Top

Child and Adolescent Psychiatry and Mental Health

Published in:

Open Access 01-12-2018 | Research Article

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

Authors: Veronica Kirsch, Ferdinand Keller, Dunja Tutus, Lutz Goldbeck

Published in: Child and Adolescent Psychiatry and Mental Health | Issue 1/2018

Abstract

Background

It 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.

Methods

TE, 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.

Results

Patients’ 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).

Conclusions

TE 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.

Norcross JC, Lambert MJ. Psychotherapy relationships that work II. Psychotherapy. 2011;48:4–8. https://doi.org/10.1037/a0022180.CrossRefPubMed

Hofmann SG, Barlow DH. Evidence-based psychological interventions and the common factors approach: the beginnings of a rapprochement? Psychotherapy. 2014. https://doi.org/10.1037/a0037045.

Wampold BE. How important are the common factors in psychotherapy? An update. World Psychiatry. 2015;14:270–7.CrossRefPubMedPubMedCentral

Benish SG, Imel ZE, Wampold BE. The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons. Clin Psychol Rev. 2008;28:746–58.CrossRefPubMed

Wampold BE, Imel ZE, Laska KM, Benish SG, Miller ME, Flückinger C, Budge S. Determining what works in the treatment of PTSD. Clin Psychol Rev. 2010;30:923–33. https://doi.org/10.1016/j.cpr.2010.06.005.CrossRefPubMed

Ehlers A, Bisson J, Clark DM, Creamer M, Pilling S, Richards D, Yule W. Do all psychological treatments really work the same in posttraumatic stress disorder? Clin Psychol Rev. 2010;30:269–76. https://doi.org/10.1016/j.cpr.2009.12.001.CrossRefPubMedPubMedCentral

Shirk SR, Karver M. Prediction of treatment outcome from relationship variables in child and adolescent therapy: a meta analytic review. J Consult Clin Psychol. 2003;71:452–64. https://doi.org/10.1037/0022-006X.71.3.452.CrossRefPubMed

Ormhaug SM, Jensen TK, Wentzel-Larsen T, Shirk SR. The therapeutic alliance in treatment of traumatized youth: relation to outcome in a randomized controlled trial. J Consult Clin Psychol. 2014;82:52–64. https://doi.org/10.1037/a0033884.CrossRefPubMed

Frank JD, Frank JB. Persuasion and Healing. A comparative study of psychotherapy. 3rd ed. Baltimore: The John Hopkins University Press; 1991.

10.

Constantino M, Arnkoff D, Glass C, Ametrano R, Smith JZ. Expectations. J Clin Psychol. 2011;67:184–92.CrossRefPubMed

11.

Compas B, Connor-Smith J, Saltzman H, Thomsen A, Wadsworth M. Coping with stress during childhood and adolescence: problems, progress, and potential in theory and research. Psychol Bull. 2001;127:87–127.CrossRefPubMed

12.

Veneziano E. Language and internal states: a long developmental history at different levels of functioning. Rivista di psicolinguistica applicata. 2009;9:15–34. https://doi.org/10.1400/122907.

13.

Schonert-Reichl K, Muller J. Correlates of help-seeking in adolescence. J Youth Adolesc. 1996;25:705–31.CrossRef

14.

Ormhaug SM, Shirk SR, Wentzel-Larsen T. Therapist and client perspectives on the alliance in the treatment of traumatized adolescents. Eur J Psychotraumatol. 2015;6:27705. https://doi.org/10.3402/ejpt.v6.27705.CrossRefPubMed

15.

Cohen J. Factors that mediate treatment outcome of sexually abused preschool children. J Am Acad Child Adolesc Psychiatry. 1996;35:1402–10.CrossRefPubMed

16.

Haine-Schlagel R, Walsh N. A review of parent participation in child and family mental health treatment. Clin Child Fam Psychol Rev. 2015;18:133–50. https://doi.org/10.1007/s10567-015-0182-x.CrossRefPubMedPubMedCentral

17.

DeFife J, Hilsenroth MJ. Starting off the right foot: common factor elements in early psychotherapy process. J Psychother Integr. 2011;21:172–91. https://doi.org/10.1037/a0023889.CrossRef

18.

Lewin AB, Peris TS, Bergman RL, McCracken JT, Piacentini J. The role of treatment expectancy in youth receiving exposure-based CBT for obsessive compulsive disorder. Behav Res Ther. 2011;49:536–43. https://doi.org/10.1016/j.brat.2011.06.001.CrossRefPubMedPubMedCentral

19.

Curry J, Rohde P, Simons A, Silva S, Vitiello B, Kratochvil C, Reinecke M, Feeny N, Wells K, Pathak S, Weller E. Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS). J Am Acad Child Adolesc Psychiatry. 2006;45:1427–39. https://doi.org/10.1097/01.chi.0000240838.78984.e2.CrossRefPubMed

20.

Bohart A and Wade S. The client in psychotherapy. In: Bergin and Garfield’s Handbook of psychotherapy and behavior change, 6th edn. Hoboken: Wiley; 2013. p. 219–57.

21.

McClintock A, Anderson T, Petrarca A. Treatment expectations, alliance, session positivity, and outcome: an investigation of a three-path mediation model. J Clin Psychol. 2016;71:41–9.CrossRef

22.

Bordin E. The generaliziability of the psychoanalytic concept of the working alliance. Psychother Theory Res Pract. 1979;16:252–60.CrossRef

23.

Flückinger C, Del Re AC, Wampold BE, Symonds D, Horvath AO. How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. J Counc Psychol. 2012;59:10–7. https://doi.org/10.1037/a0025749.CrossRef

24.

Martin D, Garske JDM. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J Consult Clin Psychol. 2000;68:438–50. https://doi.org/10.1037/0022-006X.68.3.438.CrossRefPubMed

25.

McLeod BD. Relation of the alliance with outcomes in youth psychotherapy: a meta-analysis. Clin Psychol Rev. 2011;31:603–16. https://doi.org/10.1016/j.cpr.2011.02.001.CrossRefPubMed

26.

Shirk SR, Karver MS, Brown R. The alliance in child and adolescent psychotherapy. Psychotherapy. 2011;48:17–24. https://doi.org/10.1037/a0022181.CrossRefPubMed

27.

Abrishami GF, Warren JS. Therapeutic alliance and outcomes in children and adolescents served in a community mental health system. J Child Adolesc Behav 2013;1:110. https://doi.org/10.4172/jcalb.1000110.CrossRef

28.

Zorzella KM, Muller RT, Cribbie RA. The relationships between therapeutic alliance an internalizing and externalizing symptoms in Trauma-Focused Cognitive Behavioral Therapy. Child Abuse Negl. 2015;50:171–81.CrossRefPubMed

29.

Capaldi S, Asnaani A, Zandberg LJ, Carpenter JK, Foa EB. Therapeutic alliance during prolonged exposure versus client-centered therapy for adolescent posttraumatic stress disorder. J Clin Psychol. 2016;72:1026–36.CrossRefPubMed

30.

Goldbeck L, Muche R, Sachser C, Tutus D, Rosner R. Effectiveness of Trauma-Focused Cognitive Behavioral Therapy for children and adolescents: a randomized controlled trial in eight german mental health clinics. Psychother Psychosom. 2016;85:159–70. https://doi.org/10.1159/000442824.CrossRefPubMed

31.

Nader K, Kriegler J, Blake D. The clinician-administered PTSD scale for children and adolescents for DSM-IV (CAPS-CA). White River Junction: National Centre for PTSD; 2002.

32.

Miller-Graff L, Campion K. Interventions for posttraumatic stress with children exposed to violence: factors associated with treatment success. J Clin Psychol. 2015;72:226–48.CrossRefPubMed

33.

Cohen J, Mannarino AP, Deblinger E. Treating trauma and traumatic grief in children and adolescents. New York: Guilford Press; 2006.

34.

Klein D, Schwartz J, Santiago N, Vivian D, Vocisano C, Castonguay L, Arnow B, Blalock JA, Manber R, Markowitz J. Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics. J Consult Clin Psychol. 2003;71:997–1006. https://doi.org/10.1037/0022-006X.71.6.997.CrossRefPubMed

35.

Tracey T, Kokotovic A. Factor structure of the Working Alliance Inventory. Psychol Assess. 1989;1:207–10.CrossRef

36.

Flückinger C, Horvath AO, DelRe AC, Symonds D, Holzer C. Die Bedeutung der Arbeitsallianz in der Psychotherapie—Übersicht aktueller Metaanalysen. Psychotherapeut. 2015. https://doi.org/10.1007/s00278-015-0020-0.

37.

Anderson RE, Spence SH, Donovan CL, March S, Prosser S, Kenardy J. Working alliance in online cognitive behavior therapy for anxiety disorders in youth: comparison with clinic delivery and its role in predicting outcome. J Med Internet Res. 2012;14(3):e88. https://doi.org/10.2196/jmir.1848.CrossRefPubMedPubMedCentral

38.

Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, Erikson P. Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) measures: report of the ISPOR task force for translation and cultural adaptation. Value Health. 2005;8(2):94–104.CrossRefPubMed

39.

Muthén L, Muthén B. MPlus user’s guide, version 7. Los Angeles: Muthén & Muthén; 2015.

40.

McDonald R, Ho M-HR. Principles and practice in reporting structural equation analyses. Psychol Methods. 2002;7:64–82.CrossRefPubMed

41.

Stage F, Carter H, Nora A. Path analysis: an introduction and analysis of a decade of research. J Educ Res. 2010;98:5–13.CrossRef

42.

Kaufman N, Rohde P, Seeley J, Clarke G, Stice E. Potential mediators of cognitive-behavioral therapy for adolescents with co-morbid major depression and conduct disorder. J Consult Clin Psychol. 2005;73:38–46. https://doi.org/10.1037/0022-006X.73.1.38.CrossRefPubMed

43.

Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38:319–45.CrossRefPubMed

44.

Kleim B, Grey N, Wild J, Nussbech FW, Stott R, Hackmann A, Ehlers A. Cognitive change predicts symptom reduction with cognitive therapy for posttraumatic stress disorder. J Consult Clin Psychol. 2013;81:383–93.CrossRefPubMed

45.

Kumpula MJ, Rentel KZ, Foa EB, LeBlanc NJ, Bui E, McSweeney LB, Knowles K, Bosley H, Simon NM, Rauch SA. Temporal sequencing of change in posttraumatic cognitions and PTSD symptom reduction during prolonged exposure therapy. Behav Ther. 2017;48:561–651.CrossRef

46.

Contractor A, Roley-Roberts M, Lagdon S, Armour C. Heterogeneity in patterns of DSM5 posttraumatic stress disorder and depression symptoms: latent profile analyses. J Affect Disord. 2017;212:17–24.CrossRefPubMed

47.

Flor J, Yehuda R. Comorbidity between post-traumatic stress disorder and major depressive disorder: alternative explanations and treatment considerations. Dialogues Clin Neurosci. 2015;17:141–50.

48.

Ramirez de Arellano MA, Lyman DR, Jobe-Shields L, George P, Dougherty RH, Daniels AS, Huang L, Delphin-Rittmon ME. Trauma-Focused Cognitive Behavioral Therapy: assessing the evidence. Psychiatr Serv (Washington, D.C.). 2014;65(5):591–602. https://doi.org/10.1176/appi.ps.201300255.CrossRef

49.

Ahmed M, Westra H. Impact of a treatment rationale on expectancy and engagement in cognitive behavioural therapy for social anxiety. Cogn Ther Res. 2009;33:314–22. https://doi.org/10.1007/s10608-008-9182-1.CrossRef

50.

Meyer B, Pilkonis P, Krupnick J, Egan M, Simmens S, Sotsky S. Treatment expectancies, patient alliance, and outcome: further analyses from the National institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol. 2002;70:1051–5. https://doi.org/10.1037/0022-006X.70.4.1051.CrossRefPubMed

51.

Ormhaug SM and Jensen TK. Investigating treatment characteristics and first-session relationship variables as predictors of dropout in the treatment of traumatized youth. Psychother Res. 2018;28(2). 235–249https://doi.org/10.1080/10503307.2016.1189617.

52.

Loos S and Goldbeck L. Working alliance and its association with treatment outcome in Trauma-Focused Cognitive Behavioral Therapy with children and adolescents. 2017 (submitted manuscript).

53.

Glickman K, Shear M, Wall M. Mediators of outcome in complicated grief. J Clin Psychol. 2016;73:817–28. https://doi.org/10.1002/jclp.22384.CrossRefPubMed

54.

Samuelson K, Wilson C, Padrón E, Lee S, Gavron L. Maternal PTSD and children’s adjustment: parenting stress and emotional availability as proposed mediators. J Clin Psychol. 2016;73:693–706. https://doi.org/10.1002/jclp.22369.CrossRefPubMed

55.

Shirk SR, Saiz CC. Clinical, empirical, and developmental perspectives on the therapeutic relationship in child psychotherapy. Dev Psychopathol. 1992;4:713–28. https://doi.org/10.1017/S0954579400004946.CrossRef

Title: Treatment expectancy, working alliance, and outcome of Trauma-Focused Cognitive Behavioral Therapy with children and adolescents
Authors: Veronica Kirsch
Ferdinand Keller
Dunja Tutus
Lutz Goldbeck
Publication date: 01-12-2018
Publisher: BioMed Central
Published in: Child and Adolescent Psychiatry and Mental Health / Issue 1/2018
Electronic ISSN: 1753-2000
DOI: https://doi.org/10.1186/s13034-018-0223-6

At a glance: The STEP trials

Springer Medicine

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

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2018

Multidimensional family therapy in adolescents with a cannabis use disorder: long-term effects on delinquency in a randomized controlled trial

Prevalence and correlates of burnout among collegiate cycle students in Sri Lanka: a school-based cross-sectional study

Effectiveness of a cognitive behavioural therapy-based anxiety prevention programme at an elementary school in Japan: a quasi-experimental study

Supervision trajectories of male juvenile offenders: growth mixture modeling on SAVRY risk assessments

Obituary for Lutz Goldbeck

Assessment of dynamic change in psychotherapy with adolescents