Evidence-based psychotherapy relationships: The alliance in child and adolescent psychotherapy
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This entry is our analysis of a review or synthesis of research findings added to the Effectiveness Bank. The original review was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. The summary conveys the findings and views expressed in the review. Below is a commentary from Drug and Alcohol Findings.

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Evidence-based psychotherapy relationships: The alliance in child and adolescent psychotherapy.

Shirk S.R., Karver M.S., Brown R.
Psychotherapy: 2011, 48(1), p. 17–24.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Shirk at sshirk@du.edu. You could also try this alternative source.

This meta-analytic review commissioned by the American Psychological Association finds that the relationship between therapist and young clients matters about as much as for adults. Practice recommendations will aid counsellors, therapists and mental health teams dealing with young substance users.

Summary Updated in 2018. See Effectiveness Bank analysis.

[Though not specific to patients with drug and alcohol problems, studies in the analyses described included such patients, and the principles are likely to be applicable to these disorders among others, not least because substance use problems generally form part of a complex of broader psychosocial problems.]

This review is one of several in a special issue of the journal Psychotherapy devoted to evidence-based, effective therapist-client relationships. It reports on a research synthesis of the links between outcomes of individual psychotherapy for children under 18 and/or their parents, and the alliance between therapist and client or parent. In child therapy 'alliance' was first seen as an emotional attachment between the young person and the therapist which enables the child to work purposefully on the tasks of therapy – the active ingredients in the outcomes. In other formulations, the alliance itself is seen as the active ingredient. Both perspectives have been criticised for omitting another dimension – the degree to which client and therapist agree on treatment goals and methods, an agreement complicated by the fact that children are generally 'sent' to therapy rather than electing to go. At present it is not clear if agreement between therapist and parent, or between therapist and child, is a better predictor of treatment outcome. A strong alliance with parents may be important for treatment continuation, whereas the youth alliance may be more critical for treatment outcomes.

The review incorporated meta-analyses A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. synthesising results from relevant studies to provide estimates of the overall strength of the link between outcomes and alliance, and to be able to probe for influences on the strength of that link. Strength is expressed as effect sizes A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. By convention, in the behavioural sciences an effect size of the type used in the featured analyses is considered a small effect at 0.10, a medium effect at 0.30, and a large effect at 0.50. using the 'r' metric, which can be squared to calculate how much of the difference in outcomes can be attributed to differences in the therapy dimension being investigated. The assumption was made that there is no single, true strength of the link between outcomes and alliance which appears to vary only because of methodological differences, but that instead the strength really might vary across the studies included in the analysis.

Only English-language studies with at least 10 participants were included and then only if they measured alliance before the outcomes in question and followed up the clients to assess the relationship between the two. Sixteen such studies were found involving 658 young clients and 648 parents. All but two assessed alliance between therapist and the young client and six assessed it with the parent.

Main findings

Overall the strength of the link between alliance and outcomes equated to an effect size of 0.22, a statistically significant link representing a moderate relationship which accounts for about 5% of the variance in outcomes, not very different from among adults. In other words, the more solid the working relationship or bond between therapist and client, the better the outcomes. Alliance is an important predictor of youth therapy outcomes and may very well be an essential ingredient that makes diverse child and adolescent therapies work.

However, effect size varied substantially across the studies. Possible reasons for this variation were explored by dividing the studies in to different categories based on problem area, category of client, and type of therapy, but there were so few studies in each category that the variations in effect size rarely met criteria for statistical significance. At a non-significant 0.1, the alliance-outcome correlation was lower across the three studies with substance abuse clients than it was in other youth problem areas (primarily internalising problems). It is not clear if this result reflects unique difficulties with alliance assessment with substance abusing teens, or accurately reflects the limited contribution of the alliance to outcomes with these clients.

Practice recommendations

The alliance is an important influence on child and adolescent therapy outcomes and a good alliance may be an essential ingredient in making diverse therapies work.

Alliances with young clients and their parents predict treatment outcomes, so therapists need to attend to both. A solid alliance with the parent may be particularly important for treatment continuation.

Parents and children often differ about treatment objectives. Forming a therapeutic alliance with both requires the therapist to attend to several perspectives and develop a treatment plan to accommodate child and parent perspectives.

Maintenance of a positive alliance not just early but throughout treatment predicts good outcomes. Therapists are advised to monitor and foster alliances throughout treatment.

Youngsters often have little understanding of therapy. Early alliance formation requires the therapist to balance active listening with providing an explicit framework for understanding therapy. Too much of the latter appears to interfere with alliance formation with adolescents.

Findings logo commentary This article was in a special issue of the journal Psychotherapy devoted to effective therapist-client relationships. For other Findings entries from this issue see:
Evidence-based psychotherapy relationships: Psychotherapy relationships that work II
Evidence-based psychotherapy relationships: Alliance in individual psychotherapy
Evidence-based psychotherapy relationships: Alliance in couple and family therapy
Evidence-based psychotherapy relationships: Cohesion in group therapy
Evidence-based psychotherapy relationships: Empathy
Evidence-based psychotherapy relationships: Goal consensus and collaboration
Evidence-based psychotherapy relationships: Positive regard
Evidence-based psychotherapy relationships: Congruence/genuineness
Evidence-based psychotherapy relationships: Collecting client feedback
Evidence-based psychotherapy relationships: Repairing alliance ruptures
Evidence-based psychotherapy relationships: Managing countertransference
Evidence-based psychotherapy relationships: Research conclusions and clinical practices

The special issue which contained the article featured above was the second from the task force. The first was a special issue of the Journal of Clinical Psychology. While the second aimed to identify elements of effective therapist-client relationships ('What works in general'), the first aimed to identify effective ways of adapting or tailoring psychotherapy to the individual patient ('What works in particular'). For Findings entries from this first special issue see this bulletin. Both bodies of work have also been summarised in this freely available document from the US government's registry of evidence-based mental health and substance abuse interventions.

Last revised 26 May 2011. First uploaded

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