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 role of expressive suppression and cognitive reappraisal in cognitive behavioral therapy for social anxiety disorder: A study of self-report, subjective, and electrocortical measures.

BACKGROUND: Contemporary models of cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) emphasize emotion dysregulation as a core impairment whose reduction may play a causal role in psychotherapy. The current study examined changes in use of emotion regulation strategies as possible mechanisms of change in CBT for SAD. Specifically, we examined changes in expressive suppression and cognitive reappraisal during CBT and whether these changes predict treatment outcome. METHODS: Patients (n = 34; 13 females; Mean age = 28.36 (6.97)) were allocated to 16-20 sessions of CBT. An electrocortical measure of emotion regulation and a clinician-rated measure of SAD were administered monthly. Self-report measures of emotion regulation and social anxiety were administered weekly. Multilevel models were used to examine changes in emotion regulation during treatment and cross-lagged associations between emotion regulation and anxiety. RESULTS: CBT led to decreased suppression frequency, increased reappraisal self-efficacy, and decreased unpleasantness for SAD-related pictures (ps < .05). At post-treatment, patients were equivalent to healthy controls in terms of suppression frequency and subjective reactivity to SAD-related stimuli. Gains were maintained at 3-months follow-up. Decreases in suppression frequency and electrocortical reactivity to SAD-related pictures predicted lower subsequent anxiety but not the other way around (ps < .05). Lower anxiety predicted greater subsequent increases in reappraisal self-efficacy. LIMITATIONS: The lack of a control group precludes conclusions regarding mechanisms specificity. CONCLUSIONS: Decreased frequency of suppression is a potential mechanism of change in CBT for SAD.

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.