Intervention format and therapist–child agreement associated with therapeutic alliance and outcomes.

Abstract

Objective: The study examined the effects of therapeutic alliance (TA; relational bond, task collaboration) on externalizing behavior outcomes, how TA can operate differently when children are seen in individual versus group sessions, and how therapist-child disagreement in perceptions of TA affects outcomes. Method: Three hundred sixty children (Ages 9.2-11.8; 65% male; 78.1% Black) identified as having high rates of aggressive behavior by the fourth-grade teachers, and their 20 elementary schools were randomized to group versus individual delivery of the cognitive behavioral intervention, Coping Power. TA ratings were collected from children and therapists at mid and end of intervention using the Therapeutic Alliance Scale for Children. Teacher ratings of children's externalizing and internalizing behavior problems were collected prior to intervention and at 1-year follow-up after intervention using the Behavior Assessment System for Children. Results: Children receiving the intervention individually reported significantly higher trait-like levels of task collaboration than did children seen in groups. Independent of intervention format, higher trait-like levels of therapist-rated bond and task collaboration predicted reduced levels of externalizing problems, and higher trait-like levels of child-and therapist-rated task-collaboration and therapist-rated bond predicted reduced levels of internalizing problems. Differences between therapist and child reports of bond predicted weaker reductions in internalizing behavior for children seen in groups. Conclusions: It is essential to train therapists to develop and assess for TA by midintervention with children with aggressive behavior problems, especially if they are seen in small groups, and to determine if therapists may misperceive the strength of TA.What is the public health significance of this article? Therapeutic alliance affects outcomes for children with aggressive behavior and findings add to the strength of the evidence-base for cognitive behavioral intervention. Therapeutic alliance is stronger in individual delivery of intervention to these children. Group-based delivery likely requires intensive training to assist therapists to establish strong task collaboration.