Child–therapist alliance and clinical outcomes in cognitive-behavioral therapy for child anxiety disorders

Franz Hall Psychology Clinic, University of California, Los Angeles, CA 90095, USA.
Journal of Child Psychology and Psychiatry (Impact Factor: 6.46). 11/2008; 50(6):751-8. DOI: 10.1111/j.1469-7610.2008.01996.x
Source: PubMed


Few studies have examined the link between child-therapist alliance and outcome in manual-guided cognitive behavioral therapy (CBT) for children diagnosed with anxiety disorders. This study sought to clarify the nature and strength of this relation.
The Therapy Process Observational Coding System for Child Psychotherapy - Alliance scale (TPOCS-A; McLeod, 2005) was used to assess the quality of the child-therapist alliance. Coders independently rated 123 CBT therapy sessions conducted with 34 children (aged 6-13 years) diagnosed with anxiety disorders. Parents reported on children's symptomatology at pre- mid-, and post-treatment.
A stronger child-therapist alliance early in treatment predicted greater improvement in parent-reported outcomes at mid-treatment but not post-treatment. However, improvement in the child-therapist alliance over the course of treatment predicted better post-treatment outcomes.
The quality of the child-therapist alliance assessed early in treatment may be differentially associated with symptom reduction at mid- and post-treatment. Results underscore the importance of assessing the relation between alliance and outcome over the course of therapy to clarify the role the child-therapist alliance plays in child psychotherapy.

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Available from: Bryce D McLeod, Mar 07, 2014
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    • "ist alli - ance ratings demonstrated a predominantly linear , downward slope for alliance over time . The magnitude of the decline was small in each instance ( approximately . 04e . 06 points for every two ses - sions ) and is consistent with previous studies that have found either stable or slight alliance decreases from early to later sessions ( Chiu et al . , 2009 ; Liber et al . , 2010 ) . Therapists are able to sustain a high level of alliance with their child clients throughout therapy . Child involvement and therapist flexibility measures demonstrated a concave quadratic curve , indicating a single peak occurring roughly around mid - treatment ( session 8 and 9 ) . Like alliance re - sults ab"
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    ABSTRACT: Background: This study examined the relations between treatment process variables and child anxiety outcomes. Method: Independent raters watched/listened to taped therapy sessions of 151 anxiety-disordered (6-14 yr-old; M = 10.71) children (43% boys) and assessed process variables (child alliance, therapist alliance, child involvement, therapist flexibility and therapist functionality) within a manual-based cognitive-behavioural treatment. Latent growth modelling examined three latent variables (intercept, slope, and quadratic) for each process variable. Child age, gender, family income and ethnicity were examined as potential antecedents. Outcome was analyzed using factorially derived clinician, mother, father, child and teacher scores from questionnaire and structured diagnostic interviews at pretreatment, posttreatment and 12-month follow-up. Results: Latent growth models demonstrated a concave quadratic curve for child involvement and therapist flexibility over time. A predominantly linear, downward slope was observed for alliance, and functional flexibility remained consistent over time. Increased alliance, child involvement and therapist flexibility showed some albeit inconsistent, associations with positive treatment outcome. Conclusion: Findings support the notion that maintaining the initial high level of alliance or involvement is important for clinical improvement. There is some support that progressively increasing alliance/involvement also positively impacts on treatment outcome. These findings were not consistent across outcome measurement points or reporters.
    Behaviour Research and Therapy 10/2013; 52C(1):1-8. DOI:10.1016/j.brat.2013.09.011 · 3.85 Impact Factor
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    • "Further, this limited assessment approach precludes studying patterns of alliance that may be more revealing than a limited sampling approach. Even using an aggregation approach (e.g., Chiu et al., 2008), evidence suggests fluctuations in alliance over time and that alliance shifts are important in predicting outcome. A number of formulations have been offered to characterize alliance curves in therapy. "
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    ABSTRACT: Multilevel growth analysis was used to establish the shape of change (mean growth trajectory) for youth- and therapist-rated alliance in cognitive behavioral therapy (CBT) for anxious youth and to identify between-youth predictors of alliance trajectory. Youth (N = 69; ages 7-17; 52.2% female) and their parents participated in an empirically supported CBT protocol. Therapists rated alliance each session and youth every four sessions. Data were fit to four growth models: linear, quadratic, a dual slope, and a novel "alliance rupture" model. Two-level models were estimated to examine the effect of youth age, sex, pretreatment symptom severity, diagnostic comorbidity, early treatment factors (use of Selective Serotonin Reuptake Inhibitors), and coping styles (engagement, disengagement, and involuntary coping). A dual slope model fit therapist data best, whereas youth data did not evidence systematic growth. Two-level growth models identified that pretreatment anxiety severity predicted higher initial alliance levels. Depressive symptoms predicted less linear growth and engagement coping predicted greater growth during exposure sessions. No variables predicted preexposure growth. In the therapist model, 22% of initial alliance, 50% of preexposure growth, and 75% of postexposure growth were accounted for by between youth variables (mood disorder, anxiety and depression symptoms, engagement and involuntary coping). Therapist-reported alliance ratings may grow over the course of manual-based CBT, even during exposure-focused sessions. Pretreatment youth factors and coping style may influence the absolute value and linear trajectory of alliance during CBT. Findings about alliance-influencing factors can help set expectations for, and enhance training in, empirically supported treatments.
    Journal of Clinical Child & Adolescent Psychology 04/2013; 43(5). DOI:10.1080/15374416.2013.785358 · 1.92 Impact Factor
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    • "Stiles et al. (2004) found that a rupture-repair or V-shaped trajectory of TA was associated with better outcomes , while Kramer et al. (2009) found that a linear trajectory predicted the best outcomes (also see Kivlighan and Shaughnessy 1995, 2000). Within youth psychotherapy, the evidence base remains extremely limited regarding TA trajectories , especially in the case of youth mental health treatment, and has focused predominantly on measurement at discrete time points as opposed to longitudinal measurements of treatment outcome over time (Chiu et al. 2009; Eltz et al. 1995; Hawley and Weisz 2005; Hawley and Garland 2008; Kazdin et al. 2005; Kazdin et al. 2006; Kazdin and Whitley 2006; Kendall et al. 2009). Overall, current findings from the literature regarding the exact relationship between TA trajectories and treatment outcome remain inconclusive. "
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    ABSTRACT: This paper presents the psychometric evaluation of brief measures of therapeutic alliance (TA) for youths, clinicians and caregivers and a longitudinal analysis of relationships between changes in TA and changes in youth symptom and functioning severity. Psychometric analyses using methods from Classical Test Theory, Item Response Theory, and Factor Analysis indicate that the measures of TA used in this study offer something new for both practice and research. The measures have variability, sensitivity to change over time, brevity and can be used with multiple parties through parallel forms. The longitudinal analyses, employing hierarchical linear modeling with time-varying covariates, found that TA ratings of the clinician correlated with symptom improvement as rated by the clinician, caregiver and youth. Additional analyses showed that decreases in clinician-rated youth TA was most important in predicting a lower rate of youth improvement. Implications for future research and clinical practice are discussed.
    Administration and Policy in Mental Health and Mental Health Services Research 03/2012; 39(1-2):78-89. DOI:10.1007/s10488-011-0398-0 · 3.44 Impact Factor
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