Journal of Consulting and Clinical Psychology

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1 Journal of Consulting and Clinical Psychology The Therapeutic Alliance in Treatment of Traumatized Youths: Relation to Outcome in a Randomized Clinical Trial Silje M. Ormhaug, Tine K. Jensen, Tore Wentzel-Larsen, and Stephen R. Shirk Online First Publication, July 29, doi: /a CITATION Ormhaug, S. M., Jensen, T. K., Wentzel-Larsen, T., & Shirk, S. R. (2013, July 29). The Therapeutic Alliance in Treatment of Traumatized Youths: Relation to Outcome in a Randomized Clinical Trial. Journal of Consulting and Clinical Psychology. Advance online publication. doi: /a

2 Journal of Consulting and Clinical Psychology 2013 American Psychological Association 2013, Vol. 81, No. 5, X/13/$12.00 DOI: /a The Therapeutic Alliance in Treatment of Traumatized Youths: Relation to Outcome in a Randomized Clinical Trial Silje M. Ormhaug Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway Tine K. Jensen Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway, and University of Oslo Tore Wentzel-Larsen Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway, and Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway Stephen R. Shirk University of Denver Objective: We examined the contribution of alliance to the outcome of therapy with traumatized youths across two different treatment conditions (trauma-focused cognitive behavioral therapy [TF-CBT] and therapy as usual [TAU]). Method: Participants were 156 youths (M age 15.1 years, range 10 18; 79.5% girls), randomly assigned to TF-CBT or TAU. Symptoms were assessed pretreatment, midtreatment (Session 6), and posttreatment (Session 15). Alliance was assessed after Sessions 1 and 6, using the Therapeutic Alliance Scale for Children Revised (TASC-R). Results: Alliance scores were comparable across treatment conditions, but TF-CBT participants had significantly lower posttraumatic stress symptoms (PTSS) posttreatment (d 0.51). Hierarchical regression analyses showed that there were no significant alliance effects in models without an Alliance Treatment Group interaction: Alliance ratings were significant predictors of reduction in PTSS (Est. 0.53, p.003, 95% confidence interval [CI] 0.87 to 0.18) and additional outcomes measured in TF-CBT but not in TAU (PTSS posttreatment: Est. 0.01, p.647, 95% CI 0.29 to 0.47). Conclusion: This study was the first to investigate the contribution of alliance to outcome among adolescents with posttraumatic symptoms, treated with TF-CBT or TAU. Our findings indicated that there was an important interaction between alliance and therapeutic approach, as alliance predicted outcome in TF-CBT, but not in the nonspecific treatment condition. A positive working relationship appeared to be especially important in the context of this evidence-based treatment, which requires youth involvement in specific therapy tasks. Further, findings showed that use of a manual did not compromise alliance formation. Keywords: working alliance, mixed trauma population, treatment outcome, manual guided therapy, trauma-focused CBT Clinicians have long emphasized the importance of a strong therapeutic relationship for the successful treatment of traumatized children and adolescents (Eltz, Shirk, & Sarlin, 1995; Kearney, Wechsler, Kaur, & Lemos-Miller, 2010; Lawson, 2009). Although the therapeutic alliance, commonly defined as agreement on goals, task collaboration, and an emotional bond (Bordin, 1979), has been shown to be linked with outcome in individual child, adolescent, and adult therapy (Horvath, Del Re, Flücikger, & Symonds, 2011; Silje M. Ormhaug, Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway; Tine K. Jensen, Norwegian Centre for Violence and Traumatic Stress Studies and Department of Psychology, University of Oslo, Oslo, Norway; Tore Wentzel-Larsen, Norwegian Centre for Violence and Traumatic Stress Studies and Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway; Stephen R. Shirk, Department of Psychology, University of Denver. Correspondence concerning this article should be addressed to Silje M. Ormhaug, NKVTS, P.O. Box 181 Nydalen, 0409 Oslo, Norway. s.m.ormhaug@nkvts.unirand.no Shirk, Karver, & Brown, 2011), only one study has evaluated this association in the treatment of maltreated youths (Eltz et al., 1995); and none have examined alliance outcome relations among youths with posttraumatic stress symptoms (McLeod, 2011; Shirk et al., 2011). Studies report rates of maltreatment and abuse among youths in mental health care ranging from 18 60%, (Lau & Weisz, 2003; McKay, Lynn, & Bannon, 2005; Reigstad, Jørgensen, & Wichstrøm, 2006). In a nonclinical sample of youths, 18% reported trauma-related posttraumatic stress disorder (PTSD), depression, or substance abuse after experiencing physical or sexual abuse (Kilpatrick et al., 2003), and studies indicate that in clinical care, between 42 90% of the abused youths have PTSD (Kearney et al., 2010). Thus, traumatized youths pose substantial public mental health challenges because of the devastating consequences trauma may have on mental health, and the absence of empirical research into alliance outcome relations among traumatized youths represents a significant gap in the literature. There are a number of reasons why the therapeutic alliance may be pivotal in the treatment of traumatized youths, and an especially strong predictor of outcome. First, the experience of trauma may 1

3 2 ORMHAUG, JENSEN, WENTZEL-LARSEN, AND SHIRK alter core assumptions about the world as a safe place and others as benign and trustworthy (Cloitre, Cohen, & Scarvalone, 2002; DePrince, Combs, & Shanahan, 2009; Meiser-Stedman, Dalgleish, Clucksman, Yule, & Smith, 2009). Consequently, traumatized youths may be reluctant to engage in a therapeutic relationship, and the ability to overcome this reluctance could be critical for treatment success (Eltz et al., 1995; Lawson, 2009). Further, since many trauma victims experience shame and other negative emotions related to the traumatic experience, such as PTSD (DePrince, Chu, & Pineda, 2011; Kearney et al., 2010), they will often avoid trauma-related material that evokes intense negative emotions. In particular, exposure tasks, a core feature of most evidence-based trauma treatments, are thought to be very challenging for patients, and a limited body of evidence with adults suggests that the quality of the alliance is an important contributor to PTSD treatment outcomes, in part, by facilitating participation in exposure components (Cloitre, Koenen, Cohen, & Han, 2002; Cloitre, Stovall- McClough, Miranda, & Chemtob, 2004; Keller, Zoellner, & Feeny, 2010). In the child trauma field, a recent study suggests that completion of the exposure-based narrative component of traumafocused cognitive behavioral therapy (TF-CBT) is associated with significantly greater and more rapid reductions in abuse-related fear and general anxiety (Deblinger, Mannarino, Cohen, Runyon, & Steer, 2011), thus helping youths engage in this core treatment component seems particularly important. Research into how alliance formation may contribute to outcome is scarce, however, so the first aim of this study was to evaluate associations between alliance and outcome in the treatment of traumatized youths. Although clinical observation and some limited research suggests that the alliance may be important in therapy with traumatized youths, it is not clear whether this association might vary by treatment type. Previous meta-analytic results point to consistent associations across diverse diagnoses and therapies for both youths (McLeod, 2011) and adults (Flückiger, Del Re, Wampold, Symonds, & Horvath, 2012). However, comparative estimates of alliance outcome association across treatments are based largely on aggregate results from samples of clients with different disorders. Few studies have directly compared alliance outcome associations with a sample randomized to different treatment conditions, particularly in the child and adolescent literature (McLeod, 2011). A second aim of this study, then, was to evaluate alliance outcome associations in different types of treatment for the same target problem: posttraumatic symptoms. Although alliance is regarded as a common factor in therapy it has been suggested that the alliance is especially critical in nonbehavioral forms of therapy that emphasize the therapeutic relationship as a change mechanism (Shirk et al., 2011). Little is known about the therapeutic interventions characterizing therapy as usual in community care (Garland, Hurlburt, Brookman-Frazee, Taylor, & Accurso, 2010), but studies indicate that therapists employ a wide array of treatment strategies and that these strategies are delivered at a relatively low intensity (Garland, Hurlburt, et al., 2010; Weersing & Weisz, 2002). By comparison, TF-CBT, like most evidence-based therapies, involves specific therapeutic procedures, with therapists organizing sessions around specified therapeutic tasks (Cohen, Mannarino, & Deblinger, 2006). These are procedures that, in the context of a strong therapeutic relationship, are assumed to account for therapeutic change. Theoretically, one might expect the alliance to be more strongly related to outcome in treatments like TAU that have less focus on specific procedures than those that emphasize treatment tasks. On the other hand, one recent meta-analysis of alliance outcome relations with youths revealed a somewhat stronger association in behavioral therapies than nonbehavioral therapies, although this difference did not attain statistical significance (Shirk et al., 2011). Consequently, there are also reasons for predicting a stronger association in behaviorally based therapy than in TAU. There is also some evidence that strength of alliance outcome associations vary by phase of treatment, that is, whether alliance is evaluated early or later in therapy (Chiu, McLeod, Har, & Wood, 2009; Shirk & Karver, 2003). Such findings point to the importance of measuring the degree of alliance at multiple points over the course of therapy. In this study, alliance was assessed after the first session and at the midpoint of treatment. This study had two primary aims; first, to evaluate the strength of association between alliance and outcome with a sample of referred youths presenting with posttraumatic stress symptoms and, second, to compare whether alliance outcome relations were significantly different in TF-CBT compared to TAU. The outcome measures included posttraumatic stress symptoms (PTSS), depression, anxiety, and general mental health problems. Consistent with prior literature on individual youth therapy, it was predicted that alliance would be associated with outcome such that more positive alliance would be associated with greater symptom reduction. To address the second aim, which was to directly compare alliance outcome associations across the treatments, the interaction between alliance and treatment condition as a predictor of outcome was evaluated. Although theory could support the prediction of a stronger link in TAU than TF-CBT, emerging evidence suggests the opposite, that is, stronger alliance outcome associations in the behaviorally based treatment than in TAU. Method Participants Participants were 156 adolescents (79.5% girls), with a mean age of 15.1 years (SD 2.20, range 10 18) referred for treatment at eight child and adolescent community mental health clinics. Four of the clinics were situated in small cities, two were in a large city, and two in suburban areas; the clinics received between new referrals each year. The majority of participants had at least one Norwegian-born parent (81.4%) and lived in one-parent households (63.6%; Table 1). Adolescents reported being exposed to an average of 3.6 different types of traumatizing events (SD 1.8, range 1 10). When asked to specify which event they perceived as the most disturbing or severe ( worst event ), at intake 32.5% reported exposure to domestic violence and physical abuse, 29.1% sexual abuse, 18.0% violent attacks outside the family context, 16.6% traumatic loss (i.e., sudden death of a caregiver or a close person), and the remaining 4.0% were exposed to accidents or other forms of noninterpersonal traumas. All participants reported clinically elevated symptoms of PTS, as assessed according to the Child Posttraumatic Symptom Scale (CPSS; Foa, Johnson, Feeny, & Treadwell, 2001), mean levels at pretreatment were 27.2 (SD 7.7). The majority of the sample (66.9%) met diagnostic criteria for PTSD on clinical interview (Clinician Administered PTSD Scale, Child and Adoles-

4 THERAPEUTIC ALLIANCE IN TREATMENT OF TRAUMATIZED YOUTHS 3 Table 1 Participant Characteristics Variable % n Worst traumatic experience Physical abuse and domestic violence Sexual abuse Violence outside the family Traumatic loss Accidents/hospitalization War/refuge Ethnic background Both parents Norwegian One parent Norwegian Asian Other European countries African Latin American Housing situation With both parents With one parent Foster care Alone/other arrangements Missing Parent education Elementary school High school Vocational training College (1 4 years after high school) University ( 5 years) Missing Total house income a USD 35, USD 35,000 88, USD 88, , USD 174, Did not know/not want to say a Mean income in Norway 2012 USD 79,800 ( cent Version [CAPS-CA]; Nader et al., 2004). In addition, 72.8% scored above clinical cutoff for depression (Mood and Feelings Questionnaire [MFQ]; Angold, Costello, Messer, & Pickles, 1995), 66.4% above cutoff for anxiety (Screen for Child Anxiety Related Disorders [SCARED]; Birmaher et al., 1999) and 59.1% for other behavioral and attention problems (Strengths and Difficulties Questionnaire [SDQ]; Goodman, 2001). On average, participants scored above clinical cutoff on 2.0 (SD 1.1, range 0 3) of the three co-occurring conditions, adding up to 3.6 conditions (SD 1.3, range 1 5) with the two PTSS measures included. Treatment Condition: TF-CBT Therapists. Twenty-six therapists volunteered to participate and receive training in TF-CBT. This group was predominantly female (88.5%, n 23), and therapists treated on average 3.0 (SD 1.4, range 1 6) participants each. Most therapists were psychologists (80.8%, n 21), 7.7% (n 2) were psychiatrists, 7.7% (n 2) were educational therapists (masters of education and additional clinical training), and 3.8% (n 1) was a clinical social worker (a bachelor-level degree with additional clinical training). On average, therapists had 10.2 years of experience (SD 6.4, range 3 28). When asked about theoretical orientation, 66.7% (n 16) characterized their background as cognitive behavioral, 25.0% (n 6) as psychodynamic, and 8.3% (n 2) as family/systemic. All therapists received between 4 to 6 days of initial training and were encouraged to read the treatment manual (Cohen et al., 2006) and complete a Web-based learning course for trauma-focused cognitive behavioral therapy ( Treatment adherence was supported through initial session-by-session supervision provided by trained TF-CBT therapists based on reviews of audio-recorded sessions. As the therapist became more familiar with the model, supervision was reduced to biweekly sessions. TF-CBT treatment. TF-CBT is a component based manualguided treatment specifically developed to target posttraumatic stress symptoms (Cohen et al., 2006). The model is based on theoretical principles from cognitive, behavioral, interpersonal and family therapy, in addition to trauma-theory. Both children and parents are involved in the treatment, and both parallel and co-joint session are provided. The treatment typically consists of sessions that are provided once a week and last approximately min per session. In this study, participants had, on average, 13.0 (SD 3.1, Mdn 14, range 4 17) sessions before the posttreatment assessment and a total of 18.8 (SD 8.4, Mdn 16.0, range 8 49) sessions before the case was discharged from the clinic. Therapy sessions were audio-recorded, and each session was coded for fidelity by at least one of two trained TF-CBT therapists, using a treatment adherence checklist for TF-CBT from the treatment developers. In those cases where there were questions about fidelity, these were discussed, and fidelity was determined by consensus. In five cases the core TF-CBT components were not provided (i.e., psychoeducation, relaxation, emotion regulation, trauma narrative and cognitive restructuring), and these cases were excluded from the analyses. Treatment Condition: TAU TAU therapists. In the TAU condition, 45 therapists volunteered to participate, and they treated, on average, 1.7 (SD 1.3, range 1 9) participants each. The majority of therapists were female (84.4%, n 38), and the sample consisted of 51.1% (n 23) psychologists, 26.6% (n 12) clinical social workers, 17.8% (n 8) educational therapists, and 4.4% (n 2) psychiatrists. On average, therapists had 12.5 years of experience (SD 10.3, range 1 40). Therapists in the TAU condition reported receiving, on average, 1.4 (SD 5.3, range 0 40) hours of supervision of their therapies with study participants in total. TAU treatment. In the TAU condition, therapists were asked to provide the treatment they believed to be effective for the particular case. Based on self-report, 45.9% (n 17) of the therapists described their theoretical orientation as psychodynamic, 29.7% (n 11) as cognitive behavioral, and 24.3% (n 9) as family or systemic. Treatment was for the most part provided individually, but in 55.3% (n 42) of the cases parents were also involved in the therapy process. All TAU sessions were recorded, and at least five sessions for each case were checked (first, second, third, sixth, and ninth; M 5.7 sessions, SD 3.5, range 1 19). As the main aim was to ensure that the TAU condition was different from TF-CBT, the same fidelity checklist was used. In those cases where treatments had features resembling TF-CBT, additional sessions were checked, adding up to a total of 392 checked sessions. In the TAU condition, the following TF-CBT

5 4 ORMHAUG, JENSEN, WENTZEL-LARSEN, AND SHIRK components were provided: 15.6% (n 12) psycho-education, 11.6% (n 8) affective expression and modulation, 8.7% (n 6) relaxation skills, and 7.2% (n 5) cognitive restructuring. In 5.8% (n 4) of the cases there was some therapeutic work addressing the traumatic event but none of the cases included the parents in the trauma work. None of the cases met the adherence criteria for TF-CBT. On average, participants in the TAU condition had 12.9 (SD 4.8, Mdn 15, range 1 21) sessions before the posttreatment assessment and an average of 23.8 (SD 21.4, Mdn 19, range 1 114) sessions before the case was discharged from the clinic. Measures Therapeutic alliance. Alliance was measured using the Therapeutic Alliance Scale for Children (TASC), developed by Shirk and Saiz (1992). The TASC was the first alliance scale designed specifically for use with children and adolescents and is one of the most commonly used alliance measures for this age group. In this study, the revised version of the scale was used (TASC-R; Shirk, 2003). The TASC-R consists of 12 items that measure emotional aspects (e.g., I like my therapist ) and degree of task collaboration (e.g., I work with my therapist on solving my problems ). All items are written as statements, and the youth is asked to answer on a 4-point scale (not at all to very much). The scale was translated and back translated, and the scales first author approved the Norwegian version. Reliability analyses with the current sample showed that the scale had good internal consistency at both time points (Session 1.88; Session 6.91). Primary outcome measures. Self-reported posttraumatic stress symptoms. Adolescents posttraumatic stress symptoms were first measured by means of the self-completion questionnaire Child PTSD Symptom Scale (CPSS; Foa et al., 2001). The CPSS consists of two parts. The first measures the 17 symptoms of PTSD defined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM IV; American Psychiatric Association, 1994), covering the three factors Reexperiencing, Avoidance, and Hyperarousal. Symptom frequency is rated based on the last 2 weeks, with a 4-point scale ranging from never or once to almost every day. The second part measures how the symptoms impact daily functioning, covering friendships, family, school work, hobbies and activities, house chores, and general life satisfaction. Principal component analyses of a comparable sample of 312 youths confirmed the factor structure in the original version (Hukkelberg & Jensen, 2011), and satisfactory internal consistencies were found for each of the three factors (Reexperience.84, Avoidance.80, Hyperarousal.76) and the functional impairment scale (.90). The scale was translated and back translated, and the developers of the scale approved the Norwegian version. Clinician rated PTSS symptoms. In addition to the self-report measure, a clinician-administered PTSD interview was conducted (CAPS-CA; Nader et al., 2004). The CAPS-CA is a structured interview that assesses the frequency and intensity of the 17 DSM IV defined symptoms of PTSD, and it is adapted from the adult version to be suitable both for younger children and adolescents up to 18. Items are scored on 5-point frequency scales (e.g., from 0 none of the time to 4 most of the time) and 5-point intensity rating scales (e.g., from 0 not a problem to 4 a big problem, I have to stop what I am doing), assessing the past month. Items are scored based on both the youths answers and clinical judgment during the interview. The interview was translated and back translated, and the first author of the CAPS-CA approved the Norwegian version. The whole scale showed satisfactory internal consistency (.90), as did the DSM IV defined tripartite model (Reexperiencing.87, Avoidance.77, Hyperarousal.79). Interrater reliability for total sum score was excellent (intraclass correlation.99; 95% confidence interval [CI] ), and kappa value on diagnostic status was.80. Secondary outcome measures. Depressive symptoms. The Mood and Feelings Questionnaire (MFQ; Angold et al., 1995) was used to assess depressive symptoms. This is a self-report questionnaire designed to assess depressive symptoms in children and adolescents between eight and 18 years of age. The questionnaire consists of 34 questions measuring both the full range of DSM IV diagnostic criteria for depressive disorders, as well as additional items reflecting common affective, cognitive, and somatic features of childhood depression. In this sample, the instrument (scale 0 68) showed good internal consistency (.91). The scale has been translated and back translated, and the Norwegian version approved by the originator (Sund, Larsson, & Wichstrøm, 2001). Anxiety symptoms. The Screen for Child Anxiety Related Disorders (SCARED) is a self-report questionnaire developed by Birmaher et al. (1999). It measures anxiety symptoms in children and adolescents aged 8 18 years. The instrument consists of 41 items that cover five specific anxiety disorders: (a) panic disorder or significant somatic symptoms, (b) generalized anxiety disorder, (c) separation anxiety disorder, (d) social anxiety disorder, and (e) significant school avoidance. In this sample, the instrument (scale 0 82) showed satisfactory internal consistency on the total scale (.93). The scale was translated and back translated, and the originators approved with the Norwegian version. General mental health. The Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001) is a self-report questionnaire covering general mental health problems in children and adolescents. The SDQ contains 25 items, covering five areas of clinical interest: hyperactivity/inattention, emotional symptoms, conduct problems, peer relation problems, and prosocial behavior. The total score of general difficulties is based on the four problem-oriented sub scores. The authorized translated version of the SDQ was used ( and the scale (range 0 40) showed satisfactory internal consistencies of.73. Procedure Data in this study were derived from an effectiveness study investigating effect and process variables in the treatment of traumatized youths aged All participants were referred through standard referral procedures (i.e., by primary physician or the child protective services), and the treatment offered at the clinics was free of charge. Youths reporting exposure to at least one traumatizing event at intake and presenting with posttraumatic stress symptoms above cutoff (CPSS scores 15) were invited to participate. Exclusion criteria were acute suicidal behavior, psychosis, intellectual disability or need for an interpreter. Recruitment took place from April 2008 to February A total of 200 adolescents met inclusion criteria, out of which 156 agreed to

6 THERAPEUTIC ALLIANCE IN TREATMENT OF TRAUMATIZED YOUTHS 5 participate. Information about the study was given both verbally and in written form, and written consent was obtained from both the caretaker and the adolescent. Procedures were reviewed and approved by the Regional Committee for Medical and Health Research (REC). After consent was given, participants were randomized to either a TF-CBT (n 79) or a TAU (n 77) condition. Computer-generated randomized block procedures were used, one for each clinic, and participants were not stratified on any specific features. Symptom level was assessed pretreatment, midtreatment (after six sessions) and posttreatment (after completion or the 15th session). The SDQ and clinical diagnostic interview (CAPS-CA) were included only pre- and posttreatment. As TF-CBT, normally delivered over a course of sessions, was the experimental condition, it was decided that all posttreatment assessments should be conducted after (or as close to as possible) the 15th session, even though some participants in the TAU and TF-CBT condition were still in treatment at this time point. Alliance ratings were collected after sessions one and six, and the adolescents informed that their therapist would not be able to see their scorings. Licensed psychologists from the research group administered all the assessments, and they were naïve regarding treatment condition. The participating adolescents received a small gift card (e.g., a movie pass) after completing the posttreatment assessment, but no other economic compensation was given. More details of study procedures are described in Jensen et al. (in press). Data Analyses As therapists were not randomized to treatment conditions, therapist variables for the two groups were compared using independent sample t tests, and chi-square tests. Alliance and outcome scores across the two treatment conditions were analyzed with independent-sample t tests, and we investigated the relationship between pretreatment symptom scores and alliance ratings using linear regression analyses. As outcome was measured after the 15th session (or before for those who terminated earlier), and not after the true end-point of treatment, we investigated the relationship between the alliance ratings and total number of sessions attended before discharge from the clinic with Pearson correlations. Alliance outcome relationships were investigated by means of hierarchical regression analyses, and three models were tested. In the first model; midtreatment symptom scores were used as the dependent variable; and pretreatment symptom level, treatment condition, and Session 1 therapeutic alliance were entered as predictors in the first step. In the second step an interaction between treatment condition and therapeutic alliance was included. In Model 2, midtreatment symptom levels, treatment group, and Session 6 alliance was entered in the first step, and the alliance treatment group interaction was included in the second step. The third model included changes in alliance scores instead of the single-point assessments in the first step, and again an interaction effect with group was included in the second step. For Models 2 and 3, posttreatment symptom scores were used as dependent variables. In all models, slopes within each treatment group were computed in the fourth step (Table 2). As control analyses, we investigated whether the alliance ratings were influenced by early symptom reduction by looking at the relationships between changes in symptom levels from pre- to midtreatment and alliance scores using linear regression analyses. To facilitate comparisons between our findings and previous studies, effect sizes (ES) for alliance outcome relations were calculated with Pearson correlation between the alliance scores, and symptom scores posttreatment. Thus, negative correlations would indicate that a stronger alliance was associated with lower symptom levels posttreatment. Following guidelines by Cohen (1992) r is a small effect when at least.10, a medium effect when at least.30, and a large effect when at least.50. To test differences in the average correlations in the two conditions, bootstrap BC a intervals were used (10,000 bootstrap replications). Missing data. Out of the total sample of 156 recruited adolescents, 112 completed the TASC-R after Session 1, 130 completed the TASC-R after Session 6, 91 completed both alliance evaluation following Session 1 and had outcome measured midtreatment and 109 completed alliance evaluation following Session 6 and had outcome measured posttreatment. The noncompleters included participants that never started treatment (n 4), participants that dropped out of the treatment prior to Session 6 (n 29) and those that continued treatment beyond the assessment point, but failed to complete the measurements (after Session 1 n 40; midtreatment n 4; posttreatment n 5). In addition, five cases were removed from the analyses because they did not receive the allocated intervention (Figure 1). Missing rates were not significantly different in the two treatment conditions ( , p.741), but compared to noncompleters, the completing participants were, on average, younger, (14.9 vs years old), t(154) 2.1, p.038; reported, on average, fewer different traumatic experiences (3.4 vs. 4.4), t(151) 2.8, p.005; and reported higher alliance scores midtreatment (38.8 vs. 32.4), t(128) 3.1, p.003. As this shows that the missingness could not be assumed to be completely at random (MCAR), discarding data using listwise deletion could increase the risk of a biased result (Schafer & Graham, 2002). To investigate this, several steps were taken. First, weighted regression analyses were completed. The weighting model was based on a logistic regression for valid endpoint, with age, total number of traumas reported, and either Session 1 or midtreatment alliance scores as covariates, respectively. These analyses did not yield substantially different results compared to complete-case analyses. Second, to account for missing values in covariates analyses were repeated using multiple imputation (200 completed data sets). The imputation model was based on age, gender, number of traumas reported, pretreatment symptom levels and treatment group. Again, analyses with imputed data yielded similar results to the complete-case analyses. Reported results will be based on complete case analyses. 1 Initial analyses were conducted using PASW Statistics 19.0 (IBM SPSS Statistics, 2011). The remaining analyses were run in R (The R Foundation for Statistical Computation, Vienna, Austria), with multiple imputations calculated using the R package mice, and bootstrapping with the R package boot. 1 Results from the weighted and multiple imputation-based analyses can be made available upon request from first author.

7 6 ORMHAUG, JENSEN, WENTZEL-LARSEN, AND SHIRK Table 2 Midtreatment Alliance Scores and Outcome Posttreatment Variable Est. p 95% CI R 2 CPSS Symptom Step 1 CPSS Symptoms midtreatment to 0.68 Group to 1.63 Alliance to 0.02 Step 2 CPSS Symptoms midtreatment to 0.68 Group to 0.66 Alliance, slope within TAU to 0.60 Alliance, slope within TF-CBT to 0.16 Alliance Treatment Group to 0.13 CPSS Impairment Step 1 Impairment midtreatment to 0.77 Group to 0.26 Alliance to 0.01 Step 2 Impairment midtreatment to 0.77 Group to 0.08 Alliance, slope within TAU to 0.12 Alliance, slope within TF-CBT to 0.03 Alliance Treatment Group to 0.03 CAPS-CA Step 1 CAPS-CA pretreatment to 0.85 Group to 0.92 Alliance to 0.13 Step 2 CAPS-CA pretreatment to 0.83 Group to 1.21 Alliance, slope within TAU to 1.46 Alliance, slope within TF-CBT to 0.22 Alliance Treatment Group to 0.05 Depression (MFQ) Step 1 MFQ Symptoms midtreatment to 0.73 Group to 1.54 Alliance to 0.14 Step 2.02 MFQ Symptoms midtreatment to 0.73 Group to 0.46 Alliance, slope within TAU to 0.74 Alliance, slope within TF-CBT to 0.00 Alliance Treatment Group to 0.12 Anxiety symptoms (SCARED) Step 1 SCARED midtreatment to 0.81 Group to 0.02 Alliance to 0.05 Step 2 SCARED midtreatment to 0.80 Group to 1.77 Alliance, slope within TAU to 0.93 Alliance, slope within TF-CBT to 0.18 Alliance Treatment Group to (table continues)

8 THERAPEUTIC ALLIANCE IN TREATMENT OF TRAUMATIZED YOUTHS 7 Table 2 (continued) Variable Est. p 95% CI R 2 General mental health (SDQ) Step 1.32 SDQ pretreatment to 0.84 Group to 1.08 Alliance to 0.07 Step 2.03 SDQ pretreatment to 0.84 Group to 0.73 Alliance, slope within TAU to 0.16 Alliance, slope within TF-CBT to 0.15 Alliance Treatment Group to 0.00 Note. CI confidence interval; CPSS Child PTSD Symptom Scale (Foa et al., 2001); CPSS Impairment CPSS Functional Impairment scale; CAPS-CA Clinician Administered PTSD Scale, Child and Adolescent Version (Nader et al., 2004); MFQ Mood and Feelings Questionnaire (Angold et al., 1995); SCARED Screen for Child Anxiety Related Disorders (Birmaher et al., 1999); SDQ Strengths and Difficulties Questionnaire (Goodman, 2001); TAU therapy as usual; TF-CBT trauma-focused cognitive behavioral therapy. p.100. p.050. p.010. p.001. Results Initial Analyses Comparisons of therapists in TF-CBT and TAU. There were no statistically significant differences between the groups in terms of therapists gender or years of experience, but there were significant differences in therapists educational background, as there were more psychologists in the TF-CBT condition ( , p.024), and the TF-CBT therapists had significantly more participant cases compared to TAU, t(1, 69) 4.0, p.001. Alliance ratings. There were no significant differences in alliance scores across the two treatment conditions TF-CBT and TAU, neither as assessed after Session 1 nor Session 6 (Table 3). Alliance scores rated at the two time points were moderately correlated in the total sample (r.42, p.001) and within the TAU condition (r.30, p.042), whereas they were within the large range in the TF-CBT condition (r.54, p.001). When alliance scores were correlated with total number of sessions, there were no significant relationships between the first-session alliance ratings and number of sessions completed, neither in the total sample (r.04, p.661) nor split by treatment condition (TF-CBT r.10, p.491; TAU r.06, p.661). Alliance rated midtreatment, however, was associated with significantly fewer sessions in TF-CBT (r.28, p.029), and significantly more sessions in TAU (r.32, p.010). Pretreatment symptom scores and alliance ratings. There was a significant relationship between pretreatment SDQ scores and alliance measured at Session 6 (SDQ Est..27, p.050), but none of the other symptom measures predicted any of the alliance sores (Session 1 alliance: CPSS symptoms Est..06, p.702; CPSS Impairment Est..83, p.065; CAPS-CA Est..05, p.143; MFQ Est..06, p.260; SCARED Est..07, p.074; SDQ Est..22, p.087; Session 6 alliance: CPSS symptoms Est..00, p.969; CPSS Impairment Est..44, p.369; CAPS-CA Est.00, p.994; MFQ Est..02, p.734; SCARED Est..04, p.365). Outcome posttreatment in the two treatment conditions. Investigations of posttreatment symptom scores showed that adolescents in the TF-CBT conditions reported significantly lower symptom levels compared to participants in TAU on all of the PTS measures, depression and general mental health but not on the anxiety measure (Table 3). For further details, see also Jensen et al. (in press). Alliance as a Predictor of Symptom Reduction First-session alliance. When first-session alliance ratings were entered as a predictor in the model, there were no significant effects neither in the total sample nor within the two treatment conditions. This finding was consistent across all outcome measures (data not shown). 2 Midtreatment alliance. Hierarchical analyses showed that there was a trend level relationship between Session 6 alliance and reduction of PTS symptoms and a significant relationship between alliance and general mental health in the full sample. There were no main effects of alliance in relation to any other outcome measures. However, there was a significant interaction effect between alliance and treatment group for all measures except MFQ depression. Analyses of slopes within each treatment condition showed that the alliance significantly predicted symptom reduction across all measures in the TF-CBT condition but not in TAU (Table 2, Figure 2). Changes in alliance. When changes in alliance scores from Session 1 to Session 6 were entered in the models, there were no main effects in the full sample (CPSS Est. 0.24, p.113, 95% CI 0.06 to 0.54; CPSS Impairment Est. 0.03, p.370, 95% CI 0.03 to 0.09; CAPS-CA Est. 0.10, p.796, 95% CI 0.88 to 0.68; MFQ Est. 0.09, p.692, 95% CI 0.35 to 0.53; SCARED Est. 0.13, p.563, 95% CI 0.33 to 0.59; SDQ Est. 0.00, p.955, 95% CI 0.15 to 0.16). Further, we did not find any interaction effects between change scores and treatment condition (interaction effects in model with CPSS Est. 0.41, p.194, 95% CI 0.18 to 1.00; CPSS Impairment 2 Results are available upon request from first author.

9 8 ORMHAUG, JENSEN, WENTZEL-LARSEN, AND SHIRK Enrolment Assessed for eligibility (n = 454) Excluded (n = 298) Not meeting inclusion criteria (n = 254) Declined to participate (n = 44) Randomized (n=156) Allocated to TF-CBT (n = 79) Did not complete alliance rating (n = 23) Did not start treatment (n = 3) Did not complete mid-treatment alliance (n = 15) or outcome ratings (n = 16) Dropped out from treatment < 6 sessions (n =11) Did not complete post-treatment outcome assessment (n = 20) Excluded from analysis (n = 5, did not receive allocated intervention) Figure 1. as usual. Included in complete case analyses: Alliance session one (n = 40) Alliance mid-treatment (n = 54) Est. 0.06, p.305, 95% CI 0.06 to 0.18; CAPS-CA Est. 1.18, p.146, 95% CI 0.42 to 2.78; MFQ Est. 0.72, p.104, 95% CI 0.15 to 1.59; SCARED Est. 0.69, p.134, 95% CI 0.22 to 1.59; SDQ Est. 0.28, p.249, 95% CI 0.03 to 0.58). Early treatment gain and alliance ratings. Changes in adolescent-rated PTS symptoms (CPSS) from pre- to midtreatment did not significantly predict alliance scores neither in the full sample (Est. 0.03, p.652, 95% CI 0.11 to 0.18) nor split by group (TF-CBT Est. 0.08, p.470, 95% CI 0.14 to 0.30; TAU Est. 0.00, p.978, 95% CI 0.20 to 0.19). This pattern was the same across all outcome measures that were assessed at midtreatment (CPSS Impairment Est. 0.54, p.176, 95% CI 0.24 to 1.31; MFQ Est. 0.00, p.941, 95% CI 0.11 to 0.12; SCARED Est. 0.10, p.102, 95% CI 0.02 to 0.21). Allocation Session one Mid-treatment Post-treatment Analysis Allocated to TAU (n = 77) Did not complete alliance rating (n = 17) Did not start treatment (n = 1) Did not complete mid-treatment alliance (n = 11) or outcome ratings (n = 17) Dropped out from treatment < 6 sessions (n = 18) Did not complete post-treatment outcome assessment (n = 14) Excluded from analysis (n = 0, all received allocated intervention) Included in complete case analyses: Alliance session one (n = 45) Alliance mid-treatment (n = 52) Flowchart for participants. TF-CBT trauma-focused cognitive behavioral therapy; TAU therapy Strength of Alliance Outcome Associations All significant correlations between alliance and outcome were in the medium range (Table 4). Mean effect size across the total sample was small and nonsignificant (r.13, p.205). Split by groups, mean correlation was r.35 (p.013) in TF-CBT and r.06 (p.660) in TAU. The difference in mean correlation between the two groups was statistically significant (difference 0.41, 95% CI 0.71 to 0.03). Discussion The therapeutic alliance has been viewed as a critical component of effective treatment for traumatized children, adolescents, and adults. This clinical hypothesis was evaluated using a sample of traumatized adolescents who were randomly assigned to TF- CBT and TAU in a community-based effectiveness trial. Although

10 THERAPEUTIC ALLIANCE IN TREATMENT OF TRAUMATIZED YOUTHS 9 Table 3 Alliance and Symptom Scores Across Treatment Conditions Scale Group n M score SD a df t p TASC-R Session 1 TF-CBT TAU Midtreatment TF-CBT TAU CPSS Symptom scale Pretreatment TF-CBT TAU Midtreatment TF-CBT TAU Posttreatment TF-CBT TAU CPSS Impairment Pretreatment TF-CBT TAU Midtreatment TF-CBT TAU Posttreatment TF-CBT TAU CAPS-CA Pretreatment TF-CBT TAU Posttreatment TF-CBT TAU MFQ Pretreatment TF-CBT TAU Midtreatment TF-CBT TAU Posttreatment TF-CBT TAU SCARED Pretreatment TF-CBT TAU Midtreatment TF-CBT TAU Posttreatment TF-CBT TAU SDQ Pretreatment TF-CBT TAU Posttreatment TF-CBT TAU Note. TASC-R Therapeutic Alliance Scale for Children Revised (Shirk, 2003); CPSS Child PTSD Symptom Scale (Foa et al., 2001); CPSS Impairment CPSS Functional Impairment scale; CAPS-CA Clinician Administered PTSD Scale, Child and Adolescent Version (Nader et al., 2004); MFQ Mood and Feelings Questionnaire (Angold et al., 1995); SCARED Screen for Child Anxiety Related Disorders (Birmaher et al., 1999); SDQ Strengths and Difficulties Questionnaire (Goodman, 2001); TAU therapy as usual; TF-CBT trauma-focused cognitive behavioral therapy. a Test of homogeneity of variance: All Levene ps.05. it was hypothesized that alliance would be associated with symptom reduction across treatments, this association only attained statistical significance for one out of six outcomes when alliance was measured at midtreatment. Further, there were no relationships between early alliance or changes in alliance during early treatment and outcomes. However, a major finding of this study was that midtreatment alliance outcome associations were moderated by treatment condition. A consistent pattern of Alliance Condition interactions was observed across all outcome measures, including both adolescent self-reports and clinician-rated symptoms. Results showed that alliance was more strongly associated with outcome in TF-CBT than TAU. In fact, there was only a minimal overall association in TAU compared to a medium effect in TF- CBT. This pattern could not be attributed to differences in alliance or outcome variability across groups, or to differences in pretreatment symptom levels. The finding that alliance predicted outcome only in TF-CBT is not consistent with the view that relationship processes are more critical in nonbehavioral than behaviorally based therapies. Results are consistent, however, with findings from at least one adult study showing stronger alliance outcome relations in cognitive behavioral therapy compared to a nonbehavioral treatment in a randomized clinical trial (Arnow et al., 2013). Results from the current study suggest that both alliance and specific treatment components contribute to positive outcomes with traumatized youths. TF-CBT yielded better outcomes than TAU, and within this condition, youths with stronger alliances showed better outcomes. In addition a more positive Session 6 alliance was associated with fewer therapy sessions in the TF-CBT condition. Thus, not only did alliance predict better outcomes in TF-CBT, it also appears to be related to more efficient use of therapy. Although not examined directly in this study, it is possible that the alliance promotes active involvement in TF-CBT tasks, which, in turn, contribute to symptom reduction. The therapeutic alliance may be particularly important, then, in treatments with more challenging therapeutic components, such as exposure. Here, the alliance could function as a catalyst for engagement and involvement in active therapy components, a finding that is in line with adult studies of PTSS treatments (Cloitre, Koenen, et al., 2002; Keller et al., 2010) and studies of depressed youths (Karver et al., 2008). In the absence of such components, variations in alliance seem to have substantially less connection with outcomes. Alliance might, however, be related to number sessions attended, which may in turn be positively related to outcomes at a later time point in TAU. Our results show that first session alliance did not predict outcome in TF-CBT. Although Session 1 ratings were associated with later ratings (r.54, p.001), it might have been difficult for youths to make judgments about bond and task collaboration after only one session. It can be assumed that these first session ratings reflect more the youths first impressions about the therapeutic relationship and that this does not constitute the type of alliance formation that is predictive of outcome in TF-CBT. In line with this, it is also possible that alliance, as an indicator of bond and task collaboration, gains traction as a predictor of outcome following exposure to specific treatment tasks. Alternatively, to the degree that the alliance is a catalyst for involvement in TF- CBT components, later alliance scores are more proximal to core TF-CBT components. Further, this is in line with studies involving adults where the overall alliance outcome relationship has been found to be stronger for alliance rated later in treatment (Flückiger et al., 2012). In addition, the scale used in this study might not have been optimal for assessment at such an early time point as some items may have been difficult to rate after just one encounter (e.g., I like spending time with my therapist or I spend time with my therapist making changes in my life ). The finding that changes in alliance during treatment did not predict outcome contrasts in part with results from other studies of

11 10 ORMHAUG, JENSEN, WENTZEL-LARSEN, AND SHIRK 40 Black = TF-CBT White = TAU 30 = TF-CBT = TAU CPSS t CBT with anxious youths. In a study by Chiu et al. (2009), changes in child-rated alliance significantly predicted reductions in anxiety posttreatment. However, in this study the early alliance was not measured at Session 1 but at Sessions 2 and 4. In contrast, Marker, Comer, Abramova, and Kendall (2013) measured the alliance after each session and did not find significant relationships between changes in youth-rated scores and outcome (Marker et al., 2013). Although TF-CBT was manual-guided and more structured than TAU, the level of alliance was comparable across treatment conditions. This finding is consistent with results obtained by Langer, McLeod, and Weisz (2011), who showed that manual use did not undermine the alliance in youth therapy. These investigators did not report on alliance outcome relations in their study, so current Table 4 Pearson Correlations Midtreatment Alliance Scores and Symptom Levels Posttreatment TASC scores Figure 2. Scatterplot alliance and posttraumatic stress symptom reduction posttreatment. TAU therapy as usual; TF-CBT trauma-focused cognitive behavioral therapy; CPSS Child PTSD Symptom Scale (Foa et al., 2001); TASC Therapeutic Alliance Scale for Children Revised (Shirk, 2003). Variable Total sample TF-CBT TAU CPSS Symptom scale CPSS Impairment scale CAPS-CA MFQ SCARED SDQ M correlation Note. CPSS Child PTSD Symptom Scale (Foa et al., 2001); CPSS Impairment CPSS Functional Impairment scale; CAPS-CA Clinician Administered PTSD Scale, Child and Adolescent Version (Nader et al., 2004); MFQ Mood and Feelings Questionnaire (Angold et al., 1995); SCARED Screen for Child Anxiety Related Disorders (Birmaher et al., 1999); SDQ Strengths and Difficulties Questionnaire (Goodman, 2001); TAU therapy as usual; TF-CBT trauma-focused cognitive behavioral therapy. Mean is the mean of the six correlations with individual symptom scores. p.100. p.050. p.010. results extend these findings by showing that alliance does not suffer in manual-guided therapy and, in fact, remains a robust predictor of treatment outcomes. Many studies of alliance outcome relations in the youth research literature have failed to consider the possibility that alliance could be the consequence rather than a predictor of symptom change (Shirk et al., 2011). We evaluated this possibility in two ways. First, results indicated that alliance at midtreatment was not significantly related to early change in PTS and other symptoms. Second, alliance at midtreatment predicted subsequent change in PTS symptoms, that is, change that occurred between mid- and posttreatment. These findings provide strong support for alliance as a predictor, rather than a consequence of symptom change. Prior meta-analytic findings in both the adult (Horvath et al., 2011) and youth literatures (McLeod, 2011; Shirk & Karver, 2003) have indicated that the alliance is a modest but consistent predictor of outcomes across treatment types. A recent meta-analysis of alliance-outcome relations in individual youth therapy suggested somewhat stronger associations in behavioral than nonbehavioral therapies (Shirk et al., 2011). Current results are consistent with the latter pattern. Developmental factors could play a role in this emerging difference with the adult literature. To the degree that behavior therapies are more structured, and specific treatment tasks more explicit, youths may have more concrete anchors for evaluating their collaborative bond in behavioral than nonbehavioral therapy. Similarly, the therapist stance in youth behavior therapy is more coach than process facilitator as is common in nonbehavioral therapy, and youths may be more familiar with the former role. If ambiguity translates into less accurate judgments, alliance outcome associations could suffer. However, treatment equivalence has been less common in the youth literature than the adult literature (Silverman & Hinshaw, 2008; Weisz, Weiss, Han, Granger, & Morton, 1995), with behaviorally based therapies outperforming their nonbehavioral counterparts. Thus, it may be