The alliance with young people: Where have we been, where are we going?

Abstract

The therapeutic alliance is considered an important mechanism of change in youth psychotherapy. Accordingly, it has become one of the most investigated psychotherapy variables. Yet, the theoretical and empirical literature on the alliance with young people is complex and has received criticism. This article aims to (a) critically review the existing knowledge on the alliance in youth psychotherapy from its definition to the existing research and (b) discuss some of the implications of this knowledge for clinical practice ad future research. This review highlights that the alliance in youth psychotherapy, as commonly measured, has a significant, although small, impact on outcomes; and that the alliance–outcome association may be influenced by the young person and the therapist’s characteristics, as well as therapy types. This points to the importance of finding tailored ways of fostering a strong alliance when working with young people and questions the assumption of the alliance as a generic aspect of all types of youth psychological treatments. Attention to repairing alliance ruptures also emerged as key, especially to preventing early dropout in adolescent therapy. It is argued that despite its limitations, alliance research in youth psychotherapy can have important clinical implications to improve youth psychotherapy. A resumption of a conversation between the clinical and research field on the alliance is needed to better understand the nature and role of this important variable when working with young people and to use this knowledge to inform and improve clinical practice and therapeutic training.

Repairing alliance ruptures in psychodynamic psychotherapy with young people: The development of a rational–empirical model to support youth therapists.

“…Moreover, unresolved ruptures early in treatment have been linked to treatment dropout among youths (O’Keeffe et al, 2020). Despite these findings, compared to adult psychotherapy, there is a dearth of research and guidance on how to address alliance ruptures in psychotherapy with young people (Cirasola & Midgley, 2023; DiGiuseppe et al, 1996; Nof et al, 2019).…”

Patient personality and therapist responses in the psychotherapy of adolescents with depressive disorders: toward the <i>Psychodynamic Diagnostic Manual</i> - third edition

“…Evidence has suggested a reciprocal influence between the therapeutic alliance and therapists’ emotional reactions to both adult and adolescent patients (Norcross & Lambert, 2019 ). Overall, building a positive therapeutic alliance is particularly challenging when working with adolescents (Cirasola & Midgley, 2023 ), especially those with greater impairments in personality functioning and symptom severity. At the same time, therapists working with severe adolescent patients tend to experience particularly intense and negative countertransference reactions (Satir et al , 2009 ; Tanzilli et al , 2020 ).…”

“You can’t really have a relationship with them because they just ask you questions”: understanding adolescent dropout – an empirical single case study

“…Adolescence is marked by a push-pull between seeking autonomy and needing support and guidance, often leading to difficulties in forming and sustaining a therapeutic alliance with an adult clinician. Additionally, factors like evolving self-perception, changing interpersonal relationships, risk-taking behaviors, and cognitive development add to the complexities of engaging adolescents in therapy ( Gulliver et al, 2010 ; Schenk et al, 2019 ; Cirasola and Midgley, 2023 ).…”