Patterns of alliance development in cognitive behavioral therapy versus attention bias modification for social anxiety disorder: Sawtooth patterns and sudden gains.

OBJECTIVES: We examined patterns in alliance development in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). We focused on the occurrence of sawtooth patterns (increases within- and decreases between-sessions) and sudden gains and their association with outcome. METHODS: Clients received CBT (n = 33) or ABM (n = 17). Client-rated alliance was measured before and after each session. Self-reported and clinician-rated anxiety were measured weekly and monthly, respectively. RESULTS: The alliance increased in CBT in a sawtooth pattern and did not change in ABM. When examining individual clients, sawtooths were more common in CBT (61% clients) than in ABM (6%) and predicted worse outcome in CBT. Sudden gains were equally frequent (CBT, 18%; ABM, 18%) and did not predict outcome. CONCLUSION: The alliance in CBT is dynamic and important for outcome. Sawtooths are common in CBT and may mark worse outcome.

The alliance mediates outcome in cognitive-behavioral therapy for social anxiety disorder, but not in attention bias modification.

Objective: The aim of the current study was to examine changes in the therapeutic alliance and its role as a mediator of treatment outcome in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). Method: Patients were randomized to 16-20 sessions of CBT (n = 33) or 8 sessions of ABM (n = 17). Patient-rated alliance and self-reported social anxiety were measured weekly and evaluator-rated social anxiety was measured monthly. Results: Early alliance predicted greater subsequent anxiety reduction in CBT but not in ABM. The alliance increased and weekly improvements in alliance predicted weekly contemporaneous and subsequent decreases in anxiety only in CBT. Decreases in anxiety did not predict subsequent improvements in alliance. Both treatments were effective in reducing anxiety, but treatment effects were mediated by stronger early alliance and stronger cross-lagged effects of alliance on outcome in CBT compared to ABM. Conclusions: The results highlight the importance of the alliance in CBT for SAD. Further studies should examine the role of alliance alongside additional mediators to better understand differential mechanisms in CBT and ABM.

Patient alliance with the program predicts treatment outcomes whereas alliance with the therapist predicts adherence in internet-based therapy for panic disorder.

This study examines relationships among different aspects of therapeutic alliance with treatment outcome, adherence and attrition in internet delivered cognitive behavioral therapy (ICBT) for panic disorder.We examined alliance-outcome relationships in ICBT (N = 74) using a newly developed self-report alliance measure that disentangles alliance with program content (Internet Patient's Experience of Attunement and Responsiveness with the program; I-PEARp) and with the therapist (I-PEARt). We compared ICBT outcomes of patient rated and therapist-rated alliance with conventional alliance scales (WAI-6 and WAI-T).Consistent with our hypothesis, I-PEARp and I-PEARt distinguished between different aspects of the alliance and predicted outcomes better than standard alliance scales. Furthermore, higher ratings of I-PEARp were associated with subsequent lower symptoms and lower symptoms were associated with higher subsequent alliance. In contrast, I-PEARt predicted adherence, but not symptoms. Although therapists' ratings of alliance (thI-PEAR) improved significantly during treatment, they did not predict subsequent symptoms, adherence, or dropout.Results indicate that the patient experience of the alliance in ICBT includes two aspects, each of which uniquely contributes to outcomes; patient connection to the program is related to symptom outcomes whereas the dyadic relationship with the therapist serves as the glue to allow the treatment to hold.

Clinical and cognitive insight in panic disorder: phenomenology and treatment effects in internet cognitive behavior therapy.

Clinical observations suggest that individuals with panic disorder (PD) vary in their beliefs about the causes of their panic attacks. Some attribute these attacks to psychological factors, while others to physiological or medical factors. These beliefs also extend to whether individuals perceive panic attacks as dangerous. In other areas of psychiatric nosology, these phenomena are commonly called clinical insight (recognition of disorder and the need for treatment) and cognitive insight (the ability to reflect on one's beliefs). Despite its importance, limited research exists on insight in PD and its relation to symptoms and treatment outcomes. This study examines clinical and cognitive insight in 83 patients with PD who received internet-based cognitive behavioral therapy, investigating their relationship with symptoms, treatment outcomes, and changes in insight. We assessed patients using interview and self-report measures of insight and symptoms. Clinical and cognitive insight were correlated and both constructs improved significantly during treatment. Good clinical insight pretreatment was positively correlated with more severe pretreatment symptoms. Pretreatment clinical and cognitive insight were not correlated with symptom change or attrition. Greater change in clinical and cognitive insight was related to greater change in symptoms. The findings highlight the significance of clinical and cognitive insight in PD, and the importance of distinguishing between them. This suggests the need to develop interventions according to patients' level of insight, particularly focusing on those lacking insight. Further research is essential to advance our understanding of the relationship between insight and the phenomenology and treatment of PD.

Reevaluating ruptures and repairs in alliance: Between- and within-session processes in cognitive-behavioral therapy and short-term psychodynamic psychotherapy.

OBJECTIVE: Ruptures and repairs in alliance and their association with treatment outcome have been studied widely. Many of these studies have used indirect methods, focused on decreases in alliance across sessions while measuring alliance at postsession. However, this approach does not establish whether observed decreases occur within (as insinuated by most theories) or between sessions. In the current study, we examined decreases of alliance measured both pre- and postsession in 3 clinical trials and explored the phenomenology and interpretation of these decreases. Additionally, we investigated the effects of rupture magnitude and the interpretation of repairs on treatment outcome, examining whether the "repairs benefit" or the "unrepaired ruptures damage" theories were supported by the data. METHOD: Presession and postsession therapeutic alliance and outcome measures were examined from patients who participated in 1 of 3 studies: cognitive-behavioral therapy (CBT) for social anxiety disorder (N = 29), CBT for panic disorder (N = 31), or short-term psychodynamic psychotherapy for depression (N = 44). Patterns of change in alliance are described. Ruptures and repairs are examined according to several criteria and are used to predict outcome using longitudinal multilevel modeling. RESULTS: In all samples, alliance systematically decreased between sessions and increased within them. Decreases in alliance as measured by traditional postsession to postsession were unreliable predictors of within-session decreases in alliance and of outcomes. CONCLUSIONS: Decreases in alliance across sessions are not valid measures of ruptures as defined by most theories. Instead, we suggest that they are indicative of an ebb-and-flow model for the development of alliance. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Predicting sudden gains before treatment begins: An examination of pretreatment intraindividual variability in symptoms.

Objective: Sudden gains during psychotherapy have been found to be predictive of positive treatment outcomes. Previous attempts at predicting occurrence of sudden gains have yielded equivocal findings. Recently, intraindividual variability in symptoms during treatment was suggested as a trans-therapeutic and trans-diagnostic predictor of sudden gains. The goal of the present study was to examine this predictor in Internet-delivered treatment for social anxiety disorder (SAD) and to examine whether this predictor predicts sudden gains when measured before treatment begins. Method: We examined data from a preregistered randomized controlled trial (RCT) of Internet-delivered cognitive-behavioral therapy (CBT) for SAD (n = 101). We measured variability in symptoms both within-treatment and before treatment (i.e. during waitlist). Results: Intraindividual variability in symptoms significantly predicted sudden gains both when measured before treatment or within-treatment and correctly classified 84% and 83% of individuals to sudden gains versus non-sudden gains status, respectively. Conclusions: Intraindividual variability in symptoms can predict sudden gains in Internet-delivered treatment for SAD, thus supporting its trans-diagnostic and trans-therapeutic nature. Predicting sudden gains before treatment begins has implications for treatment planning and clinical decision making as well as for personalized tailoring of interventions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

What matters more? Common or specific factors in cognitive behavioral therapy for OCD: Therapeutic alliance and expectations as predictors of treatment outcome.

CBT for obsessive-compulsive disorder (OCD) is a strong challenge to the contention that common factors explain most of the variance in outcomes in all therapies and all disorders, given that the treatment is focused and placebo response is low. In this study, the relative contributions of expectancy and therapeutic alliance as predictors of outcome in the treatment of OCD are examined and compared to the contribution of specific treatment effects. One hundred and eight patients with OCD were randomly assigned to two forms of CBT: exposure and response prevention (EX/RP) or stress management training (SMT). Measures of OCD symptoms, quality of life, therapist and patient expectancy and alliance were collected at several timepoints. Treatment type was a substantially stronger predictor of symptom reduction compared to alliance and expectancy. However, neither specific nor common factors predicted improvement in quality of life very well. Only in EX/RP, symptom change was associated with subsequent changes in alliance. Finally, therapist effects were estimated using Bayesian methods and were negligible. In the context of CBT for OCD, the data support the specific factor model, and suggest that the relative contribution of common vs. specific factors likely varies by disorder and by treatment type.