Elsevier

Psychiatry Research

Volume 228, Issue 1, 30 July 2015, Pages 53-58
Psychiatry Research

Therapist competence and therapeutic alliance are important in the treatment of health anxiety (hypochondriasis)

https://doi.org/10.1016/j.psychres.2015.03.042Get rights and content

Highlights

  • We assessed therapist adherence and competence as well as therapeutic alliance.

  • Four perspectives (raters, therapists, patients, and supervisors) could be considered.

  • Therapist competence and therapeutic alliance were predictors of therapy outcome.

  • The competence–outcome relationship was mediated by therapeutic alliance.

Abstract

The role of treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) is rarely investigated in psychotherapeutic treatment for health anxiety. This study aimed to investigate the role of the assessment perspective for the evaluation of treatment delivery factors and their relevance for treatment outcome. Therapist adherence, therapist competence, and therapeutic alliance were evaluated by independent raters, therapists, patients, and supervisors in 68 treatments. Patients with severe health anxiety (hypochondriasis) were treated with cognitive therapy or exposure therapy. Treatment outcome was assessed with a standardized interview by independent diagnosticians. A multitrait–multimethod analysis revealed a large effect for the assessment perspective of therapist adherence, therapist competence, and therapeutic alliance. The rater perspective was the most important for the prediction of treatment outcome. Therapeutic alliance and therapist competence accounted for 6% of the variance of treatment outcome while therapist adherence was not associated with treatment outcome. Therapist competence was only indirectly associated with treatment outcome, mediated by therapeutic alliance. Both therapeutic alliance and therapist competence demonstrated to be important treatment delivery factors in psychotherapy for health anxiety. A stronger consideration of those processes during psychotherapy for health anxiety might be able to improve psychotherapy outcome.

Introduction

The conceptualizations of hypochondriasis (health anxiety) as an anxiety disorder led to effective psychotherapeutic treatment approaches which address disorder-specific cognitive as well as behavioral processes (Olatunji et al., 2009, Olatunji et al., 2014). The role of treatment delivery factors have rarely been investigated in psychotherapy for health anxiety. Important treatment delivery factors, which are also the focus of the current study, are therapist adherence, therapist competence, and therapeutic alliance (Dimidjian and Hollon, 2011).

Therapist adherence refers to the extent to which a therapist uses interventions as described in the treatment manual and therapist competence refers to the level of skill shown by the therapist in delivering the treatment and includes the consideration of and response to relevant contextual variables by the therapist (Waltz et al., 1993). Therapist competence is rarely investigated in psychotherapy research in general but was found to be significantly related to therapy outcome in a meta-analysis, at least for the treatment of depression (r=0.28; Webb et al., 2010). Moreover, several recent studies which addressed anxiety disorders also found significant relationships between therapist competence and therapy outcome (r=0.22–0.79; Westra et al., 2011, Ginzburg et al., 2012, Brown et al., 2013). On the other hand, some studies found no significant relationships between therapist competence and outcome in the treatment of anxiety disorders (e.g., Boswell et al., 2013, Huppert et al., 2001). However, inappropriate methodological approaches, like the evaluation of therapist competence with only one global item might be responsible for the heterogeneous findings in research (Simons et al., 2013, Webb et al., 2010, Weck et al., 2011a). There is no consistent evidence which supports that therapist adherence impacts therapy outcome (Baldwin and Imel, 2013, Webb et al., 2010).

Therapeutic alliance was described as the collaborative and affective bond between therapist and patient (Luborsky, 1984) and was investigated frequently in psychotherapy research (Wiseman and Tishby, 2014). Therapeutic alliance was consistently found to have a significant impact on therapy outcome in meta-analyses (r=0.22–0.28; Horvath et al., 2011, Martin et al., 2000).

An important methodological aspect of evaluating process variables is the perspective from which the assessment was made. For the assessment of therapist adherence and competence, only poor concordance was found among the view of independent raters, therapist׳s self-rating, and the supervisor׳s perspective (e.g., Chevron and Rounsaville, 1983, Carrol et al., 1998, Dennhag et al., 2012, Martino et al., 2009). Also, patients׳ and therapists׳ views of the therapeutic alliance were found to be only moderately correlated in a meta-analysis of 53 studies (Tryon et al., 2007). No significant differences between varying perspectives (patient vs. therapist vs. observer) were found for the alliance–outcome relationship (Horvath et al., 2011). Regarding competence, there is some evidence that the competence–outcome relationship is stronger for the supervisor perspective in comparison to the rater or therapist perspectives (Chevron and Rounsaville, 1983).

Therapist competence and therapeutic alliance are closely related constructs (see Sharpless and Barber, 2007). Therapeutic competence can be seen as a precondition for a good therapeutic alliance. Only when the therapist is able to deliver the treatment competently, can a good therapeutic alliance be formed. Therefore, the therapeutic alliance can be considered as an important mediator for the relationship between therapist competence and treatment outcome. Some studies support this perspective and found that therapeutic alliance mediates the relationship between competence and outcome (e.g., Barber et al., 1996, Despland et al., 2009, Weck et al., 2015).

In the current study, we evaluated therapist adherence, therapist competence, and therapeutic alliance in the treatment of health anxiety. Therein, we considered two treatment approaches (i.e., cognitive therapy and exposure therapy) and four assessment perspectives (i.e., independent raters, therapists, supervisors, and patients). The first aim of our study was to evaluate the extent of method effects, attributable to the assessment of process variables by different perspectives. Based on previous studies, we expected a large method effect using a multitrait–multimethod (MTMM) approach (Hypothesis 1). The second aim was to investigate the roles of therapist adherence, therapist competence, and therapeutic alliance on therapy outcome. We hypothesized that therapist adherence is not, while therapist competence and therapeutic alliance are significant predictors of therapy outcome (Hypothesis 2). Moreover, we hypothesized that the therapeutic alliance mediates the relationship between therapist competence and therapy outcome (Hypothesis 3).

Section snippets

Study design

The current study is a secondary analysis of a randomized controlled trial treating patients with hypochondriasis (Weck et al., 2014). The study was approved by the institutional review board and is registered under NCT01119469. The aim of the main study was to compare the efficacy of cognitive therapy (CT) and exposure therapy (ET). Patients were randomized to CT, ET, or a waiting list (WL). The primary outcome measure was the Yale–Brown Obsessive Compulsive Scale for Hypochondriasis (H-YBOCS;

Results

We preliminary analyzed whether central demographic characteristics were related to treatment outcome in the considered sample (N=68). We found no significant relationship between demographic variables (i.e., sex, age, and educational level) and therapy outcome (p>0.10).

Discussion

The aim of the current study was to investigate the role of treatment delivery factors, namely therapist adherence, therapist competence, and therapeutic alliance in the treatment of health anxiety. In line with our first hypothesis, we found a large method effect regarding the assessment of those treatment delivery factors by different perspectives. In accordance with our second hypothesis, therapist adherence was not, while therapist competence and therapeutic alliance were associated with

Acknowledgments

This research was supported by Grants WE 4654/2-1 and WE 4654/2-3 from the German Research Foundation.

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