Differential effects of alliance and techniques on Panic-Specific Reflective Function and misinterpretation of bodily sensations in two treatments for panic

Abstract

ABSTRACTObjective: To examine whether working alliance quality and use of techniques predict improvement in Panic-Specific Reflection Function (PSRF), and misinterpretation of bodily sensations in treatments for panic disorder. Method: A sample of 161 patients received either CBT or PFPP (Panic-focused Psychodynamic therapy) within a larger RCT. Data were collected on patient-reported working alliance, misinterpretations, PSRF, observer-coded use of techniques, and interviewer-rated panic severity. Random-Intercept Cross-Lagged Panel Models assessed bi-directional associations, disentangling within- and between-patient effects, and accounting for prior change. Results: Higher alliance predicted subsequent within-patient improvement in PSRF in PFPP, but worsening in CBT. In both treatments, focus on interpersonal relationships predicted PRSF improvement (with stronger effects in CBT), while focus on thoughts and behaviors predicted worsening in PSRF. In CBT only, early focus on affect and moment-to-moment experience predicted reduced misinterpretation, while high focus on thoughts and cognitions predicted subsequent increase in misinterpretation. Conclusion: The quality of the alliance has differential effects on PSRF in distinct treatments. Interpersonal, rather than cognitive or behavioral focus, even when delivered differently within distinct treatments with high adherence, could facilitate improvement in PSRF. Additionally, early focus on affect and moment-to-moment experiences in CBT could reduce misinterpretations.

Trial registration: ClinicalTrials.gov NCT00043550 NCT00353470.

Keywords: alliance; anxiety; cognitive behavior therapy; outcome research; process research; psychoanalytic/psychodynamic therapy.

Figure 1.

Random-Intercept Cross-Lagged Panel Model (RI-CLPM) testing hypotheses regarding the alliance-misinterpretation of bodily sensations as well as alliance-PSRF relationships over time. Paths of interest are bolded. The top and bottom circles (“Between”) represent the random intercepts –latent between-level variables. The squares represent observed variables (each assigned with a loading of 1 on the latent between-level variable). The circles represent latent within-level variable for each time-point. Misinterpretation of bodily sensations and panic-specific reflective function were tested in separate models.

Figure 2.

Random-Intercept, and standard Cross-Lagged Panel Model (RI-CLPM; CLPM) testing the hypotheses regarding the association between use of techniques and PSRF as well as misinterpretation of bodily sensations. The top part of the figure represents CLPM for techniques measured using the MULTI subscales. The bottom part represents RI-CLPM for panic-focused reflective function (PSRF). The bottom circle represent the random intercepts – the latent between-level variable. The squares represent the observed variables (each assigned with a loading of 1 on the latent between-level variable). The circles represent latent within-level variable for each time-point for misinterpretations and PSRF. Misinterpretation of bodily sensations and panic-specific reflective function were tested in separate models