The therapeutic alliance in exposure therapy for anxiety-related disorders: A critical review
Abstract
The therapeutic alliance has been the subject of a great deal of psychotherapy research, and evidence from numerous empirical studies suggests that a strong patient-therapist relationship predicts favorable treatment outcomes. Despite the consistency of the alliance outcome relationship across treatment modalities and diagnoses, little attention has been given to this potential prognostic indicator in exposure therapy for anxiety-related disorders. Given that exposure therapy requires patients to engage in challenging and distressing activities (e.g., confrontation with feared stimuli), a strong alliance between patient and therapist is conceptually relevant to treatment. Relatively few published exposure therapy trials have included the therapeutic alliance as a process variable, and no single review summarizes findings from this body of literature. Accordingly, the purpose of this review is to provide an overview and synthesis of existing research on the alliance-outcome relationship in exposure therapy. Methodological and conceptual considerations will be discussed, and future research priorities will be identified.
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Low motivation for treatment and poor working alliance have often been associated with a poorer treatment response.
“Low motivation for treatment and poor working alliance, which are factors common to all psychotherapies, have often been associated with a poorer treatment response [42,48,49,50,51].”
All 3 studies that investigated the specific role of the components of the working alliance (1 on posttraumatic stress disorder and 2 on obsessive-compulsive disorder) revealed that agreement on tasks was related to treatment outcome.
“All 3 studies (ie, 1 on posttraumatic stress disorder and 2 on obsessive-compulsive disorder) revealed that the agreement on tasks was related to treatment outcome.”
Buchholz and Abramowitz found 7 studies on anxiety disorders suggesting that global measures of alliance predicted treatment outcome, and 4 studies that did not find this result.
“They found 7 studies on anxiety disorders, suggesting that the global measures of alliance predicted treatment outcome, and 4 studies that did not find this result [14].”
The contribution of the components of the working alliance to change in generalized anxiety disorder symptoms, especially in cognitive behavioral therapy delivered by videoconference, has not yet been studied.
“The contribution of the components of the working alliance to change in GAD symptoms, especially in CBT delivered by VC, has not yet been studied.”
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- Authors
- Buchholz, J. L., & Abramowitz, J. S.
- Affiliations
- University of North Carolina at Chapel Hill (US)
- Corresponding author
- Buchholz, Jennifer L.
- Venue
- Journal of Anxiety Disorders
- Publisher
- Elsevier BV
- Published
- 2020-03
- Volume
- 70
- Pages
- 102194
- ISSN
- 0887-6185 (ISSN-L)
- OpenAlex
- W3000434067
- Cited by
- 77
- References
- 74
- Citations by year
- 2026: 8 · 2025: 16 · 2024: 13 · 2023: 11 · 2022: 15 · 2021: 10 · 2020: 4
- FWCI
- 0.79
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Anxiety Disorders (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- therapeutic relationship, exposure therapy, anxiety disorders, treatment outcomes, prognostic factors, process parameters, psychotherapy
- MeSH terms
- Therapeutic Alliance, Anxiety, Anxiety Disorders, Humans, Implosive Therapy, Professional-Patient Relations, Treatment Outcome
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