Abstract
Some critics of treatment manuals have argued that their use may undermine the quality of the client-therapist alliance. This notion was tested in the context of youth psychotherapy delivered by therapists in community clinics. Seventy-six clinically referred youths (57% female, age 8-15 years, 34% Caucasian) were randomly assigned to receive nonmanualized usual care or manual-guided treatment to address anxiety or depressive disorders. Treatment was provided in community clinics by clinic therapists randomly assigned to treatment condition. Youth-therapist alliance was measured with the Therapy Process Observational Coding System--Alliance (TPOCS-A) scale at 4 points throughout treatment and with the youth report Therapeutic Alliance Scale for Children (TASC) at the end of treatment. Youths who received manual-guided treatment had significantly higher observer-rated alliance than usual care youths early in treatment; the 2 groups converged over time, and mean observer-rated alliance did not differ by condition. Similarly, the manual-guided and usual care groups did not differ on youth report of alliance. Our findings did not support the contention that using manuals to guide treatment harms the youth-therapist alliance. In fact, use of manuals was related to a stronger alliance in the early phase of treatment.
Highlights
Surveys and focus groups have revealed concerns that the use of treatment manuals may impede the development of a positive client–therapist alliance
Some critics have raised concerns that treatment manuals may negatively impact the quality of the alliance
The groups converged over time, such that there was no significant alliance difference between the two groups at mid-treatment or late in treatment; this was consistent with findings from the self-report alliance measure (TASC) showing no alliance difference at post-treatment
Summary
Youth and therapist pre-treatment differences between conditions were examined first and no significant differences were found (see Table 2). Overall observed alliance was not significantly different between conditions, γ1 = 0.20, p = .179 (0.26 SDs on the TPOCS-A) This test had a power of .70 to detect a coefficient of 0.37 (0.47 SDs on the TPOCS-A scale; Snijders & Bosker, 1999). Condition had a significant impact on alliance scores when included as a fixed factor on the model intercept and the slope of time (Model 1b). Youth gender was a significant predictor of initial alliance levels, with females showing significantly higher alliance early in treatment.. Power was .70 (two-tailed α = .05) to detect a condition effect of approximately 0.50 SDs on the intercept and 0.27 SDs on the slope, on the TPOCS-A scale (Snijders & Bosker, 1999)
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