Category: Dissemination / Implementation
The therapeutic alliance has long been considered an important contributor to mental health treatment but has been understudied in the evidence-based practice of child and adolescent therapy (Green, 2006). Additionally, maintaining the therapeutic alliance is a primary concern of practitioners hesitant to adopt and use evidence-based practice, contributing to difficulties in the dissemination and implementation of these practices (Addis & Krasnow, 2000). The current study is exploratory and examines the relationship between observationally-coded therapeutic alliance and therapist-delivered competence and use of evidence-based (EB) strategies. Data come from a feasibility trial with 24 youths and their families testing FIRST, a time-limited, modular, trans-diagnostic therapy developed for acceptability to community providers (Weisz et al., 2017). Three therapy sessions from the beginning, middle, and end of treatment were randomly selected for coding. Therapeutic alliance was measured using the Therapeutic Process Observational Coding System for Child Psychotherapy – Alliance scale (TPOCS-A), while competence and use of EB strategies were measured using the Therapist Integrity in Evidence Based Interventions coding system for FIRST (TIEBI; Bearman, Herren, & Weisz, 2012). Coders rated alliances between parent and therapist and also between child and therapist. Reliability ranged from acceptable to excellent (for child alliance items, mean ICC (2,2) = 0.81, for parent alliance items, mean ICC (2,2) = 0.64). All coders scored in the good-to-excellent range for observed use of EB strategies (mean ICC (2,2) = 0.83) and competence in delivering those strategies (mean ICC (2,2) = 0.78). Data were analyzed in HLM and results indicated that therapist competence and use of EB strategies were highly associated (r = 0.842, p < 0.01). Alliance, competence, and use of EB strategies did not appear to grow over time, but across sessions and controlling for the contextual effects of individual dyads, higher rates of therapist competence in delivering EB strategies predicted higher observed alliance (β1 = 0.05, SE=0.02, p = 0.003). Higher rates of observed use of EB strategies also predicted higher rates of alliance (β1 =0.04, SE = 0.02, p = 0.006). This finding supports the idea that evidence-based practice and prioritizing the alliance are not contradictory; rather, they are complementary elements that support good clinical practice.