Therapists’ behaviors and youths’ therapeutic alliance during trauma-focused cognitive behavioral therapy.

Abstract

Objective: Trauma-focused cognitive-behavioral therapy (TF-CBT) is a recommended treatment for posttraumatic stress (PTS) in youth, and a strong therapeutic alliance predicts reductions of PTS in TF-CBT. However, little is known of how therapists can build a strong alliance. This study seeks to understand which therapist behaviors are associated with the strength of alliance in TF-CBT. Method: Participants were 65 youth (M age ϭ 15.1, SD ϭ 2.19; 77% girls) engaged in TF-CBT and their therapists (n ϭ 24). The alliance was assessed midtreatment using the Therapeutic Alliance Scale for Children-revised. Therapists' behaviors were coded using the Adolescent Alliance-Building Scale-revised, and youth engagement behavior was coded using the Behavioral Index of Disengagement Scale. Linear mixed-effects models were used to evaluate clients' and therapists' in-session behaviors as predictors of the alliance, in addition to assessing the potential moderating effects of youth behaviors. Results: Rapport-building behaviors were significantly predictive of higher alliance scores (Est. ϭ 1.81, 95% CI [0.11, 3.52], p ϭ .038), whereas there was no predictive effect of treatment socialization or trauma-focusing behavior on alliance scores. Initial youth behavior significantly moderated the effect of trauma-focusing on the alliance (p ϭ .007); greater focus on trauma was associated with higher alliance scores among passively disengaged youth (Est. ϭ 4.92, 95% CI [1.80, 8.05], p ϭ .003). Conclusions: Rapport-building behaviors are associated with a stronger alliance in TF-CBT. Gradual exposure through initial trauma-eliciting does not appear to undermine alliance formation but is rather associated with higher alliance-scores among passively disengaged youth. What is the public health significance of this article?This study suggests that therapist rapport-building behaviors (i.e., focusing on youth's experiences, providing support, and cognitive restructuring) during the early phase of TF-CBT are associated with a stronger therapeutic alliance. Focusing on youth's traumatic experiences early in treatment does not undermine alliance building in TF-CBT. For youth who are marginally engaged when entering treatment, therapists' elicitation of trauma-related content seems to be beneficial for alliance formation.

Does the therapist matter? Therapist characteristics and their relation to outcome in trauma-focused cognitive behavioral therapy for children and adolescents

“…The majority of studies, which mostly investigated adult patients, report moderate therapist effects of approximately 5% (Johns et al, 2019 ), but the overall range of therapist effects is relatively large and varies from 0.2% to 48.7% (Crits-Christoph et al, 1991 ; Crits-Christoph & Mintz, 1991 ; Johns et al, 2019 ; Lutz, Leon, Martinovich, Lyons, & Stiles, 2007 ). Frequently researched therapist variables are the therapists’ theoretical background/orientation (Anderson, Ogles, Patterson, Lambert, & Vermeersch, 2009 ; Berglar et al, 2016 ; Okiishi et al, 2006 ), professional interpersonal skills or self-rated professional characteristics (Heinonen & Nissen-Lie, 2019 ), therapists’ alliance-building behaviours (Jungbluth & Shirk, 2009 ; Ovenstad, Ormhaug, Shirk, & Jensen, 2020 ), professional experience (e.g. years of experience doing therapy; Huppert et al, 2001 ; Turner, Nicholson, & Sanders, 2011 ), age (Anderson et al, 2009 ; Schauenburg, Dinger, & Strack, 2005 ) and gender (Shiner, Westgate, Harik, Watts, & Schnurr, 2017 ; Zorzella, Muller, & Cribbie, 2015 ).…”

“…Since most of the studies on the role of therapists are conducted with adult samples, little is known about therapist effects in psychotherapy with children and adolescents (Fjermestad, McLeod, Tully, & Liber, 2016 ). So far, only preliminary results on single factors such as therapists’ relationship skills (Alexander, Barton, Schiavo, & Parsons, 1976 ), therapists’ alliance building behaviours (Jungbluth & Shirk, 2009 ; Ovenstad et al, 2020 ) or ethnicity and language of the therapist are available (Halliday-Boykins, Schoenwald, & Letourneau, 2005 ; Yeh, Eastman, & Cheung, 1994 ). A study by Wintersteen, Mensinger, and Diamond ( 2005 ) found that ‘same gender’ matched dyads of therapists and patients in the treatment of 600 adolescent substance abusers reported higher alliance ratings and that the patients were more likely to complete treatment compared with ‘different-gender’ dyads.…”

Nurses' responses to adolescent distress in an acute child and adolescent mental health inpatient unit: A qualitative interpretive descriptive study

“…With the majority of young people admitted to acute inpatient units having a history of trauma, therapeutic touch could be viewed as either detrimental or helpful. Some adolescents may experience PTSD trigger type responses, while others may feel comforted, and potentially learn to trust adults (Ovenstad et al, 2020). Further research into the acceptance and effectiveness of therapeutic touch for this population.…”

“…Integral to all nursing interventions in an acute inpatient unit is the therapeutic alliance and relationships that nurses can establish, maintain and repair with the young people for whom they provide care. Many young people admitted to acute inpatient units have experiences of childhood trauma and attachment disruption, and these experiences impact the young person's beliefs of adult helpfulness and trust (Ovenstad et al, 2020). Establishing therapeutic relationships with adolescents in the inpatient setting requires nurses to have specialist interpersonal communication skills and to consider the developmental factors associated with the child and adolescent mental health population (Delaney, 2017; Engstrom et al, 2020).…”

Therapists’ Contributions to the Alliance in Home-Based Family Treatment: The Role of Alliance Building Behaviors, Personality, and Clinical Experience

“…Therapists' observed in-session behavior could be an important contributor to the alliance, as has been shown in several studies in individual youth therapy (Creed & Kendall 2005;Fjermestad et al, 2020;Ovenstad et al, 2020). For conjoint family treatment however, studies on alliance building behaviors are scarce.…”