Abstract

Objective Although clients’ hostile behavior directed at therapists (hostile resistance) predicts worse outcomes in cognitive–behavioral therapy (CBT) for panic disorder, the process by which this happens remains unknown. This study examines two putative mechanisms: working alliance and therapist adherence. Method: Seventy-one adults with primary panic disorder received CBT in a larger trial. Hostile resistance and adherence in Sessions 2 and 10 were reliably coded using observer-rated measures; client- and therapist-rated questionnaires assessed working alliance. Outcome measures were attrition and symptomatic improvement, assessed at multiple timepoints with the Panic Disorder Severity Scale. Results: Hostile resistance was significantly related to both preexisting (r = −.36, p = .04) and subsequent declines (r = −.58, p < .0001) in the working alliance. Nevertheless, hierarchical linear modeling revealed that neither a declining alliance nor therapist adherence (whether treated as linear or curvilinear) was independently predictive of symptom change, nor did these factors mediate hostile resistance's association with worse symptomatic improvement. Exploratory logistic regressions similarly indicated that neither adherence nor alliance moderated whether hostilely resistant clients dropped out. Conclusion: This is the first study to establish a bidirectional association between hostile resistance and a declining working alliance. Findings also add to a mixed literature on the adherence-outcome relationship.

摘要

目的尽管来访者针对治疗师的敌对行为（敌对抵抗）预示着惊恐障碍的认知行为疗法 (CBT) 的结果会更差，但发生这种情况的过程仍然未知。本研究检验了两种假定的机制：工作联盟和治疗师依从性。方法： 71 名患有原发性恐慌症的成年人在一项更大规模的试验中接受了 CBT。第 2 节和第 10 节的敌对抵抗和坚持使用观察员评定的措施可靠地编码；客户和治疗师评定的问卷评估了工作联盟。结果测量是减员和症状改善，在多个时间点使用恐慌症严重程度量表进行评估。结果：敌对抵抗与工作联盟中先前存在的 ( r = −.36, p = .04) 和随后的衰退 ( r = −.58, p < .0001) 显着相关。然而，分层线性模型显示，无论是联盟下降还是治疗师依从性（无论是线性还是曲线治疗）都不能独立预测症状变化，这些因素也不会介导敌对抵抗与较差症状改善的关联。探索性逻辑回归同样表明，无论是坚持还是联盟都不会缓和敌意抵制的客户是否退出。结论：这是第一项在敌对抵抗与衰落的工作联盟之间建立双向关联的研究。调查结果还增加了关于依从性-结果关系的混合文献。