The therapeutic alliance in treatment of traumatized youths: relation to outcome in a randomized clinical trial

Objective: We examined the contribution of alliance to the outcome of therapy with traumatized youths across two different treatment conditions (trauma-focused cognitive behavioral therapy [TF-CBT] and therapy as usual [TAU]).

Method: Participants were 156 youths (M age = 15.1 years, range = 10-18; 79.5% girls), randomly assigned to TF-CBT or TAU. Symptoms were assessed pretreatment, midtreatment (Session 6), and posttreatment (Session 15). Alliance was assessed after Sessions 1 and 6, using the Therapeutic Alliance Scale for Children-Revised (TASC-R).

Results: Alliance scores were comparable across treatment conditions, but TF-CBT participants had significantly lower posttraumatic stress symptoms (PTSS) posttreatment (d = 0.51). Hierarchical regression analyses showed that there were no significant alliance effects in models without an Alliance × Treatment Group interaction: Alliance ratings were significant predictors of reduction in PTSS (Est. = -0.53, p = .003, 95% confidence interval [CI] = -0.87 to -0.18) and additional outcomes measured in TF-CBT but not in TAU (PTSS posttreatment: Est. = 0.01, p = .647, 95% CI = -0.29 to 0.47).

Conclusion: This study was the first to investigate the contribution of alliance to outcome among adolescents with posttraumatic symptoms, treated with TF-CBT or TAU. Our findings indicated that there was an important interaction between alliance and therapeutic approach, as alliance predicted outcome in TF-CBT, but not in the nonspecific treatment condition. A positive working relationship appeared to be especially important in the context of this evidence-based treatment, which requires youth involvement in specific therapy tasks. Further, findings showed that use of a manual did not compromise alliance formation.