Research papers
The therapeutic alliance in the cognitive behavioral treatment of pediatric obsessive–compulsive disorder

https://doi.org/10.1016/j.janxdis.2011.03.017Get rights and content

Abstract

Although cognitive-behavioral therapy (CBT) for pediatric obsessive–compulsive disorder (OCD) is considered a first-line treatment, not all youth have a positive treatment response, suggesting need for investigating factors that may enhance or reduce treatment effects. Few studies have investigated predictors of treatment response in pediatric OCD, and there is an absence of studies examining the influence of treatment process variables (e.g., therapeutic alliance [TA]) on treatment outcome. Using a multiple-informant and multiple-time point design, the current study examined the role of the TA in family-based CBT for pediatric OCD. Analyses examined (1) the predictive value of the TA on OCD symptom reduction and (2) whether changes in the TA over time predict treatment response. Findings indicated that (1) stronger child-rated, parent-rated, and therapist-rated TAs were predictive of better treatment outcome and (2) larger and more positive early alliance shifts (as rated by changes in child-rated TA between sessions 1 and 5) were predictive of better treatment outcome. Implications for the treatment of youth with OCD within family-based CBT are discussed.

Highlights

► Stronger child, parent, and therapist-rated TAs predicted better treatment outcomes. ► Larger and more positive early alliance shifts predicted better treatment outcomes. ► Both initial and mid-treatment ratings of the TA are robust predictors of outcome.

Section snippets

Participants

Twenty-five youth aged 7–17 years (M = 13.16, SD = 2.69) with a principal diagnosis of OCD and their parents participated in the current study. Participants (11 females) were recruited from families who presented to a specialty OCD Clinic. Eighty percent of the sample was Caucasian, 8% was African American, 8% was Hispanic, and 4% was biracial. The average age of OCD onset for the sample was 10.48 years of age. Inclusion criteria were as follows: (a) principal diagnosis of OCD based on the Anxiety

Sample characteristics

Means, standard deviations, and ranges for each study measure are presented in Table 1. As can be seen in Table 3, scores on the CY-BOCS were reduced across treatment, with an overall Cohen's d effect size of 2.89. Fifty-nine percent of the current study's sample achieved remission status (CY-BOCS < 10) which was measured immediately following the last treatment session. All measures demonstrated acceptable internal consistency; alpha coefficients ranged from .70 to .98. Independent group t-tests

Discussion

The primary aim of the current study was to examine the role of the TA in CBT for pediatric OCD. We found that both child-rated and therapist-rated child–therapist TAs were significantly related to treatment outcome, such that stronger ratings of the alliance at the beginning of treatment and at mid-treatment predicted a greater reduction in OCD symptoms at post-treatment. Additionally, results indicated that both the parent-rated and the therapist-rated parent–therapist TA was also a

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    Author note: Portions of this paper were supported by grants from the Society of Clinical Child and Adolescent Psychology (Division 53 of the American Psychological Association) to the first author.

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