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Objective: Trauma-focused cognitive-behavioral therapy (TF-CBT) is a recommended treatment for posttraumatic 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. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Objective: We examined the contribution of alliance to the outcome of therapy with traumatized youths across two different treatment conditions (trauma-focused cognitive behavioral therapy [TF-CBT] and therapy as usual [TAU])., Method: Participants were 156 youths (M age = 15.1 years, range = 10-18; 79.5% girls), randomly assigned to TF-CBT or TAU. Symptoms were assessed pretreatment, midtreatment (Session 6), and posttreatment (Session 15). Alliance was assessed after Sessions 1 and 6, using the Therapeutic Alliance Scale for Children-Revised (TASC-R)., Results: Alliance scores were comparable across treatment conditions, but TF-CBT participants had significantly lower posttraumatic stress symptoms (PTSS) posttreatment (d = 0.51). Hierarchical regression analyses showed that there were no significant alliance effects in models without an Alliance × Treatment Group interaction: Alliance ratings were significant predictors of reduction in PTSS (Est. = -0.53, p = .003, 95% confidence interval [CI] = -0.87 to -0.18) and additional outcomes measured in TF-CBT but not in TAU (PTSS posttreatment: Est. = 0.01, p = .647, 95% CI = -0.29 to 0.47)., Conclusion: This study was the first to investigate the contribution of alliance to outcome among adolescents with posttraumatic symptoms, treated with TF-CBT or TAU. Our findings indicated that there was an important interaction between alliance and therapeutic approach, as alliance predicted outcome in TF-CBT, but not in the nonspecific treatment condition. A positive working relationship appeared to be especially important in the context of this evidence-based treatment, which requires youth involvement in specific therapy tasks. Further, findings showed that use of a manual did not compromise alliance formation., (PsycINFO Database Record (c) 2014 APA, all rights reserved.)