Therapist Adherence to Two Treatments for Adolescent Suicide Risk: Association to Outcomes and Role of Therapeutic Alliance

Abstract

In psychotherapy research, adherence refers to the extent to which therapists deliver a treatment as intended. This study examined whether therapist adherence to two different manualized treatments was associated with improved client outcomes and whether the association was moderated by therapeutic alliance. The study sample included 320 video recordings of therapy sessions from 118 cases in a randomized controlled trial (RCT) comparing attachment‐based family therapy (ABFT) with family‐enhanced nondirective supportive therapy (FE‐NST). Recordings were selected from early, middle, and late stages of treatment. The adherence measure consisted of 24 items representing essential therapist interventions from both treatments. Trained raters coded tapes from both therapies. Adolescent self‐report of alliance was measured at session 4. Adherence to ABFT was associated with a significant increase in family cohesion at mid‐treatment but not at posttreatment. Adherence to FE‐NST was significantly associated with an increase in suicide ideation posttreatment. Using therapeutic alliance as a moderator, adherence to ABFT was significantly associated with a reduction in suicide ideation, family conflict, and higher client satisfaction posttreatment. Alliance did not positively affect the association of FE‐NST adherence to outcomes. Findings suggest that adherence to ABFT interventions may be better linked to treatment outcomes when adolescents feel a strong alliance with their therapist. Implications for future research and therapist training are explored.

The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review

“…A fifth study investigated the therapeutic alliance as a moderator between therapy adherence and suicidal ideation upon therapy cessation. The interaction between good therapy adherence and the client perception a stronger therapeutic alliance was significantly correlated with lower frequency of suicidal thoughts (Ibrahim et al, 2021).…”

“…However, the Suicide Probability Scale (SPS; Cull & Gill, 1982), which assessed a combination of suicidal ideation, negative thoughts, hopelessness and hostility, was used and analysed as a composite measure in one study (Haddock et al, 2019). Two studies included a population of adolescents and so used the Suicidal Ideation Questionnaire-Junior to examine suicidal ideation (Ibrahim et al, 2018(Ibrahim et al, , 2021.…”