involved in the reduction of AS
through the use of MET. It would be beneficial to assess
whether the mechanisms involved this effect is primarily
related to change in motivation, or whether there are other
processes, such as change in cognitions, that are also
involved in this association. Further, it would be interesting
to examine whether the use of MI/MET is effective at
reducing symptoms in other ‘‘at-risk’’ populations, such as
those high in negative affect, behavioral inhibition, or
subclinical anxiety symptoms. These studies could provide
an important step in enhancing our knowledge of how to
increase the efficacy of our existing preventive
interventions.
Overall, the results of the present study provide novel
findings in the area of anxiety prevention. Importantly, this
study is the first to show that the use of MI/MET signifi-
cantly reduces AS and that this effect is mediated by
changes in motivation (i.e., confidence to change AS). This
adds to the existing prevention literature showing that CBT
and exercise-based interventions are effective at reducing
AS by demonstrating that the use MI/MET is also effective
at reducing this risk factor. Although the prevention of
anxiety disorders has received increased attention in recent
years, this area of work is still in the nascent stage.
Increased efforts aimed at the development of preventive
interventions to reduce malleable risk factors, such as AS,
are crucial for advancement in this area of study. Increas-
ing efforts aimed at preventing anxiety disorders, will lead
to innovative approaches to help reduce the prevalence and
economic burden of these disorders.
Conflict of interest All authors declare that they have no conflicts
of interest to disclose.
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