The role of therapeutic alliance and its ruptures and resolutions in the treatment of adolescent depression

The therapeutic alliance is considered an important mechanism of change in youth psychotherapy. Yet, alliance research with young people is scarce and hampered by methodological limitations. This PhD aimed to seek a deep understanding of the alliance and its role in psychotherapy for adolescent depression. Study 1 aimed to learn more about the empirical definition of the alliance and examined the factor structure of the most used alliance measure, the Working Alliance Inventory short-form. The theorised multidimensional structure was not supported, and a single, overall alliance dimension was found to be empirically more valid. Study 2 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. The average alliance strength was found to differ across treatment types, being highest in cognitive therapy and lower in brief psychosocial intervention and especially psychoanalytic psychotherapy. Study 3 aimed to better understand the direction of the effect between alliance and outcome by investigating 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. Early alliance was found to predict subsequent outcomes even after controlling for patients’ baseline severity and prior symptom change. The strength of this relationship was moderated by treatment type. Study 4 described and explored alliance rupture and resolution events and their impact on the change process in a single-case of a successful short-term psychoanalytic-psychotherapy. Frequent alliance ruptures occurred, but most of them were repaired. There was converging evidence that the patient-therapist relationship and its dynamics played a crucial role in promoting change. Together, these studies provide a rich picture of the role of the alliance in youth psychotherapy while challenging some of the assumptions in the current alliance literature

The Alliance With Young People: Where Have We Been, Where Are We Going?

The therapeutic alliance is considered an important mechanism of change in youth psychotherapy. Accordingly, it has become one of the most investigated psychotherapy variables. Yet, the theoretical and empirical literature on the alliance with young people is complex and has received criticism. This article aims to (a) critically review the existing knowledge on the alliance in youth psychotherapy from its definition to the existing research and (b) discuss some of the implications of this knowledge for clinical practice ad future research. This review highlights that the alliance in youth psychotherapy, as commonly measured, has a significant, although small, impact on outcomes; and that the alliance-outcome association may be influenced by the young person and the therapist's characteristics, as well as therapy types. This points to the importance of finding tailored ways of fostering a strong alliance when working with young people and questions the assumption of the alliance as a generic aspect of all types of youth psychological treatments. Attention to repairing alliance ruptures also emerged as key, especially to preventing early dropout in adolescent therapy. It is argued that despite its limitations, alliance research in youth psychotherapy can have important clinical implications to improve youth psychotherapy. A resumption of a conversation between the clinical and research field on the alliance is needed to better understand the nature and role of this important variable when working with young people and to use this knowledge to inform and improve clinical practice and therapeutic training. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Alliance ruptures and resolutions in short-term psychoanalytic psychotherapy for adolescent depression: an empirical case study

Most research on alliance rupture-repair processes in psychotherapy has been carried out with adults and little is known about the alliance dynamics with adolescents, especially in psychodynamic treatments. OBJECTIVE: This study aimed to better understand the process of alliance rupture–resolution and its role in a good-outcome case of a depressed adolescent treated with short-term psychoanalytic-psychotherapy (STPP). METHOD: A longitudinal, mixed-methods empirical single-case approach was employed. Multiple sources of information (questionnaires, interviews, sessions recordings) from various perspectives (adolescent, therapist, observer) were assembled and analysed. RESULTS: The different sources of evidence converged and showed that, despite the presence of frequent alliance ruptures, patient and therapist managed to resolve these and develop a good and collaborative relationship. Both patient and therapist regarded the evolution in their relationship as the treatment factor mainly responsible for the positive changes experienced by the adolescent. Based on both theoretical and empirical data, a preliminary model of how to explore and repair alliance ruptures in STPP is presented. CONCLUSION: This study illustrates one way of applying an empirical, mixed-method approach to a single case. Its finding supports the idea that the process of repairing ruptures is an important mechanism of change. Strengths, limitations, and possible implications 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

Repairing alliance ruptures in psychodynamic psychotherapy with young people: The development of a rational-empirical model to support youth therapists

Alliance ruptures in youth psychotherapy can have a significant impact on treatment outcomes. However, there is currently limited guidance on how to effectively repair these ruptures with young people. This study aims to address this gap specifically in the context of psychodynamic psychotherapy with adolescents. The objectives of the study are (a) to understand the therapeutic interventions and attitudes that either facilitate or hinder the resolution of alliance ruptures and (b) to develop a model for repairing these ruptures within this particular treatment approach. To accomplish this, a task analysis of a previously developed rational model of resolving alliance ruptures was conducted using 16 sessions from short-term psychodynamic psychotherapy with depressed adolescents. The analysis supported some stages of the hypothesized rational model while revealing the need for revisions. As a result, the study developed a rational-empirical model that includes flexible strategies that therapists can use to repair alliance ruptures. This model emphasizes the significance of a collaborative, open, and empathetic approach to resolving ruptures. In contrast, rigid, defensive, or invalidating therapist attitudes can hinder the resolution process. The evidence-based model developed from the study can provide valuable guidance to psychodynamic psychotherapists working with young people, offering insights on how to approach ruptures and employ effective strategies to promote their resolution. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

The evidence-base for Psychodynamic Psychotherapy with children and adolescents: A narrative synthesis

Despite a rich theoretical and clinical history, psychodynamic child and adolescent psychotherapy has been slow to engage in the empirical assessment of its effectiveness. This systematic review aims to provide a narrative synthesis of the evidence base for psychodynamic therapy with children and adolescents. Building on two earlier systematic reviews, which covered the period up to 2017, the current study involved two stages: an updated literature search, covering the period between January 2017 and May 2020, and a narrative synthesis of these new studies with those identified in the earlier reviews. The updated search identified 37 papers (28 distinct studies). When combined with papers identified in the earlier systematic reviews, this resulted in a combined total of 123 papers (82 distinct studies). The narrative synthesis of findings indicates that there is evidence of effectiveness for psychodynamic therapy in treating a wide range of mental health difficulties in children and adolescents. The evidence suggests this approach may be especially effective for internalizing disorders such as depression and anxiety, as well as in the treatment of emerging personality disorders and in the treatment of children who have experience of adversity. Both the quality and quantity of empirical papers in this field has increased over time. However, much of the research demonstrates a range of methodological limitations (small sample sizes, lack of control groups etc.), and only 22 studies were Randomized Controlled Trials. Further high-quality research is needed in order to better understand the effectiveness of psychodynamic psychotherapy for children and young people

The Reflective Fostering Programme—improving the wellbeing of children in care through a group intervention for foster carers: a randomised controlled trial

Background: The needs of children in care are a government priority, yet the evidence base for effective interventions to support the emotional wellbeing of children in care is lacking. Research suggests that supporting the carer-child relationship, by promoting the carer’s reflective parenting, may be an effective approach to improving the wellbeing of these children. Methods: The study comprises a definitive, superiority, two-armed, parallel, pragmatic, randomised controlled trial, with embedded process evaluation and economic evaluation, and an internal pilot, to evaluate the effectiveness, and cost-effectiveness, of the Reflective Fostering Programme. Randomisation is at the individual level using a 1:1 allocation ratio. The study is being conducted in local authority sites across England, and is targeted at foster carers (including kinship carers) looking after children aged 4 to 13. Consenting participants are randomly allocated to the Reflective Fostering Programme (intervention arm) in addition to usual support or usual support alone (control arm). The primary outcome is behavioural and emotional wellbeing of the child 12 months post-baseline, and secondary outcomes include the following: foster carer’s level of stress, quality of life, reflective capacity, compassion fatigue and burnout, placement stability, the quality of the child-carer relationship, child’s capacity for emotional regulation, and achievement of personalised goals set by the carer. Discussion: A feasibility study has indicated effectiveness of the Programme in improving the child-carer relationship and emotional and behavioural wellbeing of children in care. This study will test the effectiveness and cost-effectiveness of implementing the Reflective Fostering Programme as an additional aid to the support already available to local authority foster carers. Trial registration: ISRCTN 70832140

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 disorder s, 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 15 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 person- ality disordered and non psychiatric subjects. We also investigate 20 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. 25 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 have no specific associations with particular PD 30 subtypes when current psychiatric distress is taken into account