Building a working alliance with adolescent clients
In this week’s study, Orlowski and colleagues (2023) perform a systematic review and meta-analysis to uncover what a therapist must do to build a working alliance with a teenage client. As those who work with adolescents well know (and those of us who rarely, if ever, work with teens are blissfully unaware of), there are some key differences from building an alliance with adults. For example (and by the way, these examples are all by Orlowski and his co-workers so blame them if these are out of touch), when working with adults, it’s recommended that the therapist explores the client’s own understanding of their problems and what’s causing them; this will likely strengthen rapport. However, adolescents usually have less insight into how their difficulties got started and are now maintained. Adult clients are more likely to have some idea of what to expect from therapy and how it might be able to help. Adolescents will probably have less idea of what is expected of them and what they may hope to get out of therapy. Rapport with adult clients seems to be influenced by how professional and competent the clinician appears, however, it’s not clear adolescents value these same qualities (on average); they may prefer someone who is friendly, warm and more like them. Working with adolescent clients usually means maintaining alliances with multiple people at once including separated parents, schools and sometimes, other government departments. Finally, adolescents are usually referred to treatment by someone else, rather than it being their choice to attend. No wonder so many of us avoid this work! Until this review, there had only been one review into which clinician behaviours contribute to alliance formation with young clients, and this was based on only four studies. So, it was high time a larger systematic review was performed.
The review had few limits and yet uncovered only 13 studies that could be included in the quantitative meta-analysis (covering n=651 adolescents). An additional 39 studies were reviewed for qualitative information. The average age of clients across the studies was 14. Across the 52 studies narratively reviewed, there was a diverse range of presentations (35% general psychopathology, 17% anxiety and depression, 10% substance use, 2% attention disorders, 2% trauma histories). A minority of studies included youth from foster care (4%) or youth justice (6%) systems. Most were treated in outpatient mental health clinics (54%), with small numbers treated in either home-based interventions (14%), inpatient/residential settings (12%), school settings (10%), juvenile detention centres (6%) or emergency shelters (2%). Surprisingly, 60% of the studies didn’t report whether a specific kind of treatment was used or not, which reflects poorly on the state of adolescent mental health literature. Approximately, 17% involved CBT and another 17% involved family therapy. Only one study measured working alliance from the perspective of the client, therapist, and an observer (gold standard), half the studies measured both client and therapist perspective, but most commonly (46%) only an observer perspective was taken. Alliance was always measured within the first 3 sessions.
Quantitatively, alliance-building therapist behaviours had a weak relationship with alliance (r = .17 [.09, 0.26] – in other words <3% variance in working alliance could be explained by therapist behaviours). Alliance-reducing behaviours also had a small but slightly larger effect on the alliance (~5.6% variance) than alliance-building behaviours (r = -.24 [-.38, -.10]), although this was based on only 5 studies. Box 1 lists the major themes identified within the qualitative studies (usually based on focus group interviews) that were also evident in the quantitative studies (see the original article for other themes extracted from qualitative studies alone).
So, perhaps adults and adolescents aren’t so different after all. The results here mirror the adult working alliance literature quite closely. Who would have thought that teenagers were people too. Almost as if every adult was once a teenager. A possible exception is that teenagers really don’t want to be pushed to talk before they are ready whereas qualitative studies have documented that many adult clients recognise and appreciate that effective therapists will push them to push themselves, within acceptable limits. However, given the quality and quantity of child and adolescent mental health literature, it is probably premature to disregard adolescent-specific needs in alliance-building. The same things that make it challenging to work with adolescent clients make it exponentially challenging to research children and adolescents. Addressing these challenges should be an international priority for governments and universities. The authors note that even though the same behavioural goals apply to forming alliances with adults and adolescents, the specific methods to implement these behaviours may yet vary with developmental age. However, more research is needed to support this idea at this stage.
Clinician implications
In building alliances with adolescent clients:
Embody the same facilitative interpersonal skills that you would with clients of any age (e.g., genuine, empathic, respectful, trustworthy, nonjudgmental, friendly etc)
Orient them to therapy (teach them what therapy involves) and present a model of treatment; i.e., explain how the changes you recommend they make will help reduce their problems/facilitate them reaching their goal
Remember to praise them and convey that you believe in their capability to achieve their goals
Work hard to avoid criticising, distorting, or misunderstanding what they say, or missing signs of significant emotions they’re experiencing (clinician lapse)
Avoid pushing adolescents to talk about something when they’re not ready to
For the original article, go to: https://www.sciencedirect.com/science/article/pii/S0272735823000314
REFERENCES
Orlowski, E. W., 3rd, Bender, A. M., & Karver, M. S. (2023). A systematic review and meta-analysis of clinician behaviors and characteristics related to alliance building with youth clients. Clinical psychology review, 102, 102273. https://doi.org/10.1016/j.cpr.2023.102273