Stephen R. Shirk

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.

Subtypes of Rumination in Adolescence: Associations Between Brooding, Reflection, Depressive Symptoms, and Coping

Prior research has indicated that rumination contributes to the maintenance or intensification of depressive symptoms among adults. This study examined associations between rumination and depressive symptoms in early adolescence. Using a short-term longitudinal design, we evaluated relations between subtypes of rumination and both depressive symptoms and coping among a community sample of 168 adolescents (70 boys, 98 girls, age M = 13.58). Results provided support for brooding and self-reflective subtypes of rumination. Brooding, but not reflection, predicted the development of depressive symptoms over time, particularly for girls. Brooding was related to maladaptive disengagement coping strategies, whereas reflection was related to adaptive primary and secondary coping strategies. These results suggest that not all types of self-focus on emotion contribute to the maintenance or intensification of depressive symptoms.

Clinical, empirical, and developmental perspectives on the therapeutic relationship in child psychotherapy

Despite substantial interest in the therapeutic relationship by child clinicians, relationship processes in child therapy have been neglected by clinical researchers. In this paper, clinical and empirical perspectives on the therapeutic relationship in child treatment were reviewed. Initial findings indicated that the quality of the childs affective relationship with the therapist is associated with collaboration on therapy tasks. Given the recurrent finding of links between treatment collaboration and treatment outcome, research on factors that influence childrens ability to form therapeutic relationships is recommended. To this end, a developmental social cognitive model of therapeutic alliance formation is proposed.

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.

The Children's Global Assessment Scale in Clinical Practice: An Empirical Evaluation

OBJECTIVE The purpose of this study was to examine characteristics of the Childrens Global Assessment Scale (CGAS) in the context of clinical practice. METHOD Ninety-five children admitted to a psychiatric inpatient unit were rated by their attending psychiatrist and by milieu staff on the CGAS. Measures of severity and type of symptomatology; social, behavioral, and school competence; intellectual level; social relatedness; and family stress were completed by parents and staff raters. RESULTS Results indicated that there was significant convergence in CGAS ratings by independent raters. CGAS ratings were unrelated to measures of symptomatology but were significantly related to indices of childrens competence. CONCLUSIONS This pattern of results diverged from findings from highly controlled research settings and indicated that CGAS ratings obtained in clinical contexts may reflect evaluations of functional competence rather than severity of symptomatology.

Alliance formation and treatment outcome among maltreated adolescents

This study examined relationships among maltreatment experience, therapeutic alliance formation, and treatment outcome in a sample of 38 psychiatrically hospitalized adolescents. It was hypothesized that the experience of maltreatment would interfere with alliance formation, thereby compromising the effectiveness of therapy. Results indicated that maltreatment, multiplicity of maltreatment, and type of perpetrator of maltreatment were all associated with initial alliance difficulties. None of these variables predicted change in the alliance over time; instead, severity of interpersonal problems was the best predictor of alliance development. Maltreatment status was not directly related to treatment outcome; however, maltreated adolescents who failed to develop positive alliances with their therapists tended to show the poorest outcomes. Given the strong relationship between alliance formation and outcome, clinical recommendations for therapists who treat maltreated adolescents are presented.

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.

Alliance and outcome in cognitive-behavioral therapy for adolescent depression

This study examined predictive relations between therapeutic alliance and treatment outcomes in manual-guided, cognitive-behavioral therapy for adolescent depression. Fifty-four adolescents met criteria for a depressive disorder and were treated in school-based clinics. Alliance was measured after the third session from both therapist and adolescent perspectives, and change in depressive symptoms was assessed by structured interview and self-report. Two models of alliance–outcome relations were assessed, one direct and one through treatment participation. Results showed significant associations between adolescent-reported alliance and change in depressive symptoms, even after controlling for number of sessions completed. Therapist-reported alliance was only marginally related to outcomes but was predictive of number of sessions completed. On average, alliance showed a modest relation with outcomes (r = .26). Results are discussed in the context of differential alliance–outcome relations in prior studies of cognitive-behavioral compared to nonbehavioral therapy with children and adolescents.

School-Based Cognitive-Behavioral Therapy for Adolescent Depression

The current study evaluated cognitive-behavioral therapy (CBT) for adolescent depression delivered in health clinics and counseling centers in four high schools. Outcomes were benchmarked to results from prior efficacy trials. Fifty adolescents diagnosed with depressive disorders were treated by eight doctoral-level psychologists who followed a manual-guided, 12-session, individual CBT protocol. Referred adolescents presented with high rates of comorbidity, traumatic experiences, and prior suicide attempts. Posttreatment response to school-based CBT (64%) was comparable to results obtained in efficacy trials. On average, symptom reduction in this school-based study was similar to prior efficacy trials, exceeded results from an efficacy trial using the original manual, and exceeded results from a prior school-based CBT trial. Examination of predictors of symptom change and treatment response showed that life stress, trauma history, and depressive symptom severity were negatively associated with outcomes. Results suggest that school-based CBT is a relatively robust treatment for adolescent depression across gender, age, and ethnic groups as well as for adolescents with varied patterns of comorbidity.

Positive Affect Stimulation and Sustainment (PASS) Module for Depressed Mood: A preliminary investigation of treatment-related effects.

Positive affective functioning (PAF) is critical to the development, course and treatment of depressive symptoms. Targeting key features of PAF during treatment may provide a new angle through which to improve affective functioning and reduce symptoms. The current study was a treatment development trial for the Positive Affect Stimulation and Sustainment (PASS) Module. PASS is conceptualized as a means of capitalizing on positive events (e.g., planned through behavioral activation) by enhancing and sustaining positive affective states through savoring, and establishing positive attributions and expectancies. Participants were 27 female college students with dysphoric symptoms. There was a moderate effect of PASS on depressive symptoms. There was also a significant within session increase in positive affect from pre to post session among the PASS group, relative to active control; and a significant decrease in positive affect from pre (baseline) to post (follow-up) treatment among the control group, relative to PASS. Results provide preliminary evidence for the efficacy of the treatment module among young adults with depressed mood, and lay the foundation for future research.