Child involvement, alliance, and therapist flexibility: Process variables in cognitive-behavioural therapy for anxiety disorders in childhood

doi:10.1016/j.brat.2013.09.011

Behaviour Research and Therapy

Volume 52, January 2014, Pages 1-8

https://doi.org/10.1016/j.brat.2013.09.011 Get rights and content

Highlights:

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Therapists maintained a high level of alliance with their clients.
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Child involvement and therapist flexibility peaked around mid treatment.
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Therapist flexibility was related to child involvement in the initial sessions.
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Improvements in alliance and were associated with increases in child involvement.
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Initial (and improved) alliance or involvement are related to positive outcome.

Abstract

Background

This study examined the relations between treatment process variables and child anxiety outcomes. Method: Independent raters watched/listened to taped therapy sessions of 151 anxiety-disordered (6–14 yr-old; M = 10.71) children (43% boys) and assessed process variables (child alliance, therapist alliance, child involvement, therapist flexibility and therapist functionality) within a manual-based cognitive-behavioural treatment. Latent growth modelling examined three latent variables (intercept, slope, and quadratic) for each process variable. Child age, gender, family income and ethnicity were examined as potential antecedents. Outcome was analyzed using factorially derived clinician, mother, father, child and teacher scores from questionnaire and structured diagnostic interviews at pretreatment, posttreatment and 12-month follow-up. Results: Latent growth models demonstrated a concave quadratic curve for child involvement and therapist flexibility over time. A predominantly linear, downward slope was observed for alliance, and functional flexibility remained consistent over time. Increased alliance, child involvement and therapist flexibility showed some albeit inconsistent, associations with positive treatment outcome. Conclusion: Findings support the notion that maintaining the initial high level of alliance or involvement is important for clinical improvement. There is some support that progressively increasing alliance/involvement also positively impacts on treatment outcome. These findings were not consistent across outcome measurement points or reporters.

Section snippets

Participants

Children (N = 151 ages 6–14; 71 boys) and their parents completed independent structured diagnostic interviews conducted by separate diagnosticians. Child diagnoses were obtained from the Anxiety Disorders Interview Schedule (ADIS-IV-C/P or ADIS-III-R-C/P; Silverman, 1987, Silverman et al., 1996) conducted at the Child and Adolescent Anxiety Disorders Clinic (CAADC), Temple University. Children participated in an RCT (n = 44 from Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008; n = 58

Coder training

Coders (n = 12) were provided readings on childhood anxiety, its treatment, coding manuals for the process measures, then tested to evaluate their knowledge. Coders used manuals to code each of the process variables, watching and coding training sessions. Coders were required to reach a reliability of .80 on each of the factor scores (intra-class correlation for interval data; Kappa for agreement data). Coders not reaching the criteria continued watching training tapes and coding separate tapes

Reliability assessments

Inter-rater reliability was conducted at post training; midway and at the end of coding. Tapes were given to coders at intervals throughout. Coders discussed their ratings, and discrepancies were discussed and resolved. At the end of coding, overall ICC for all scale and subscale scores was assessed. Child variables: Therapeutic Alliance = .81; Child Work = .83; Child Readiness = .83; CIRS = .90. Therapist Variables: Therapeutic Alliance = .80; Technical Work = .75; Technical Lapse = .69;

Discussion

The current study used taped sessions from multiple RCT's of CBT for children with anxiety disorders. Results found that measures of child and therapist process variables demonstrated several between-process relations and associations with treatment outcome. The current study was the first to utilize observer-ratings of weekly sessions for multiple client and therapist factors and provides the most comprehensive description available in the literature of the shape of change for child and

Acknowledgements

This research was supported by NIMH grant MH60653 awarded to Philip C. Kendall, Jennifer L Hudson, Elizabeth Gosch and Brian Chu. Thank you to the many committed coders involved in this study.

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To examine the impact of youth- and caregiver-reported pretreatment worries about treatment (i.e., concerns about the effect of, perceptions of, or aspects involved in treatment) before cognitive behavioral therapy for anxiety on (1) clinician-rated therapeutic process factors (i.e., client engagement, client-therapist alliance, content mastery, and homework completion) and symptom change (i.e., improvement, anxiety severity) assessed throughout treatment and (2) independent evaluator-rated posttreatment outcomes (i.e., response, remission, and functional impairment).
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Therapist- and therapy-related predictors of outcomes in a randomized controlled trial of school-based treatments for pediatric anxiety
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It is possible that these therapeutic styles relate to change in other important aspects of treatment (e.g., child buy-in and/or motivation for treatment), but more research is needed in this area. Child perception of the therapeutic alliance, although associated with therapists seeing more than one child, was unrelated to treatment response, which contradicts some previous outpatient findings (e.g., Chiu et al., 2009; Hudson et al., 2014; Hughes & Kendall, 2007; Keeley et al., 2011). That said, other studies have not found this link (Kendall, 1994; Kendall et al., 1997; McLeod et al., 2016; Southam-Gerow et al., 2021), particularly in community settings (McLeod et al., 2016), and the impact of therapeutic relationship is weaker for youth overall (McLeod, 2011; Murphy & Hutton, 2018).
The current study examined predictors of outcomes across two school clinician-delivered treatments (i.e., treatment as usual [TAU] or modular cognitive-behavioral therapy [M-CBT]) for youth with anxiety disorders. Predictors reflected two broad domains—therapist factors (i.e., education, years of experience, therapeutic orientation, work related stressors/barriers, self-efficacy, and attitudes towards evidence-based practices) and treatment-related factors (i.e., dosage, child compliance with treatment, therapeutic alliance, therapeutic nonspecifics, and proportion and quality of evidence-based structure elements). One hundred and ninety-five youth (mean age 10.98; 50.3% female, 53.5% non-Hispanic Caucasian) and 54 therapists (90.7% female, 72.2% non-Hispanic Caucasian) that were enrolled and randomized in a previous study (Ginsburg et al., 2020) participated. Results showed that incorporation of more evidence-based structure elements (e.g., agenda setting, assigning homework) and higher child compliance with treatment significantly increased odds of response to treatment. These findings provide important information about key ingredients to successful treatments, regardless of treatment condition/modality, and can be used to inform future training and implementation of school-based treatments for youth with anxiety disorders.
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Research on specific aspects of working alliance have been limited, although consistent with our findings, prior work has pointed to therapist flexibility as a facilitator and therapist rigidity as an impediment to strong working alliance across treatment approaches (Ackerman & Hilsenroth, 2001, 2003). Further, among therapists treating children with anxiety, flexible application of cognitive-behavioral therapy has been associated with greater patient engagement (Chu & Kendall, 2009; Hudson et al., 2014). We recommend that future research on the specific elements of therapeutic rapport that facilitate PE/CPT completion incorporate objective data (e.g., session ratings) and examine both direct and moderating effects.
Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists’ flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions.
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Shorter communicationChild involvement, alliance, and therapist flexibility: Process variables in cognitive-behavioural therapy for anxiety disorders in childhood

Highlights:

Abstract

Background

Section snippets

Participants

Coder training

Reliability assessments

Discussion

Acknowledgements

Clinical Psychology Review

Cognitive and Behavioral Practice

Cognitive & Behavioral Practice

Behavior Therapy

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Integrative guide for the 1991 CBCL/4-18, YSR, and TRF

Manual for the TRF and the child behaviour profile

Manual for the ASEBA school-age forms and profiles

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

Therapist responsiveness to child engagement: flexibility within manual-based CBT for anxious youth

Journal of Clinical Psychology

An introduction to latent growth curve modeling: Concepts, issues, and applications

The impact of nonnormality on full information maximum-likelihood estimation for structural equation models with missing data

Psychological methods

The development of the child psychotherapy process scale

Psychotherapy Research

Relationship factors and outcome in child anxiety treatment studies

Clinical Child Psychology and Psychiatry

Group and individual cognitive-behavioral treatments for youth with anxiety disorders: a randomized clinical trial

Cognitive Therapy and Research

When youth mental health care stops: therapeutic relationship problems and other reasons for ending youth outpatient treatment

Journal of Consulting and Clinical Psychology

Youth versus parent working alliance in usual clinical care: distinctive associations with retention, satisfaction, and treatment outcome

Journal of Clinical Child and Adolescent Psychology

The alliance psychotherapy relationships that work: Therapist contributions and responsiveness to patients

Empirical and clinical focus of child and adolescent psychotherapy research

Journal of Consulting and Clinical Psychology

Shorter communication
Child involvement, alliance, and therapist flexibility: Process variables in cognitive-behavioural therapy for anxiety disorders in childhood