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Necessary But Insufficient: Evidence Supporting the Important Role of Therapeutic Relationship
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Evidence Supporting the Important
Role of Therapeutic Relationship
Dr. Linda L. Baker,
Executive Director
Centre for Children & Families in the Justice System
November 21, 2008
Importance of Evidenced-based Treatment
Increased emphasis since mid 90s
What? Who? When?
Complex challenge? (e.g., mediators-moderators-
interactions, cost, client needs, measurement tools)
body of evidence versus individual study
Why does Treatment Work?: Deconstructing
Treatment
Specific factors
technique; modality
e.g., CBT, psychoanalysis, behaviour modification
Common factors
process; nonspecific
client characteristics, therapist qualities, change
processes, treatment structure, therapeutic relationship
Other?
Learning Objectives:
Better understand the role of 2 common
factors in CYMH treatment
Describe the empirical support for pre-
treatment client expectations and
therapeutic relationship
Discuss implications for practice and future
research
Evidence: Adult vs Child & Youth Treatment
1996 APA Task Force lists ESTs for particular adult MH
disorders
Later (1999, 2001, 2002) lists of ESTs included youth
treatment
2001 APA Task Force lists ESTRs for adults
Meta analyses or reviews on ESTRS in youth research:
1992: Therapeutic relationship (Shirk and Saiz)
2003: Relationships variables (Shirk & Karver)
2005: Client expectancies (Dew & Bickman)
2006: Relationship variables (Karver, Handelsman, Fields, Bickman)
2008:Therapeutic Alliance (Elvins & Green)
Perspective
Specific and common factors play role in producing
therapeutic change
Empirical support, while increased rigor needed,
exists for both
Child and youth research and evidence on ESTs and
ESTRs has lagged behind adult research
Focus on ESTRs may be more salient and likely to be
more complex for youth than adults
Why might Relationship variables be
equally if not more critical in child and
adolescent work? Why more complicated?
What is a Therapeutic Relationship (TR)?
A common factor (i.e., transcends treatment
technique or modality)
Appears to have the strongest association with
outcomes relative to other common factors studied
Also referred to as therapeutic alliance (TA) or
working alliance (WA)
Conceptualization of TR between therapist
and client:
Personal alliance: a bond; client views therapist as
caring, understanding, knowledgeable
Task alliance: agreement on the intervention goal
(e.g., reduction of symptoms) and agreement on
plan for achieving goal (e.g., CBT)
Association of therapeutic relationship (TR)
to outcomes in child and youth treatment:
TR plays a role in producing change in clients
Meta-analysis show TR is related to outcome across
diverse types treatment across developmental levels
Small to medium effect size (r=.22)
Predictive ability similar to that of chronicity or
comorbidity
Similar effect size in adult studies, where TR is found
to be the most consistent predictor of outcome
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