Examining the Relation Between the Therapeutic Alliance, Treatment Adherence, and Outcome of Cognitive Behavioral Therapy for Children With Anxiety Disorders

doi:10.1016/j.beth.2009.02.003

Behavior Therapy

Volume 41, Issue 2, June 2010, Pages 172-186

https://doi.org/10.1016/j.beth.2009.02.003 Get rights and content

Abstract

Little is known about the contribution of technical and relational factors to child outcomes in cognitive behavioral therapy (CBT) for children with anxiety disorders. This study investigated the association between treatment adherence, the child-therapist alliance, and child clinical outcomes in manual-guided individual- and group-based CBT for youths diagnosed with anxiety disorders. Trained observers rated tapes of therapy sessions for treatment adherence and child-therapist alliance in a sample of 52 children (aged 8 to 12) with anxiety disorders. Self-reported child anxiety was assessed at pre-, mid-, and posttreatment; parent-reported child internalizing symptoms was assessed at pre- and posttreatment. The results showed high levels of treatment adherence and child-therapist alliance in both CBT programs. Neither treatment adherence nor child-therapist alliance predicted traditional measurements of child outcomes in the present study, but a relation between alliance and outcome was found using a more precise estimation of the true pre-post differences. Implications of these findings for expanding our understanding of how treatment processes relate to child outcome in CBT for children with anxiety disorders are discussed.

Section snippets

Source

A randomized multisite trial was conducted at two university-based centers in the Netherlands comparing group-based CBT (GCBT) and individual CBT (ICBT) for childhood anxiety disorders. One-hundred thirty-three children (aged 8–12) were randomly assigned in blocks of six to GCBT (n = 62) or ICBT (n = 65); six children could not be randomized and were excluded. Treatment lasted 14 weeks and consisted of 14 sessions (10 child, 4 parent). Exclusion criteria included an IQ below 85, psychosis,

Comparison of Present Sample Versus Original Sample

The present sample (n = 52) did not differ significantly from the original sample (n = 133) in demographic or clinical characteristics (e.g., age, gender, principal diagnosis, SES). In the original study, the ICBT and GCBT conditions did not differ in demographic or clinical characteristics; however, in the present study children in the GCBT condition were younger (M = 9.80, SD = 1.07; M = 10.72, SD = 1.10, for GCBT and ICBT, respectively), t(50) = − 3.07, p < .01.³

Discussion

The primary aim of the present study was to examine the contribution of relational and technical factors to outcome in CBT for youths with anxiety. Our findings indicate that both the GCBT and ICBT conditions had high child alliance ratings, consistent with findings from past randomized controlled trials evaluating CBT for youths with anxiety (Kendall, 1994, Kendall et al., 1997). We also found that treatment adherence was high across both conditions. A stronger early child alliance appeared

Acknowledgments

This study was supported by the Netherlands Foundation for Mental Health, Utrecht. We would like to thank the children and their parents for their participation in this research project. We owe A. Franswa and S. Van der Toorn special thanks for their contribution to the treatment process, supervision of therapists, and involvement in the research project, and W. Goenee for her contribution to the translation of the TPOCS-A. Furthermore, we would like to thank the members of the Anxiety and

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Reciprocal relationships between alliance and reductions in anxiety are likely, with early measurements of alliance predicting later outcomes, and reductions in anxiety symptoms resulting in improved therapeutic alliance (Marker, Comer, Abramova, & Kendall, 2013). However, some investigations on alliance and treatment outcomes for youth with anxiety found mixed results (Chiu et al., 2009; Ginsburg et al., 2012; Liber et al., 2010; McLeod et al., 2017), while others found no significant relationship for this population (Kendall, 1994; Kendall et al., 1997; Southam-Gerow et al., 2021). It is relevant to note that most investigations on alliance are conducted in an active treatment (i.e., CBT), and not in a TAU context.
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¹: Juliette Liber is now at the Department of Clinical Child Psychology, University of Amsterdam, Amsterdam, Netherlands

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Examining the Relation Between the Therapeutic Alliance, Treatment Adherence, and Outcome of Cognitive Behavioral Therapy for Children With Anxiety Disorders

Abstract

Section snippets

Source

Comparison of Present Sample Versus Original Sample

Discussion

Acknowledgments

Behavior Therapy

Behavior Therapy

Cognitive and Behavioral Practice

Behavior Therapy

Journal of the American Academy of Child and Adolescent Psychiatry

Clinical Psychology Review

Cognitive and Behavioral Practice

Journal of Anxiety Disorders

Journal of the American Academy of Child and Adolescent Psychiatry

Manual for the ASEBA School-Aged Forms & Profiles

Research Centre for Children, Youth and Families

Barriers to dissemination of evidence-based practices: Addressing practitioners' concerns about manual-based psychotherapies

Clinical Psychology: Science and Practice

FRIENDS Support Material. Unpublished manuscript

FRIENDS for children: Group leader's manual

Contribution of the therapeutic alliance to outcome in active versus control psychotherapies

Journal of Consulting and Clinical Psychology

Systematic review of the efficacy of cognitive behaviour therapies for childhood and adolescent anxiety disorders

British Journal of Psychiatry

Standaard Beroepenclassificatie 1999 (Standardized Classification of Occupations)

Child-therapist alliance and clinical outcomes in cognitive behavioral therapy for child anxiety disorders

Journal of Child Psychology and Psychiatry

Positive association of child involvement and treatment outcome within a manual-based cognitive-behavioral treatment for children with anxiety

Journal of Consulting and Clinical Psychology

Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology

Psychological Assessment

Statistical power analysis for the behavioral sciences

Investigating treatment mediators when simple random assignment to a control group is not possible

Clinical Psychology: Science and Practice

G⁎Power: A general analysis program

Behavior Research Methods, Instruments, and Computers

The Adolescent Therapeutic Alliance Scale (ATAS): Initial psychometrics and prediction of outcome in family-based substance abuse prevention counseling

Psychotherapy Research

The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression

Journal of Consulting and Clinical Psychology

Statistical Methods for Rates and Proportions

Establishing clinically significant change: Increment of precision and the distinction between individual and group level of analysis

Behaviour Research and Therapy

Clinically significant and practical! Enhancing precision does make a difference. Reply to McGlinchey and Jacobson, Hsu, and Speer

Behaviour Research and Therapy

Pretreatment and process predictors of outcome in interpersonal and cognitive behavioral psychotherapy for binge eating disorder

Journal of Consulting and Clinical Psychology

Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems

Journal of Consulting and Clinical Psychology

Treatment techniques and outcomes in multidimensional family therapy for adolescent behavior problems

Journal of Family Psychology

Psychotherapy of childhood anxiety disorders: A meta-analysis

Psychotherapy and Psychosomatics

Relationship processes in youth psychotherapy

Journal of Emotional and Behavioral Disorders

Potential mediators of cognitive-behavioral therapy for adolescents with comorbid major depression and conduct disorder

Journal of Consulting and Clinical Psychology

G^⁎Power: A general analysis program