Forming Bonds to Challenge Fears: Course of the Working Alliance during Cognitive Behavioral Treatment for Social Anxiety Disorder

Social anxiety disorder (SAD) is the 3rd most common psychiatric diagnosis, and is associated with significant social, occupational, health, and educational impairment. Fortunately, both pharmacological and psychological treatments can reduce symptoms. Cognitive behavioral therapy is considered the gold standard treatment for SAD, and a robust literature supports its effectiveness. In contrast, process related factors, including the role of the working alliance, have received less attention in treatment of SAD. The current study examined development of the working alliance for a SAD sample. The working alliance is characterized as the collaborative relationship between a client and therapist, and includes shared goals, strategies, and an attachment bond. Within the context of SAD, the working alliance is particularly interesting, as the alliance itself is a social relationship that may elicit anxiety, which, in turn, may impact development of the alliance. The present study also investigated whether treatment type, that is, exposure group therapy (EGT) versus virtual reality exposure (VRE) therapy, or pre-treatment symptom severity influenced the working alliance trajectory. Data were provided by an adult sample presenting with a primary diagnosis of SAD. Participants were randomly assigned to one of two treatment conditions, both involved use of a manualized CBT treatment approach. Standardized measures of social anxiety were administered pre-treatment whereas working alliance ratings were obtained after each session. Results indicated high levels of working alliance and significant change in ratings over time. Treatment condition did not contribute to significant differences in the working alliance trajectory. Regarding the impact of SAD symptoms, initially high ratings of fear was associated with progressively increasing rates of growth in the working alliance whereas high initial ratings of avoidance signified steeper increase in the working alliance earlier in treatment followed by a declining rate of change over time. The current study contributes to the limited literature regarding the working alliance trajectory for clients with SAD, and is the first to consider the impact of VRE treatment on this trajectory. Findings also provide preliminary evidence for the differential impact of initial fear and avoidance as well as a potential curvature for the working alliance trajectory when using CBT. INDEX WORDS: Social anxiety disorder, Working alliance, Virtual reality exposure therapy, Cognitive behavioral group therapy FORMING BONDS TO CHALLENGE FEARS: COURSE OF THE WORKING ALLIANCE DURING COGNITIVE BEHAVIORAL TREATMENT FOR SOCIAL ANXIETY DISORDER