The role of treatment delivery factors in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia.

Treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) are considered to be important for cognitive behavioral therapy (CBT) for panic disorder and agoraphobia (PD/AG). In the current study, four independent raters conducted process evaluations based on 168 two-hour videotapes of 84 patients with PD/AG treated with exposure-based CBT. Two raters evaluated patients' interpersonal behavior in Session 1. Two raters evaluated treatment delivery factors in Session 6, in which therapists provided the rationale for conducting exposure exercises. At the 6-month follow-up, therapists' adherence (r=0.54) and therapeutic alliance (r=0.31) were significant predictors of changes in agoraphobic avoidance behavior; therapist competence was not associated with treatment outcomes. Patients' interpersonal behavior in Session 1 was a significant predictor of the therapeutic alliance in Session 6 (r=0.17). The findings demonstrate that treatment delivery factors, particularly therapist adherence, are relevant to the long-term success of CBT for PD/AG.

The Effects of Bug-in-the-Eye Supervision on Therapeutic Alliance and Therapist Competence in Cognitive-Behavioural Therapy: A Randomized Controlled Trial.

Live supervision enables a supervisor to have direct insight into the psychotherapeutic process and allows him or her to provide immediate feedback to the trainee. Therefore, live supervision might be superior to traditional supervisory formats that only allow for the provision of delayed feedback. When considering the different live supervision formats, bug-in-the-eye (BITE) supervision is particularly promising because of its improved and less invasive procedure. The current study compared the efficacy of BITE supervision with that of delayed video-based (DVB) supervision. In the present study, 23 therapists were randomly assigned to either the BITE supervision or DVB supervision groups. The participants were psychotherapy trainees who treated 42 patients (19 under BITE supervision and 23 under DVB supervision) over 25 sessions of cognitive-behavioural therapy. Two independent raters blind to the treatment conditions evaluated therapeutic alliance and therapist competence based on 195 videotapes. Therapeutic alliance was significantly stronger among the treatments conducted under BITE supervision than those conducted under DVB supervision. Moreover, a higher level of therapeutic competence was found in the BITE condition than in the DVB condition. However, no differences between supervision conditions were found when the results were controlled for the level of therapeutic alliance and therapist competence demonstrated in the first session. No differences were observed between the supervision conditions with respect to patient outcomes. There is evidence that BITE supervision is able to improve therapeutic alliance and therapist competence. However, these findings should be interpreted with caution because possible pre-treatment differences between therapists might explain the superiority of BITE supervision. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: BITE supervision positively influences the therapeutic alliance and therapeutic competencies during cognitive-behavioural therapy. A supervision format that more directly addresses therapeutic processes is more effective in improving those processes than an indirect supervision format. Pre-treatment differences between therapists might explain the superiority of BITE supervision. BITE supervision can be considered a safe intervention.

Evaluation of Treatment Integrity: The Treatment Specificity Index.

OBJECTIVE: To differentiate between treatments in a randomized controlled trial (RCT), therapies need to display not only high purity but also high specificity. The aim of this study was to demonstrate the benefits of calculating a treatment specificity index for the evaluation of treatment differentiation. METHOD: Based on an RCT of relapse prevention in depression, comparing a cognitive with a psychoeducational treatment, the specificity and the purity index were calculated. RESULTS: As indicated by the specificity index, both conditions differed in their levels of implemented specific and common interventions. A significant relationship was found between symptom change before a therapy session and treatment specificity. CONCLUSIONS: The specificity index is an appropriate method for enhancing the internal validity of RCTs in evaluating treatment integrity.

Treatment failure in cognitive-behavioural therapy: therapeutic alliance as a precondition for an adherent and competent implementation of techniques.

OBJECTIVES: Treatment failure is a common phenomenon, but little is known about the reasons. Therapeutic alliance, therapist adherence, and therapist competence are considered important aspects of treatment success and formed the focus of the current investigation. DESIGN: Three randomized controlled trials for the treatment of depression, social phobia, and hypochondriasis were the basis of the current study. METHODS: The role of therapeutic alliance, as well as therapist adherence and competence, were investigated in 61 patients, which were classified either as treatment failure or as treatment success. Process variables were evaluated by independent raters on the basis of videotapes of the first three treatment sessions. RESULTS: Therapists' adherence and therapeutic alliance differed significantly between successful treatments and those classified as failures, whereas therapists' competence did not. In cross-sectional analysis, we found a moderating effect of adherence with alliance on treatment outcome, indicating that the better the therapeutic alliance, the stronger the effect of adherence on treatment outcome. Moreover, higher therapists' competence was found to affect treatment outcome positively, only mediated by therapeutic alliance. Higher therapists' adherence affected treatment outcome positively, only mediated by the competence-alliance relationship. In additional longitudinal analyses, we found evidence that the therapeutic alliance within one session influences therapists' adherence and competence in the subsequent session, but not the other way around. CONCLUSIONS: Therapeutic alliance proved to be an important variable for the prediction of treatment failure. Furthermore, in our longitudinal analyses, we found evidence that the therapeutic alliance is a precondition for the adherent and competent implementation of therapeutic techniques, which questions the results of our cross-sectional analysis and of previous research. PRACTITIONER POINTS: Clinical implications Treatment failure is associated with a lower therapeutic alliance in cognitive-behavioural treatment. Therapeutic alliance seems to be an important precondition for the adherent and competent implementation of therapeutic techniques. Therapeutic alliance should be monitored during psychotherapeutic treatment. Cautions or limitations Results are limited to cognitive-behavioural therapy and may not be representative for other treatment approaches. Process analyses are based on highly standardized randomized controlled trials and may not be generalizable to routine care.

Assessing treatment integrity in cognitive-behavioral therapy: comparing session segments with entire sessions.

The evaluation of treatment integrity (therapist adherence and competence) is a necessary condition to ensure the internal and external validity of psychotherapy research. However, the evaluation process is associated with high costs, because therapy sessions must be rated by experienced clinicians. It is debatable whether rating session segments is an adequate alternative to rating entire sessions. Four judges evaluated treatment integrity (i.e., therapist adherence and competence) in 84 randomly selected videotapes of cognitive-behavioral therapy for major depressive disorder, social anxiety disorder, and hypochondriasis (from three different treatment outcome studies). In each case, two judges provided ratings based on entire therapy sessions and two on session segments only (i.e., the middle third of the entire sessions). Interrater reliability of adherence and competence evaluations proved satisfactory for ratings based on segments and the level of reliability did not differ from ratings based on entire sessions. Ratings of treatment integrity that were based on entire sessions and session segments were strongly correlated (r=.62 for adherence and r=.73 for competence). The relationship between treatment integrity and outcome was comparable for ratings based on session segments and those based on entire sessions. However, significant relationships between therapist competence and therapy outcome were only found in the treatment of social anxiety disorder. Ratings based on segments proved to be adequate for the evaluation of treatment integrity. The findings demonstrate that session segments are an adequate and cost-effective alternative to entire sessions for the evaluation of therapist adherence and competence.