Rauktis

Treatment Foster Care and Therapeutic Alliance: the nature of relationships between treatment parents and youth : 

Treatment Foster Care and Therapeutic Alliance: the nature of relationships between treatment parents and youth Mary Beth Rauktis, Ph.D. Shauna Reinhart, M. P. A. Lucy McDonough, M.Ed Ann Doucette, Ph.D. Ana Regina Andrade, Ph.D. CHARPP September 26-27, 2005

Pressley Ridge Mission: 

Pressley Ridge Mission To improve the adjustment & achievement of young people with troubling behaviors and their families through effective programs that focus on all aspects of their lives. To lead in the development of innovative programming, evaluating those programs, measuring their outcomes, and conducting research. To champion initiatives that impact the system of care for young people and their families.

Pressley Ridge Values : 

Pressley Ridge Values Idealism is imperative Relationships are paramount Joy in our work is essential Re-ED is our foundation We strive for quality-nothing less than our best We are all teachers and we are all learners

Where we are...: 

Where we are... Delaware Kentucky Maryland Ohio Pennsylvania Virginia Washington, D.C. West Virginia International Presence Hungary Portugal & Brazil Ukraine

What is Therapeutic Alliance?: 

What is Therapeutic Alliance? Working relationship between youth and treatment parent that is based on: Perception of an emotional bond Agreement on goals of treatment Agreement on tasks to reach goals Perception of openness & truthfulness of the relationship (Doucette & Bickman, 2001)

Why Study Alliance?: 

Why Study Alliance? All psychotherapy occurs within an interpersonal relationship. Alliance seen as critical in many orientations. Among adults, alliance is a consistent predictor of engagement and outcome (Horvath & Symonds, 1991; Martin et al., 2000). Evidence is limited among children, but practicing clinicians and treatment researchers alike report alliance is important (Brent & Kolko, 1998; Kazdin et al., 1990; Shirk & Saiz, 1992).

Treatment Foster Care: 

Treatment Foster Care Therapeutic Foster Care (TFC) is considered to be one of the few community-based, comprehensive interventions that is viewed as “evidence-based” Tremendous enthusiasm across the country “Evidence” comes almost exclusively from Patti Chamberlain’s work at Oregon Social Learning Center Little known about TFC in ‘real world’ settings (Farmer, FFTA, 7.21.2005)

Complexities of Therapeutic Alliance and Treatment Foster Care: 

Complexities of Therapeutic Alliance and Treatment Foster Care Youth rarely enter into foster care voluntarily They are in a state of change (physical, cognitive and neurological) Developmental stage may be at odds with establishing relationships with adults Youth may have experienced life situations e.g. maltreatment, that may negatively impact their ability to form alliances (Doucette et al., 2003; Eltz, Shirk & Sarlin, 1995) Treatment Foster Care is a “nested” intervention within larger systems (Pecora et. al 1995; James & Meezan, 2002)

Is There Need for Research on Alliance in the “Brave New World” of Evidence Based Treatment?: 

Is There Need for Research on Alliance in the “Brave New World” of Evidence Based Treatment? “Research to Practice” problem may be due to an incomplete understanding of how client and professional characteristics affect the therapeutic process Kazdin and Nock (2003) propose that extending therapeutic models developed from clinical trials to clinical settings without understanding the mechanisms of how treatment works is a key factor limiting transferability. A better understanding of therapeutic “Common Factors” is needed (Bickman, 1999)- what is common across all therapeutic approaches?

Is There Need for Research on Alliance in the “Brave New World” of Evidence Based Treatment?: 

Is There Need for Research on Alliance in the “Brave New World” of Evidence Based Treatment? Dropping out of mental health services is a major impediment to effective treatment for youth, adolescents and their families It is estimated that among families who begin treatment, 40% to 60% will terminate prematurely (Kazdin, 1996; Wierzbicki & Pekarik, 1993). Early termination has been associated with poorer outcomes (Prinz & Miller, 1994) and contributes to the high societal costs when mental health needs remain unmet (U.S. DHHS, 1999). In our own program, we experience “disrupted” placements in approximately 25% of our discharges.

Is There Need for Research on Alliance in the “Brave New World” of Evidence Based Treatment?: 

Is There Need for Research on Alliance in the “Brave New World” of Evidence Based Treatment? There is little research on how the parent-youth relationship impacts treatment Farmer et al. (2003) in their study of Treatment Foster Care in North Carolina found that parent-child relationship was significantly related to positive youth outcomes

Guiding Questions: 

Guiding Questions Do youth and treatment parents have similar perceptions about the relationship? Does the perception of the relationship change over time? What is the association between alliance and resistance? Is alliance associated with youth and treatment parent characteristics?

Methods and Design: 

Methods and Design Descriptive study Profiling relationships Repeated measures design Dyads (TP-youth) (TP-TC) Pressley Ridge Treatment Foster Care program in Delaware New program Implemented in response to a system of care in Delaware 40 hour Pre-service curriculum for treatment parents Treatment parents supervised in the home by a professional on a weekly basis Limited number of foster youth in the home (2 or less)

Slide14: 

Pressley Ridge Therapeutic Alliance Scales Therapeutic Alliance Questionnaire is a 30 item 3 point scale Brief form is 18 items 3 point scale English and Spanish versions Two subscales: Mutuality and perception of a collaborative relationship Resistance/unfavorable outlook on treatment

Youth Demographics & Descriptive Information (N=25): 

Youth Demographics & Descriptive Information (N=25)

Primary Treatment Parent Demographics: 

Primary Treatment Parent Demographics

Do youth and treatment parents have different perceptions about their relationship?: 

Do youth and treatment parents have different perceptions about their relationship? YES, their perceptions are different. Most youth and treatment parents alliance ratings show a favorable relationship (majority of bars are above neutral alliance). Treatment parents alliance ratings are higher than youth ratings. Treatment parents believe their relationship with the youth is better than what the youth reports (t-test p=0.03). Youth alliance changes over time “Honey moon” pattern –higher alliance followed by lower and then increasing alliance.

Youth Alliance: Modeled RatingsTime Trajectories: 

Youth Alliance: Modeled Ratings Time Trajectories Red=unstable; Blue=high & stable; Green=improving N=288 :Lack the power to determine statistical differences

Individual Curves—decreasing then increasing: 

Individual Curves—decreasing then increasing History of placement in RTC and foster care History of sexual abuse Moved to second home due to Treatment parent deciding to fostering her grandchildren

Individual Curves—decreasing then increasing: 

Individual Curves—decreasing then increasing Referred through Juvenile Justice History of running from foster homes No biological family involvement No placement changes

Youth Alliance: biological children in treatment home: 

Youth Alliance: biological children in treatment home Presence of biological children at home does not seem to prevent youth and treatment parent from building good relationships. Over time parents with biological children living at home get higher ratings that parents without biological children (less variation)

Youth Alliance by treatment parent & youth race: 

Youth Alliance by treatment parent & youth race Caucasian youth placed with African American parents or Hispanic and vise/versa reported neutral to favorable alliance. But the pattern is more variable & has a tendency to deteriorate over time.

Youth Alliance: youth gender: 

Youth Alliance: youth gender There is not much of gender differential in youth TA ratings—males slightly flatter slope

Youth Alliance: youth age: 

Youth Alliance: youth age Little age differential

Youth Alliance: previous placements: 

Youth Alliance: previous placements Youth with three or less prior placements have higher alliance scores & a flatter curve

Youth Alliance: diagnosis: 

Youth Alliance: diagnosis For youth with ODD, the alliance curve is “U” shaped, showing decreasing alliance then increasing

Youth Alliance: problems & behavior: 

Youth Alliance: problems & behavior Youth with high internalizing and externalizing behaviors have decreasing then increasing alliance

Youth Alliance: resistance: 

Youth Alliance: resistance High youth resistance associates with low alliance and a steep slope Low youth resistance associates with higher alliance and more stable alliance

Limitations: 

Limitations Descriptive and preliminary Small N (only 25 youth but multiple time points) One program—could be something different about the parents, youth or the program Measure of alliance adapted from an earlier measure used in a partial program education setting Not able to obtain TA scores on all youth from the day when they first entered the treatment home

Summary: 

Summary Overall, both youths and treatment parents report favorable alliance. Treatment Parents are more positive about the relationship than the youths. “Honey moon” pattern –higher alliance followed by lower and then increasing alliance. There appear to be different trajectories of alliance growth over time.

Summary: 

Summary The presence of biological children and treatment parent race influenced the development of youth alliance. Youth diagnosis, resistance, degree of problem severity and the number of prior placements influenced the development of youth alliance

Implications: 

Implications Policy: closely monitor & limit changes in placement. Training & Supervision: mentoring, supporting and training parents e.g. “inoculating” them for when the honeymoon period ends. supporting parents and training them to effectively deal with reactive and resistant behavior. helping treatment parents to understand that for some youth, it may take a longer time to develop a relationship. helping parents understand the role of culture and race in cross-racial placements.

Implications: 

Implications Clinical Pre-planned contingencies and individualized planning before crisis. Matching youth (highly resistant, ODD, many placements) with experienced treatment parents & providing close supervision. (Typically, new parents are paired with new youth --“rookie factor”) Pre-planned respite

Further Research: 

Further Research Random assignment of “low alliance/high resistance” profile youth to homes, then addition of increased support and respite. Compare with the non-enhanced homes on: transfers, discharge, satisfaction and parent stress Study of outcomes and alliance Does feedback to parents change the course of alliance? Does feedback help the supervision process?

Contact Information : 

Contact Information Mrauktis@pressleyridge.org Ana.andrade@vanderbilt.edu Adoucette@aol.com