The alliance mediates outcome in cognitive–behavioral therapy for social anxiety disorder, but not in attention bias modification

Yogev Kivity*, Asher Y. Strauss, Jonathan Elizur, Michal Weiss, Lior Cohen, Jonathan D. Huppert

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Objective: The aim of the current study was to examine changes in the therapeutic alliance and its role as a mediator of treatment outcome in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). Method: Patients were randomized to 16–20 sessions of CBT (n = 33) or 8 sessions of ABM (n = 17). Patient-rated alliance and self-reported social anxiety were measured weekly and evaluator-rated social anxiety was measured monthly. Results: Early alliance predicted greater subsequent anxiety reduction in CBT but not in ABM. The alliance increased and weekly improvements in alliance predicted weekly contemporaneous and subsequent decreases in anxiety only in CBT. Decreases in anxiety did not predict subsequent improvements in alliance. Both treatments were effective in reducing anxiety, but treatment effects were mediated by stronger early alliance and stronger cross-lagged effects of alliance on outcome in CBT compared to ABM. Conclusions: The results highlight the importance of the alliance in CBT for SAD. Further studies should examine the role of alliance alongside additional mediators to better understand differential mechanisms in CBT and ABM.

Original languageAmerican English
Pages (from-to)589-603
Number of pages15
JournalPsychotherapy Research
Issue number5
StatePublished - 2021

Bibliographical note

Funding Information:
The authors thank Robert J. DeRubeis for his assistance in conceptualizing the data analytic approach. The authors would like to thank Roni Pener-Tessler, Ariela Friedman, Yael Milgram, Shai Avishay, Michal Kovacs, and Maayan Langmass for their help in data collection. This work was supported by the Israel Science Foundation (grant #332/09) to the last author, the Sam and Helen Beber Chair of Clinical Psychology at The Hebrew University. The funding sources did not have any involvement in conducting the study and preparing the manuscript.

Publisher Copyright:
© 2020 Society for Psychotherapy Research.


  • alliance-outcome correlation
  • cognitive behavioral therapy
  • social anxiety disorder
  • therapeutic alliance


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