Clarifying the Direction of Effects between Alliance and Client Involvement in Treatment for Child Anxiety in Community Settings

CLARIFYING THE DIRECTION OF EFFECTS BETWEEN ALLIANCE AND CLIENT INVOLVEMENT IN TREATMENT FOR CHILD ANXIETY IN COMMUNITY SETTINGS By Nadia Y. Islam, B.A. A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science at Virginia Commonwealth University. Virginia Commonwealth University, 2013 Major Director: Bryce D. McLeod, Ph.D. Associate Professor, Psychology Department Alliance and client involvement are thought to be important therapy process factors in child psychotherapy; however, few studies have investigated them over the course of treatment. The present study examined change in alliance, client involvement, and the relationship between the two over time in an effectiveness study comparing cognitive behavioral therapy (CBT) and usual clinical care (UC) for child anxiety disorders. The sample included 40 clinically-referred children (57.50%, female, mean age = 10.81, SD = 2.11, 35.00% Caucasian, 32.50% Latino/Hispanic, 5.00% African-American, 7.50% mixed ethnicity, 20.00% not reported) and 39 therapists employed by community clinics. Two doctoral-level students comprised the coding teams for each measure and independently rated alliance and client involvement in all available recorded sessions. Unconditional multilevel growth models indicated alliance and client involvement did not significantly change over time. Findings suggest that when measured by observational coders, initial levels of alliance and client involvement remain relatively stable throughout different treatments for child anxiety in community settings. Existing therapy process models may require further specification based on treatment setting and method of measurement. In practice, these findings suggest strategies to bolster initial alliance and client involvement could help improve the impact and delivery of child anxiety treatment in community settings. Clarifying the Direction of Effects between Alliance and Client Involvement in Treatment for Child Anxiety in Community Settings It is widely recognized that children in the United States need effective mental health care services. An estimated 10% to 20% of American children (approximately 15 million) meet criteria for a mental health disorder (Kataoka, Zhang, & Wells, 2002). Researchers have responded to this need with great energy by developing evidence-based treatments (EBTs); however, when transported to and delivered in community settings, effectiveness studies have shown that EBTs do not always outperform usual care (UC) (i.e., Barrington, Prior, Richardson, & Allen, 2005; Southam-Gerow et al., 2010). Given the mixed success rate in transporting treatments from research labs to community settings, there is still a great need for improving the delivery of mental healthcare treatments in communities. In the child psychotherapy field (hereafter the terms child and children will be used to refer to children and adolescents unless distinctions need to be made), the majority of research has focused on technical factors—the therapeutic interventions (e.g. in vivo exposures, cognitive restructuring) that are involved in treatment. Yet, there is still much to understand about the therapy process, what occurs between the therapist and client and how the client responds to treatment (Hill & Lambert, 2004; McLeod, Islam, & Wheat, 2013). Alliance and client involvement are two therapy process factors that may be of key importance in child psychotherapy. Alliance is commonly defined as the affective and collaborative relationship between the client and the therapist (Elvins & Green, 2008; Shirk & Saiz, 1992). Client involvement refers to the client’s level of participation in therapeutic tasks (e.g., initiating discussion, making treatment suggestions) during a therapy session (Chu & Kendall, 2004). Unfortunately, little research has investigated these factors in the child psychotherapy field.