Therapist and client perspectives on the alliance in the treatment of traumatized adolescents

Abstract

ObjectiveClient ratings of the therapeutic alliance are an important predictor of outcome in the treatment of traumatized adolescents and adults, but less is known about the therapists’ perspective. The aim of this study was to investigate how therapists’ ratings relate to the adolescents’ perspective, how individual therapist and adolescent ratings relate to change in symptoms and treatment satisfaction, and whether discrepant alliance perspectives impact treatment outcome.MethodThe sample consisted of 156 youth (mean age 15.1, range 10–18), randomized to trauma-focused cognitive behavioral therapy or treatment as usual, and alliance ratings from 62 therapists. Alliance was measured midtreatment with the Therapeutic Alliance Scale for Children, and the factor structure of the two scales was analyzed with exploratory factor analyses. A change in posttraumatic symptoms was assessed with the Child PTSD Symptom Scale (CPSS) and the Clinicial-Administered PTSD Scale for Children and Adolescents (CAPS-CA).ResultsTherapist and client perspectives on the alliance were significantly, but moderately, associated (intraclass correlations [ICC]=0.54, p<0.001). Both scales predicted adolescent treatment satisfaction but only the client scale was significantly related to change in symptoms. Factor analyses revealed differences in factor structure with therapist ratings organized around bond and task dimensions and adolescent ratings organized by item valence. Higher therapist ratings compared to adolescent ratings predicted higher residual PTS symptoms.DiscussionAlthough adolescent and therapist alliance ratings are moderately associated, results suggest that the ratings are differentially associated with outcomes. These findings, along with results indicating important differences in factor structure, imply that adolescent and therapist ratings are not interchangeable. Future studies should investigate how therapists can improve their judgments of adolescents’ perceptions of the alliance as an overestimation of the quality of the relationship seems to be negatively related to outcome.

A dual perspective on first-session therapeutic alliance: strong predictor of youth mental health and addiction treatment outcome

“…Furthermore, it has been recommended that the alliance evaluations from these multiple sources should be incorporated to gain more insight into the alliance-treatment outcome association [11]. From the 34 independent studies among youth that were included either in the meta-analyses of Karver et al [7] and/ or Murphy & Hutton [8], only 13 studies involved both youth and therapist as informants of early alliance and agreement between both informants was generally low [12][13][14][15][16][17] or nonsignificant [18,19]. Remarkably, the alliance ratings of both sources were not used in any of these studies to investigate their combined predictive value for treatment outcome.…”

Treatment expectancy, working alliance, and outcome of Trauma-Focused Cognitive Behavioral Therapy with children and adolescents

“…Most of them do not seek help from mental health services on their own, but are sent by adult caretakers [ 13 ], and are therefore less likely to expect benefit from treatment or to establish a trustful relationship with the therapist. Additionally, children and adolescents are known to weigh affective aspects of the therapeutic alliance higher than their caregivers do [ 7 , 14 ]. Therefore, alliance ratings from children and adolescents and their caregivers or other adults may reflect different sides of a relationship and may not be interchangeable.…”

Do caregivers’ perspectives matter? Working alliances and treatment outcomes in trauma-focused cognitive behavioural therapy with children and adolescents

“…Evidence suggests that therapists' answers in self-reporting measures cluster more around item content and the commitment level and working ability of the client, whereas patients' items are structured along emotional aspects. Patients focus more on helpfulness and mutual participation in therapeutic work (Bachelor, 2013;Ormhaug et al, 2015). The differences suggest that patients and probably also caregivers report a highly helpful and valuable alliance with the therapist, which the latter may not be aware of.…”

“…In a sample of adolescents with PTSD, the alliance rating of therapists and adolescents was moderately but differentially associated with treatment outcomes (Ormhaug et al, 2014). In a further study with the same sample, factor structure of therapist item ratings of an alliance rating scale were more organized around item content whereas adolescent ratings concentrated more on item valence, the affectively positive or negative wording of items (Ormhaug, Shirk, & Wentzel-Larsen, 2015). This would suggest that these two ratings are not interchangeable.…”

“…This would suggest that these two ratings are not interchangeable. Cross-informant agreement on an alliance between therapists and young clients were significantly but only moderately associated (Ormhaug et al, 2015). But to date, neither the alliance association between therapist and caregiver nor the inclusion of the caregiver perspective as an independent outcome predictor in TF-CBT have been included in investigations over the whole age spectrum of young patients.…”