The role of setting versus treatment type in alliance within youth therapy.

Efforts to disseminate and implement evidence-based treatments (EBTs) for youth face a number of challenges. Some have raised concerns that certain characteristics of EBTs (Addis & Krasnow, 2000; Nelson, Steele, & Mize, 2006) and/or community-based service settings (e.g., organizational climate, productivity demands; Glisson et al., 2008; Green, Albanese, Cafri, & Aarons, 2014) may serve to weaken the youth-therapist alliance. If certain characteristics of EBTs and/or settings interfere with the alliance, this could reduce the appeal of EBTs for both clinicians and their clients and thus represent a potential barrier to expanding use of EBTs in community-based service settings. Determining if certain characteristics interfere with the alliance represents an important goal for the field because the alliance may be particularly important in youth therapy, as youth rarely self-refer (Karver, Handelsman, Fields, & Bickman, 2005). Indeed, a therapist’s ability to develop an alliance with a youth—one that is marked by positive affect and participation in therapeutic activities—is considered to be an important ingredient of therapy (Chu et al., 2004; Elvins & Green, 2008). A strong youth-therapist alliance (hereafter called the alliance) is associated with positive outcomes, such as reduced symptomatology and treatment attendance, across different problem types and treatments (McLeod, 2011; Shirk, Karver, & Brown, 2011). Thus, understanding factors that may influence alliance in youth therapy represents an important research objective. Some have argued that manual-guided EBTs may interfere with alliance formation (Addis & Krasnow, 2000; Nelson et al., 2006) due to a lack of flexibility to address individual client needs (e.g., Henry, Strupp, Butler, Schact, & Binder, 1993; Pagoto et al., 2007). To our knowledge, only two previous studies have addressed this issue related to youth therapy. Langer, McLeod, and Weisz (2011) compared the quality of the alliance in manual-guided EBTs and non-manualized treatment delivered to 76 youth in community-based service settings (herein called practice settings).1 Early in treatment the alliance was significantly higher in manual-guided treatment, but the two groups converged over time. Ormhaug, Jensen, Wentzel-Larsen, and Shirk (2014) compared the quality of the youth-rated alliance in a manual-guided EBT and a non-manualized treatment delivered to 156 traumatized youth in practice settings. There were no significant differences in the youth-rated alliance between the treatments at session 1 or 6. These findings suggest that the quality of the alliance may not differ significantly across manual-guided and non-manualized treatment in practice settings. However, both studies lacked some important methodological elements that could help address key alternative explanations; for example, the studies did not include a control for treatment setting. The alliance may also differ when an EBT is delivered in practice settings, rather than university-based research clinics (herein called research settings). A case could be made that alliance might be stronger in research settings. Therapists in research settings are often given time to prepare for sessions, which could focus on alliance building activities. Moreover, youth may be more motivated to participate and form an alliance given that families often seek out the brand of therapy provided in specialty research settings. By contrast, therapists in practice settings work under productivity requirements that may leave little time to prepare for sessions (Gray, Elhai, & Schmidt, 2007; Nelson et al., 2006) and may face other challenges (e.g., the need to take cases on rotation rather than focus on youth who fit the therapists’ skills best) that could interfere with alliance building (Weisz & Addis, 2006). The greater youth demographic and clinical diversity seen in practice settings (Ehrenreich et al., 2011; Southam-Gerow, Chorpita, Miller, & Gleacher, 2008) may also negatively impact the alliance. However, it is also plausible that the alliance may be higher in practice settings. In practice settings, the importance that therapists place on the alliance (Addis & Krasnow, 2000; Nelson et al., 2006) may lead them to emphasize alliance building activities over other elements of treatment delivery. Conversely, therapists in research settings may focus on delivering the components of the EBT (i.e., achieving high treatment adherence) to the detriment of the alliance. Although it is plausible that setting may influence alliance, empirical tests are lacking. If there were a difference in the alliance across settings, this could serve as a focus for quality improvement efforts. We thus investigated whether the alliance differs when the same manualized EBT is delivered across research and practice settings. To adequately address questions about alliance requires careful consideration of measurement options. Two broad strategies for alliance assessment warrant attention: self- and observer-report. Each method has certain advantages and both methods are used in the present study. Self-reports provide valuable data on the treated youth’s subjective perceptions of the alliance (Elvins & Green, 2008; Shirk & Saiz, 1992). Because a significant proportion of the research examining alliance has used self-report measures (see McLeod, 2011), including such instruments supports comparisons with existing literature. Accordingly, in the present study, we examined alliance at post-treatment using the Therapeutic Alliance Scale for Children (TASC; Shirk & Saiz, 1992), the most widely-used and thoroughly studied youth-report instrument of alliance (see Accurso, Hawley, & Garland, 2013; McLeod, 2011). Observer-rated methods also provide advantages. Observer-rated alliance instruments are not subject to youth’s varying ability to report on the alliance relationship (Shirk & Karver, 2003). Observer-rated data also avoid the confounding effects of demand characteristics (pressure to say nice things about a therapist) that can complicate interpretation of findings (Shirk & Karver, 2003; Shirk & Russell, 1998) and contribute to ceiling effects (Chu et al., 2004). In the present study we used the Therapy Process Observational Coding System for Child Psychotherapy – Alliance Scale (TPOCS-A; McLeod & Weisz, 2005), a widely researched, observer-rated instrument of alliance (see Fjermestad et al., 2012; McLeod, 2011). Another important issue in alliance assessment is timing of measurement within the treatment episode. It is useful to assess alliance early in treatment to avoid potential confounding with symptom improvement (Kazdin, 2007). It is also useful to assess alliance at multiple time points, as research suggests that the alliance may shift over the course of therapy (e.g., Chu, Skriner, & Zandberg, 2014; Hudson et al., 2014; Kendall et al., 2009). Kendall et al. (2009), for example, found that in family-focused CBT for youth anxiety, the therapist-, youth-, mother-, and father-rated alliance gradually increased and then leveled off. More recently, Chu and colleagues (2014) found that in individual CBT (ICBT) for youth anxiety, therapist-report alliance increased and then leveled off, but youth-report alliance was stable over the course of treatment. Interestingly, a different pattern has been found for observer-rated instruments. Hudson and colleagues (2014) found that in ICBT for youth anxiety, observer-rated alliance showed a slight downward slope. Given the emerging evidence that alliance may change over treatment, it seems important to assess whether differences in the alliance exist over time across treatments and settings. We evaluated the quality of the alliance with youth diagnosed with anxiety disorders who received the same manualized EBT (i.e., Coping Cat for youth diagnosed with anxiety disorders; Kendall & Hedtke, 2006a, 2006b) in research or practice settings, or non-manualized UC. In the research setting, youth were referred to an efficacy trial and treated by research therapists. Youth in the practice settings were clinically-referred and treated by therapists employed by the clinics; therapists volunteered to participate in the effectiveness trial and were randomly assigned to the EBT or UC group. Given limited prior literature in this area and competing theories about the impact of manuals on alliance, we tested two competing hypotheses. First, we tested the hypothesis that the alliance would be significantly higher in manual-guided ICBT than non-manualized UC due to the structure and focus provided by the ICBT program. Second, we tested the hypothesis that the alliance would be significantly higher in non-manualized UC than manual-guided ICBT due to the client-centered nature of UC. Because no prior published report has examined whether the alliance differs when an EBT is delivered in a research and practice setting, we offer no a priori hypothesis about the EBT delivered in the research setting.