Therapeutic Alliance With Depressed Adolescents: Predictor or Outcome? Disentangling Temporal Confounds to Understand Early Improvement

Abstract

Psychotherapy research reveals consistent associations between therapeutic alliance and treatment outcomes in the youth literature; however, past research frequently suffered measurement issues that obscured temporal relationships between alliance and symptomatology by measuring variables later in therapy, thereby precluding examination of important early changes. The current study aimed to explore the directions of effect between alliance and outcome early in therapy with adolescents by examining associations between first- and fourth-session therapeutic alliance and symptomatology. Thirty-four adolescents (~63% female, 38% ethnic/racial minority) participated in a school-based cognitive-behavioral therapy for adolescents with depression. Participants completed the Beck Depression Inventory at baseline and Session 4, and therapeutic alliance was coded from audiotapes of Sessions 1 and 4 by objective coders using the Alliance Observation Coding System. Autoregressive path analyses determined that first-session therapeutic alliance was a strong significant predictor of Session 4 depression symptoms, but pretreatment depression scores were not significantly predictive of subsequent therapeutic alliance. Adding reciprocal effects between alliance and depression scores did not adversely affect model fit, suggesting that reciprocal effects may exist. Early therapeutic alliance with adolescents is critical to fostering early gains in depressive symptomatology. Knowing alliance’s subsequent effect on youth outcomes, clinicians should increase effort to foster a strong relationship in early sessions and additional research should be conducted on the reciprocal effects of therapeutic alliance and treatment outcome in adolescence.

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

“…In youth psychotherapy, only a handful of studies has controlled for pre-treatment symptom severity or prior symptom change in the estimation of the alliance-outcome association. The few studies that controlled for initial severity found evidence for an association between early alliance and subsequent improvement at mid-treatment in cognitivebehavioural therapy (CBT) for young people with depression (Labouliere, Reyes, Shirk, & Karver, 2017) and anxiety disorders (Chiu et al, 2009). The empirical evidence on the allianceoutcome relationship while controlling for prior symptom change is scant and present mixed results.…”

The therapeutic relationship in Cognitive Behaviour Therapy with depressed adolescents: A qualitative study of good‐outcome cases

“…The therapeutic relationship has long been emphasized as a critical element in both adult and youth psychotherapies (Labouliere, Reyes, Shirk, & Karver, ). It is largely accepted that the therapeutic relationship refers to the feelings and attitudes that therapist and client have toward one another, and the manner in which these are expressed.…”

Vulnerability of personality disorder during the Covid-19 crises – a multicenter survey of treatment experiences among patients referred to treatment

“…Several authors have generally, recommended special consideration of the development of alliance in therapies with adolescents and younger adults [71,72]. In the extraordinary situation of the present study, the trusting relationship seemed more insecure or easily disrupted in the younger age group.…”