Many young people worldwide are exposed to potentially traumatizing events (PTEs; e.g., Finkelhor et al., 2015; Landolt et al., 2013; Lewis et al., 2019; McLaughlin et al., 2013). Although many youths show impressive resilience and considerable recovery in the first weeks after exposure to trauma (e.g., Miller-Graff & Howell, 2015), approximately 16% may develop post-traumatic stress disorder (PTSD; Alisic et al., 2014). Symptoms of PTSD entail intrusions, avoidance, changes in cognition and mood, arousal, and reactivity (American Psychiatric Association, 2013), and these trauma-related symptoms may negatively impact youths’ affective, behavioral, cognitive, interpersonal, and biological domains (Cohen et al., 2017). Thus, knowledge on how to help youths recover from PTSD is essential. Trauma-focused cognitive behavioral therapy (TF-CBT) is a recommended treatment for PTSD (International Society for Traumatic Stress Studies [ISTSS], 2018; National Institute for Health and Care Excellence [NICE], 2018). Research suggests that a combination of the trauma-specific interventions of TF-CBT along with a strong alliance with a therapist may be optimal for helping youths alleviate post-traumatic stress symptoms (PTSS; Ormhaug et al., 2014; Zorzella et al., 2015). However, relatively little is known about how TF-CBT facilitates change in symptoms (Alpert et al., 2021; Hayes et al., 2017). The overarching aim of this thesis is to increase understanding of youth-therapist alliances, youth in-session involvement behaviors, and therapist in-session alliance-building behaviors and to examine how these relate to treatment outcomes for youths receiving TF-CBT.
Data for this study were derived from the Norwegian TF-CBT study that investigated the effectiveness of TF-CBT in comparison to treatment as usual (TAU). Results from this randomized controlled trial study showed that TF-CBT was superior to TAU in reducing post-treatment PTSS (Jensen et al., 2014), and the treatment effects of TF-CBT seemed to be maintained at follow-up (Jensen et al., 2017). The present thesis involves participants from the TF-CBT arm (n = 65).
The thesis consists of three studies. The overarching aim of Paper I was to evaluate how therapists can best monitor youth-therapist alliances in TF-CBT. The specific aims of the study were as follows: (1) to examine which alliance perspective(s) predict post-traumatic stress (PTS) outcomes; (2) to investigate the concordance between youth, parent, therapist, and observer ratings of youth-therapist alliances; and (3) to evaluate whether discrepancies in youth, parent, and therapist ratings of the alliance predict PTS outcomes. Youths, parents, and therapists rated the alliance according to The Therapeutic Alliance Scale for Children-revised (TASC-r; Shirk, 2003, Shirk & Saiz, 1992), and observers rated the alliance using the Therapy Process Observational Coding System for Child Psychotherapy-Alliance Scale (TPOCS-A; McLeod, 2001; McLeod & Weisz, 2005). Results showed that only the youths’ alliance ratings predicted PTS outcomes. Only the parents’ alliance ratings significantly correlated with the youths’ alliance ratings. An overestimation of youth-therapist alliances by therapists and parents predicted poorer PTS outcomes. These results highlight the importance of attending to and tuning into youths’ perspectives of their alliance with therapists during TF-CBT and suggest that consulting parents to evaluate the youths’ alliances may be helpful.
The overarching aim of Paper II was to increase understanding of how therapists can build a strong alliance with traumatized youths receiving TF-CBT, and to examine whether early trauma focus impedes the alliance-formation process. This study had three research aims: (1) to examine the predictive associations between therapist alliance-building behaviors and youth-rated alliances, (2) to evaluate the degree of therapists’ trauma focus (gradual exposure) as a predictor of subsequent youth-rated alliances, and (3) to examine whether the type of initial client engagement moderates the relationship between therapist behaviors and youth-rated alliances. Youths rated the alliance according to TASC-r (Shirk, 2003, Shirk & Saiz, 1992). Therapists’ alliance-building behaviors were coded by observers using the Adolescent Alliance-Building Scale-revised (AABS-r; Shirk & Jungbluth, 2014). Two main therapist alliance-building strategies were identified from AABS-r: rapport-building (focusing on youths’ experiences by eliciting information, offering alternative perspectives through cognitive restructuring, and providing support) and treatment socialization (active structuring of the session [leading and directing], explaining the treatment model, expressing positive expectations for change, and emphasizing collaboration). To examine whether early trauma focus may impede alliance-building, the observers also coded how often the therapist talked about or probed for trauma experiences. Youths’ initial engagement behaviors within the treatment were coded by observers using the Behavioral Index of Disengagement Scale (BIDS; Peterson et al., 2011; Peterson & Shirk, 2012). From BIDS, youths’ behaviors were categorized as engaged, passively disengaged, or actively disengaged. The results showed that more rapport-building was associated with a stronger alliance, while the extensiveness of treatment socialization was not associated with the strength of the alliance. The extensiveness of therapist elicitation of trauma-related material did not predict the strength of the alliance. The only significant interaction effect between therapist behaviors and youths’ initial behaviors was that greater elicitation of trauma was associated with a stronger alliance within the group of passively disengaged youths. Together, these results suggest that using rapport-building behaviors is helpful when attempting to establish a strong alliance with traumatized youths regardless of their initial behavior. Additionally, the results suggest that therapists need not be too concerned about addressing trauma early in treatment, as this does not seem to undermine the alliance-building process. Rather, the results suggest that focusing on trauma content may be helpful for building a strong alliance with youths who initially appear to be marginally engaged.
The overarching aim of Paper III was to examine the relationships between youth-therapist alliances, involvement behaviors and outcomes of TF-CBT. The specific aims of the study were to examine the following: (1) whether youths’ positive and negative involvement behaviors in trauma narration work predict their PTS treatment outcomes and (2) whether there is a significant relationship between a youth’s alliance with a therapist and their involvement behaviors in the trauma narrative. Youths rated the alliance according to TASC-r (Shirk, 2003; Shirk & Saiz, 1992). Observers coded youths’ involvement behaviors using the Client Involvement Rating Scale (CIRS; Chu & Kendall, 1999, 2004, 2009). For the positive involvement behaviors the results suggest that greater expression of understanding the treatment and elaborating more on trauma experiences from youths were associated with greater treatment improvements while appearing enthusiastic and taking more initiative were associated with poorer treatment responses. Negative involvement behaviors were not associated with outcomes. A stronger alliance was associated with greater initiation and enthusiasm from youths and less negative involvement behaviors. Together, these results indicate that understanding the treatment rationale is associated with talking more about trauma experiences and that this, along with a strong alliance, relate to favorable PTS treatment outcomes.
Collectively, the findings from Papers I–III suggest that therapists should focus on youths’ experience of the alliance, as this predicts PTS outcomes. Overestimating youths’ perspectives of the alliance seems to be associated with poorer PTS outcomes. Focusing on rapport-building early in treatment seems to strengthen the youth-therapist alliance. Addressing youths’ trauma experiences does not seem to impede alliance-building but rather strengthens the alliance for passive youths. Youths’ initial behaviors during trauma narrative work may serve as useful markers for therapists to appraise the treatment progress. However, more research is needed to increase understanding of therapy processes during TF-CBT with traumatized youths and how these processes may facilitate changes in treatment outcomes