The therapeutic alliance in the treatment of traumatized youths. Relationship to outcome and dropout across rater perspectives and therapeutic interventions.

Ormhaug, S. M. (2016). The therapeutic alliance in the treatment of traumatized youths. Relationship to outcome and dropout across rater perspectives and therapeutic interventions. Faculty of Social Sciences, University of Oslo. (Doktorgradsavhandling).

The overarching aim of this thesis is to better understand the relationship between the therapeutic alliance and dropout and outcome in the treatment of traumatized youth.

Traumatizing events such as domestic violence, severe accidents, and sexual abuse place youths at risk of developing mental health problems, and many will be in need of therapy. To date, a variety of treatment models show promise in alleviating youths’ posttraumatic symptoms and related psychological problems, but little is known about the therapeutic change processes involved in these treatments. One process variable that is generally assumed to be pivotal in the treatment of traumatized youth is the therapeutic alliance. However, this assumption has only been rarely tested empirically. The overarching aim of this thesis is to better understand the relationship between the therapeutic alliance and dropout and outcome in the treatment of traumatized youth. Data were derived from a Norwegian randomized effectiveness trial comparing Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to therapy as usual (TAU) in regular outpatient clinics. The sample consisted of 156 youth (M age = 15.1 years; range: 10–18 years) showing significant symptoms of posttraumatic stress (PTSS), 91 caregivers, and 71 therapists. All participants reported on their perspectives on the alliance.

In the first paper the relationship between the therapeutic alliance and outcome was investigated (paper I). The results showed that youth-rated alliance was a significant predictor of lower symptom levels post-treatment, and that this relationship was moderated by treatment condition. Specifically, a strong alliance was significantly related to better outcomes in the TF-CBT condition but not in TAU. This study is one of the first to provide a direct comparison of the alliance-outcome relationship across treatment models, and the findings indicate that there is an important interaction between the alliance and the therapeutic approach. It seems that a positive working relationship is especially important in the context of TF-CBT, which requires youth involvement in specific therapy tasks but may be less related to change in the more unspecific TAU condition.
In the second paper, the therapists’ perspective on the alliance and its relationship to youths’ evaluations and outcome was examined (paper II). In addition, the consequences of discrepant youth and therapist ratings were investigated. Here, youth ratings of the alliance were significantly related to outcome and treatment satisfaction. Therapist ratings predicted youths’ treatment satisfaction, but were not related to post-treatment symptom reduction. However, level of alliance agreement was related to outcome, and dyads where the youth reported poorer alliances compared with the therapist were associated with higher residual PTSS and lower treatment satisfaction. These findings imply that youth and therapist perspectives are not interchangeable, and that therapists cannot assume that the youth share their views of the alliance. The results suggest that therapists should investigate directly how youth perceive the alliance, since the youth-rated alliance is an important predictor of outcome.

The last aim of this thesis was to learn more about the process variables involved in treatment attendance (paper III). Specifically, first session alliance ratings from youth, therapist and caregiver alliances were assessed as predictors of dropout. Furthermore, a new scale was developed (the Child- and Adolescent-Perceived Parental Approval of Therapy, CAPPATS) to evaluate to what degree the youth perceived that their parents supported the treatment, and whether this perceived support was related to dropout. The results showed that dropout was predicted by therapist-rated alliance, youths’ perceptions of caregiver approval of therapy and a lack of caregiver participation, but not by youth or caregiver alliance or the treatment method. The findings indicate that more attention should be paid to the in-treatment process variables in order to gain a better understanding of which youth are at risk of dropping out. Specifically, further investigations of the role of caregivers’ involvement in the treatment and youths’ perceptions of parental support seem warranted.

Collectively, the findings in this thesis contribute to a better understanding of the role of the therapeutic alliance in the treatment of traumatized youth, how the alliance interacts with treatment method to enact change, and how different raters’ perspectives are related to outcome and process.