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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    • "Furthermore, Zandberg et al. (2015) examined alliance discrepancies at single time points, not change in alliance over time. Research shows the alliance quality may change over the course of CBT for youth anxiety disorders (Chu et al., 2014; Kendall et al., 2009), and such changes may influence outcomes independently from single time points (Chiu et al., 2009). Finally, Zandberg et al. (2015) did not include outcome beyond posttreatment. "
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    ABSTRACT: Background: In individual cognitive behavioral therapy (ICBT) for youth anxiety disorders, it is unclear whether, and from whose perspective, the alliance predicts outcome. We examined whether youth- and therapist-rated alliance, including level of youth-therapist alliance agreement, predicted outcome in a randomized controlled trial. Methods: Youth (N = 91, M age = 11.4 years (SD = 2.1), 49.5% boys, 86.8% Caucasian) diagnosed with separation anxiety disorder, social phobia, or generalized anxiety disorder drawn from the ICBT condition of an effectiveness trial were treated with an ICBT program. Youth- and therapist-rated alliance ratings, assessed with the Therapeutic Alliance Scale for Children (TASC-C/T), were collected following session 3 (early) and 7 (late). Early alliance, change in alliance from early to late, and level of youth-therapist agreement on early alliance and alliance change were examined, in relation to outcomes collected at posttreatment and 1-year follow-up. Outcome was defined as primary diagnosis loss and reduction in clinicians' severity ratings (CSR; Anxiety Disorders Interview Schedule; ADIS-C/P) based on youth- and parent-report at posttreatment and follow-up, and youth treatment satisfaction collected at posttreatment (Client Satisfaction Scale; CSS). Results: Early TASC-C scores positively predicted treatment satisfaction at posttreatment. Higher levels of agreement on change in TASC-C and TASC-T scores early to late in treatment predicted diagnosis loss and CSR reduction at follow-up. Conclusions: Only the level of agreement in alliance change predicted follow-up outcomes in ICBT for youth anxiety disorders. The findings support further examination of the role that youth-therapist alliance discrepancies may play in promoting positive outcomes in ICBT for youth anxiety disorders. Clinical trial number NCT00586586,
    Full-text · Article · Jan 2016 · Journal of Child Psychology and Psychiatry
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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.
    Full-text · Article · Oct 2013 · Behaviour Research and Therapy
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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.
    Full-text · Article · Apr 2013 · Journal of Clinical Child & Adolescent Psychology
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