Clinician-Client Alignment and Collaboration in Youth Psychotherapy

Abstract

Despite considerable progress in youth mental health research, experts have continued to call for efforts to enhance the effectiveness and acceptability of youth psychotherapy. These efforts may be enhanced by examinations of methods, such as shared decision-making (SDM), that are designed to increase clinician-client alignment and collaboration in youth psychotherapy. Transdiagnostic youth psychotherapies, such as the Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH), may be particularly strong candidates for these methods, as they involve complex decision-making processes that can influence treatment plans and outcomes. To this end, this dissertation includes a collection of studies that are positioned to advance our understanding of the role of clinician-client alignment and collaboration in youth psychotherapy, with a focus on MATCH. In the first study, I explored SDM as a tool for navigating caregiver-youth-clinician discrepancies in the selection of youth psychotherapy targets, which can serve as a barrier to clinical decision-making, as well as building inclusive transdiagnostic treatment plans that integrate the unique perspectives of clinicians, caregivers, and youths. In the second study, I extended this focus on clinician-client alignment in the selection of youth psychotherapy targets to clinician-client alignment in the selection of an initial MATCH treatment protocol. Specifically, I examined measure-based clinician-client alignment—that is, the extent to which a clinician selected a treatment option that aligned with the “best-fit” for a given youth client, based on the information shared by the youth and their caregiver in surveys—as a predictor of caregiver-reported and youth-reported severity ratings of youth symptoms and psychotherapy top problems across treatment. Overall, improvements in these outcomes were found to be greater when the clinician-selected MATCH protocol aligned with the best-fit protocol of at least one of the clients (i.e., caregiver client and/or youth client), compared to when the clinician-selected MATCH protocol did not align with the best-fit protocol of either client. Finally, in the third study, I complemented this work on measure-based clinician-client alignment with that focusing on a second form of clinician-client alignment in youth psychotherapy: interaction-based. Specifically, I examined interaction-based clinician-client alignment and collaboration—that is, the extent to which a clinician includes clients in decision-making processes during sessions—within the context of MATCH. First, I conducted a comprehensive scoping review of measures designed to capture SDM elements in healthcare and used this information to develop, apply, evaluate, and extract preliminary data from an observational coding system of interaction-based clinician-client collaboration in 222 audio-recorded MATCH sessions. Trained coders were found to achieve high levels of interrater reliability, and we identified challenges in assessing the construct validity of this measure. Overall, clinicians were observed to use at least one SDM element in most sessions with both youth and caregiver clients but to a minimal level. Additionally, clinicians were found to apply SDM elements to a greater extent with caregiver, compared to youth, clients, despite more frequently using SDM elements with youth, relative to caregiver, clients. Taken together, this work is positioned to advance our understanding of how clinicians approach decision-making in youth psychotherapy, as well as how clinicians can leverage multiple forms of clinician-client alignment and collaboration to cultivate more inclusive and responsive approaches to care. This collection of studies has the potential to inform future research, such as that examining the extent to which clinician use of SDM may impact youth psychotherapy outcomes and the potential therapeutic benefits of SDM-focused training for clinicians.Psycholog