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

Abstract

BackgroundIt has been shown that positive treatment expectancy (TE) and good working alliance increase psychotherapeutic success in adult patients, either directly or mediated by other common treatment factors like collaboration. However, the effects of TE in psychotherapy with children, adolescents and their caregivers are mostly unknown. Due to characteristics of the disorder such as avoidant behavior, common factors may be especially important in evidence-based treatment of posttraumatic stress symptoms (PTSS), e.g. for the initiation of exposure based techniques.MethodsTE, collaboration, working alliance and PTSS were assessed in 65 children and adolescents (age M = 12.5; SD = 2.9) and their caregivers. Patients’ and caregivers’ TE were assessed before initiation of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Patients’ and caregivers’ working alliance, as well as patients’ collaboration were assessed at mid-treatment, patients’ PTSS at pre- and post-treatment. Path analysis tested both direct and indirect effects (by collaboration and working alliance) of pre-treatment TE on post-treatment PTSS, and on PTSS difference scores.ResultsPatients’ or caregivers’ TE did not directly predict PTSS after TF-CBT. Post-treatment PTSS was not predicted by patients’ or caregivers’ TE via patients’ collaboration or patients’ or caregivers’ working alliance. Caregivers’ working alliance with therapists significantly contributed to the reduction of PTSS in children and adolescents (post-treatment PTSS: β = − 0.553; p < 0.001; PTSS difference score: β = 0.335; p = 0.031).ConclusionsTE seems less important than caregivers’ working alliance in TF-CBT for decreasing PTSS. Future studies should assess TE and working alliance repeatedly during treatment and from different perspectives to understand their effects on outcome. The inclusion of a supportive caregiver and the formation of a good relationship between therapists and caregivers can be regarded as essential for treatment success in children and adolescents with PTSS.

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

“…In TF-CBT, the only therapist-related factor that has been researched to any extent is the working alliance between patient, therapist and caregiver (Kirsch, Keller, Tutus, & Goldbeck, 2018 ). The alliance between patient and therapist has been proven to have a significant impact on therapy outcome (Ormhaug, Jensen, Wentzel-Larsen, & Shirk, 2014 ) and female therapists seem to have higher rates of alliance with their patients (Zorzella et al, 2015 ).…”

Therapeutic Alliance in Cognitive Behavioural Therapy in Child and Adolescent Mental Health-Current Trends and Future Challenges

“…The observers and coders who rated either video or audiotaped sessions were blinded to the study hypotheses ( Hudson et al, 2014 ; Boyer et al, 2018 ; Kirsch et al, 2018 ; Puls et al, 2019 ).…”

“… Anderson et al (2012) randomised participants to individual CBT and internet-based CBT. Internet-based CBT ( Stjerneklar et al, 2019 ), Multimodal CBT-( Klebanoff et al, 2019 ), Trauma focused CBT- ( Zorzella et al, 2015 , 2017 ; Valadez-Sanchez, 2017 ; Kirsch et al, 2018 ; Loos et al, 2020 ), and Emotion regulation focused CBT was used by Albaum et al (2020) .…”

“…Although concerned that observations of parents ratings were all "good" or "excellent, " in their study, the authors felt that the parents were eager and hoping for the recovery of their children from debilitating symptoms of PTSD, would have voiced any degree of concern they had and therefore the ratings were acceptable for study analysis due to the consistent ratings across the cohort, although it was felt that introducing independent raters would give more definitive answers to this observation (Zorzella et al, 2015(Zorzella et al, , 2017. It was observed that repeated measures could have affected the outcome of analysis as their study showed no effect of TE on treatment outcomes (Kirsch et al, 2018), in contrast to another study that did, but that study was in OCD (Lewin et al, 2011). Pre-treatment to treatment changes of depressive symptoms (Gamble et al, 2010) were not assessed in the alliance study in depressed children.…”

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

“…In a community-based Canadian sample of young children (7-12 years) and their caregivers, alliance remained positive and stable over the course of TF-CBT (Zorzella, Rependa, & Muller, 2017). The caregivers' treatment expectancy at the beginning of the TF-CBT treatment phase did not predict a reduction in posttraumatic stress symptoms (PTSS), but their midtreatment WA rating did do so (Kirsch, Keller, Tutus, & Goldbeck, 2018).…”