Alliance after evidence: the impact of youth-therapist alliance on treatment outcome for internalizing youth, over and above protocol effects

Abstract

Empirically supported treatment (EST) protocols have been identified for the most common emotional and behavioral problems in youth (e.g., Chorpita et al., 2011; Lonigan, Elbert, & Johnson, 1998; Weisz, Doss, & Hawley, 2005). The role of the therapeutic alliance has received relatively less empirical examination, although when examined, it consistently accounts for at least a modest amount of variance in treatment outcome (Shirk & Karver, 2003; Karver et al., 2006). Furthermore, the impact of the alliance on youth treatment outcome typically is examined in lieu of, rather than in concert with, the impact of treatment procedures or content. The purpose of the current study, therefore, was to examine the impact of the youth-therapist alliance on treatment outcome, over and above the impact of treatment protocol. The study was conducted in a sample of youth with internalizing behavior problems (N = 75), randomly assigned to either empirically supported or usual care treatment conditions. Results indicated that whereas internalizing youth improved by the end of treatment under all conditions, the impact of treatment protocol was negligible, as was the impact of the youth-therapist alliance as measured at the end of treatment, over and above treatment protocol and when considered independently. Both methodological and conceptual factors may be indicated in these results, including choice of alliance measure, restriction of range encountered when applied to an internalizing population, and issues of temporal precedence.