Do patients internalize the positive regard they are offered? A dyadic test of a Rogerian condition.

OBJECTIVE: Positive regard (PR) reflects a therapist's unconditional prizing of their patient, which meta-analytically correlates positively with patient improvement. However, most research has been limited to single-participant ratings of PR at a specific time, which neglects the dyadic and dynamic nature of PR (i.e., fundamental to benefitting from therapist-offered PR is that a patient internalizes it). Testing this premise, we hypothesized that therapist-offered PR at one session would predict patient-felt PR at a subsequent session (two sessions later), which would in turn predict the patient's next-session outcome (within-patient mediation). METHOD: Eighty-four patients with generalized anxiety disorder received cognitive-behavioral therapy with or without motivational interviewing. Therapists and patients provided postsession ratings of their offered and felt PR, respectively, at odd-numbered sessions throughout treatment. Patients rated their worry following each even-numbered session. We used multilevel structural equation modeling to test our hypothesis. We explored whether treatment condition moderated the mediational path. RESULTS: As predicted, when a therapist regarded their patient more than usual following one session, the patient felt more regarded than usual. In turn, this internalized regard was negatively associated with worry. Treatment condition did not moderate this path. DISCUSSION: Results support internalized positive regard as a treatment-common, ameliorative relationship process.

A mixed methods investigation of reasons underlying fear of positive evaluation.

Fear of negative evaluation (FNE) is a hallmark feature of social anxiety disorder (SAD). There is also evidence that people with SAD fear receiving positive evaluation and that fear of positive evaluation (FPE) is distinct from FNE. However, researchers have speculated that concerns related to negative evaluation may actually underlie FPE. This study sought to advance our understanding of FPE by employing both quantitative and qualitative methods to assess the reasons underlying participants' endorsement of FPE on the Fear of Positive Evaluation Scale and the extent to which these reasons reflect FNE versus FPE in a sample of individuals with SAD (n = 47) and a nonclinical comparison group (n = 49). Results indicated that responses to the FPES items primarily reflected an underlying FNE. Consistent with contemporary cognitive-behavioural theories of SAD, fear of proximal or eventual negative judgement emerged as the most common reason for participants' responses on the FPES. However, participants reported other reasons that did not reflect FNE, such as fear of hurting people's feelings and uncertainty associated with positive evaluation. All of the reasons underlying participants' ratings on the FPES were reported by both the SAD group and the nonclinical comparison group; however, individuals with SAD endorsed each of the reasons to a greater extent. These findings suggest that the FPES does not exclusively assess FPE as intended; however, the emergence and endorsement of reasons other than FNE suggest that FPE exists as a distinct construct.

Therapist verification of patient self-concepts as a responsive precondition for early alliance development and subsequent introject change.

OBJECTIVE: Social psychological research has indicated that people strive for self-consistent feedback and interactions, even if negative, to preserve the epistemic security of knowing themselves. Without such self-verification, any interpersonal exchange may become frustrated, anxiety-riddled, and at risk for deterioration. Thus, it may be important for therapists to meet patients' self-verification needs as a responsive precondition for early alliance establishment and development. We tested this hypothesis with patients receiving cognitive behavioral therapy for generalized anxiety disorder-a condition that may render one's self-verification needs especially strong. We also tested the hypothesis that better early alliance quality would relate to subsequent adaptive changes in and posttreatment level of patients' self-concepts. METHOD: Eighty-four patients rated their self-concepts at baseline and across treatment and follow-up, their postsession recollection of their therapist's interpersonal behavior toward them during session 2, and their experience of alliance quality rated after sessions 3-6. RESULTS: As predicted, the more therapists verified at session 2 a patient's baseline self-concepts (which trended toward disaffiliative and overcontrolling, on average), the more positively that patient perceived their next-session alliance. Moreover, better session 3 alliance related to more adaptive affiliative and autonomy-granting self-concepts at posttreatment. CONCLUSION: Results are discussed within a therapist responsiveness framework.

French adaptation and validation of the Panic Disorder Severity Scale-self-report.

BACKGROUND: The aims of this study were to conduct a cross-cultural validation of the Panic Disorder Severity Scale - Self-Report (PDSS-SR) and to examine psychometric properties of the French-Canadian version. METHODS: A sample of 256 adults were included in the validation study based on data from the baseline interview of a clinical trial on transdiagnostic cognitive-behavioral therapy for mixed anxiety disorders. Participants completed the Anxiety and Related Disorders Interview Schedule (ADIS-5), and self-report instruments including the PDSS-SR, Beck Anxiety Inventory (BAI), Mobility Inventory for Agoraphobia (MIA), Sheehan Disability Scale (SDS), Patient Health Questionnaire (PHQ-9), Social Phobia Inventory (SPIN), Insomnia Severity Index (ISI) and Penn State Worry Questionnaire (PSWQ). The cross-cultural adaptation in French of the PDSS-SR included a rigorous back-translation process, with an expert committee review. Sensitivity to change was also examined with a subgroup of patients (n = 72) enrolled in the trial. RESULTS: The French version of the PDSS-SR demonstrated good psychometric properties. The exploratory factor analysis supported a one factor structure with an eigenvalue > 1 that explained 64.9% of the total variability. The confirmatory factor analysis (CFA) corroborated a one-factor model with a good model fit. Internal consistency analysis showed a .91 Cronbach's alpha. The convergent validity was adequate with the ADIS-5 clinical severity ratings for panic disorder (r = .56) and agoraphobia (r = .39), as well as for self-report instruments [BAI (r = .63), MIA (accompanied: r = .50; alone: r = .47) and SDS (r = .37)]. With respect to discriminant validity, lower correlations were found with the SPIN (r = .17), PSWQ (r = .11), ISI (r = .19) and PHQ-9 (r = .28). The optimal threshold for probable diagnosis was 9 for the PDSS-SR and 4 for the very brief 2-item version. The French version showed good sensitivity to change. CONCLUSIONS: The French version of the PDSS-SR has psychometric properties consistent with the original version and constitutes a valid brief scale to assess the severity of panic disorder and change in severity over time, both in research and clinical practice.

Therapist affiliation and hostility in cognitive-behavioral therapy with and without motivational interviewing for severe generalized anxiety disorder.

OBJECTIVE: Although therapist supportive, rather than directive, strategies have been particularly indicated during client resistance, little systematic research has examined how therapists responsively navigate resistance in different therapy approaches and how this responsiveness is related to outcome. METHOD: In the context of disagreement episodes in cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD; Westra, H. A., Constantino, M. J., & Antony, M. M. Integrating motivational interviewing with cognitive-behavioral therapy for severe generalized anxiety disorder: An allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical Psychology, 84(9), 768-782. https://doi.org/10.1037/ccp0000098, 2016), the present study examined (1) the degree to which therapist management of resistance differed between therapists trained in CBT integrated with motivational interviewing (MI-CBT; i.e., training centered on the responsive management of resistance) and therapists trained in CBT-alone, and (2) the impact of specific therapist behaviors during disagreement on client worry outcomes immediately posttreatment and 1-year posttreatment. Episodes of disagreement were rated used the Structural Analysis of Social Behavior (Benjamin, L. S. Structural analysis of social behavior. Psychological Review, 81(5), 392-425. https://doi.org/10.1037/h0037024, 1974). RESULTS: Therapists trained in MI-CBT were found to exhibit significantly more affiliative and fewer hostile behaviors during disagreement compared to those trained in CBT-alone; both of these, in turn, were found to mediate client 1-year posttreatment outcomes, such that increased affiliation during disagreement was associated with improved outcomes. CONCLUSION: This study highlights the value of training therapists in the responsive detection and management of resistance, as well as the systematic integration of MI into CBT.

Association between therapist attunement to patient outcome expectation and worry reduction in two therapies for generalized anxiety disorder.

Patients' higher psychotherapy outcome expectation (OE) correlates with improvement. Thus, it seems important that therapists attune to this belief, both in the moment and over time, to capitalize on its value when higher or respond to its potential risk when lower. Conceptually, attunement can have different guises, including the extent to which therapists (a) accurately estimate their patients' momentary OE level (low directional discrepancy), (b) become more accurate in estimating OE over time (convergence), (c) accurately track shifts in their patients' OE (temporal congruence), and (d) become more temporally congruent over time (alignment). To date, though, little is known empirically about therapist attunement to patient OE. Thus, we examined the presence of attunement indices and their relation to posttreatment outcome. Data derived from a randomized trial that compared cognitive-behavioral therapy (CBT; n = 43) to CBT plus motivational interviewing (n = 42) for patients with generalized anxiety disorder. After each session, patients rated their OE, and therapists estimated their patients' OE. Patients rated worry at baseline and posttreatment. Dyadic multilevel modeling revealed that across both treatments, therapists were directionally discrepant in that they underestimated patients' OE (p < .001), which did not change over time (no average convergence/divergence pattern; p = .43). Additionally, therapists exhibited temporal congruence with patients' OE (p < .001) and became more aligned with this rating over time (p = .008). Only greater OE convergence, when it occurred, predicted lower worry (p = .04). A therapist's increasingly accurate empathy about their patients' OE may be therapeutic. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clinical trial.

BACKGROUND: Transdiagnostic group cognitive-behavioral therapy (tCBT) is a delivery model that could help overcome barriers to large-scale implementation of evidence-based psychotherapy for anxiety disorders. The aim of this study was to assess the effectiveness of combining group tCBT with treatment-as-usual (TAU), compared to TAU, for the treatment of anxiety disorders in community-based mental health care. METHODS: In a multicenter single-blind, two-arm pragmatic superiority randomized trial, we recruited participants aged 18-65 who met DSM-5 criteria for principal diagnoses of generalized anxiety disorder, social anxiety disorder, panic disorder, or agoraphobia. Group tCBT consisted of 12 weekly 2 h sessions. There were no restrictions for TAU. The primary outcome measures were the Beck Anxiety Inventory (BAI) and clinician severity rating from the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) for the principal anxiety disorder at post-treatment, with intention-to-treat analysis. RESULTS: A total of 231 participants were randomized to either tCBT + TAU (117) or TAU (114), with outcome data available for, respectively, 95 and 106. Results of the mixed-effects regression models showed superior improvement at post-treatment for participants in tCBT + TAU, compared to TAU, for BAI [p < 0.001; unadjusted post-treatment mean (s.d.): 13.20 (9.13) v. 20.85 (10.96), Cohen's d = 0.76] and ADIS-5 [p < 0.001; 3.27 (2.19) v. 4.93 (2.00), Cohen's d = 0.79]. CONCLUSIONS: Our findings suggest that the addition of group tCBT into usual care can reduce symptom severity in patients with anxiety disorders, and support tCBT dissemination in routine community-based care.

A transdiagnostic perspective of constructs underlying obsessive-compulsive and related disorders: An international Delphi consensus study.

BACKGROUND: The Research Domain Criteria seeks to bridge knowledge from neuroscience with clinical practice by promoting research into valid neurocognitive phenotypes and dimensions, irrespective of symptoms and diagnoses as currently conceptualized. While the Research Domain Criteria offers a vision of future research and practice, its 39 functional constructs need refinement to better target new phenotyping efforts. This study aimed to determine which Research Domain Criteria constructs are most relevant to understanding obsessive-compulsive and related disorders, based on a consensus between experts in the field of obsessive-compulsive and related disorders. METHODS: Based on a modified Delphi method, 46 experts were recruited from Australia, Africa, Asia, Europe and the Americas. Over three rounds, experts had the opportunity to review their opinion in light of feedback from the previous round, which included how their response compared to other experts and a summary of comments given. RESULTS: Thirty-four experts completed round one, of whom 28 (82%) completed round two and 24 (71%) completed round three. At the final round, four constructs were endorsed by ⩾75% of experts as 'primary constructs' and therefore central to understanding obsessive-compulsive and related disorders. Of these constructs, one came from the Positive Valence System (Habit), two from the Cognitive Control System (Response Selection/Inhibition and Performance Monitoring) and the final construct was an additional item suggested by experts (Compulsivity). CONCLUSION: This study identified four Research Domain Criteria constructs that, according to experts, cut across different obsessive-compulsive and related disorders. These constructs represent key areas for future investigation, and may have potential implications for clinical practice in terms of diagnostic processes and therapeutic management of obsessive-compulsive and related disorders.

Dyadic, longitudinal associations among outcome expectation and alliance, and their indirect effects on patient outcome.

Research indicates that patient outcome expectation (OE) correlates with improvement, and that this association may be mediated by better patient-therapist alliances. However, despite OE and alliance being dyadic and dynamic constructs, most research on these direct and indirect associations has assessed these variables from only one dyad member's perspective and at single time points. Addressing these gaps, we used a longitudinal actor-partner interdependence model to first examine OE-alliance associations. Namely, we assessed "actor" effects (relation between each member's OE at 1 session and his or her own next session alliance) and "partner" effects (relation between each member's partner's OE at 1 session and his or her own next session alliance). Second, we tested whether significant actor or partner effects of OE on alliance translated into better patient outcomes (indirect effects). Analyses were conducted at within- and between-dyad levels. Data derived from a generalized anxiety disorder trial in which 85 patients received 15 sessions of either cognitive-behavioral therapy (CBT) or CBT integrated with motivational interviewing. After every session, patients and therapists rated OE and alliance, and patients rated their worry. At the within-dyad level, there were OE-alliance actor effects for both patients and therapists. There was also a within-dyad partner effect; when patients had greater OE at one session their therapists reported better next-session alliances. Finally, all within-dyad effects in turn related to lower subsequent worry. Results reveal ways in which session-by-session fluctuations in both patient and therapist OE translate into better outcomes through their influence on alliance quality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The predictive capacity of self-reported motivation vs. early observed motivational language in cognitive behavioural therapy for generalized anxiety disorder.

Client motivation to change is often considered a key factor in psychotherapy. To date, research on this client construct has largely relied on self-report, which is prone to response bias and ceiling effects. Moreover, self-reported motivation has been inconsistently related to treatment outcome. Early observed client in-session language may be a more valid measure of initial motivation and thus a promising predictor of outcome. The predictive ability of motivational factors has been examined in addiction treatment but has been limited in other populations. Addressing this lack, the present study investigated 85 clients undergoing cognitive behavioural therapy (CBT) alone and CBT infused with motivational interviewing (MI-CBT) for severe generalized anxiety disorder. There were two aims: (1) to compare the predictive capacity of motivational language vs. two self-report measures of motivation on worry reduction and (2) to examine the influence of treatment condition on motivational language. Findings indicated that motivational language explained up to 35% of outcome variance, event 1-year post-treatment. Self-reported motivation did not predict treatment outcome. Moreover, MI-CBT was associated with a significant decrease in the most detrimental type of motivational language compared to CBT alone. These findings support the importance of attending to in-session motivational language in CBT and learning to respond to these markers using motivational interviewing.

Client reflections on confirmation and disconfirmation of expectations in cognitive behavioral therapy for generalized anxiety disorder with and without motivational interviewing.

Objective: Addressing methodological shortcomings of prior work on process expectations, this study examined client process expectations both prospectively and retrospectively following treatment. Differences between clients receiving cognitive behavioral therapy (CBT) versus motivational interviewing integrated with CBT (MI-CBT) were also examined. Method: Grounded theory analysis was used to study narratives of 10 participants (N = 5 CBT, 5 MI-CBT) who completed treatment for severe generalized anxiety disorder as part of a larger randomized controlled trial. Results: Clients in both groups reported and elaborated expectancy disconfirmations more than expectancy confirmations. Compared to CBT clients, MI-CBT clients reported experiencing greater agency in the treatment process than expected (e.g., that they did most of the work) and that therapy provided a corrective experience. Despite nearly all clients achieving recovery status, CBT clients described therapy as not working in some ways (i.e., tasks did not fit, lack of improvement) and that they overcame initial skepticism regarding treatment. Conclusions: Largely converging with MI theory, findings highlight the role of key therapist behaviors (e.g., encouraging client autonomy, validating) in facilitating client experiences of the self as an agentic individual who is actively engaged in the therapy process and capable of effecting change.

Specific and common processes as mediators of the long-term effects of cognitive-behavioral therapy integrated with motivational interviewing for generalized anxiety disorder.

OBJECTIVE: A trial of psychotherapy for generalized anxiety disorder (GAD) demonstrated that motivational interviewing (MI) integrated with cognitive-behavioral therapy (CBT) outperformed CBT alone on clients' worry reduction across a 12-month follow-up. In the present study, we hypothesized and tested that less client resistance and greater client-perceived therapist empathy (specific foci of MI) would account for MI's additive effect. Exploratory analyses assessed whether the common processes of homework completion and therapeutic alliance quality mediated the treatment effect. METHOD: Clients with GAD were randomized to 15 sessions of MI-CBT (n = 42) or CBT alone (n = 43). Worry was assessed throughout treatment and follow-up. Observers rated resistance at midtreatment, and clients reported on perceived therapist empathy, alliance, and homework completion throughout treatment. Mediation was tested with bootstrapping methods. RESULTS: Expectedly, MI-CBT clients evidenced less resistance and perceived greater therapist empathy, each of which related to lower 12-month worry. However, when both variables were tested simultaneously, only resistance remained a significant mediator of treatment. No indirect effects through homework completion or alliance emerged. CONCLUSIONS: Reducing client resistance may be a theory-consistent mechanism through which integrative MI-CBT promotes superior long-term improvement than traditional CBT when treating GAD. Clinical or methodological significance of this article: This study further supports the long-term clinical benefit of integrating MI into CBT when treating the highly prevalent and historically difficult-to-treat condition of GAD. In particular, it points to the theory-specific mechanism of MI (helping to reduce/resolve patients' in-treatment resistance) as accounting for the integrative treatment's additive effect on worry reduction across a follow-up period. Therapists using CBT to treat patients with GAD should be trained to incorporate MI principles (e.g., empathy, collaboration, autonomy support) in general and in response to explicit markers of resistance.

A pragmatic randomized controlled trial of group transdiagnostic cognitive-behaviour therapy for anxiety disorders in primary care: study protocol.

BACKGROUND: Anxiety disorders are the most common mental disorders in community settings, and they are associated with significant psychological distress, functional and social impairment. While cognitive behaviour therapy (CBT) is the most consistently efficacious psychological treatment for anxiety disorders, barriers preclude widespread implementation of CBT in primary care. Transdiagnostic group CBT (tCBT) focuses on cognitive and behavioural processes and intervention strategies common to different anxiety disorders, and could be a promising alternative to conventional CBT. This study aims to examine the effectiveness of a transdiagnostic group CBT for anxiety disorders program as a complement to treatment-as-usual (TAU) in primary mental health care. METHODS/DESIGN: The trial is a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment, and follow-up at 4, 8 and 12-months design. Treatment and control groups. a) tCBT (12 weekly 2-h group sessions following a manualized treatment protocol); b) TAU for anxiety disorders. Inclusion criteria comprise meeting DSM-5 criteria for primary Panic Disorder, Agoraphobia, Social Anxiety Disorder and/or Generalized Anxiety Disorder. Patients are recruited in three regions in the province of Quebec, Canada. The primary outcome measures are the self-reported Beck Anxiety Inventory and the clinician-administered Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5); secondary outcome measures include treatment responder status based on the ADIS-5, and self-reported instruments for specific anxiety and depression symptoms, quality of life, functioning, and service utilisation. STATISTICAL ANALYSIS: Intention-to-treat analysis. A mixed effects regression model will be used to account for between- and within-subject variations in the analysis of the longitudinal effects of the intervention. DISCUSSION: This rigorous evaluation of tCBT in the real world will provide invaluable information to decision makers, health care managers, clinicians and patients regarding the effectiveness of the intervention. Widespread implementation of tCBT protocols in primary care could lead to better effectiveness, efficiency, access and equity for the large number of patients suffering from anxiety disorders that are currently not obtaining evidence-based psychotherapy. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02811458 .

Treatment of Storm Fears Using Virtual Reality and Progressive Muscle Relaxation.

BACKGROUND: The present study examined the efficacy of virtual reality (VR) exposure therapy for treating individuals with storm fears by comparing a one-session VR exposure treatment with a one-session progressive muscle relaxation (PMR) and psychoeducation session. AIMS: It was predicted that there would be a reduction in storm-related fear post-treatment for individuals in both conditions, but that this reduction would be greater for those in the VR exposure condition. It was predicted that improvements would be maintained at 30-day follow-up only for those in the VR exposure condition. METHOD: Thirty-six participants each received one of the two treatment conditions. Those in the PMR treatment group received approximately 30 minutes of PMR and approximately 15 minutes of psychoeducation regarding storms. Those in the VR treatment group received approximately 1 hour of VR exposure. Additionally, participants were asked to complete a pre-treatment and post-treatment 5-minute behavioural approach test to assess changes in storm fears. They were also asked to complete a measure assessing storm phobia. RESULTS: There was a significant interaction between treatment group and self-reported fear at post-treatment, such that fear decreased for both groups, although the reduction was stronger in the VR group. Results also showed that reductions in storm fear were maintained at 30-day follow-up for both groups. CONCLUSIONS: Although this study used a small non-clinical sample, these results offer preliminary support for the use of VR exposure therapy in the treatment of storm-related fear.

The impact of resistance on empathy in CBT for generalized anxiety disorder.

OBJECTIVE: Client resistance has been shown to relate to poorer therapy outcomes, thus making it important to better understand the mechanisms underlying this association. Given observational research suggesting that therapist empathy decreases during moments of resistance, the present study examined client-rated therapist empathy as a potential mediator of the resistance-outcome association. METHOD: Participants included 44 therapist-client dyads receiving cognitive-behavioral therapy for generalized anxiety disorder. Trained observers rated an early therapy session for the level of client resistance, and clients completed a corresponding postsession measure of therapist empathy. Posttreatment outcome was measured via client-rated worry severity. RESULTS: Higher client resistance was significantly associated with poorer treatment outcome and lower client postsession ratings of therapist empathy; however, therapist empathy was not observed to mediate the relationship between resistance and treatment outcomes. CONCLUSIONS: As empathy did not mediate the association between resistance and outcome, future research is needed to uncover other potential mechanisms of this association. However, the current results underscore an important link between resistance and client perceived therapist empathy. As empathy has been shown to relate positively to therapy outcomes, our result highlights the need to enhance therapist in-session responsivity to resistance in psychotherapy research and training.

Client interpersonal impacts as mediators of long-term outcome in cognitive-behavioral therapy integrated with motivational interviewing for generalized anxiety disorder.

OBJECTIVE: A recent trial of generalized anxiety disorder treatment (Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Integrating Motivational Interviewing With Cognitive-Behavioral Therapy for Severe Generalized Anxiety Disorder: An Allegiance-Controlled Randomized Clinical Trial. Journal of Consulting and Clinical Psychology, 84, 768-782. doi: 10.1037/ccp0000098 ) revealed that cognitive-behavioral therapy (CBT) integrated with motivational interviewing (MI) outperformed CBT alone across a 12-month follow up. The present study examined whether this treatment effect was mediated by MI-CBT clients engaging over time in during-session interpersonal behaviors reflecting more friendly dominance, or agentic actions, and less friendly submissiveness (FS), or trustingly compliant actions both theory-specific MI mechanisms. METHOD: Clients received 15 sessions of MI-CBT (n = 42) or CBT alone (n = 43). Therapists rated client interpersonal behavior following five sessions, and clients rated their worry at baseline, each session, and 6- and 12-month follow up. Mediator and outcome variables were derived from multilevel models. Mediation was tested using a bootstrapping procedure. RESULTS: There was a significant indirect effect for FS. As expected, CBT clients evidenced greater increases in FS than MI-CBT clients, which in turn, though unexpectedly, related to lower 12-month worry. However, long-term CBT outcomes remained inferior to MI-CBT outcomes even with CBT clients'greater increase in FS. CONCLUSIONS: Results suggest that CBT outcomes are more positive when clients trustingly comply; however, MI-CBT remained superior, but for as yet unexplained reasons.

Patient-therapist convergence in alliance ratings as a predictor of outcome in psychotherapy for generalized anxiety disorder.

OBJECTIVE: Although patients and therapists aligning over time on their perceptions of alliance quality is regarded as clinically important, few studies have examined the influence of such dyadic convergence on psychotherapy outcomes. This study tested whether early treatment convergence in patient-therapist alliance ratings was associated with subsequent worry and distress reduction in psychotherapy for generalized anxiety disorder (GAD), and whether treatment type and the dyad members' initial alliance perceptions moderated these associations. METHOD: Data derived from a randomized trial for which patients with severe GAD received either 15 sessions of standard cognitive-behavioral therapy (CBT; n = 43) or CBT integrated with motivational interviewing (n = 42). Patients and therapists rated the alliance after each session. Patients rated worry after each session, and their distress multiple times. RESULTS: As predicted, dyadic multilevel modeling revealed that early alliance convergence was associated with greater subsequent worry (p = .03) and distress (p = .01) reduction, and the combination of low initial patient-rated alliance and low convergence was associated with the worst outcome for the distress variable (p = .04). CONCLUSIONS: Results suggest that alliance convergence may be an important clinical process that bears on outcome, rendering it an important marker for therapist responsiveness.

The prevalence and incidence of perinatal anxiety disorders among women experiencing a medically complicated pregnancy.

Over 20% of pregnancies involve medical difficulties that pose some threat to the health and well-being of the mother, her developing infant, or both. We report on the first comparison of the prevalence and incidence of maternal anxiety disorders (AD) in pregnancy and the postpartum, across levels of medical risk in pregnancy. Pregnant women (N = 310) completed postnatal screening measures for anxiety. Women who scored at or above cutoff on one or more of the screening measures were administered a diagnostic interview (n = 115) for AD. Pregnancies were classified into low, moderate, or high risk based on self-report and contact with high-risk maternity clinics. The incidence of AD in pregnancy was higher among women classified as experiencing a medically moderate or high-risk pregnancy, compared with women classified as experiencing a medically low-risk pregnancy. Across risk groups, there were no differences in AD prevalence or in the incidence of AD in the postpartum. Demographic characteristics and parity did not contribute meaningfully to outcomes. Pregnancies characterized by medical risks are associated with an increased likelihood of new onset AD. Women experiencing medically complex pregnancies should be screened for anxiety and offered appropriate treatment.

Therapist empathy, homework compliance, and outcome in cognitive behavioral therapy for generalized anxiety disorder: partitioning within- and between-therapist effects.

Although client-perceived therapist empathy relates to positive therapy outcomes, including in cognitive behavioral therapy (CBT), little is known about how empathy exerts its ameliorative effect. One possible way is by promoting clients' subsequent homework compliance, a variable that also predicts positive outcomes in CBT. The present study sought to investigate simultaneously, in the context of 43 therapist-client dyads receiving 15 sessions of CBT for generalized anxiety disorder, (1) the association of early client-perceived therapist empathy (averaged over sessions 1, 3, 5) with mid-treatment client homework compliance (averaged over sessions 6, 8, 10); (2) the association of mid-treatment homework compliance on client posttreatment worry severity; and (3) the indirect effect of early perceived therapist empathy on posttreatment worry through mid-treatment homework compliance. Given that clients were nested within therapists, we examined both within- and between-therapist differences in clients' ratings of therapist empathy and homework compliance, and tested both of these indices as predictors of the relevant dependent variables in a multilevel model. At the within-therapist level (i.e., differences between clients within a given therapist's caseload), greater early empathy was associated with greater mid-treatment homework compliance. At the between-therapist level (i.e., differences between therapists across all of their cases), greater between-therapist homework compliance was related to lower posttreatment worry. Finally, homework compliance was not found to mediate the relationship between empathy and posttreatment outcome. The results underscore the importance of parsing client and therapist effects, and are discussed with regard to their training and research implications.

Using interpersonal process recall to compare patients' accounts of resistance in two psychotherapies for generalized anxiety disorder.

In a trial examining whether cognitive-behavioral therapy (CBT) could be improved by integrating motivational interviewing (MI) to target resistance, MI-CBT outperformed CBT over 12-month follow-up (Westra, Constantino, & Antony, 2016). Given that effectively addressing resistance is both a theoretically and an empirically supported mechanism of MI's additive effect, we explored qualitatively patients' experience of resistance, possibly as a function of treatment. For 5 patients from each treatment who exhibited early in-session change ambivalence, and thus were at risk for later resistance, we conducted interpersonal process recall interviews after a session. Transcripts were analyzed with grounded theory and consensual qualitative research. A salient contrast in patient narratives was a sense of compliance engendered in standard CBT versus connection in MI-CBT. Yet both narratives supported the superordinate category of resistance as an interpersonal process triggered by patient perceptions of therapist beliefs and behaviors. Findings contribute to the conceptualization of resistance from patients' first-hand accounts.