The therapeutic alliance in cognitive behavioral therapy for youth anxiety disorders Krister Westlye Fjermestad Dissertation for the degree philosophiae doctor (PhD) University of Bergen, Norway 2012 2 Scientific network The professional network involved in this dissertation is The Bergen Group for Treatment Research, Department of Clinical Psychology, Faculty of Psychology, University of Bergen, and the Anxiety Disorders Research Network, Haukeland University Hospital, Norway. Considerable input has also been provided by researchers affiliated at Florida International University, Stockholm University, University of Oslo, University of Virginia, and Virginia Commonwealth University. 3 Table of contents Acknowledgements ........................................................................................................ 4 List of papers .................................................................................................................. 7 List of abbreviations ...................................................................................................... 8 Abstract ........................................................................................................................ 10 Introduction .................................................................................................................. 12 Background .............................................................................................................. 12 Definitions of Key Concepts .................................................................................... 13 Rationale .................................................................................................................. 18 Theoretical Foundation ............................................................................................ 20 Research Aims ......................................................................................................... 22 Methods ........................................................................................................................ 23 The ATACA Study .................................................................................................. 23 Measures .................................................................................................................. 28 Data Analytic Procedures and Statistics .................................................................. 32 Results .......................................................................................................................... 34 General Discussion ...................................................................................................... 36 Relation of Results to Other Studies ........................................................................ 36 Methodological Considerations and Limitations ..................................................... 42 Strengths of the Dissertation .................................................................................... 49 Implications for Clinical Practice ............................................................................ 50 Implications for Research ........................................................................................ 51 Conclusions .............................................................................................................. 53 References .................................................................................................................... 55 4 Acknowledgements This dissertation is part of the child section of the “Assessment and Treatment – Anxiety in Children and Adults (ATACA)” study, which has received support from the Western Norway Regional Health Authority through project numbers 911366 and 911253. The Meltzer Research Foundation has provided travel grants that contributed to the completion of this dissertation. The dissertation project was supported by "The National Program for Integrated Clinical Specialist and PhD-training for Psychologists" in Norway (Prosjekt “Dobbelkompetanse”). This program is a joint cooperation between the Universities of Bergen, Oslo, Tromsø, The Norwegian University of Science and Technology (Trondheim), the Regional Health Authorities, and the Norwegian Psychological Association. The program is funded jointly by The Ministry of Education and Research and The Ministry of Health and Care Services. As part of the program, I did my clinical work at the Child In-Patient Unit (Barneposten), Haukeland University Hospital. I enjoyed my time there and I am grateful to Sture Larsen and the rest of the team for taking such good care of me. I would like to thank the youth and parents, as well as the therapists, assessors, and administrative clinic staff who volunteered for the ATACA study and made this dissertation possible. I am also very grateful to my main supervisor, Dr. Bente Storm Mowatt Haugland. Bente, you have been good at trying to keep me grounded, helped me not get too lost on sidetracks, and constantly reminded me of the overall purpose of clinical research. It has been a benefit to have a supervisor who I appreciate and respect so much. I would also like to thank my co-supervisors, Professors Einar R. Heiervang and Odd E. Havik, who are also the principal investigators of ATACA. Einar, you have been excellent at making international contacts and getting us 5 noticed. Odd, you have been available to an extent that exceeded all expectations, which has been a great support. To my third co-supervisor, professor Lars-Göran Öst, your opinions have been of high value, and I have learnt much from you about treatment research. Gro Janne Henningsen Wergeland, my fellow PhD-candidate, this project would never have landed had it not been for you. You have kept a thorough overview of all the details of ATACA throughout the project, and I have learnt much from you. I have enjoyed our mutual travels and projects. I have grown very fond of you as a colleague and a friend, and I hope we continue working together for a long time! I also owe warm thanks to the other members of the ATACA project group, with special thanks to the clinical supervisors, Kristin Oeding and Jon F. Bjåstad, as well as the PhD-candidates in the adult part of ATACA, Tine Nordgreen and Thomas Haug. Stine Hauge, Charlotte Jevne, Gerd Bjørkedal, Gerd Kvale, Ingvar Bjelland, Ole Johan Hovland, and Tone Tangen are all valuable members of the project group. I am also grateful to Marianne Christensen and Randi Skogstad for coding videotapes for Paper II, and to Torbjørn Torsheim for statistical input and practical help with the data. Joakim Jonsen has done an incredible job with data punching. I have also had other collaborators who I owe much gratitude. Dr. Bryce D. McLeod, Virginia Commonwealth University, has been invaluable as a co-author on two of the papers in this dissertation, as well as on other projects. Bryce, you have been extremely generous with your time and knowledge, and you and your family were very welcoming to me during my stay in Richmond. My gratitude to you is enormous and can not be expressed properly in words. Professors Paula M. Barrett, University of Queensland, and Wendy K. Silverman, Florida International University, have also been excellent research tutors. The staff members at Pathways Health and 6 Research Clinic in Brisbane were incredibly helpful to me during my stay there in 2007 – warm thanks to Sarah Anticich and Dr. Emily O’Leary, and to Ben Walker. Matthew D. Lerner, University of Virginia – you’re a stats star and I hope to work more with you in the future. I would also like to thank my parents Åse and Kjell, my brother Thomas and my sister Silje for their support. To my niece Signe and my nephew Åsmund - thank you both for being such bright sparks! And my fabulous friends, you all know who you are. Ingrid, Otto, Marit, Tim, Fredrik, Silje, Herleiv, Filli, Gro, Sigve, Dag, Bernt… And Linda, sharing joys, frustrations, conference hotels, flights, and airline lounges with you has been just priceless. 7 List of papers Paper I Fjermestad, K. W., Haugland, B. S. M., Heiervang, E. R., & Öst, L.-G. (2009). Relationship factors and outcome in child anxiety treatment studies. Clinical Child Psychology and Psychiatry, 14(2), 195-214. Paper II Fjermestad, K. W., McLeod, B. D., Havik, O. E., Heiervang, E. R., Öst, L.-G., & Haugland, B. S. M. (in press). Factor structure and psychometric properties of the Therapy Process Observational Coding System – Alliance Scale. Journal of Clinical Child and Adolescent Psychology. Paper III Fjermestad, K. W., Lerner, M. D., McLeod, B. D., Wergeland, G. J. H., Haugland, B. S. M., Havik, O. E., Öst, L.-G., & Silverman, W. K. (2011). Predictors of early alliance and alliance change in CBT for youth with anxiety. Manuscript submitted for publication. 8 List of abbreviations ADIS-C/P Anxiety Disorders Interview Schedule – child and parent version APA American Psychological Association ATACA Assessment and Treatment – Anxiety in Children and Adults CBCL Child Behavior Checklist CBT Cognitive behavioral therapy CS Credibility Scale DAWBA Development and Well-being Assessment GAD Generalized anxiety disorder GCBT Group-based cognitive behavioral therapy HLM Hierarchical linear modeling ICBT Individual-based cognitive behavioral therapy ICC Intraclass correlation coefficient MASC Multidimensional Anxiety Scale for Children MFA Multi-level factor analysis NML Nijmegen Motivation List RC Reliable change RCT Randomized controlled trial SAD Separation anxiety disorder SP Social phobia TASC-C/T Therapeutic Alliance Scale for Children – child and therapist version TC Treatment credibility 9 TPOCS-A Therapy Process Observational Coding System – Alliance Scale WAI Working Alliance Inventory 10 Abstract This dissertation is about the therapeutic alliance in cognitive behavioral therapy (CBT) for youth anxiety disorders. It comprises three papers, as well as a summary in which I describe the background and rationale for the papers and discuss the findings. Paper I is a systematic review of 19 randomized controlled trials (RCTs) assessing the link between relationship factors and outcome in CBT for youth anxiety disorders. The identified relationship factors were parental participation, treatment involvement, and the therapeutic relationship. Paper I highlighted the paucity of studies that have examined relationship factors in CBT for youth anxiety disorders. The need to both further explore relationship factors and to establish psychometrically sound relationship measures was emphasized. I examined these questions in Papers II and III. Paper II examined the factor structure and psychometric properties of an observation-based alliance measure for youth psychotherapy, the Therapeutic Process Observational Coding System –Alliance Scale (TPOCS-A; McLeod & Weisz, 2005). The TPOCS-A was used to assess client-therapist alliance in a subsample drawn from a RCT for youth anxiety disorders comparing individual-based CBT, group-based CBT, and a waitlist condition. We found support for the reliability as well as the convergent and divergent validity of the TPOCS-A. Principal axis factor analysis supported a one-factor solution of the alliance. This is in contrast to theories that postulate separate alliance dimensions, but in line with findings from previous factor analytic studies of youth alliance measures. Paper III examined youth motivation and perceived treatment credibility as predictors of youth- and therapist-rated early alliance and alliance change from early to late in treatment. This paper was based on a larger sample drawn from the same