The working alliance in manualized CBT for generalized anxiety disorder: Does it lead to change and does the effect vary depending on manual implementation flexibility?

Abstract

Objective:The investigation of session-to-session effects of working alliance on symptoms and coping experiences in patients diagnosed with generalized anxiety disorder. In addition, investigating these effects dependent on whether therapists are primed to work with patients strength (resource priming) or to adhere to the treatment manual (adherence priming). Method: Data was drawn from a randomized controlled trial in which 57 patients were randomly assigned to either the resource priming condition or the adherence priming condition. Within-and between patient associations were disentangled using dynamic structural equation modeling. Results: The total score of the working alliance, as well as all its overlapping components (i.e., goal agreement, task consensus, bond) showed significant within-patient effects on next session coping experiences. More specifically, better alliance scores in one session were followed by more coping experiences in the subsequent session. With regard to anxiety symptoms, an association was found only with the working alliance total score as well as for the bonds component, but not for the goals and task components of the working alliance. The priming condition (resource priming vs. adherence priming) had no influence on the within-patient alliance-outcome association. Betweenpatient alliance associations were only present with coping experiences, but not with anxiety symptoms. Conclusion:The findings provide further empirical evidence for the hypothesis that the working alliance may be a robust facilitative factor for change in CBT treatments for generalized anxiety disorder, which evolves irrespective of the strictness with which therapists adhere to the treatment manual. What is the public health significance of this article?The present study shows that for a homogeneous sample of patients suffering from generalized anxiety disorder, fluctuations in patients' ratings of the working alliance predict anxiety symptoms and coping experiences in the subsequent session. This alliance-outcome association was more pronounced for patients with higher average alliance scores over the course of the treatment but was not influenced by the strictness with which therapists adhered to the treatment manual.

Agency and alliance as change factors in psychotherapy.

“…The experience of being an agent in psychotherapy can promote hope, initiate remoralization, and facilitate the activation of resources necessary to solve targeted problems (Flückiger et al, 2010;Frank, 1974;Grawe & Grawe-Gerber, 1999;Howard et al, 1993). Process-outcome research supports the relevance of patients' active involvement in psychotherapy, including patient's salutary activity (Wampold & Imel, 2015), participation (Orlinsky et al, 2004), coping skills (Rubel et al, 2017(Rubel et al, , 2019, and collaboration (Tryon & Winograd, 2011) for therapy outcome. Patients' agency may be relevant to address as a within-person change factor for patients' active participation and alliance in therapy as well as for symptomatic improvement (Bohart & Wade, 2013;Coleman & Neimeyer, 2015).…”

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

“…According to Roberge et al [30], approximately 80% of the people with GAD do not receive an appropriate treatment due to geographical constraints (ie, diminished availability in rural areas). Only a few studies have examined the association between the working alliance and therapeutic change for patients with GAD [14,31]. From these studies, 2 studies suggest that a strong working alliance is associated with a greater change in GAD symptoms following face-to-face CBT [31,32].…”

“…Only a few studies have examined the association between the working alliance and therapeutic change for patients with GAD [14,31]. From these studies, 2 studies suggest that a strong working alliance is associated with a greater change in GAD symptoms following face-to-face CBT [31,32]. However, 2 studies did not find such a result following face-to-face CBT [33] or internet-delivered CBT [34].…”

The evolution of patients’ concept of the alliance and its relation to outcome: A dynamic latent-class structural equation modeling approach.

“…In patients diagnosed with generalized anxiety disorder (GAD), relatively few studies appear to have investigated the alliance–outcome relation (see Coyne et al, 2019; Rubel et al, 2019). This lack of studies is somewhat unexpected as interpersonal problems are a focal consideration in GAD (e.g., Borkovec et al, 2002; Newman et al, 2013; Zinbarg et al, 2007).…”