The therapeutic alliance in psychotherapy for adolescent depression: Differences between treatment types and change over time

Although the alliance is usually considered a generic factor common to all therapies, there are theoretical reasons to suspect that it may develop differently in different types of therapies. Yet, in youth psychotherapy, little is known about this issue to date. This study investigated whether the mean strength of the alliance, as well as its trajectory over time, differed between three equally effective psychological treatments for adolescent depression. Data were drawn from the IMPACT study, a randomized controlled trial comparing cognitive-behavioral therapy (CBT) and short-term psychoanalytic psychotherapy (STPP) versus a brief psychosocial intervention (BPI) in the treatment of adolescent depression. Adolescents’ (N = 338) and therapists’ (n = 159) ratings of the alliance were collected using the Working Alliance Inventory short form at 6, 12, and 36 weeks after randomization. Data were analyzed using multilevel linear models. Results showed that adolescents’ and therapists’ mean alliance ratings differed between treatment types, being highest in CBT and lowest in the STPP at all time points. Mean therapists’ alliance ratings increased slightly over time in all arms, while mean adolescents’ ratings were stable over time in CBT and BPI but slightly increased in the STPP group. These findings suggest that the mean strength of the alliance differs between treatment type, and future research is required to pinpoint what factors contribute to these differences and their relationship with treatment outcomes

Categorical and dimensional approaches in the evaluation of the relationship between attachment and personality disorders: An empirical study

Although several studies have highlighted the relationship between attachment states of mind and personality disorders (PD), their findings have not been consistent, possibly due to the application of the traditional taxonomic classification model of attachment. A more recently developed dimensional classification of attachment representations, including more specific aspects of trauma-related representations, may have advantages. In this study we compare specific associations and predictive power of the categorical attachment and dimensional models applied to 230 Adult Attachment Interview transcripts obtained from personality disordered and non-psychiatric subjects. We also investigate the role that current levels of psychiatric distress may have in the prediction of PD. The results showed that both models predict the presence of PD, with the dimensional approach doing better in discriminating overall diagnosis of PD. However, both models are less helpful in discriminating specific PD diagnostic subtypes. Current psychiatric distress was found to be the most consistent predictor of PD capturing a large share of the variance and obscuring the role played by attachment variables. The results suggest that attachment parameters correlate with the presence of PD alone and has no specific associations with particular PD subtypes when current psychiatric distress is taken into account

A qualitative analysis of goals set by foster carers seeking support for their child’s emotional well-being

The needs of foster carers are complex as children in their care often present with complex emotional and behavioural difficulties. Previous studies have examined foster carers’ perceptions of the unmet needs of the children in their care but there is a lack of knowledge regarding carers’ own goals when seeking professional help. The present study seeks to fill this gap by examining the goals that carers who are looking after children with emotional and/or behavioural difficulties set at the start of an intervention, the Reflective Fostering Programme, designed to support them. Twenty-six foster carers were asked to complete a Goal-Based Outcome Measure (GBOM) before starting the programme. Qualitative content analysis revealed five main categories of goals. Three were child focused (child’s relationships, challenging behaviours and emotions) and two were foster carer focused (personal goals and goals related to participating in the programme). By understanding the types of goals meaningful to foster carers, interventions can be developed to better target their specific needs and allow outcome measures to be more closely aligned to their goals. Results are discussed in terms of implications for the development and evaluation of interventions to support foster carers and the children they look after

The alliance–outcome association in the treatment of adolescent depression

A growing body of research has consistently demonstrated a relationship between alliance and treatment outcomes in youth psychotherapy. However, past research often suffered methodological issues that prevented detailed investigation of temporal relationships between alliance and symptomatology. The current study explored the directions of effect between alliance and outcome by examining the associations between early alliance and subsequent outcome while controlling for patients’ baseline severity and prior symptom change. It also examined potential moderators of this association. Data were drawn from the IMPACT study, a randomized controlled trial comparing cognitive-behavioural therapy (CBT) and short-term psychoanalytic psychotherapy (STPP) versus a brief psychosocial intervention (BPI) in the treatment of adolescent depression. Adolescents (N=224) and therapist (n=139) rated the alliance 6 weeks after randomization. Depression severity and overall psychopathology were assessed at baseline, 6, 12, 36, 52 and 86 weeks after randomization. Patients’ age, gender, baseline depression severity, conduct disorder symptoms and treatment type were examined as potential moderators of the alliance-outcome association. Data were analysed using multilevel models. Findings suggested that higher early alliance ratings were associated with subsequent symptom reduction, even after controlling for prior symptom change and baseline severity. There was evidence that the strength of this association was strongest in CBT patients, weaker in STPP, and statistically indistinguishable from zero in BPI. These findings suggest that early therapeutic alliance with adolescents may influence subsequent outcome independent of prior symptom change and initial severity but that the effect of the alliance on outcome might vary across treatment types

The factor structure of the Working Alliance Inventory Short-form in youth psychotherapy: an empirical investigation

Objective: The Working Alliance Inventory short form (WAI-S) is one of the most commonly used alliance measures with adolescents. Yet, its factor structure has received minimal attention in the youth alliance literature. This study investigated the factor structure of the WAI-S in psychotherapy for adolescent depression and explored its measurement invariance across time, therapeutic approaches and patients’ and therapists’ perspectives. The existence of method effects associated with the negatively worded items of the scale was also assessed. Method: The setting of this study is the IMPACT trial, a randomised controlled trial assessing the effects of three therapeutic interventions in the treatment of adolescent depression. The WAI-S was completed at 6, 12 and 36 weeks after randomisation by 338 adolescents and 159 therapists. Data were analysed using confirmatory factor analysis. Results: The hypothesised Bond-Task-Goal alliance structure was not supported and a general, one-factor model was found to be more psychometrically valid. The existence of a method effect and measurement invariance across time and treatment arms were also found. Conclusions: While the distinction between the specific alliance dimensions is conceptually and clinically interesting, at an empirical level the alliance features of the WAI-S in youth psychotherapy remain strongly intercorrelated

Four years comparative follow-up evaluation of community-based, step-down, and residential specialist psychodynamic programmes for personality disorders

Although the fulcrum of service provision for personality disorder (PD) has shifted from hospital-based to psychodynamically- and cognitively-oriented outpatient programmes, very few studies have attempted to compare specialist moderate intensity outpatient programmes with specialist high-intensity residential models, or to explore whether a period of inpatient treatment may be necessary to improve outcome and prognosis. In this article, we prospectively compare changes over a 4-year period in 3 groups of patients with personality disorders (N = 162) treated in a specialist community-based (CBP, N = 30), a step-down (RT-CBP, N = 87), and a specialist residential programme (RT, N = 45) in psychiatric distress, deliberate self-injury, and suicide attempt using multilevel modelling and multivariate logistic regression analyses. The results showed that percentages of early-dropout were significantly different (p = .0001) for the 3 programmes (CBP = 13.4%, RT-CBP = 10.2%, and RT = 41.4%). A significant interaction between treatment model and time was found for psychiatric distress (p = .001), with CBP and RT-CBP achieving more marked changes (g = 1.20 and g = 0.68, respectively) compared to RT (g = 0.30) at 48-month follow-up. CBP and RT-CBP were found to significantly reduce impulsive behaviour (deliberate self-injury and suicide attempt) compared to RT. Severity of presentation was not found to be a significant predictor of outcome. Long-term RT showed no advantage over long-term CBP, either as stand-alone or as step-down treatment. Replication may be needed to confirm generalizability of results, and a number of limitations in the study design may moderate the inferences that can be drawn from the results

Assessing changes in the internal worlds of early- and late-adopted children using the Story Stem Assessment Profile (SSAP)

A growing body of literature has consistently shown how adopted children often have previous history of trauma and neglect, and in turn develop negative representations of the self and others. This study assesses the internal representations of three groups of children, as measured by the Story Stem Assessment Profile (SSAP). These were: (1) a maltreated, late-adopted (MLA) sample (n = 63); (2) a non-maltreated, early-adopted (EA) sample (n = 48); and (3) a non-maltreated community sample (COMM) (n = 80). In addition, it examined whether MLA and EA adopted children’s attachment and internal representations changed over time. Results showed that children in the MLA sample significantly displayed more disorganised, avoidant and negative representations and fewer representations characteristic of ‘secure’ attachment when compared with EA and, especially, COMM children. Longitudinal follow-up of both MLA and EA samples demonstrated significant changes over a two-year period in SSAP representation; secure representations increased while the avoidant and disorganised ones diminished. These findings are discussed and the limitations and implications of the study presented

Mapping the road from childhood adversity to personality disorder: The role of unresolved states of mind

Childhood adversity has been found to be an important aetiological factor in the development of personality disorder (PD) in several studies. However, the role of disorganized attachment with unresolved mental states for traumatic experiences requires further investigation. This study explores the relationship between childhood adversities, unresolved states of mind, PD diagnosis and psychiatric distress. Two hundred forty-five adult participants, 124 from a clinical PD group and 121 non-psychiatric controls were assessed using the Structured Clinical Interview for DSM-IV, the Cassel Baseline Questionnaire, the Symptom Checklist-90-R and the Adult Attachment Interview, in order to ascertain presence of PD, childhood adversity, level of psychiatric distress and unresolved states of mind. Within the overall unresolved (U-overall) attachment category, a distinction was made between unresolved for abuse (U-abuse) and unresolved for loss (U-loss). The results indicated that childhood adversity was significantly associated with unresolved states of mind, as well as with overall PD diagnosis, paranoid PD, borderline PD, avoidant PD and psychiatric distress. Mediation analyses confirmed that U-overall and U-loss were significant mediators between childhood adversity and PD diagnoses, but surprisingly, U-abuse was not a significant mediator. The strength, limitations and clinical implications of the findings are discussed

The Reflective Fostering Programme fidelity rating scale: development and inter-rater reliability

Purpose: The purpose of this study is to describe the development of the 14-item reflective fostering fidelity rating (RFFR), an observational rating system to evaluate model fidelity of group facilitators in the Reflective Fostering Programme (RFP), a mentalisation-based psychoeducation programme to support foster carers. The authors assess usability, dimensionality, inter-rater reliability and discriminative ability of the RFFR. Design/methodology/approach: Eighty video clip extracts documenting 20 RFP sessions were independently rated by four raters using the RFFR. The dimensionality of the RFFR was assessed using principal components analysis. Inter-rater agreement was assessed using the intra-class correlation coefficient. Findings: The proportion of missing ratings was low at 2.8%. A single principal component summarised over 90% of the variation in ratings for each rater. The inter-rater reliability of individual item ratings was poor-to-moderate, but a summary score had acceptable inter-rater reliability. The authors present evidence that the RFFR can distinguish RFP sessions that differ in treatment fidelity. Originality/value: To the best of the authors’ knowledge, this is the first investigation and report of the RFFR’s validity in assessing the programme fidelity of the RFP. The paper concludes that the RFFR is an appropriate rating measure for treatment fidelity of the RFP and useful for the purposes of both quality control and supervision

The reflective fostering programme: evaluating the intervention co-delivered by social work professionals and foster carers

PURPOSE: There is little evidence regarding how to best support the emotional well-being of children in foster care. This paper aims to present the evaluation of an adaptation of the reflective fostering programme, a group-based programme to support foster carers. This study aimed to explore whether a version of the programme, co-delivered by a social work professional and an experienced foster carer, was acceptable and relevant to foster carers and to gather data on programme effectiveness. DESIGN/METHODOLOGY/APPROACH: In total, 38 foster carers attended the programme and took part in this study. Data was collected regarding carer- and child-focused outcomes at pre-intervention, post-intervention and four-month follow-up. Focus interviews were also conducted to further assess acceptability and relevance for foster carers. FINDINGS: Analysis of quantitative outcome showed statistically significant improvements in all outcomes considered including foster carers stress and carer-defined problems, as well as carer-reported measures of child difficulties. Focus group interviews with foster carers suggested that the programme as co-delivered by a foster carer and a social worker was felt to be relevant and helpful to foster carers. ORIGINALITY/VALUE: These results provide a unique contribution to limited understandings of what works for supporting foster carers and the children in their care. Promising evidence is provided for the acceptability and relevance of the revised version of this novel support programme and its effectiveness in terms of carer- and child-related outcome measures. This work paves the way for further necessary impact evaluation