Therapist responsiveness to child engagement: flexibility within manual-based CBT for anxious youth

Therapy process research helps delineate common and specific elements essential to positive outcomes as well as develop best practice training protocols. Child involvement and therapist flexibility were rated in 63 anxious youth (ages 8-14) who received cognitive-behavioral therapy. Therapist flexibility, defined as therapist attempts to adapt treatment to a child's needs, was hypothesized to act as an engagement strategy that serves to increase child involvement during therapy. Flexibility was significantly related to increases in later child engagement, which subsequently predicted improvement in posttreatment diagnosis and impairment. Therapist flexibility was not associated with earlier measures of child engagement, so a mediation model could not be supported. It was also hypothesized that the impact of flexibility would be greatest for cases who began treatment highly disengaged (i.e., early involvement would moderate the effect of flexibility). Basic descriptive data supported this model, but formal analyses failed to confirm. Further descriptive analyses suggest therapists employ a range of adaptations and a profile of flexible applications within a manual-based treatment is provided. Treatment, measurement, and dissemination issues are discussed.