Youths’ Alliance, Involvement Behaviors, and Therapists’ Alliance-building: A Process-Outcome Study of Youths Receiving Trauma-Focused Cognitive Behavioral Therapy

Abstract

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. (...) 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