Therapist Adherence to Two Treatments for Adolescent Suicide Risk: Association to Outcomes and Role of Therapeutic Alliance.

In psychotherapy research, adherence refers to the extent to which therapists deliver a treatment as intended. This study examined whether therapist adherence to two different manualized treatments was associated with improved client outcomes and whether the association was moderated by therapeutic alliance. The study sample included 320 video recordings of therapy sessions from 118 cases in a randomized controlled trial (RCT) comparing attachment-based family therapy (ABFT) with family-enhanced nondirective supportive therapy (FE-NST). Recordings were selected from early, middle, and late stages of treatment. The adherence measure consisted of 24 items representing essential therapist interventions from both treatments. Trained raters coded tapes from both therapies. Adolescent self-report of alliance was measured at session 4. Adherence to ABFT was associated with a significant increase in family cohesion at mid-treatment but not at posttreatment. Adherence to FE-NST was significantly associated with an increase in suicide ideation posttreatment. Using therapeutic alliance as a moderator, adherence to ABFT was significantly associated with a reduction in suicide ideation, family conflict, and higher client satisfaction posttreatment. Alliance did not positively affect the association of FE-NST adherence to outcomes. Findings suggest that adherence to ABFT interventions may be better linked to treatment outcomes when adolescents feel a strong alliance with their therapist. Implications for future research and therapist training are explored.

En la investigación sobre psicoterapia, la adhesión se refiere al grado en el cual los terapeutas brindan un tratamiento según lo previsto. Este estudio analizó si la adhesión del terapeuta a dos tratamientos estandarizados diferentes estuvo asociada con mejores resultados en los pacientes y si la asociación estuvo moderada por la alianza terapéutica. La muestra del estudio incluyó 320 videograbaciones de sesiones de terapia de 118 casos en un ensayo aleatorizado controlado donde se comparó la terapia familiar basada en el apego (TFBA) con la terapia de apoyo no directiva optimizada por la familia (TAND-OF). Se eligieron grabaciones de las etapas iniciales, intermedias y finales del tratamiento. El instrumento de medición de la adhesión consistió en 24 ítems que representaban intervenciones esenciales del terapeuta de ambos tratamientos. Un grupo de calificadores capacitados codificaron las grabaciones de ambas terapias. El autoinforme de alianza de los adolescentes se midió en la cuarta sesión. La adhesión a la TFBA estuvo asociada con un aumento considerable de la cohesión familiar en la mitad del tratamiento, pero no después del tratamiento. La adhesión a la TAND-OF estuvo asociada considerablemente con un aumento de la ideación suicida después del tratamiento. Utilizando la alianza terapéutica como moderadora, la adhesión a la TFBA estuvo asociada considerablemente con una reducción de la ideación suicida, el conflicto familiar y una mayor satisfacción del paciente después del tratamiento. La alianza no afectó positivamente la asociación de la adhesión a la TAND-OF con los resultados. Los resultados sugieren que la adhesión a las intervenciones de TFBA puede asociarse mejor con los resultados del tratamiento cuando los adolescentes sienten una alianza fuerte con su terapeuta. Se analizan las implicancias para futuras investigaciones y para la capacitación de los terapeutas.

Behavioral Activation as an 'active ingredient' of interventions addressing depression and anxiety among young people: a systematic review and evidence synthesis.

BACKGROUND: Psychological interventions such as behavioral activation (BA) that focus on overt behaviors rather than complex cognitive skills may be developmentally well-suited to address youth mental health problems. The current systematic review synthesized evidence on the characteristics, effectiveness and acceptability of behavioral activation (BA) to examine its role as a potential 'active ingredient' for alleviating depression and anxiety among young people aged 14 to 24 years. METHODS: Evidence across the following sources were synthesized: (i) randomized control trials (RCT) evaluating interventions where BA has been used as a standalone intervention or as part of a multicomponent intervention, (ii) qualitative studies examining the acceptability of BA as an intervention or as a coping strategy among young people with lived experiences. Consultations with a youth advisory group (YAG) from India were used to draw inferences from existing evidence and identify future research priorities. RESULTS: As part of the review, 23 RCTs were identified; three studies examined BA as a standalone intervention, and the remaining studies examined multicomponent intervention where BA was a constituent element. The intervention protocols varied in composition, with the number of intervention elements ranging between 5 to 18. There was promising but limited evidence in standalone interventions for thse effectiveness of BA for depression. The impact of BA in multicomponent interventions was difficult to evaluate in the absence of focal assessment of activation outcomes. Evidence from 37 additional qualitative studies of youth lived experience literature, corroborated by the YAG inputs, indicated that young people preferred using behavioral strategies similar to BA to cope with depression in their own life. Themes indicated that the activities that are important to an individual and their socio-contextual factors need to be considered in the planning and implementing BA intervention. Evidence for the use of BA in anxiety was limited across data sources. CONCLUSIONS: Overall, there was preliminary empirical evidence for the effectiveness and acceptability of BA for youth depression. Further research is needed to examine the components and mechanisms that contribute to its effectiveness as an active intervention ingredient for depression and anxiety.