Marc S. Karver

Prediction of treatment outcome from relationship variables in child and adolescent therapy: a meta-analytic review.

Results from 23 studies examining associations between therapeutic relationship variables and treatment outcomes in child and adolescent therapy were reviewed with meta-analytic procedures. Results indicated that the overall strength of the relationship-outcome associations was modest and quite similar to results obtained with adults. This modest association was moderated by 1 substantive factor, type of patient problem, and 5 methodological factors, timing and source of relationship measurement, type and source of outcome, and shared versus cross-source measurement of relationship and outcome variables. Type, mode, structure, and context of treatment did not moderate associations between relationship variables and outcomes. Findings indicated that the association between the therapeutic relationship and treatment outcome was consistent across developmental levels and across diverse types and contexts of child and adolescent therapy. Recommendations for future process research on the therapeutic relationship in child psychotherapy are offered.

The alliance in child and adolescent psychotherapy.

The therapeutic alliance has a long history in the child and adolescent psychotherapy literature. This article examines prominent views on the alliance with youth and considers a number of issues that distinguish youth alliance from its adult counterpart. A meta-analysis of alliance-outcome associations in individual youth therapy is presented. In order to provide a direct comparison with the adult literature, the review included only prospective studies of individual youth therapy that used an explicit measure of alliance. Results from 16 studies revealed consistency with the adult literature with a weighted mean correlation of .22 (k = 16, n = 1306, p < .001) between alliance and outcome (CI = +/-.06). Although there were trends showing stronger alliance-outcome associations for child versus adolescent therapy and for behavioral versus nonbehavioral therapies, only problem type (substance abuse and mixed problems vs. eating disorders) significantly moderated alliance-outcome associations. Limitations of the research and implications for therapeutic practice are discussed.

Relationship Processes in Youth Psychotherapy: Measuring Alliance, Alliance-Building Behaviors, and Client Involvement

This study explores hypothesized associations among therapist engagement strategies, therapeutic alliance, client involvement, and treatment outcome in a randomized clinical trial comparing cognitive behavioral psychotherapy and nondirective supportive psychotherapy for adolescents with depressive symptoms who have attempted suicide. Ratings from audiotapes and self-report of the first four sessions for 23 adolescent clients were used. It was expected that therapeutic relationship variables would be equally important in both treatments. However, preliminary evidence appeared to be emerging only for therapeutic alliance and client involvement being related to treatment outcome in the cognitive behavioral treatment. Therapist lapse behaviors were found to predict alliance across both treatments. On the other hand, there was some preliminary evidence for different therapist behaviors to be related to the therapeutic alliance in each treatment. Results suggest that there may be variation in effective relationship factors, depending on the specific therapeutic approach.

Multiple informants in the assessment of psychological, behavioral, and academic correlates of bullying and victimization in middle school

The present study assessed agreement between student self-report and teacher ratings of bullying and victimization relative to psychological, behavioral, and academic correlates. Middle school students (N=1442) and teachers completed surveys evaluating peer relationships and psychosocial adjustment. Analyses of variance and logistic regressions were used to examine rater agreement on bullying/victimization and adjustment among groups (bullies, victims, bully/victims, and uninvolved) identified by rater (student self-report only, teacher-report only, concordant reports, and controversial reports). Concordant and controversial groups had among the greatest psychosocial and academic difficulties. Student learning difficulties and moodiness interacted with teacher reports of bullying and victimization, respectively, with agreement between teacher and student self reports of bullying greater at higher levels of learning problems and agreement for victimization lower at higher levels of moodiness. The results indicate biases in rater perspective of student behavior and continue to support the need for multiple raters of student functioning.

The relationship between change in therapeutic alliance ratings and improvement in youth symptom severity: Whose ratings matter the most?

This paper presents the psychometric evaluation of brief measures of therapeutic alliance (TA) for youths, clinicians and caregivers and a longitudinal analysis of relationships between changes in TA and changes in youth symptom and functioning severity. Psychometric analyses using methods from Classical Test Theory, Item Response Theory, and Factor Analysis indicate that the measures of TA used in this study offer something new for both practice and research. The measures have variability, sensitivity to change over time, brevity and can be used with multiple parties through parallel forms. The longitudinal analyses, employing hierarchical linear modeling with time-varying covariates, found that TA ratings of the clinician correlated with symptom improvement as rated by the clinician, caregiver and youth. Additional analyses showed that decreases in clinician-rated youth TA was most important in predicting a lower rate of youth improvement. Implications for future research and clinical practice are discussed.

Therapeutic Alliance With Depressed Adolescents: Predictor or Outcome? Disentangling Temporal Confounds to Understand Early Improvement

Psychotherapy research reveals consistent associations between therapeutic alliance and treatment outcomes in the youth literature; however, past research frequently suffered measurement issues that obscured temporal relationships between alliance and symptomatology by measuring variables later in therapy, thereby precluding examination of important early changes. The current study aimed to explore the directions of effect between alliance and outcome early in therapy with adolescents by examining associations between first- and fourth-session therapeutic alliance and symptomatology. Thirty-four adolescents (∼63% female, 38% ethnic/racial minority) participated in a school-based cognitive-behavioral therapy for adolescents with depression. Participants completed the Beck Depression Inventory at baseline and Session 4, and therapeutic alliance was coded from audiotapes of Sessions 1 and 4 by objective coders using the Alliance Observation Coding System. Autoregressive path analyses determined that first-session therapeutic alliance was a strong significant predictor of Session 4 depression symptoms, but pretreatment depression scores were not significantly predictive of subsequent therapeutic alliance. Adding reciprocal effects between alliance and depression scores did not adversely affect model fit, suggesting that reciprocal effects may exist. Early therapeutic alliance with adolescents is critical to fostering early gains in depressive symptomatology. Knowing alliances subsequent effect on youth outcomes, clinicians should increase effort to foster a strong relationship in early sessions and additional research should be conducted on the reciprocal effects of therapeutic alliance and treatment outcome in adolescence.

Linking insomnia and suicide ideation in college females: The role of socio-cognitive variables and depressive symptoms in suicide risk.

BACKGROUND Although insomnia symptoms are associated with risk of suicide ideation, the means by which insomnia influences ideation, as well as the role depression plays in these relationships, require further study. In this study, we examined whether certain socio-cognitive variables (fatigue, social problem-solving, and hopelessness) in conjunction with depression explained this relationship among female college students. METHODS 483 female students completed measures assessing insomnia and depressive symptoms, fatigue, social problem-solving ability, hopelessness, and suicide ideation. RESULTS Path analyses indicated that socio-cognitive variables partially explained the insomnia-ideation relationship above the influence of depressive symptoms. Higher depressive symptoms exacerbated relationships between social problem-solving and hopelessness, heightening ideation risk. CONCLUSIONS Our findings expand knowledge of intermediate socio-cognitive variables that may contribute to the insomnia-ideation relationship, and indicate that clinically-severe depressive symptoms compound the contribution of negative self and future appraisals to thoughts of suicide. Suicidal females with insomnia and depressive symptoms may benefit from interventions targeting problem-solving skills and improving sleep.

The Relationship of Perceived Campus Culture to Mental Health Help-Seeking Intentions.

Despite mental health issues being widespread on college campuses, the majority of college students do not seek help. Prior research suggests several individual factors that may be related to mental health help-seeking including age, gender, and prior treatment experience. However, there has been little work considering the broader role of the college environment on person-level predictors of mental health help-seeking, specifically the relationship with perceived campus culture. Thus, informed by the theory of planned behavior (Ajzen, 1991), the purpose of this study was to examine the relationship between perceived campus cultural perspectives on different personal processes, such as attitudes toward treatment, stigma, and treatment barriers that are believed to relate to mental health help-seeking intentions. Participants were 212 undergraduate students from a large university in the southeastern United States. As hypothesized, we found a significant mediation relationship for personal attitudes in the relationship between perceived campus attitudes and help-seeking intentions. In contrast, analyses did not support mediation relationships for personal barriers or personal stigma. These findings suggest that perceived campus culture may serve an important role in personal mental health treatment beliefs. Campus mental health policies and prevention programming may consider targeting perceived campus culture as an important means for increasing personal positive beliefs toward mental health treatment. (PsycINFO Database Record

The acceptability of treatments for depression to a community sample of adolescent girls.

An efficacious treatment is diminished in value if consumers do not seek it out and adhere to it, making treatment acceptability an important predictor of the effectiveness of treatment. This study examined the acceptability of treatments for depression to 67 female high school students. All participants read a vignette describing a depressed adolescent and rated the acceptability of four single treatments for depression (cognitive-behavioral therapy, interpersonal therapy, family therapy, and pharmacotherapy) and three treatment combinations. Psychotherapy approaches were generally more acceptable to adolescents than combinations of psychotherapy and pharmacotherapy; and, pharmacotherapy used alone was not acceptable. For interpersonal therapy and family therapy only, treatment acceptability was related to perceived causes of depression. Across all treatments, acceptability was not associated with symptom severity. Implications for increasing the utilization of mental health services in this population are discussed.

Limited Motivation, Patient-Therapist Mismatch, and the Therapeutic Alliance

While empirically supported treatments have made great headway for patients with anxiety disorders, many barriers continue to exist in order for patients to experience symptom remission. In this chapter, we consider the roles of patient motivation for change, patient-therapist mismatch, and the therapeutic alliance as understudied factors that can be used to enhance outcomes. While these factors are often portrayed as in conflict with or as obviating the use for structured interventions, we display how these approaches can be used in tandem to enhance the efficacy of existing interventions.