Elsevier

Behaviour Research and Therapy

Volume 52, January 2014, Pages 26-34
Behaviour Research and Therapy

Therapist effects and the outcome–alliance correlation in cognitive behavioral therapy for panic disorder with agoraphobia

https://doi.org/10.1016/j.brat.2013.11.001Get rights and content

Highlights

  • Therapist effects were not found in 2 large trials of CBT for panic disorder.

  • Patient perspective of alliance predicted outcomes at the patient level only.

  • Therapist perspective of alliance did not predict outcome at any level.

  • Patient perspective of alliance predicted attrition at patient and therapist levels.

  • Alliance is a common factor that is important for CBT for anxiety disorders.

Abstract

Although the alliance–outcome correlation is well established, no published studies to date have separated between therapists' and patients' contributions while controlling for early symptom change. In this study, we examined therapist effects in two trials of CBT for panic disorder with agoraphobia (PDA) and the impact of therapists' and patients' contribution to the alliance on outcome and attrition in one trial. Alliance ratings were obtained from patients and therapists early and late in treatment (n = 133). Data were analyzed using multi-level modeling controlling for early symptom change. No therapist effects were found. The patients' contribution to the alliance predicted outcome (in both panic severity and anxiety sensitivity) and attrition. The therapists' contribution to the alliance predicted attrition but not outcome. Results suggest that the patient's contribution to the alliance plays an important role in CBT for PDA and that including common factors into research on CBT may help elucidate treatment processes.

Section snippets

The multicenter collaborative study for the treatment of panic disorder (MCSTPD)

For full details of the trial and the previous therapist effects analysis see Barlow et al. (2000) and Huppert et al. (2001). In the current analyses, all CBT groups (e.g., CBT only and CBT combined with imipramine/placebo pill) were combined and analyzed together.

Participants. Of the 205 patients diagnosed with primary panic disorder with or without agoraphobia that were randomized to CBT, 183 patients (70 men, 113 women) had sufficient data to be included in our analyses.

Therapists. Fourteen

Effect size of treatment in the LTS

The effect size of treatment on PDSS-IE was calculated as pre-to-post Cohen's d and was found to be large, t(255) = 21.83, p < 0.001, d = 1.36, 95% CI [1.19, 1.53].

Effect sizes of treatment on PDSS-SR and ASI were calculated as the percent of variance which was explained by the addition of time as a predictor to a model without time as a predictor at level 1. Using this approach, we found that the effect sizes of treatment were large for both PDSS-SR, t(309) = −18.95, p < 0.001, ES = 0.40 and

Discussion

The present study examined therapist effects on outcome and attrition in CBT for PDA and the therapeutic alliance at the patient and therapist levels as a predictor of change in therapy. In a large-scale clinical trial (LTS), we found that the patient's contribution to the therapeutic alliance, as perceived by patients themselves, usually predicted outcome and attrition, both early (session 3) and late (session 9) in the course of treatment, even after controlling for early symptom improvement.

Acknowledgments

The results of this study were presented in part at the Association for Behavioral and Cognitive Therapies (ABCT) 45th Annual Convention, Toronto, Canada. Supported by the National Institute of Mental Health with grants: R01 MH45963, MH45964, MH45965, and MH45966. The authors would like to thank Avraham N. Kluger for his helpful comments on an earlier version of this paper.

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    The first and second authors contributed equally to this manuscript.

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