Parsing the Within- and Between-Therapist Positive Regard-Outcome Association in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder

Positive regard—rated from multiple perspectives across various psychotherapies—correlates positively with patient improvement. Yet, existing research has not parsed this total correlation into its within- and between-therapist components, which limits its interpretability. Thus, the present study explored (a) the association between patients’ experience of therapist-offered positive regard and their treatment outcome at both the within- and between-therapist levels, (b) whether between-therapist differences in positive regard moderated the within-therapist positive regard-outcome association, and (c) whether treatment condition (cognitive-behavioral therapy [CBT] versus CBT that integrated client-centered principles) moderated either level of the positive regard-outcome association. Adults with generalized anxiety disorder were randomly assigned to CBT alone (n = 43) or CBT integrated with motivational interviewing (MI-CBT; n = 42) to responsively address patient resistance (Westra et al., 2016). Twelve therapists treated patients in CBT and nine distinct therapists treated patients in MI-CBT. Patients rated therapist-offered positive regard repeatedly across 15 sessions and their worry and general distress outcomes at baseline and posttreatment. Multilevel structural equation modeling revealed a significant association between patients’ experience of higher early treatment positive regard and lower posttreatment general distress at the within-therapist level (this effect was similar for worry, though nonsignificant). There was no between-therapist association for either outcome. Additionally, neither between-therapist positive regard nor treatment condition moderated the within-therapist effect of positive regard on either outcome. Results underscore the value of therapists working to foster their patients’ felt regard irrespective of the treatment they use or the general ability they have in cultivating this relational experience.