Adherence, Competence and Alliance As Predictors of Long-Term Outcome in CBT for Anxiety Disorders in Youth
Costello et al., Therapist adherence, Anxiety, anxiety, anxiety disorders, depressive disorders
DISORDERS
Anxiety disorders in youth are highly prevalent and associated with significant functional impairment (Costello et al., Therapist adherence is defined as the degree to which the therapist applies prescribed procedures and avoids non-prescribed procedures, whereas therapist competence is defined as the level of the therapist’s skills in delivering the treatment interventions (Perepletchikova et al., In CBT for youth anxiety, the avoidance often exhibited by patients, may require particular therapist skills, and hence give therapist’s adherence and competence a particularly important role. For instance, since conducting exposures is considered a main intervention in CBT for anxiety disorders, adherence and competence related to conducting exposures may be particularly relevant, as avoidance is linked to anxiety, and exposures are often anxiety-provoking and may require specific therapist skills. Youth may be less motivated to do exposure tasks than adults as treatment is often initiated by their parents rather than based on the youth’s own wish. This may put extra demand on therapist skills in motivating, using developmentally appropriate language to explain the rationale behind exposure, and helping the youth with conducting exposures. However, there is limited research investigating the relationship between therapist adherence and competence on outcomes for CBT for anxiety disorders in youth, and findings are mixed (Bjaastad et al., One potential reason that the studies on adherence and competence provide such mixed findings is that variables likely to interact with these therapist effects in affecting outcomes are not included. Several variables are likely to influence how adherence and competence affect outcomes. The current study included the alliance, defined as a collaborative bond between therapist and youth receiving treatment (Karver et al., In addition to including the alliance as a predictor, the current study also considered several other treatment factors that may influence the interplay between adherence, competence, and alliance for outcomes. The first is treatment format. Treatment format (individual or group CBT) has been found to provide comparable effects regarding youth anxiety treatment (James et al., The second factor we included was baseline symptom severity. Higher symptom-severity at pre-treatment has been found to be a predictor of poorer CBT outcomes in youth with anxiety and depressive disorders (Kunas et al., Finally, we also considered therapist formal CBT training, which has been suggested to be related to better outcomes (Rakovshik & McManus, To sum up, there is limited knowledge regarding the effect of adherence, competence and alliance on treatment outcome in CBT for youth anxiety, interaction effects may be present, and studies on long-term follow-up are lacking. Most studies to date have also been carried out in university clinic settings and not in routine clinical care, and there may be differences between these settings in patient characteristics (e.g., it has been found that patients in routine clinical care have more severe symptoms and are more functionally impaired) (Villabø et al., The aim of the present study was to investigate whether therapist adherence, therapist competence, and patient-therapist alliance predict long-term treatment outcome in CBT for youth with anxiety disorders in community clinics. Given that prior research suggests interaction effects between these variables and treatment format, baseline symptom severity and formal CBT training of therapists, we also investigate these effects.The current study is a long-term follow-up study (