The alliance mediates outcome in cognitive–behavioral therapy for social anxiety disorder, but not in attention bias modification

Abstract

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.

Keywords:

• cognitive behavioral therapy
• social anxiety disorder
• therapeutic alliance
• alliance-outcome correlation

Acknowledgements

The authors thank Robert J. DeRubeis for his assistance in conceptualizing the data analytic approach. The authors would like to thank Roni Pener-Tessler, Ariela Friedman, Yael Milgram, Shai Avishay, Michal Kovacs, and Maayan Langmass for their help in data collection. This work was supported by the Israel Science Foundation (grant #332/09) to the last author, the Sam and Helen Beber Chair of Clinical Psychology at The Hebrew University. The funding sources did not have any involvement in conducting the study and preparing the manuscript.

Supplemental data

Supplemental data for this article can be accessed https://doi.org/10.1080/10503307.2020.1836423

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Notes

1 WAI ratings were also collected after each session to examine changes in alliance within sessions. Analyses of these data are outside the scope of the current manuscript but see relevant sensitivity analyses in the results section.

Additional information

Funding

This work was supported by Israel Science Foundation: [Grant Number 332/09].