Therapists' Behaviors and Youths' Therapeutic Alliance During Trauma-Focused Cognitive Behavioral Therapy

Objective: Trauma-focused cognitive-behavioral therapy (TF-CBT) is a recommended treatment for post-traumatic stress (PTS) in youth, and a strong therapeutic alliance predicts reductions of PTS in TF-CBT. However, little is known of how therapists can build a strong alliance. This study seeks to understand which therapist behaviors are associated with the strength of alliance in TF-CBT. Method: Participants were 65 youth (M age = 15.1, SD = 2.19; 77% girls) engaged in TF-CBT and their therapists (n = 24). The alliance was assessed midtreatment using the Therapeutic Alliance Scale for Children-revised. Therapists' behaviors were coded using the Adolescent Alliance-Building Scale-revised, and youth engagement behavior was coded using the Behavioral Index of Disengagement Scale. Linear mixed-effects models were used to evaluate clients' and therapists' in-session behaviors as predictors of the alliance, in addition to assessing the potential moderating effects of youth behaviors. Results: Rapport-building behaviors were significantly predictive of higher alliance scores (Est. = 1.81, 95% CI [0.11, 3.52], p=.038), whereas there was no predictive effect of treatment socialization or trauma-focusing behavior on alliance scores. Initial youth behavior significantly moderated the effect of trauma-focusing on the alliance (p=.007); greater focus on trauma was associated with higher alliance scores among passively disengaged youth (Est. = 4.92, 95% CI [1.80, 8.05], p=.003). Conclusions: Rapport-building behaviors are associated with a stronger alliance in TF-CBT. Gradual exposure through initial trauma-eliciting does not appear to undermine alliance formation but is rather associated with higher alliance-scores among passively disengaged youth.