title: Working alliance and competence as predictors of outcome in cognitive behavioral therapy for social anxiety and panic disorder in adults.
abstract: OBJECTIVE
  The research on the association between the working alliance and therapist competence/adherence and outcome from cognitive behavioral therapy (CBT) is limited and characterized by inconclusive findings. This study investigates the working alliance and competence/adherence as predictors of outcome of CBT for social anxiety disorder (SAD) and panic disorder (PD).
  
  
  METHODS
  Eighty-two clinically referred patients (58.5% female; age: M = 33.6 years, SD = 10.3) with PD (n = 31) or SAD (n = 51) were treated with 12 sessions of manualized CBT by 22 clinicians with limited CBT experience in a randomized controlled effectiveness trial. Independent assessors rated the CBT competence/adherence of the therapists using a revised version of the Cognitive Therapy Adherence and Competence Scale, and the patients rated the quality of the working alliance using the Working Alliance Inventory-short form in therapy sessions 3 and 8. The outcome was assessed by independent assessors as well as by patients self-report. A total of 20.7% of the patients (27.5% SAD, 9.7% PD) dropped out during treatment. The association between the alliance, competence/adherence, outcome and dropout was investigated using multiple regression analyses.
  
  
  RESULTS
  Higher therapist' competence/adherence early in the therapy was associated with a better outcome among PD patients, lower competence/adherence was associated with dropout among SAD patients. Higher rating of the alliance late in the therapy was associated with a better outcome, whereas lower alliance rating late in the therapy was associated with dropout.
  
  
  CONCLUSIONS
  The findings indicate that the therapist competence/adherence and the working alliance have independent contributions to the outcome from CBT for anxiety disorders, but in different phases of the treatment.
authors.affiliation: Anxiety Disorders Research Network, Haukeland University Hospital, Postboks 1400, 5021 Bergen, Norway; Department of Clinical Psychology, University of Bergen, Postboks 7800, 5020 Bergen, Norway. Electronic address: Thomas.haug@psykp.uib.no.
authors.forename: Thomas
authors.initials: T
authors.lastname: Haug
authors.affiliation: Anxiety Disorders Research Network, Haukeland University Hospital, Postboks 1400, 5021 Bergen, Norway; Department of Clinical Psychology, University of Bergen, Postboks 7800, 5020 Bergen, Norway.
authors.forename: Tine
authors.initials: T
authors.lastname: Nordgreen
authors.affiliation: Anxiety Disorders Research Network, Haukeland University Hospital, Postboks 1400, 5021 Bergen, Norway; Department of Psychology, University of Stockholm, SE-106 91 Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institute, 171 77 Stockholm, Sweden.
authors.forename: Lars-Göran
authors.initials: LG
authors.lastname: Öst
authors.affiliation: Anxiety Disorders Research Network, Haukeland University Hospital, Postboks 1400, 5021 Bergen, Norway; Department of Psychiatry, University of Bergen, Postboks 7800, 5020 Bergen, Norway.
authors.forename: Tone
authors.initials: T
authors.lastname: Tangen
authors.affiliation: Anxiety Disorders Research Network, Haukeland University Hospital, Postboks 1400, 5021 Bergen, Norway; Department of Clinical Psychology, University of Bergen, Postboks 7800, 5020 Bergen, Norway.
authors.forename: Gerd
authors.initials: G
authors.lastname: Kvale
authors.affiliation: Anxiety Disorders Research Network, Haukeland University Hospital, Postboks 1400, 5021 Bergen, Norway.
authors.forename: Ole Johan
authors.initials: OJ
authors.lastname: Hovland
authors.affiliation: Anxiety Disorders Research Network, Haukeland University Hospital, Postboks 1400, 5021 Bergen, Norway; Institute of Clinical Medicine, University of Oslo, Postboks 1171, Blindern, 0318 Oslo, Norway.
authors.forename: Einar R
authors.initials: ER
authors.lastname: Heiervang
authors.affiliation: Anxiety Disorders Research Network, Haukeland University Hospital, Postboks 1400, 5021 Bergen, Norway; Department of Clinical Psychology, University of Bergen, Postboks 7800, 5020 Bergen, Norway.
authors.forename: Odd E
authors.initials: OE
authors.lastname: Havik
mesh_terms: D000328:Adult; D015928:Cognitive Behavioral Therapy / Q000379:methods* / Q000592:standards*; D005260:Female; D005544:Forecasting; D006282:Health Personnel / Q000523:psychology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016584:Panic Disorder / Q000628:therapy; D010349:Patient Compliance / Q000523:psychology; D000072861:Phobia, Social / Q000628:therapy; D011361:Professional Competence; D011369:Professional-Patient Relations; D057566:Self Report; D016896:Treatment Outcome
keywords: Cognitive behavioral therapy; Panic disorder; Social anxiety disorder; Therapist competence; Working alliance