Discussion
anxiety disorders, anxiety, Consbruch
DISORDER, EVENTS, REMISSION, DISORDERS
The first aim of this study was to investigate whether therapist adherence, therapist competence, and therapist-youth alliance predicted outcome at long-term follow-up in CBT for anxiety disorders in youth. The results indicated that neither therapist adherence, therapist competence, nor the alliance predicted long-term follow-up when these variables were investigated separately. Given the mixed results across previous studies investigating adherence and competence as predictors of outcome, the research questions related to adherence and competence were explored openly. The present finding that neither of these variables predicted outcome is in line with several prior studies (e.g., Southam-Gerow et al., The second aim was to examine if there were interaction effects between the predictor variables and treatment format (GCBT versus ICBT), baseline symptom severity and formal CBT training. None of these variables predicted long-term follow-up when considered alone. However, several interaction effects were found. Therapists displaying both high adherence and high competence achieved better long-term outcomes in terms of loss of principal diagnosis. Traditionally, research has investigated adherence and competence as separate predictors, and the results from the current study suggest that although none of these variables predict long-term outcomes when considered alone, the combination of displaying high adherence and high competence does. Fairburn & Cooper (It could be argued that our findings regarding adherence and competence may only be relevant for clinicians using treatment manuals. A survey among U.S. mental health clinicians (Regarding treatment format, the interaction effects suggested that predictors could play different roles for long-term follow-up outcomes following GCBT versus ICBT. Therapist-rated alliance was related to long-term outcomes for both loss of principal diagnosis and loss all diagnoses when treatment was given in groups. This suggests that alliance may be particularly important in GCBT for anxiety disorders in youth. Correlational results indicated that receiving GCBT was associated with youth-rated alliance. Thus, increasing alliance in GCBT could be a clinical implication that may increase the effectiveness of GCBT. It is particularly interesting that the alliance finding only applied to GCBT. On the one hand, the finding may appear counterintuitive. There is less room for individual therapist-patient relations in GCBT, and other processes such as group cohesion may be more relevant process variables in this format (Burlingame et al., In ICBT, the results suggested that adherence was particularly important for loss of principal diagnosis, whereas it was not in GCBT. Although speculative, it may be that because ICBT gives more room to work individually tailored on the various CBT components (e.g., cognitive restructuring, exposure tasks), adherence plays a more important role in ICBT. Clinicians have been found to reduce adherence to treatment manuals over time (Chu et al., Therapists’ formal CBT training did not predict outcomes at long-term follow-up. This suggests that receiving treatment protocol training and supervision specific for treating youth anxiety disorders may be sufficient to provide effective long-term treatment. All study therapists had a relatively high level of training in the CBT protocol, which could indicate that reaching a certain level of CBT training is sufficient and resulting in formal CBT training not contributing to better long-term outcomes. Type of treatment format did not predict any outcomes at long-term follow-up, which is in line with post-treatment results in youth anxiety treatment (James et al., We found that the interaction effects predicted loss of principal diagnosis but not reduced anxiety symptom ratings (child and parent). This finding seems counterintuitive, given that loss of diagnosis should also reflect symptom improvement. This finding may be an effect of how symptoms and diagnosis were assessed. Diagnosis was based on the ADIS-IV interview, while symptoms were assessed with the SCAS. Prior research has demonstrated that the convergent validity between SCAS-rated symptoms (child and parent) and clinician rated disorder (ADIS-IV) is significant and satisfactory (Brown-Jacobsen et al., Prior research on predictors of long-term outcome following CBT for youth anxiety is still limited, and results are mixed. Some predictors associated with outcome have been identified, although these results are in most cases found in single studies, as opposed to across studies. Predictors that have been identified in more than one study, include patient factors such as negative life events during follow-up period and a diagnosis of social anxiety, both predicting negative long-term outcome, while post-treatment remission has been found to be associated with a positive long-term outcome (Ginsburg et al., The current study has several strengths, including the use of an RCT design with a large clinical sample and assessment methods with well-established psychometric properties. Four measurement points were included in the models to make the model estimations more precise. Furthermore, the longitudinal design with a long-term follow-up assessment gave us the opportunity to examine long-term predictor effects, which has not been subject to much previous research. The current study also included alliance as a predictor, which has been suggested to reduce the effect of adherence and competence on outcome (Webb et al., There are also limitations. These include the therapists being White and mainly female, possibly limiting generalizability of the results. Furthermore, the sample consisted of limited diversity (90.7% White) and participants were from primarily medium-high SES. The results are also limited to the anxiety disorders treated in the current study. Further research is warranted to investigate the role of the included predictors for other anxiety disorders. Furthermore, as adherence and competence were rated by the same rater due to limited resources, instead of applying different raters to measure the two variables, this may possibly influence the correlation between adherence and competence. The raters also assessed the same patient and the same therapist more than once, indicating that the sample of rated sessions is not independent, which can introduce a possible rater confound (Consbruch et al., In the present study, we found that therapists displaying both high levels of adherence and competence achieved better long-term outcomes, and that alliance between therapist and youth may be particularly important for long-term outcomes in GCBT, whereas adherence may be particularly important for long-term outcomes in ICBT. These results indicate that interaction effects should be subject to more research in this area. The study has several clinical implications for CBT for youth anxiety disorders. Therapists should be supported through training and supervision to enhance both adherence and competence, as they may achieve better long-term outcomes this way. In GCBT, therapist behaviors that facilitate alliance (e.g., Fjermestad et al., 