The alliance–outcome association in the treatment of adolescent depression.

Abstract

A growing body of research has consistently demonstrated a relationship between alliance and treatment outcomes in youth psychotherapy. However, past research often suffered methodological issues that prevented detailed investigation of temporal relationships between alliance and symptomatology. The current study explored the directions of effect between alliance and outcome by examining the associations between early alliance and subsequent outcome while controlling for patients' baseline severity and prior symptom change. It also examined potential moderators of this association. Data were drawn from the IMPACT study, a randomized controlled trial comparing cognitive-behavioural therapy (CBT) and short-term psychoanalytic psychotherapy (STPP) versus a brief psychosocial intervention (BPI) in the treatment of adolescent depression. Adolescents (N=224) and therapist (n=139) rated the alliance 6 weeks after randomization. Depression severity and overall psychopathology were assessed at baseline, 6, 12, 36, 52 and 86 weeks after randomization. Patients' age, gender, baseline depression severity, conduct disorder symptoms and treatment type were examined as potential moderators of the alliance-outcome association. Data were analysed using multilevel models. Findings suggested that higher early alliance ratings were associated with subsequent symptom reduction, even after controlling for prior symptom change and baseline severity.There was evidence that the strength of this association was strongest in CBT patients, weaker in STPP, and statistically indistinguishable from zero in BPI. These findings suggest that early therapeutic alliance with adolescents may influence subsequent outcome independent of prior symptom change and initial severity but that the effect of the alliance on outcome might vary across treatment types.

Therapeutic Alliance: A Comparison Study between Adolescent Patients and Their Therapists

“…As expected, we found that the alliance ratings of both adolescents and therapists were quite stable over time. This adds to the previously scarce evidence on the development and change over time of alliance with adolescents [ 25 , 64 ], supports the previous findings that the alliance is formed at an early stage of treatment [ 22 , 30 , 31 ], and raises the importance of focusing on building the relationship at the very beginning of treatment. According to this finding, the alliance measurement timing would not be of great importance in terms of predicting the treatment outcome.…”

“…However, as Karver et al (2018) [ 24 ] highlighted, high ratings on average might suggest that rating of alliance at the midpoint or lower by adolescents should be noted as an alarming sign. One interpretation could also be that the effect of the assessment sessions before the actual therapy started was so significant in terms of early symptom improvement that it affected the perceived alliance at baseline measurement and throughout the treatment [ 22 ]. Furthermore, adolescents with less severe symptoms might be more open to new positive relationships or more optimistic about the possibility that the therapist understands their situation and will be able to help.…”

“…Even positive alliance may not predict successful treatment if certain variables (e.g., problem type, referral source, timing of alliance assessment) are present [ 19 ]. Type of treatment might also be a significant moderator of the alliance–outcome relation [ 22 ]. These would be prominent research questions for further studies.…”

“…In previous studies on youth psychotherapy, the association between alliance and outcome was found to be stronger if the alliance is rated by therapists rather than by young patients [ 23 , 33 ]. However, in the meta-analysis by Karver et al (2018) [ 24 ], the alliance perspective did not moderate the relation, and recent findings from Cirasola et al (2021a) [ 22 ] suggest that both adolescent and therapist early ratings of the alliance are associated with symptom change. Yet, agreement between adolescent and therapist evaluation of alliance has previously been low or nonsignificant [ 19 , 24 ].…”

“…Research on alliance between adolescent patients and their therapists is still scarce [ 19 , 20 ] and there is large methodological variability between the studies, e.g., studying a wider set of relational variables instead of focusing on alliance, using different alliance measurements or information sources, and variety of the timing of alliance measurement [ 21 , 22 , 23 ]. Yet, therapeutic alliance has been found to be an important treatment outcome predictor also with adolescents [ 19 , 22 , 24 , 25 ]. Studies on youth alliance have failed to fully support the three-factor model, suggesting that features of the alliance are less differentiated at a younger age, and instead propose a single-factor solution [ 26 , 27 , 28 , 29 ].…”