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Therapist fidelity in two family-based treatments: association with client outcomes, therapeutic alliance and the role of therapist factors in treatment
Dissertation   Open access

Therapist fidelity in two family-based treatments: association with client outcomes, therapeutic alliance and the role of therapist factors in treatment

Maliha Ibrahim
Doctor of Philosophy (Ph.D.), Drexel University
28 Feb 2019
DOI:
https://doi.org/10.17918/j8kk-ab24
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Abstract

Couples therapy Family psychotherapy Counseling psychology Family therapists
Introduction. Efforts to determine effective psychotherapy interventions are confounded by a variation in treatment delivery by therapists. For high-risk populations impacted by depression and suicidal behavior, therapist interventions are important to consider. Methods & Aims. Using outcomes data from a large randomized controlled trial (RCT), this study evaluated therapist fidelity to 16 weeks of interventions in Attachment Based Family Therapy (ABFT) and Family-Enhanced non-directive supportive therapy (FE-NST), for their impact on client outcomes for 129 adolescents. The researcher coded fidelity data from recorded therapy tapes and utilized existing outcomes data. This dissertation explores three research questions. First, does therapist overall fidelity to the treatment manual predict improved client outcomes? (Reduced suicidal thoughts and behaviors, reduced depression symptoms, increased family functioning and client satisfaction) Second, does therapists' use of relational interventions unique to ABFT, contribute to outcomes? Third, do peripheral factors such as therapeutic alliance and therapist demographics moderate this adherence-outcome association? 17 therapists participated in the study and independent coders rated 280 therapy sessions on a fidelity measure that comprised interventions from both treatments. Analysis & Results. The tool was psychometrically validated through a factor analysis using the principal component analysis method. Inter-rater reliability was established between coders and between coders and trainers at [alpha]=0.90. Multi-level analysis using pre-post change scores in the Hierarchical Linear Regression (HLM) method, accounted for nesting by treatment and therapist. Findings revealed that overall therapist fidelity was associated with reduced suicidal ideation and increased client satisfaction in the presence of a positive therapeutic alliance. Utilization of relational interventions in family therapy promoted youth-reported family cohesion. Mediation analysis revealed that therapist fidelity to ABFT mechanisms in early and middle stages of treatment increased family functioning, which in turn improved depression outcomes. Discussion. The above findings are presented in the context of existing fidelity research. The opportunities and challenges associated with training therapists in manualized treatments are discussed. Research and clinical implications for different therapy models and future therapist training are also noted.

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