The Role of Intolerance of Uncertainty and Working Alliance in the Outcome of Cognitive Behavioral Therapy for Generalized Anxiety Disorder Delivered by Videoconference: Mediation Analysis

Abstract

Background Previous meta-analyses have shown a significant relationship between working alliance and treatment outcome in general. Some studies have examined the relationship between working alliance and treatment outcome during telepsychotherapy, but to the best of our knowledge, no study has examined the mediating role of individual components of the working alliance. Objective As part of a clinical trial of cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) delivered by videoconference (VC), the aim of this study is to examine the mediating role of intolerance of uncertainty on the relationship between the components of the working alliance and treatment outcome. Methods A sample of 46 adults with primary GAD received 15 sessions of CBT for GAD delivered over VC. Participants completed the measure of working alliance immediately after the fifth therapy session. The degree of change in intolerance of uncertainty (a key psychological process) was assessed from pre- to posttreatment. Treatment outcome was assessed via changes in GAD symptoms from pretreatment to the 6-month follow-up. Results The results revealed that the therapeutic bond did not predict treatment outcome (r=−0.23; P=.12). However, agreement on therapeutic goals and tasks did predict treatment outcome (r=−0.42; P=.004 and r=−0.37; P=.01, respectively). In addition, the relationship between consensus on therapeutic tasks and treatment outcome was completely mediated by changes in intolerance of uncertainty (unstandardized β=−0.03; r2=0.12), whereas consensus relative to treatment goals had a direct impact on treatment outcome. Conclusions These results provide a better understanding of the differential role of the components of the working alliance in telepsychotherapy as a facilitative factor for changes in key cognitive processes, leading to therapeutic change. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 12662027; http://www.isrctn.com/ISRCTN12662027.

Observing the Working Alliance in Videoconferencing Psychotherapy for Alcohol Addiction: Reliability and Validity of the Working Alliance Inventory Short Revised Observer

“…Nonetheless, the versions mentioned have shown different data regarding the mean score and prediction of therapeutic results. The mean scores of the client version are higher than those of the therapist version, a fact also observed in telepsychotherapy (Watts et al, 2020 ), although the therapist and observer versions have been more related to psychotherapeutic outcomes (Horvath and Symonds, 1991 ; Cecero et al, 2001 ; Fenton et al, 2001 ; Meier and Donmall, 2006 ; Bickman et al, 2012 ; Andrade-González and Fernández-Liria, 2015a , b ; McLeod et al, 2017 ). This phenomenon is called the Rashomon Experience (Caskey et al, 1984 ; Ardito and Rabellino, 2011 ) and indicates the need for measurements that assess the working alliance more homogeneously.…”

“…In the face of this highly damaging context for mental health, especially for those who have already suffered from some disorder, therapists have been forced to migrate to telepsychotherapy to continue psychological treatments. Therefore, telepsychotherapy, that is, the practice of psychotherapy through technologies, is an opportunity to surmount these challenges, enabling access to mental healthcare in such a difficult time (Inchausti et al, 2020 ; Simpson et al, 2020 ; Watts et al, 2020 ). Even before the pandemic, telepsychotherapy has already gained notoriety for allowing practitioners to confront the perceived stigma, and to respond to the insufficient supply of specialized treatments (Clement et al, 2015 ; Norwood et al, 2018 ).…”

“…On the one hand, this fear is being overcome by the context of the pandemic. On the other hand, some psychotherapists still believe that it is inconceivable to develop an optimum working alliance by means of telepsychotherapy, even when studies show the opposite (Sucala et al, 2013 ; Berger, 2017 ; Roesler, 2017 ; Topooco et al, 2017 ; Norwood et al, 2018 ; Connolly et al, 2020 ; Doorn et al, 2020 ; Watts et al, 2020 ). It is noteworthy that studies indicated similar results between online and face-to-face psychotherapies (Andersson, 2016 ; Carlbring et al, 2018 ; Karyotaki et al, 2018 ; Bouchard et al, 2020 ), and that some participants express a preference to develop an online working alliance rather than a face-to-face one (Watts et al, 2020 ).…”

“…Videoconferencing psychotherapy is the closest to the conventional psychotherapy model among the possibilities (e.g., telephone, chat, e-mails), being one of the methods indicated to overcome barriers of physical distance (Norwood et al, 2018 ; Watts et al, 2020 ). It allows audio and video information to be shared simultaneously, enabling the observation of non-verbal behavior and the development of a social presence that promotes familiarity, connectedness, and comfort (Backhaus et al, 2012 ; Cavanagh and Millings, 2013 ; Nelson and Duncan, 2015 ).…”

“…Finally, Norcross and Lambert ( 2014 ) argued that brief observer measurements of the alliance constitute a promising evaluation methodology. In the case of telepsychotherapy, Norwood et al ( 2018 ) and Watts et al ( 2020 ) highlighted the fact that working alliance data obtained exclusively from clients could be a problem, since psychotherapists usually underestimate the quality of the telepsychotherapy relationship. For these reasons, the WAI Short Revised Observer (WAI-SR-O; Kazantzis et al, 2021 ) was developed, initially for face-to-face psychotherapy.…”