The Role of Intolerance of Uncertainty and Working Alliance in the Outcome of Cognitive Behavioral Therapy for Generalized Anxiety Disorder Delivered by Videoconference: Mediation Analysis

Abstract

Background Previous meta-analyses have shown a significant relationship between working alliance and treatment outcome in general. Some studies have examined the relationship between working alliance and treatment outcome during telepsychotherapy, but to the best of our knowledge, no study has examined the mediating role of individual components of the working alliance. Objective As part of a clinical trial of cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) delivered by videoconference (VC), the aim of this study is to examine the mediating role of intolerance of uncertainty on the relationship between the components of the working alliance and treatment outcome. Methods A sample of 46 adults with primary GAD received 15 sessions of CBT for GAD delivered over VC. Participants completed the measure of working alliance immediately after the fifth therapy session. The degree of change in intolerance of uncertainty (a key psychological process) was assessed from pre- to posttreatment. Treatment outcome was assessed via changes in GAD symptoms from pretreatment to the 6-month follow-up. Results The results revealed that the therapeutic bond did not predict treatment outcome (r=−0.23; P=.12). However, agreement on therapeutic goals and tasks did predict treatment outcome (r=−0.42; P=.004 and r=−0.37; P=.01, respectively). In addition, the relationship between consensus on therapeutic tasks and treatment outcome was completely mediated by changes in intolerance of uncertainty (unstandardized β=−0.03; r2=0.12), whereas consensus relative to treatment goals had a direct impact on treatment outcome. Conclusions These results provide a better understanding of the differential role of the components of the working alliance in telepsychotherapy as a facilitative factor for changes in key cognitive processes, leading to therapeutic change. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 12662027; http://www.isrctn.com/ISRCTN12662027.