Working alliance and competence as predictors of outcome in cognitive behavioral therapy for social anxiety and panic disorder in adults

• Published in: Behaviour research and therapy Vol. 77; pp. 40 - 51
• Main Authors: Haug, Thomas, Nordgreen, Tine, Öst, Lars-Göran, Tangen, Tone, Kvale, Gerd, Hovland, Ole Johan, Heiervang, Einar R., Havik, Odd E.
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01-02-2016; Elsevier Science Ltd
• Subjects: Adherence; Adult; Adults; Anxiety; Assessors; Behavior modification; Cognitive ability; Cognitive behavioral therapy; Cognitive therapy; Cognitive Therapy - methods; Cognitive Therapy - standards; Cognitive-behavioral factors; Competence; Dropping out; Female; Forecasting; Health Personnel - psychology; Humans; Male; Medicin och hälsovetenskap; Middle Aged; Panic attacks; Panic disorder; Panic Disorder - therapy; Patient Compliance - psychology; Patients; Phobia, Social - therapy; Professional Competence; Professional-Patient Relations; Psychology; psykologi; Self Report; Social anxiety; Social anxiety disorder; Therapeutic alliances; Therapist competence; Therapists; Treatment Outcome; Working alliance; Working alliance; Social anxiety disorder; Therapist competence; Cognitive behavioral therapy; Panic disorder
• ISSN: 0005-7967; 1873-622X; 1873-622X
• DOI: 10.1016/j.brat.2015.12.004

The research on the association between the working alliance and therapist competence/adherence and outcome from cognitive behavioral therapy (CBT) is limited and characterized by inconclusive findings. This study investigates the working alliance and competence/adherence as predictors of outcome of CBT for social anxiety disorder (SAD) and panic disorder (PD).
Eighty-two clinically referred patients (58.5% female; age: M = 33.6 years, SD = 10.3) with PD (n = 31) or SAD (n = 51) were treated with 12 sessions of manualized CBT by 22 clinicians with limited CBT experience in a randomized controlled effectiveness trial. Independent assessors rated the CBT competence/adherence of the therapists using a revised version of the Cognitive Therapy Adherence and Competence Scale, and the patients rated the quality of the working alliance using the Working Alliance Inventory-short form in therapy sessions 3 and 8. The outcome was assessed by independent assessors as well as by patients self-report. A total of 20.7% of the patients (27.5% SAD, 9.7% PD) dropped out during treatment. The association between the alliance, competence/adherence, outcome and dropout was investigated using multiple regression analyses.
Higher therapist' competence/adherence early in the therapy was associated with a better outcome among PD patients, lower competence/adherence was associated with dropout among SAD patients. Higher rating of the alliance late in the therapy was associated with a better outcome, whereas lower alliance rating late in the therapy was associated with dropout.
The findings indicate that the therapist competence/adherence and the working alliance have independent contributions to the outcome from CBT for anxiety disorders, but in different phases of the treatment.
•We investigate alliance and therapist competence as predictors in manualized CBT.•The study is conducted in a naturalistic setting.•The sample comprised patients with social anxiety disorder or panic disorder.•Both alliance and therapist competence predicted the outcome and dropout.•Alliance and competence had independent contributions to explaining the outcome.