The therapeutic alliance and psychotherapy outcomes for young adults aged 18 to

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1 Title registration for a review proposal: The therapeutic alliance and psychotherapy outcomes for young adults aged 18 to 25 To start a Campbell review, a title must be registered and approved by the appropriate Campbell review group. For information about the title registration and protocol and review steps, visit the Campbell website: Submitted to the Coordinating Group of: Crime and Justice Education _X Social Welfare Other Plans to co-register: _X No Yes _X Cochrane Other TITLE OF THE REVIEW The therapeutic alliance and psychotherapy outcomes for young adults aged 18 to The Campbell Collaboration

2 BACKGROUND Briefly describe and define the problem A large body of evidence points to the therapeutic alliance as one of the major factors contributing to outcomes in psychotherapy (Orlinsky, Ronnestad, & Willutzki, 2004). The alliance (also called the therapeutic alliance and working alliance) is conceptualized as the strength and quality of a helping relationship. However, little is known about the therapeutic alliance and its potential effects on psychotherapy outcomes among year olds. Although there are hundreds of studies and dozens of meta-analyses of the alliance and outcomes for adult psychotherapy clients, far fewer studies and no systematic reviews examine the impact of the alliance on psychotherapeutic outcomes for young adult clients. Briefly describe and define the population Young adults are distinct cohort of increasing importance to mental health professionals, due to recent socio-cultural trends such as growth in college attendance, delayed marriage, and poorer employment opportunities. In the last decade, this group has become more likely to remain at home and demonstrate a longer trajectory towards adult responsibilities and lifestyles in the United States (U.S. Census Bureau, 2010). There is reason to believe that the prevalence and seriousness of mental health problems among young adults may be increasing, at least in certain sectors. A national survey of approximately 20,500 college students on 39 U.S. campuses performed by the American College Health Association found that 43.2% of the students surveyed reported feeling so depressed it was difficult to function at least one time over the past year (Miller & Chung, 2009). The 2010 survey of College Counselling Center Directors reported a large majority seeing greater numbers of students with more severe mental health problems on their college campuses (American College Counselling Association, 2010). Problems such as psychological crises, medication issues and alcohol problems are at the top of a list of growing mental health needs that impact students, families, and communities. Therefore, effective mental health treatment is essential for this population. This review may shed light on one of the most important factors in effective psychotherapy for young adults. Briefly describe and define the intervention 2 The Campbell Collaboration

3 Of many factors that influence outcomes in psychotherapy, one of the most consistent contributions has been theorized to be the qualities of the therapeutic relationship itself. Hundreds of studies have found that a positive alliance predicts more positive outcomes including symptom reduction and client goal attainment (Bordin, 1979; Horvath & Symonds, 1991). The alliance is not an intervention per se, but it is thought to be one of the active ingredients in all modalities of therapy. The major theoretical conceptualizations of the alliance focus on critical qualities of effective working relationships, including the strength of the bond between therapist and client, and the extent to which therapists and clients create (or share) common treatment goals and tasks (Bordin, 1979; Gaston, 1990; Horvath & Symonds, 1991; Saunders, Howard, & Orlinsky, 1989). The alliance can be measured from the perspective of the therapist, client, and/or an observer. It can be measured at any point in psychotherapy, and for treatments that vary in length from one session to long-term treatment. In addition, the alliance may be measured across specific therapeutic modalities, techniques, diagnostic categories, age groups as well as other categories. Some studies do include comparison groups, but random assignment and blinding are rare, and most studies are correlational. Given the correlational nature of studies of the alliance and outcomes, questions have been raised about the direction of causality. It is possible that early, positive outcomes lead to a stronger therapeutic alliance. This possibility is not always addressed in primary studies; hence, it is important to take time order into account. Some examples of popular alliance measures are the Working Alliance Inventory (with three subscales which assess bonds, goals, and tasks), the Counselor Rating Form (with scales for trustworthiness and expertness), the Empathy scale of the Relationship Inventory, and the Therapeutic Alliance Rating System. Outcomes: What are the intended effects of the intervention? Numerous outcome measures are used in therapeutic alliance studies and these can be condensed into five categories that include scales that assess mood (e.g. Beck Depression Inventory), symptoms (e.g., Symptom Checklist-90), global symptoms e.g., Global Assessment Scale), specific outcomes (e.g., Target Complaints), and termination status or whether the client attends the agreed upon number of sessions 3 The Campbell Collaboration

4 (Martin, Garske & Davis, 2000). Many studies use multiple measures to evaluate outcomes in more than one category. OBJECTIVES The objective of this review is to estimate effects of the therapeutic alliance on outcomes of psychotherapy for 18 to 25 year olds. We will pay careful attention to the extent to which primary studies can support causal inferences and may need to describe results in terms of associations, rather than effects. Since the alliance is thought to have several components (bonds and collaboration on the goals and tasks of treatment) we will examine the relative predictive power of these components separately. Additionally, we will determine whether client, therapist, or observer reports of the alliance are better predictors of outcomes. If possible, we will analyze the level of agreement between client and therapist ratings of the alliance as a possible predictor of outcomes. Finally, we will attempt to address issues of time order and causality, by synthesizing results from studies that use baseline characteristics and/or initial outcome measures as control variables in analyses of associations between later alliance measures and more distal outcomes. METHODOLOGY What types of studies designs are to be included and excluded? Inclusion criteria: Observational studies of young adults (18-25) in face-to-face psychotherapy with licensed mental health professionals using direct observation, interviews, selfreports, and/or clinical records. Studies may include comparison groups with or without randomization. Designs must include multiple observations in which the alliance measure(s) precede the outcome measure(s). Exclusion criteria: If studies include a wider age range, they must report data for young adults separately. No qualitative studies will be included. 4 The Campbell Collaboration

5 Your method of synthesis: Will you use meta-analysis, etc? Meta-analysis of associations between alliance measures and outcomes. SOURCES OF SUPPORT Internal funding: External funding: DECLARATIONS OF INTEREST None REQUEST SUPPORT Do you need support in any of these areas (methodology, statistics, systematic searches, field expertise, review manager etc?) We need expert assistance with literature searching, for both published and unpublished studies. AUTHOR(S) REVIEW TEAM Include the complete name and address of reviewer(s) (can be changed later).this is the review team -- list the full names, affiliation and contact details of author s to be cited on the final publication. Lead reviewer: Stacy Green, MSS LCSW The lead author is the person who develops and co-ordinates the review team, discusses and assigns roles for individual members of the review team, liaises with the editorial base and takes responsibility for the on-going updates of the review Name: Stacy J. Green, MSS LCSW Title: Licensed Clinical Social Worker, Doctoral Candidate Affiliation: Bryn Mawr College Graduate School of Social Work and Social Research Address: 300 Airdale Road City, State, Province or County: Bryn Mawr, PA Postal Code: Country: USA Phone: Mobile: s2green@brynmawr.edu Co-author(s): Julia H. Littell, PhD Name: Dr. Julia H. Littell Title: Professor Affiliation: Bryn Mawr School of Social Work and Social Research Address: 300 Airdale Road 5 The Campbell Collaboration

6 City, State, Province or County: Bryn Mawr, PA Postal Code: Country: USA Phone: Mobile: ROLES AND RESPONSIBLIITIES Please give brief description of content and methodological expertise within the review team. The recommended optimal review team composition includes at least one person on the review team who has content expertise, at least one person who has methodological expertise and at least one person who has statistical expertise. It is also recommended to have one person with information retrieval expertise. Who is responsible for the below areas? Please list their names: Content: SJG, JHL Systematic review methods: SJG, JHL Statistical analysis: SJG, JHL Information retrieval: C 2 TSC (Karianne Hammerstrøm, if possible) PRELIMINARY TIMEFRAME Approximate date for submission of Draft Protocol (please note this should be no longer than six months after title approval. If the protocol is not submitted by then, the review area may be opened up for other reviewers): Title registration approved: July 1, 2011 Draft Protocol: submitted by October 31, The Campbell Collaboration