Acknowledging religion in cognitive behavioural therapy: The effect on alliance, treatment expectations and credibility in a video-vignette study

OBJECTIVES

Developing mental health services which are accessible and acceptable to those from minority backgrounds continues to be a priority. In the United Kingdom, individuals who identify with a religion are underrepresented in Talking Therapies services as compared to those with no religion. This necessitates an understanding of how therapy is perceived. This online study explored the impact of explicitly acknowledging religion on anticipated alliance, treatment credibility and expectations of therapy in a non-clinical sample of British Muslims.

METHODS

A video-vignette experimental design was used in which participants who self-reported as either high or low in religiosity were randomly allocated to receiving information about cognitive behavioural therapy either with or without an explicit mention of religion as a value in the therapeutic process.

RESULTS

One hundred twenty-nine British Muslim adults aged 18-70+ years from various ethnic backgrounds participated in the study. Between-subjects ANOVAs showed that scores on the perceived credibility of therapy and treatment expectations were significantly higher when religion was explicitly mentioned by the 'therapist', but that acknowledging religion did not impact upon anticipated alliance.

CONCLUSIONS

These findings suggest that mentioning religion as a value to be considered in therapy has some positive impacts upon how therapy is perceived by British Muslims. Although video vignettes do not provide insight into the complexity of actual therapeutic encounters, acknowledging religion in mental health services more broadly remains an important consideration for improving equity of access and may bear relevance to other minoritized groups.

Exploring the Role of Age and Gender on the Impact of Client Suicide in Mental Health Practitioners

Objective: Previous research has revealed that mental health professionals (MHPs) often experience severe, yet varying, levels of short-term impact in the aftermath of client suicide. Individual differences are significant, yet what factors help explain these differences remains unclear. The current study investigated the role of the MHPs' and the clients' age and gender upon the impact of client suicide. Method: An international sample of 213 MHPs, aged between 18 and 75, reported on a client's suicide and its short-term impact (IES-R). Results: The results indicate that both MHPs' and clients' gender did not affect impact. MHPs' and clients' age did not affect impact individually, although a significant interaction effect was revealed. Conclusion: Age, not gender, of the MHP and client are relevant in light of the impact of client suicide. Potential implications and suggestions for future research are discussed.

Sex differences in response to cognitive behavioural therapy for insomnia: A chart review of 455 patients with chronic insomnia

BACKGROUND

Insomnia is more prevalent in females, however studies examining sex differences in response to insomnia treatment are scarce. This study assessed sex-specific differences in cognitive behavioural therapy for insomnia (CBT-I)-related changes in insomnia symptoms in a large clinical cohort.

METHODS

A chart review was conducted of a clinical cohort (females n = 305, males n = 150) referred to a sleep clinic. Participants had a registered psychologist confirm diagnosis of chronic insomnia according to DSM-IV/V criteria and a Level 1 or 2 sleep study. Daily sleep diaries and questionnaires including the Insomnia Severity Index (ISI), Flinders Fatigue Scale (FFS), the Daytime Feelings and Functioning Scale (DFFS), and the Depression, Anxiety and Stress Scale-21 items (DASS), were administered at baseline, post-treatment, and three-month follow-up. Linear mixed models determined interactions between sex and timepoint on symptoms.

RESULTS

Mean (SD) age was 51.7 yrs (15.7, range = 18-90 yrs), and mean BMI was 26.3 kg/m2 (4.9), neither of which differed by sex. At pre-treatment, females demonstrated higher objective total sleep time (min) [343.5 (97.6) vs 323.8 min (92.1), p = 0.044], ISI [19.7 (4.2) vs 18.6 (4.4), p = 0.033], and FFS scores [19.2 (6.0) vs 16.9 (7.2), p = 0.003]. Compared to males, females experienced a greater reduction in FFS and DFFS scores and DASS depressive symptoms (p for interaction: 0.017, 0.043, 0.016 respectively) from baseline to follow-up. The greater reduction in depressive symptoms did not persist after controlling for age, BMI, and sleep apnea severity. Subjective total sleep time similarly increased across treatment for both males [baseline: 335.7 (15.1), post: 357.9 (15.5)] and females [baseline: 318.3 (10.4), post: 354.4 (10.7)], p for interaction: 0.22.

CONCLUSION

Females and males experience similar, substantial benefits from CBT-I after accounting for comorbidities, suggesting the same treatment can resolve insomnia in both sexes.

Who With Whom: Matching Therapist and Client in Correctional Institutions

The current study investigated variables that are being considered when assigning psychotherapists to individuals convicted of sexual and violent offences. Its main aim is to inform practitioners and researchers alike of potentially beneficial combinations between therapist and client and infer hypotheses for future studies. A mixed-methods approach, combining interviews and a follow-up questionnaire, was employed. Nineteen interviews with forensic practitioners working in socio-therapeutic facilities in Germany were conducted. Relevant matching criteria were extracted from all interviews. 1.) Capacities of therapist, 2.) therapist's professional background, 3.) (severity of) clinical disorder, 4.) personal fit, and 5.) fit of client into existing groups emerged as top five matching criteria. Directive therapists were viewed as a good match for antisocial or psychopathic offenders. Opinions diverged regarding personality similarity or complementarity in client-therapist dyads. A flexible matching approach may offer unique strengths to enhance treatment outcome. Implications and ideas for future research are discussed.

The Strong Black Woman Archetype and Therapeutic Outcomes: Examining Relationships Among Women with Childhood Sexual Abuse Histories

The Strong Black Woman archetype (SBWA) describes a cultural pattern where Black women are expected to and present as physically and mentally strong, regardless of past and ongoing stressors. The SBWA has served the historical purpose of aiding survival for Black women throughout years of racial and gender oppression. However, the practice has also been associated with adverse mental health and with behaviors, such as self-silencing, that could impede therapeutic process. The purpose of this empirical study was to investigate the relationships between adherence to the SBWA and therapeutic outcomes (i.e., satisfaction with therapy, satisfaction with therapist, perceptions of one's global improvement in therapy) among Black women with childhood sexual abuse histories-a subpopulation at increased need for mental health treatment and who may be susceptible to high levels of adherence to the SBWA. Black adult female participants (N = 103) completed an online survey including a demographic questionnaire, an assessment of SBWA endorsement, and treatment outcomes from their current or most recent therapy experience. Three hierarchical linear regressions were conducted with SBWA as the independent variable and (i) satisfaction with therapist, (ii) satisfaction with therapy, and (iii) global improvement as the dependent variables. Consistent with our hypotheses, we found that SBWA inversely predicted satisfaction with therapy and the therapist. While the relationship between SBWA and global improvement was statistically significant, the finding was not practically significant. Still, our study findings suggest that higher levels of SBWA predict less favorable therapy outcomes. Future research directions and clinical implications are discussed.

"It's Important to Work with People that Look Like Me": Black Patients' Preferences for Patient-Provider Race Concordance

A compelling body of research supports the race concordance hypothesis, which asserts that racially minoritized patients who share the same race and ethnicity with their provider have improved communication, better perceptions of care, and better health outcomes. Using a mixed methods approach, this study examined (1) the association between racial identity and patients' preference for race-concordant patient-provider dyads and (2) Black patients' subjective experiences of race concordance. Data were gathered from 47 Black caregivers who completed both a survey and participated in a focus group. Quantitative analyses revealed that the majority (83%) of caregivers reported that it is important to have a mental health provider of the same race and ethnicity. Greater racial centrality, but not private or public regard, was associated with a stronger race concordance preference. Thematic analysis of qualitative data revealed six themes related to race-concordant preferences: aspects related to the patient care experience, cultural humility, relatability, diversity in cultural experiences, role models for children, and intersecting identities. Patients with a race concordance preference felt more comfortable with their provider, perceived that it was easier to build a rapport with their provider, and emphasized the value of representation for themselves and their children. Patients who were neutral in their race concordance preference emphasized professionalism over race, valued diverse perspectives, and appreciated their providers' cultural awareness and willingness to self-educate. The integration of these findings will help to elucidate a more nuanced understanding of the factors that build the therapeutic relationship and cultivate a framework of comfort and understanding in the clinical setting.

Validation of the Working Alliance Inventory- Short Form for Patient (WAI-S-P) in Peruvian Adults

Background

Although the importance of the therapeutic alliance in the treatment process and health outcomes is recognized, so far, there has been no evaluation in the Peruvian context that considers possible individual differences that could influence this assessment.

Purpose

This study assessed the psychometric properties of the WAI-S-P in a sample of individuals from Peru who are receiving psychological therapy. Furthermore, a network analysis was conducted to investigate the direct relationships between the therapeutic alliance and several relevant sociodemographic variables.

Methods

The short version of the Working Alliance Inventory was used in a sample of 241 participants (Mage=32.58, SD=12.67) that had attended less than 6 sessions. Three models were considered, including a three-factor and a two-factor correlated model, as well as a bifactor model. In addition, a network of partial associations was created including the overall therapeutic alliance, sex, age, and number of psychotherapeutic sessions.

Results

The bifactor model, with an overall therapeutic alliance factor and two specific factors ("contact" and "contract"), better fit the data. Invariance of the structure by sex and age showed equitable measurement. On the other hand, network analysis revealed a positive correlation between total session attendance and therapeutic alliance. Men reported higher therapeutic alliance, while women had higher total session attendance.

Conclusion

The results of this study suggest that the therapeutic alliance is better represented by a bifactor model and demonstrates invariance across sex and age in Peruvian adults. Additionally, findings indicate that differences in life experiences and the sex of patients may need to be verified in future studies to better understand nuanced needs in forming therapeutic alliances at least in the early stages of session attendance.

Treatment Engagement as a Predictor of Therapy Outcome Following Cognitive Behaviour Therapy for Autistic Children

PURPOSE

Active engagement in one's therapy is a key contributor to successful outcomes. Research on child engagement in cognitive behaviour therapy (CBT) has largely focused on youth without autism. This longitudinal study examined multiple indicators of child engagement in relation to outcomes for autistic children who took part in CBT for emotion regulation.

METHOD

Data were collected from 60 autistic children who were between 8 and 13 years of age (86.7% male; Mage = 9.58 years, SD = 1.44 years; 75% White). Indicators of child engagement included independent observer ratings of in-session involvement, as measured by the Child Involvement Rating Scale, and therapist ratings of the therapeutic relationship and homework completion using single-item measures. Indicators of engagement were measured at early (i.e., first third), middle (i.e., mid third), and late (i.e., final third) stages of treatment. Parent-reported emotion regulation was the primary treatment outcome, as measured by the Emotion Regulation Checklist.

RESULTS

After controlling for pre-treatment scores, in-session involvement significantly predicted some aspects of post-treatment emotion regulation, whereas therapeutic relationship and homework completion did not.

CONCLUSIONS

Child in-session involvement throughout therapy may be particularly relevant for treatment change. Addressing issues related to in-session involvement early in treatment may help to promote therapeutic success for autistic children.

A balancing act: how interpreters affect the therapeutic alliance in psychotherapy with trauma-affected refugees-a qualitative study with therapists

Objective

The therapeutic alliance (TA) has the highest predictive value concerning the success of psychotherapy. The presented study aimed to explore how the presence of an interpreter affects the TA when working with trauma-affected refugees.

Method

Semi-structured interviews were conducted with seven psychologists working in an outpatient clinic specialized in mental health care for migrant and refugee patients with trauma-related mental health problems in Denmark. Interviews were transcribed verbatim and analyzed using a structuring content analysis approach.

Results

TA has been described as a dynamic therapist-interpreter-patient alliance triangle consisting of three distinct but highly intertwined and mutually influential dyadic alliances. Specific factors affecting the quality of the TA were identified, e.g., interpreter being emotionally attuned yet not overly involved; interpreter being barely visible yet present as a human being. Characteristics of trauma-affected refugee patients affecting the TA formation were also identified, e.g., a high level of personal distrust, different understandings of mental disorders and psychotherapy, stigmatization, perceptions of authorities.

Conclusion

The presence of interpreters was perceived ambivalently and the formation of a good TA seems to be a balancing act. Based on the findings, recommendations for forming and maintaining a good TA in interpreter-mediated psychotherapy are provided.

Conceptualizing Community Mental Health Service Utilization for BIPOC Youth

Historically, children and adolescents who identify as Black, Indigenous, and other people of Color (BIPOC) have had inequitable access to mental healthcare, and research shows that they are significantly less likely than their white American counterparts to utilize available services. Research identifies barriers that disproportionately impact racially minoritized youth; however, a need remains to examine and change systems and processes that create and maintain racial inequities in mental health service utilization. The current manuscript critically reviews the literature and provides an ecologically based conceptual model synthesizing previous literature relating to BIPOC youth barriers for service utilization. The review emphasizes client (e.g. stigma, system mistrust, childcare needs, help seeking attitudes), provider (e.g. implicit bias, cultural humility, clinician efficacy), structural/organizational (clinic location/proximity to public transportation, hours of operation, wraparound services, accepting Medicaid and other insurance-related issues), and community (e.g. improving experiences in education, the juvenile criminal-legal system, medical, and social service systems) factors that serve as barriers and facilitators contributing to disparities in community mental health service utilization for BIPOC youth. Importantly, we conclude with suggestions for dismantling inequitable systems, increasing accessibility, availability, appropriateness, and acceptability of services, and ultimately reducing disparities in efficacious mental health service utilization for BIPOC youth.

Expanding the reach of psychosocial services for youth: Untapped potential of mentor-delivered single session interventions

At present, the mental healthcare system cannot meet the demand for services, and the need-to-access gap is widest among children and adolescents. Single session interventions (SSIs) are brief, intentional, and mechanism-targeted programs that have shown promise in increasing the reach of effective, evidence-based services; yet, a wide gap still remains due to structural barriers (e.g., lack of awareness, workforce shortages). The present paper posits the integration of SSIs and mentor-delivered programs as a promising future step to further overcome the inaccessibility of youth mental health services. Capitalizing on the advantages of mentoring relationships (e.g., the associated interpersonal benefits and mentors' pre-existence in most community settings) has the potential to complement and enhance the value of SSIs, and to expand the acceptability and reach of evidence-based mental health services. In this paper, we discuss the anticipated benefits of mentor-delivered SSIs, as well as cautionary considerations related to the proposed model. To conclude, we highlight the necessary implementation and research implications.

A systematic review and meta-analysis of clinician behaviors and characteristics related to alliance building with youth clients

The literature on developing alliance with youth clients has severely lagged behind that of adults. To date, there has been no meta-analytic review and limited qualitative synthesis of clinician variables which may contribute to the alliance with youth clients. Systematic literature search found a total of 49 relevant citations. Of the identified articles, 13 (27.08%) reported quantitative methods. Results of the qualitative review suggested that the majority of this research has focused on developing an emotional bond and a sense of collaboration. Meta-analysis found significant relations between alliance building and reducing variables and alliance (r_{alliance building} = 0.17; r_{alliance reducing} = -0.24). This analysis revealed specific behaviors particularly facilitative to youth alliance development, including collaborating with the client, finding common ground, exploring subjective experiences, orienting to treatment, providing praise, and enhancing facilitative conditions. In contrast, clinician lapse and pushing the client to talk were most predictive of a worse alliance. These results indicate certain behaviors which may be particularly important for clinicians to facilitate and not impair youth alliance formation. There is a need for greater youth alliance formation research to better determine how alliance formation may differ across stages of development and treatment modalities.

Client-therapist dyads and therapy outcome: Does sex matching matters? A cross-sectional study

Matching clients and therapist based on demographic variables might enhance therapeutic outcomes. Even so, research in this field is still inconclusive and not much is known about same-gender client therapist dyads in the context of cognitive behavioral (CBT) and psychodynamic methods. For this purpose, we studied the therapy outcomes of N = 1.212 participants that had received therapy (3 months-6 years) in Germany. The results showed a trend for same-gender client therapist dyads in terms of symptom reduction and quality of life specific to psychodynamic approaches. The latter applied specifically to female client-therapist dyads. On the other hand, this trend was not fully evident for CBT-based therapies. In conclusion, despite the robust sample and observed trends, it is not clear whether matching same gender dyads is advantageous with regards to symptom reduction and quality of life. Regardless, these results are preliminary and further studies are needed in order to find out whether same gender client-therapist dyads enhance therapy outcomes or not.

The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review

It is well established that there is a fundamental need to develop a robust therapeutic alliance to achieve positive outcomes in psychotherapy. However, little is known as to how this applies to psychotherapies which reduce suicidal experiences. The current narrative review summarizes the literature which investigates the relationship between the therapeutic alliance in psychotherapy and a range of suicidal experiences prior to, during and following psychotherapy. Systematic searches of MEDLINE, PsycINFO, Web of Science, EMBASE and British Nursing Index were conducted. The search returned 6472 studies, of which 19 studies were eligible for the present review. Findings failed to demonstrate a clear link between suicidal experiences prior to or during psychotherapy and the subsequent development and maintenance of the therapeutic alliance during psychotherapy. However, a robust therapeutic alliance reported early on in psychotherapy was related to a subsequent reduction in suicidal ideation and attempts. Study heterogeneity, varied sample sizes and inconsistent reporting may limit the generalizability of review findings. Several recommendations are made for future psychotherapy research studies. Training and supervision of therapists should not only highlight the importance of developing and maintaining the therapeutic alliance in psychotherapy when working with people with suicidal experiences but also attune to client perceptions of relationships and concerns about discussing suicidal experiences during therapy.

Clinician Racial Biases: Preliminary Investigation on Predictors of Poor Therapeutic Alliance and Retention in Home Visiting Intervention Program

BACKGROUND

Home visiting programs are effective in improving maternal-child health, and higher therapeutic alliance is associated with improved program retention and outcomes. Black, single, low-income mothers have a higher risk for poorer health outcomes in pregnancy and postpartum and for early termination of therapeutic services.

OBJECTIVE

To examine associations between clinician and client alliance and social, economic, and racial demographics.

METHODS

Mothers (N = 71) who were pregnant or had an infant (age < 24 m) receiving Infant Mental Health (IMH) services through community health service agencies and their clinicians (N = 50) completed the Scale to Assess Therapeutic Relationships (clinicians: STAR-C, clients: STAR-P) at 3-, 6-, 9-, and 12 months, and provided demographic information.

RESULTS

Survival analysis showed those with higher alliance ratings, both client and clinician ratings, at the 3-month time-point were more likely to remain in treatment longer (for clients est = -1.67, p = .0017; for clinician est = -.75, p = .031). Controlling for clinician experience and frequency of reflective supervision, Black clinicians had higher alliance ratings than white clinicians, (b = 3.1 (1.6), p = .049). Neither clinician-client racial match nor client marital status predicted alliance. Black clinicians' ratings of alliance did not vary by client race, but white clinicians reported weaker alliance with their Black, relative to white, clients (β = .40, p = .045).

CONCLUSIONS

Weaker alliance reported by white clinicians with Black clients, coupled with a lack of client-race related differences for Black clinicians, suggests white clinician racial bias may be important to consider in regards to program retention and health disparities.

A Knowledge Synthesis of Cross-Cultural Psychotherapy Research: A Critical Review

This article presents a current knowledge synthesis of empirical studies on cross-cultural psychotherapy since 1980. Guided by a critical review framework, our search in seven relevant databases generated 80 studies published in English. Main themes are organized into (1) therapists’ cultural competence ( n = 46); (2) therapy process in cross-cultural dyads ( n = 22); and (3) cross-cultural differences in gender, sexual orientation, or social class ( n = 12). Compared to previous reviews on cross-cultural psychotherapy, the findings of this review highlight a broad range of methodological rigor in both quantitative and qualitative studies. Most studies examined actual therapy participants rather than participants in analog studies, thus emulating more therapy-near experiences in cross-cultural psychotherapy research. Also, several studies explored cross-cultural compositions beyond racial and ethnic majority therapist-minority client dyads, and included therapists of color as the participants, exploring reverse power dynamics in therapy and giving voices to foreign-born therapists. The therapy process research provides rich and full descriptions around the dynamic and interactional therapy process in cross-cultural dyads, which can be used to foster cultural sensitivities among therapists in their practice and training. We discuss the limitations of the studies included in the review and its implications for psychotherapy practice, training, and future research.

Prevalence and perceived importance of racial matching in the psychotherapeutic dyad: a national survey of addictions treatment clinical practices

Background

Despite conflicting results in the literature concerning its efficacy in practice, racial matching has been identified as a component of culturally sensitive treatment.

Methods

This study examined the perceived importance and prevalence of racial matching by surveying a national sample of substance use disorder (SUD) centers from the Substance Abuse and Mental Health Services Administration (SAMHSA).

Results

Using univariate statistical analysis, results for the prevalence of racial matching revealed that in 58% of the clinics, there was the potential to match a counselor with a racially similar client, while in 39% of the clinics, there was no potential to provide such a match. Among the agencies that displayed a potential for racial matching, 26% of the respondents indicated that they never racially matched clients and therapists, 71% reported that they sometimes practice racial matching, 15% indicated that they usually racially match, and only 7% purported to always racially match clients and therapists. Results for the perceived importance of racial matching revealed that in both situations where treatment centers had the potential for racial matching and did not have the potential for racial matching, supervisors reported that it was relatively important to provide culturally sensitive treatment but that it was not as important to match clients in SUD centers with racially/ethnically similar counselors.

Conclusion

The topic of racial matching can be very complex and has shown variation amongst SUD centers; however, this study emphasizes the importance of providing culturally sensitive treatment and an appreciation of differences among members within each racial group.

Does the therapist matter? Therapist characteristics and their relation to outcome in trauma-focused cognitive behavioral therapy for children and adolescents

BACKGROUND

There is a broad evidence-base for the effectiveness of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) in treating children and adolescents with posttraumatic stress disorder (PTSD). The effect of therapist characteristics on patient symptoms has been neglected in psychotraumatology research and necessitates further investigation.

OBJECTIVE

This study aims to investigate the impact of therapist characteristics (gender, clinical experience and theoretical background) on posttraumatic stress symptoms (PTSS) in a heterogeneous and international sample of traumatized children and adolescents.

METHOD

Data from two RCTs on the effectiveness of TF-CBT in Norway and Germany were included, comprising N = 52 therapists (78.8% female) and N = 153 patients (72.3% female). All therapists underwent thorough training and continuous supervision in TF-CBT. The Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) assessed pre- and post-treatment served as the outcome variable in a linear mixed-effects model with therapists' theoretical background, prior clinical experience and gender as independent variables, adjusted for patient gender, measurement time and country. The possibility of an interaction between therapist and patient gender was investigated subsequently.

RESULTS

None of the therapist characteristics were significantly related to PTSS. There was no indication of an interaction between patient and therapist gender (p =.878).

CONCLUSION

The lack of evidence for a relationship of therapists' theoretical orientation and clinical experience with outcome suggests that a wider dissemination of TF-CBT may be warranted. More studies with larger therapist and patient sample sizes and including only community practice are needed.

How do applicants, students and physicians think about the feminisation of medicine? - a questionnaire-survey

BACKGROUND

The implications of the feminisation of medicine, which is characterised by a growing proportion of female doctors, is a topic currently being debated worldwide. To date, however, there has been no systematic survey of the viewpoint of present and future doctors on this subject. The aim of the present study is to determine how future and present doctors view this trend in terms of its relevance to the medical profession and its present impacts.

METHODS

Of a total sample of 3813 people, 181 applicants for the winter term 2014, 590 medical students and 225 doctors of the UMG participated in this cross-sectional electronic questionnaire. The answers were analysed by means of the statistics program IBM SPSS Statistics 22. Open answers were qualitatively evaluated and categorised using the "Basiswissengeleitete offene Kategorienfindung" (Werner Früh) and coded for statistical analysis.

RESULTS

The majority of our participants favoured a balanced gender-ratio among doctors: 77% of applicants, 68% of students and 61% of doctors rated this as important or very important. The results from the student and applicant groups differed concerning female gender. When answering in the role of a patient, the doctor's gender was found to be more relevant than when the participants were answering in the role of the doctor. The majority of the respondents opined that feminisation had had an impact on their workplace: particular factors included part-time work, work-related organisation and the diversity of the medical profession. Commentaries were mostly categorised as negative.

CONCLUSIONS

The feminisation of medicine was viewed largely critically by the participants of this study. The respondents evaluated gender as being relevant for the medical profession and favoured a diverse workforce; however, the significance of one's own gender in medical practice was underrated in comparison, implying a need for more awareness of the effect of a doctor's gender on the patient-doctor-relationship. The mainly negative comments concerning the impact of feminisiation on work organisation, work satisfaction and patient care show the need for further research and action to adapt current medical work practices to the changing demographics in order to improve work satisfaction and quality of care.

The therapeutic alliance between the child, parents, and health professionals

Therapeutic alliance (TA), a term first used by Zetzel (1956), refers to the collaborative relationship between a patient and a therapist, leading to the development of an affective bond during the process of treatment/therapy and an agreement on treatment/therapy-related tasks and goals. Over time, it became clear that therapeutic alliance has a bidirectional nature, not unique to any one form of therapy but universal in all forms of helping relationships. Engagement of both patient and therapist is essential to its development. Trust, empathy, acceptance, and honesty are among the many constituents of a TA. Alongside this, characteristics of healthcare professionals influence TA, with a warm, empathic, gentle, and accepting therapist enhancing positive TA and a rigid, critical, and less involved therapist posing a hindrance to the development of TA. Literature is sparse for TA in children, and it also essentially involves multiple relationships, namely child alliance, caregiver alliance, and child-parent relationship, which need to be taken into account. Developmental aspects should also be kept in mind while dealing with children and adolescents. It is seen that a strong and positive caregiver alliance influences the development of child alliance. There are ways to foster TA with the child and parent/caregiver to maximize benefits from therapy.

Measuring therapeutic alliance in children with autism during cognitive behavior therapy

Therapeutic alliance (TA), or the collaborative relationship between a therapist and client, has been shown to be an important component of intervention success. The objective of this study was to examine the psychometric properties of the Therapy Process Observational Coding System-Alliance Scale (TPOCS-A). The sample consisted of 20 children (19 males) ages 8 to 12 years with autism and their parents (15 mothers, 5 fathers), who completed a cognitive-behavioural intervention designed to improve children's emotion regulation skills. Two trained coders rated early, middle, and late parent and child alliance using the TPOCS-A after watching video recorded therapy sessions. Therapist-reported child involvement, alliance, and adherence were also assessed. Psychometric findings revealed that the TPOCS-A is a reliable and valid measure of therapeutic alliance for children with autism. The implications of examining TA in empirically supported treatments for this population are discussed.

Factors Associated With Caregiver Attendance in Implementation of Multiple Evidence-Based Practices in Youth Mental Health Services

OBJECTIVE

The implementation of evidence-based practices (EBPs) in community mental health settings for youths has consistently yielded weakened effects compared with controlled trials. There is a need to feasibly measure the quality of large-scale implementation efforts to inform improvement targets. This study used therapist-reported caregiver attendance in treatment sessions as a quality indicator in the community implementation of EBPs.

METHODS

Data were collected from therapists practicing in agencies contracted to provide publicly funded children's mental health services following a system-driven implementation of multiple EBPs. Community therapists (N=101) provided information about youth clients (N=267) and psychotherapy sessions (N=685). Multivariable binomial logistic regressions were conducted to examine associations between caregiver attendance and therapist factors (e.g., licensure status, education), youth factors (e.g., gender, age), and the type of EBP delivered.

RESULTS

Caregiver attendance occurred in 42% of sessions. The following factors were associated with increased odds of caregiver attendance: younger client age, male sex of client, externalizing presenting problem, and delivery of an EBP that prescribes caregiver attendance at all sessions. Caregiver attendance at sessions targeting trauma or externalizing disorders appeared to explain the differences between boys and girls in levels of caregiver engagement.

CONCLUSIONS

Overall, the patterns of actual caregiver attendance appeared consistent with empirically informed practice parameters for involvement of caregivers in treatment. Still, the rates of caregiver attendance in externalizing-focused sessions were suboptimal, and the gender difference in these rates-which clearly disfavored girls-suggests targeted areas for quality improvement. Potential reasons for these quality gaps are discussed.

Avatar and technology assisted platforms in the treatment of co-occurring addiction and IPV among male offenders

Purpose

The purpose of this paper is to review the research on the use of technology in mental health and addiction treatment, focusing on the use of technology-assisted treatment. Although initial research investigating technology-assisted treatment for substance use has demonstrated promising results, this paper highlights the need for treatment to address co-occurring substance use and intimate partner violence (IPV). This paper defines the benefits associated with the use of behavioral health avatar coaches in mental health treatment targeting substance use and IPV as well as providing preliminary research results regarding the use of avatar coaches in clinical settings.

Design/methodology/approach

A literature review of the research relating to the use of technology in mental health and addiction treatment is provided. Additionally, a preliminary study aimed to develop an interactive therapy platform that utilizes virtual avatars as therapy coaches to help clients with substance abuse and IPV is presented. In this preliminary study, male participants were shown videos of various technology-based coaches matched on length, gestures and content. Researchers investigated whether patients preferred a virtual reality health coach, a cartoon health coach or a human health coach; as well as patient satisfaction and preference between two versions of the avatar.

Findings

A review of the relevant literature suggests that a majority of research has focused on using technology to replace face-to-face therapy with little research focusing on technology-assisted or augmented mental health and addiction treatment. Although initial research investigating avatar-assisted treatment for substance use has demonstrated promising results, research suggests a high prevalence of co-occurring substance use and IPV, suggesting the need for treatment to address co-occurring substance use and IPV. A preliminary research study was conducted to obtain patient feedback for personalizing avatar development into behavioral health interventions that target addiction and IPV.

Research limitations/implications

Although results of the preliminary study combined with previous research on avatar-assisted treatment for substance use has demonstrated promising results, theory-based research needs to be expanded to focus on randomized controlled trials of avatar-assisted treatment for co-occurring substance use and IPV.

Practical implications

This paper provides an overview of the use of technology-assisted treatment for co-occurring substance use and IPV. The preliminary results regarding patient satisfaction led to the development of additional avatars for use in interactive therapy.

Originality/value

This paper is one of the first to explore the use of avatar-assisted treatment for male offenders with co-morbid substance use and IPV.

Service needs of adolescent parents in child welfare: Is an evidence-based, structured, in-home behavioral parent training protocol effective?

SafeCare is an evidence-based behavioral parent training intervention that has been successfully implemented in multiple state child welfare systems. A statewide implementation in Oklahoma established the effectiveness of SafeCare with a diverse group of parents, which included adolescent parents under 21 years of age, a particularly at-risk group. The current study examined whether SafeCare is also effective for this subsample of 294 adolescent parents with regard to child welfare recidivism, depression and child abuse potential, and attainment of service goals. Post-treatment adolescent parent ratings of program engagement and satisfaction were also examined. Among the subsample of adolescent parents, the SafeCare intervention did not result in significantly improved outcomes in terms of preventing recidivism or reduction in risk factors associated with child abuse and neglect as compared to child welfare services as usual. Further, no significant differences in program engagement and satisfaction between SafeCare and services as usual were detected. These findings shed light on the potential differences in program effectiveness between adolescent and adult parents, and the need for future research to rigorously evaluate the effectiveness of behavioral parenting programs with adolescent parents.

Client and therapist match on gender, age, and income: Does match within the therapeutic dyad predict early growth in the therapeutic alliance?

OBJECTIVE

Because of the importance of the therapeutic alliance across psychotherapeutic treatments, it is important to study variables that predict the development of a positive therapeutic alliance. This study investigates if different levels of gender, age, and income match between therapists and clients predict early development of the therapeutic alliance.

METHOD

The sample consisted of 28 therapists and 547 adult clients receiving individual psychotherapy for depressive symptoms. There were no exclusion criteria and no control over treatment delivery. Session-to-session assessments of the therapeutic alliance were collected and a growth mixture modeling framework with a priori identified classes corresponding to different levels of therapist-client match was utilized to examine differential alliance growth trajectories.

RESULTS

No differential effect of match on any level was found on initial ratings of the alliance. Across levels of attribute match, clients tend to rate the alliance positively. Regarding growth, a "youth effect" and an "affluence effect" was noted. Dyads where the therapist is younger than the client, and dyads where the therapist is from a higher income status than the client, show additional growth in the alliance beyond positive initial ratings. This is effect is not constant across sessions.

CONCLUSIONS

Matching on gender, income, and age can be used for case assignment heuristic, in particular to produce additional growth in the alliance beyond initial positive ratings. Clinical and scientific consequences of the study are discussed.

Augmenting Prolonged Exposure therapy for PTSD with intranasal oxytocin: A randomized, placebo-controlled pilot trial

Posttraumatic stress disorder (PTSD) is a chronic, debilitating condition for which Prolonged Exposure (PE) therapy is highly efficacious. However, for some individuals, premature dropout and residual PTSD symptoms remain obstacles. The neuropeptide oxytocin is a promising candidate to enhance PE due to its ability to enhance 1) prosocial cognition and behavior, which are theorized to promote positive working alliance, and 2) extinction learning, which is the central mechanism of action underlying successful PE treatment. Despite a robust theoretical rationale, no studies to date have combined evidence-based psychotherapy for PTSD with oxytocin. This randomized, placebo-controlled, double-blind pilot trial examined the feasibility, safety, and preliminary efficacy of augmenting PE with oxytocin. Participants were 17 individuals with diverse index traumas. Participants self-administered intranasal oxytocin (40 IU) or matching placebo 45 min prior to each weekly PE therapy session. One adverse event occurred in the placebo group and three individuals dropped out (17.6%; 2 oxytocin group and 1 placebo group). The oxytocin group demonstrated lower PTSD and depression symptoms during PE, and had higher working alliance scores, although these differences did not reach statistical significance. Although preliminary, the findings support the feasibility of oxytocin combined with PE. Adequately powered studies are necessary to determine whether oxytocin enhances PE treatment outcomes and to examine potential mechanisms, such as accelerating extinction learning, enhancing early response, and preventing premature dropout. NCT03238924.

A review of mental health treatment dropout by ethnic minority youth

A large proportion of treatments in youth mental health care are prematurely terminated by the patient. Treatment dropout can have severe consequences. Since ethnic minority youth are treated less often for mental disorders than other youth, it is important to analyse their risk for dropout and to determine if there are ethnicity-specific determinants. This review aimed to provide an overview of the findings from empirical studies on child and adolescent therapy dropout by ethnic minority and to determine if there were ethnicity-specific dropout determinants. An extensive literature search was performed to locate relevant journal articles. Identified articles were inspected for relevant references and these articles were then included in the meta-analysis. A total of 27 studies were accepted for analysis. The results showed that ethnic minority patients have a higher risk of treatment dropout than ethnic majority patients and that dropout rates are ethnically specific. Several differences in dropout predictors among the ethnic groups were found. In spite of diverse results, review limitations, and the lack of several key variables in the available research, some clinical recommendations are made. The review indicates that to prevent dropout, therapists should pay attention to variables such as ethnic background, therapist-patient ethnic match, and the quality of the therapeutic relationship.

Concurrent child history and contextual predictors of children's internalizing and externalizing behavior problems in foster care

This study contributes to current research on the behavior problems of children in foster care by analyzing a more comprehensive set of concurrent child history and contextual predictors. Kinship home status and sibling status (i.e., whether the sibling was a biological sibling to the foster child) were evaluated as moderators of significant associations. Data were collected at the baseline of a foster parent training intervention program prior to any intervention services using parent phone interviews (N= 310, 51.6% male, M age = 7.57 years). Two linear hierarchical regressions were used to evaluate each set of predictors' association with behavior problems as well as each individual predictor's contribution. Results indicated that as a set, the contextual variables predicted a significant and unique amount of variability in the child's internalizing and externalizing behavior scores, but the child history variables did not. Specifically, the child's placement in a non-kinship home, being in a non-ethnically matched child-parent pair, higher parent stress scores, a greater number of prior group home placements, and higher internalizing behavior scores for the child predicted higher child externalizing scores. Higher parent stress scores, higher focal sibling externalizing behavior scores, and higher externalizing behavior scores for the child predicted higher internalizing scores for the child. The association between focal sibling externalizing behavior scores and child internalizing scores was moderated by kinship home status, such that there was a stronger association between the focal sibling's externalizing score and the child's internalizing score if the child was in a kinship compared to a non-kinship home. Implications for intervention services are discussed, particularly the importance of assessing the child's foster home environment when addressing the child's behavior problems.

The Process of Change in Ethnic Minority Males Undergoing Psychodynamic Psychotherapy: A detailed comparison of two cases

Objective

Better understanding of the connection between therapeutic processes and outcomes in minority groups can help design and use culturally-adapted treatments.

Method

To explore the active ingredient in the therapeutic process, the present case study compared two ethnic minority male clients, recruited as part of a randomized controlled trial (RCT), one with a good outcome, the other with a poor one. The 12-item Working Alliance Inventory-Observer (S-WAI-O) coding system was used to capture the process of change, alongside a qualitative analysis of content. The cases were identified based on their change in pre- to post-treatment scores on the Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HRSD).

Results

The findings suggest a rupture-resolution process in the good outcome case, including a process of negotiation of the alliance and work on issues of trust. In contrast, the poor outcome case showed strong and steady alliance, but context analysis pointed to withdrawal ruptures.

Conclusions

Although it is difficult to generalize from a two-case study analysis, the present work suggests that building and negotiating alliance with minority clients has a potential for treatment success.

Effect of Patient-Therapist Gender Match on Psychotherapy Retention Among United States Veterans with Posttraumatic Stress Disorder

Extant literature suggests that patient-therapist gender matching may be associated with psychotherapy retention. We examined this relationship in a national cohort of Veterans (n = 506,471) initiating psychotherapy for posttraumatic stress disorder (PTSD) using multivariate logistic regression models. Overall, women were retained in psychotherapy at higher rates than men. When patient and therapist factors as well as practice patterns are considered, gender match between female patients with PTSD and female therapists was not a positive predictor of psychotherapy retention. Contrary to our expectations, gender match between male patients with PTSD and male therapist was a negative predictor of psychotherapy retention.

Sociocultural Factors and Parent-Therapist Agreement on Explanatory Etiologies for Youth Mental Health Problems

Sociocultural factors were examined in relationship to parent-therapist agreement on beliefs about the etiology of mental health problems in a sample of youth receiving outpatient mental health services (n = 277 parents). When examined individually, racial/ethnic match was unrelated, but higher parental affinity to mainstream American culture, higher parent education level, and greater similarity in parent and therapist scores on affinity to mainstream American culture were all significantly associated with greater parent-therapist co-endorsement of etiological explanations, while higher parental affinity to an alternative/indigenous culture was significantly associated with lower co-endorsement. When examined simultaneously in one model, only parent education level remained significantly associated. Findings suggest a complex relationship between sociocultural factors and that attention to parent cultural affinity and parent education level may facilitate parent-therapist agreement on beliefs about child problem causes.

Continuity of Care in Children's Mental Health: development of a measure

A new measure, Continuity of Care in Children's Mental Health (C3MH), is presented. The study involved item generation, pre-testing, pilot testing, and validation. The C3MH was administered to 364 parents recruited from 13 children's mental health agencies in Ontario, Canada. The measure includes five scales supported by confirmatory factor analysis. Scale validity was supported through analyses of relationships with established measures of satisfaction, problem severity, and therapeutic alliance, as well as through known-group differences. The results of a pilot youth-report version (N = 57) are presented. The C3MH will be a useful tool for assessing improvements in system integration.