by Michael D. Anestis, Ph.D.
In the current issue of the Journal of Consulting and Clinical Psychology, David Langer, Bryce McLeod, and John Weisz have published an interesting and, in my opinion, extremely important piece examining the impact of manualized treatments on therapeutic alliance in the treatment of youths suffering from internalizing (mood or anxiety) disorders. One of the most commonly cited concerns of individuals who do not espouse the use of treatment manuals is the fear that the manuals will damage alliance by making the therapist appear to rigid and unable to flexibly attend to the child. We have covered the therapeutic alliance extensively on PBB; however, because neither Joye nor I are child therapists or researchers, we've spent less time discussing it within the context of children. The authors of this study raised the important point that, because children rarely self-refer (e.g., somebody decides they need to receive treatment), alliance might be particularly important as a way to keep them in treatment and encourage them to engage with the therapist.
In this particular study, 76 youths (ages 8-15) were randomly assigned to receive manualized treatment or nonmanualized care as usual in community clinics. The authors measured alliance using two methods. The first - the Therapeutic Alliance Scale for Children (TASC) - was a self-report scale adminitered at the end of treatment to assess the children's view of the alliance. The second - the Therapy Process Observational Coding System - Alliance (TPOCS-A) - was an observer-measure involving behavioral coding of sessions at four points throughout treatment. By using these methods, the authors were able to assess both the children's views and another viewpoint to ensure that demand characteristics (e.g., did the children feel pressured to say alliance was strong?) and insight (e.g., were the children able to conceptualize and accurately report on their feelings?) did not improperly impact results.
So what did they find? First off, post-treatment scores on the children rated alliance did not differ between groups, meaning that children receiving manualized treatment reported feeling no different about their alliance with their therapist than did children receiving nonmanualized treatment. A similar result was found using observer-rated alliance, with no differences between groups.
The authors also examined multilevel models of alliance, which allowed them to see if, at any point throughout treatment, one group rated alliance as better than the other group. In fact, in early treatment, children in the manualized group reported a stronger alliance than did children in the nonmanualized group. Overtime, the groups converged, meaning that in the middle of treatment and at the end of treatment, children in either group reported essentially identical quality alliance.
So what does this mean? The argument that treatment manuals will undermine the alliance in the treatment of youth was not supported. In fact, early in treatment (when clients are most likely to drop out), manualized treatments appear to be associated with a stronger alliance, perhaps because of the level of clarity involved in describing goals and upcoming tasks.
It is entirely understandable for individuals unfamiliar with treatment manuals to feel concern regarding the impact they might have on therapy. The bottom line, however, is that manuals do not turn therapists into robots unable to express empathy or respond to the individual client. They are a guideline that ensure that the therapist is covering all relevant material and actually providing the form of care that the manual is supposed to involve. A bad therapist might appear robotic through the use of treatment manuals, but a bad therapist is likely to appear equally flawed without a manual.
If you would like to learn more about this or other topics discussed on PBB, we recommend that you consult our online store for scientifically-based psychological resources.
Articles cited in this piece:
Langer, D.A., McLeod, B.D., & Weisz, J.R. (2011). Do treatment manuals undermine youth-therapist alliance in community clinical practice? Journal of Consulting and Clinical Psychology, 79, 427-432.