Cognitive Therapy and Research

, Volume 42, Issue 2, pp 135–145 | Cite as

Expectancies, Working Alliance, and Outcome in Transdiagnostic and Single Diagnosis Treatment for Anxiety Disorders: An Investigation of Mediation

  • Shannon Sauer-Zavala
  • James F. Boswell
  • Kate H. Bentley
  • Johanna Thompson-Hollands
  • Todd J. Farchione
  • David H. Barlow
Original Article


Patients’ outcome expectancies and the working alliance are two psychotherapy process variables that researchers have found to be associated with treatment outcome, irrespective of treatment approach and problem area. Despite this, little is known about the mechanisms accounting for this association, and whether contextual factors (e.g., psychotherapy type) impact the strength of these relationships. The primary aim of this study was to examine whether patient-rated working alliance quality mediates the relationship between outcome expectancies and pre- to post-treatment change in anxiety symptoms using data from a recent randomized clinical trial comparing a transdiagnostic treatment (the Unified Protocol [UP]; Barlow et al., Unified protocol for transdiagnostic treatment of emotional disorders: Client workbook, Oxford University Press, New York, 2011a; Barlow et al., Unified protocol for transdiagnostic treatment of emotional disorders: Patient workbook. New York: Oxford University Press, 2017b) to single diagnosis protocols (SDPs) for patients with a principal heterogeneous anxiety disorder (n = 179). The second aim was to explore whether cognitive-behavioral treatment condition (UP vs. SDP) moderated this indirect relationship. Results from mediation and moderated mediation models indicated that, when collapsing across the two treatment conditions, the relationship between expectancies and outcome was partially mediated by the working alliance [B = 0.037, SE = 0.05, 95% CI (.005, 0.096)]. Interestingly, within-condition analyses showed that this conditional indirect effect was only present for SDP patients, whereas in the UP condition, working alliance did not account for the association between expectancies and outcome. These findings suggest that outcome expectancies and working alliance quality may interact to influence treatment outcomes, and that the nature and strength of the relationships among these constructs may differ as a function of the specific cognitive-behavioral treatment approach utilized.


Outcome expectancies Working alliance Transdiagnostic Cognitive-behavioral therapy Mediation 



We would like to thank Dr. Michael Constantino for his helpful comments regarding this study and manuscript.


This study was funded by grant R01 MH090053 from the National Institutes of Health.

Compliance with Ethical Standards

Conflict of Interest

Dr. Barlow receives royalties from Oxford University Press (which includes royalties for all five treatment manuals included in this study), Guilford Publications Inc., Cengage Learning, and Pearson Publishing. Grant monies for various projects come from the National Institute of Mental Health, the National Institute of Alcohol and Alcohol Abuse, and Colciencias (Government of Columbia Initiative for Science, Technology, and Health Innovation). Consulting and honoraria during the past several years have come from the Agency for Healthcare Research and Quality, the Foundation for Informed Medical Decision Making, the Department of Defense, the Renfrew Center, the Chinese University of Hong Kong, Universidad Católica de SantaMaria (Arequipa, Peru), New Zealand Psychological Association, Hebrew University of Jerusalem, Mayo Clinic, and various American Universities. Shannon Sauer-Zavala, James F. Boswell, Kate H. Bentley, Johanna Thompson-Hollands, Todd J. Farchione declare that they have no conflict of interest.

Ethical Standard

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal studies were carried out by the authors for this article.

Informed Consent

Informed consent was obtained from all individual participants included in the study. No animal studies were carried out by the authors for this article.


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Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of Psychological and Brain Sciences, Center for Anxiety and Related DisordersBoston UniversityBostonUSA
  2. 2.Department of PsychologyUniversity at Albany, State University of New YorkAlbanyUSA
  3. 3.Massachusetts General Hospital/Harvard Medical SchoolBostonUSA
  4. 4.National Center for PTSD, Behavioral Science Division/VA Boston Healthcare System and Boston University School of MedicineBostonUSA

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