| Psychotherapy segments from 63 children (ages 8--14) diagnosed with an anxiety disorder and who had received a manual-based, cognitive-behavioral treatment were evaluated by seven independent judges, trained to a rigorous criterion of reliability, to assess the association of posttreatment outcome with measures of the child's involvement at earlier and later time points in therapy and with a measure of the therapist's level of flexible adaptation of manual-guided techniques (Therapist Flexibility). Multiple regression analyses tested the model that (1) Therapist Flexibility would be associated with greater diagnostic and anxiety-related symptom outcome and (2) that this relationship between Therapist Flexibility and outcome would be mediated by levels of later child involvement and moderated by levels of early child involvement.;Results indicated that child involvement measured just prior to midtreatment, as well as changes in involvement from earlier to later points in therapy, were associated with greater likelihood of improvement in the child's primary anxiety disorder, but not with other measures of anxiety-related symptoms. Greater Therapist Flexibility was related to higher levels of later child involvement, but was not directly related to improvements in the child's primary anxiety disorder or to other measures of anxiety-related symptoms. This relationship among Therapist Flexibility, later child involvement and treatment outcome was not moderated by high and low levels of early child involvement, suggesting that the predicted model received only minimal support. Discussion focused on the clinical significance of identifying children who, over the course of therapy, experience significant negative "slips" in involvement, and on future directions for studying the role of Therapist Flexibility within manual-based treatments. |
