How does hostile resistance interfere with the benefits of cognitive–behavioral therapy for panic disorder? The role of therapist adherence and working alliance

Abstract

Objective Although clients’ hostile behavior directed at therapists (hostile resistance) predicts worse outcomes in cognitive–behavioral therapy (CBT) for panic disorder, the process by which this happens remains unknown. This study examines two putative mechanisms: working alliance and therapist adherence. Method: Seventy-one adults with primary panic disorder received CBT in a larger trial. Hostile resistance and adherence in Sessions 2 and 10 were reliably coded using observer-rated measures; client- and therapist-rated questionnaires assessed working alliance. Outcome measures were attrition and symptomatic improvement, assessed at multiple timepoints with the Panic Disorder Severity Scale. Results: Hostile resistance was significantly related to both preexisting (r = −.36, p =.04) and subsequent declines (r = −.58, p