Clinician Competence Predicts Treatment Outcomes in Cognitive Therapy for Social Anxiety Disorder

Article summary provided by Hillary Greene

THE MAIN POINT:
A recent study examined the role of therapist competency on treatment outcomes in providing cognitive therapy for persons with social anxiety disorder (SAD). This study found that high therapist competence corresponded with treatment gains across measures of general and social anxiety-specific clinical outcomes. Therapist competence also was more important in predicting treatment outcomes than therapist adherence to treatment or patient difficulty. This research reminds clinicians of the importance of not only selecting an appropriate treatment option for someone with SAD but of obtaining adequate training and competency in the treatment in order to maximize clinical benefits. See details below, which describe this study on clinician competence and cognitive therapy treatment outcomes for SAD (Ginzburg et al., 2012).

THE DETAILS:
What were the goals of this study?
The purpose of this study was to extend prior research regarding clinician competency in providing cognitive-based interventions. Prior research has shown that clinician competence in administering cognitive-behavioral therapy for depressed individuals strongly relates to positive treatment outcomes but little research has examined this relationship in the context of treating anxiety disorders. This study sought to examine the role of clinician competence in providing cognitive-therapy (CT) for persons with social anxiety disorder (SAD) as part of a larger randomized controlled trial (RCT) for SAD. This study also sought to examine the roles of general therapist adherence to the treatment protocol and the difficulty of patients on treatment outcomes.

How did this study address these goals?

This study used data from a large randomized controlled trial (RCT) that compared cognitive therapy, interpersonal therapy, and wait-list control for persons with social anxiety disorder (SAD). Participants for this study were recruited from outpatient mental health clinics, met DSM-IV criteria for SAD, and were randomized to receive cognitive therapy as part of the RCT. For this study, cognitive therapy followed Clark and Wells’ (1995) theory regarding SAD and was outlined in a detailed treatment manual that addressed beliefs and behaviors surrounding participants’ social fears.

Treatment outcome was assessed using trained raters who were blind to whether or not participants received treatment. Raters assessed treatment outcome using the Clinical Global Impression Improvement Scale (CGI-I), which was altered previously for use with SAD. The CGI-I taps global psychological functioning and specific social anxiety-related symptoms. Raters also used the Liebowitz Social Anxiety Scale (LSAS) to assess treatment outcome specifically related to social anxiety fears and avoidant behaviors. Therapist competence was assessed by trained raters who were blind to treatment outcomes. Raters used the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP) to determine how well clinicians implemented treatment components. Using validated single-item rating scales, raters also assessed patient difficulty and treatment adherence by determining the extent to which therapists followed the treatment manuals. For each patient, raters reviewed two randomly selected treatment videotapes, one session from the middle of treatment and one session from either the beginning or the end of treatment.

What were the main findings of this study?

This study demonstrated high inter-rater reliability for the assessment of therapist competence, meaning that the blind raters generally evaluated therapists in a consistent manner. Inter-rater reliability for therapist adherence also was high, although rater consensus was more moderate for patient difficulty ratings than for therapist ratings.
Specifically, this study found that clinicians demonstrated moderate treatment competence and adherence and that patients on average were classified as low difficulty. Across the course of treatment, patients were rated as showing moderate to high improvement as measured by the Global Impression Improvement Scale (CGI-I) and as showing somewhat mild improvements as measured by the Liebowitz Social Anxiety Scale (LSAS).

Overall, this study found that clinician competence in providing cognitive therapy predicted positive treatment outcomes for persons with social anxiety disorder (SAD). Clinician competence was found to be more important in predicting treatment outcomes than the difficulty level of the patients and more important than level of general treatment adherence, which related more to frequency of using treatment components rather than skill of implementing these components.

What are the clinical implications of this study?

This study extends prior work emphasizing the importance of clinician competence in obtaining positive psychotherapy treatment outcomes. Specifically, this study demonstrates that clinician competence in providing cognitive-therapy strongly predicts treatment gains for persons with social-anxiety disorder. For clinicians working with socially anxious individuals, these findings underscore the need for obtaining adequate training and reaching high competency when using specific cognitive-behavioral therapies. For example, clinicians might seek specific training resources for their selected therapies or they might seek evaluation of their competence as a therapist through feedback from colleagues.

Interestingly, this study also found that therapist competence was important in predicting patient improvements even after considering the difficulty of the patient, which reiterates the importance of therapist factors in leading to good treatment outcomes. Additionally, for clinicians seeking to track outcomes when treating SAD, this study describes the potential benefits in using global indicators of psychological functioning and specific indicators of social anxiety symptoms, such as using a general symptom inventory and a specific social-anxiety scale.

Where can professionals learn more about this study?

The study discussed here is available at the following link:
http://www.sciencedirect.com/science/article/pii/S0005796712001374

REFERENCE

Ginzburg, D. M., Bohn, C., Hofling, V., Weck, F., Clark, D. M., & Stangier, U. (2012). Treatment specific comptence predicts outcome in cognitive therapy for social anxiety disorder. Behaviour Research and Therapy, 50, 747-752.