Working Alliance in Internet-based Cognitive Behaviour Therapy for Children and Adolescents

Renee Anderson (2011). Working Alliance in Internet-based Cognitive Behaviour Therapy for Children and Adolescents PhD Thesis, School of Psychology, The University of Queensland.

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Author Renee Anderson
Thesis Title Working Alliance in Internet-based Cognitive Behaviour Therapy for Children and Adolescents
School, Centre or Institute School of Psychology
Institution The University of Queensland
Publication date 2011-02
Thesis type PhD Thesis
Total pages 253
Total colour pages 3
Total black and white pages 250
Subjects 17 Psychology and Cognitive Sciences
Abstract/Summary Working alliance, or therapeutic alliance, refers to the quality and nature of the patient–therapist interaction, the collaborative nature of that interaction on the tasks and goals of treatment, and the personal bond or attachment that emerges in therapy (Kazdin, Whitley, & Marciano, 2006). In the adult literature, volumes of research have examined the relationship between working alliance and treatment outcome. Research suggests that the quality of working alliance is a modest, yet consistent predictor of outcome across therapeutic orientations in traditional therapy for adult populations. However, far less research has been conducted to establish the nature of the alliance-outcome relationship in a child and adolescent population, particularly so when therapy is conducted using the Internet. The focus of the current thesis is upon the nature and measurement of working alliance associated with online therapy for children and adolescents with anxiety disorders, and the extent to which working alliance is a predictor of treatment outcome. Despite the existence of efficacious face-to-face treatments for anxiety disorders, as many as two in three children and adolescents do not receive the psychological assistance they require (Essau, Conradt, & Petermann, 2000). Stigma associated with attending a clinic has been identified as a major reason for the delay observed in young people seeking help (Berger, Wagner, & Baker, 2005). Internet-based interventions represent an alternative for delivering cognitive behaviour therapy (CBT) interventions that may be more appealing and accessible to a greater proportion of anxiety disordered youths. A strong working alliance has consistently been linked with positive outcomes in traditional therapy. Therefore, one of the major criticisms levelled against online therapy has been the assumption that a lack of face-to-face contact would prohibit the development of working alliance. There is evidence from studies with adults that alliance can indeed be developed during online therapy and that the strength of this relationship is as strong, if not stronger in some cases, as face-to-face therapy (e.g., Cook & Doyle, 2002; Reynolds, Stiles, & Grohol, 2006). Little is known about what working alliance means in online therapy. The current thesis examines the nature of working alliance with a therapist-assisted Internet-based CBT program for the treatment of clinically anxious children and adolescents. Participants have an online therapist; however they receive no face-to-face contact and only brief email contact and one brief phone call. Therapy is primarily delivered via a computer through online, interactive sessions. Strategies designed to be alliance-enhancing were incorporated into the program to simulate therapist contact and therefore bolster alliance. In the present thesis, the first study aimed to establish if youth and parent working alliance was able to be reliably measured for participants completing an Internet-based CBT intervention for anxiety disorders. A confirmatory factor analysis was conducted to determine whether the factor structure of a well known alliance measure, the Working Alliance Inventory – Short Form S (WAI-S; Tracey & Kokotovic, 1989), was equivalent for online therapy to that found elsewhere in the literature. The study involved 137 youths aged 7 to 18 years with a clinical anxiety diagnosis and at least one parent to complete the parent component of the online program. Participants completed the WAI-S after session three. A single, overarching factor of alliance was found to provide the best model of working alliance for youths and parents. The measure demonstrated high internal consistency. In the second study, the aim was to examine whether young people and their parents participating in a clinic-based CBT intervention for anxiety demonst¬rated greater therapeutic alliance with a therapist with whom they had face-to-face contact, compared to participants in an online-based CBT intervention when no face-to-face contact with a therapist was experienced. The study involved 73 anxiety disordered youths (35 in the clinic-condition and 38 in the online-condition) aged 12 to 18 years and at least one parent. The results indicated that there were no significant differences in the quality of alliance scores for youths in the clinic and online conditions. Youths in both conditions rated alliance with their therapist highly. Although parents in the clinic-condition rated alliance significantly higher than parents in the online-condition, the difference was small and parents in both conditions rated the therapeutic alliance highly. In the final study, the aim was to establish if working alliance predicted treatment outcomes, and if alliance predicted treatment compliance (percentage of session tasks completed by 6-month follow-up), for young people completing an online-CBT intervention for anxiety. It was hypothesised that the relationship between alliance and outcome (Children’s Global Assessment Scale [CGAS] at 6-month follow-up) would be mediated by youth compliance with therapy tasks. The results indicated that age moderated a number of relationships. For older youths (i.e., adolescents aged 12 to 18 years), significant associations were found between alliance and outcome and compliance and outcome, as well as parent-alliance and outcome. Although alliance and compliance both predicted outcome, and were associated with each other for adolescents, their relationship with outcome was not a mediated one. No significant relationships were evident between alliance, compliance, and outcome for children (aged 7 to 11 years). Overall, the results from the thesis suggest that not only can working alliance be reliably measured in youths completing an online-CBT intervention, but the strength of this relationship is not significantly different compared to alliance rated by young people completing face-to-face therapy. This finding is relevant given that for youths participating in online therapy, contact with a therapist was minimal (i.e., brief email and phone contact) and all other youth-therapist interactions were computer generated. The research also indicated that for older youths (i.e., 12 to 18 years), there was a significant association between youth-alliance, youth-compliance, and outcome, although contrary to predictions, the impact of alliance upon outcome was not dependent upon compliance with therapy tasks. More research is required to replicate these findings and the limitations of the studies and areas for future research are discussed. The findings may not be generalisable to self-help internet based programs for anxiety.
Keyword working alliance, therapeutic alliance, online therapy, internet therapy, youths (children and adolescents), anxiety, CBT
Additional Notes 79-81

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Created: Thu, 16 Jun 2011, 17:15:14 EST by Ms Renee Anderson on behalf of Library - Information Access Service