Page 63 - Personality disorders and insecure attachment among adolescents

Introduction
Dropout of child and adolescent therapy is a common phenomenon (De Haan, Boon, De Jong, Hoeve, & Vermeiren, 2013; Hauber, Boon, & Vermeiren, 2017; Owen, Miller, Seidel, & Chow, 2016a). When youngsters drop out of psychiatric treatment, their disorders might persist or even worsen later in life. For instance, children with untreated disorders are likely to grow up as adults who rely on mental health services, which has negative consequences for themselves, their surroundings and society (Dulmus & Wodarski, 1996; Kessler, Chiu, Demler, & Walters, 2005; Reis & Brown, 1999). Therefore premature termination of therapy is considered a serious problem (Armbruster & Kazdin, 1994; Gopalan et al., 2010; Midgley & Navridi, 2006). In adolescent mental health care dropout percentages of 38.4% for outpatients (De Haan, Boon, De Jong, Hoeve, & Vermeiren, 2015) and 34.4% for inpatients (De Boer, Boon, De Haan, & Vermeiren, 2016) were found. A determinant for dropout is the quality of the therapeutic (patient-therapist) relationship (De Haan et al., 2013; Garcia & Weisz, 2002; Hawley & Weisz, 2005; Kazdin & Wassell, 1998; Owen et al., 2016a; Stevens, Kelleher, Ward-Estes, & Hayes, 2006). Therapeutic relationship or therapeutic alliance has commonly been defined as the agreement between the therapist and client on the goals for treatment as well as the ways to reach those goals and the emotional or relational bond between the client and therapist (Bordin, 1979). Although several studies have been conducted on the relation between the therapeutic relationship and dropout, it is hard to compare these studies because the time at which the therapeutic relationship was measured varies considerably (Cordaro, Tubman, Wagner, & Morris, 2012; Robbins et al., 2006; Robbins, Turner, Alexander, & Perez, 2003; Shelef, Diamond, Diamond, & Liddle, 2005). In several studies trained observers rated the therapeutic alliance at one or two therapy sessions during the course of therapy, but this approach does not take the patients’ opinion about the relationship into account. Other studies measured the relationship after therapy has ended, although this will be strongly influenced by the way patients feel at that termination point. In a review on the therapeutic relationship within youth therapy, it is advised to measure the therapeutic relationship during several sessions of the therapy process (Zack, Castonguay, & Boswell, 2007). If adolescents perceive the therapeutic relationship as supportive and agree with the topics and goals of the sessions this will facilitate their engagement (Karver, Handelsman, Fields, & Bickman, 2006). Until now however adolescent patients are hardly used as an informants about the therapeutic alliance (De Haan et al., 2013). In adult therapy a moderately strong relationship between psychotherapy dropout and therapeutic alliance is found (Sharf, Primavera, & Diener, 2010).
Studies on the relationship between the therapeutic alliance and dropout in youth therapy have been hindered by two topics: first, the method in which the therapeutic relationship was measured and second, the definition of dropout. First, most available measures for the therapeutic relationship in child and adolescent therapy are parent report measures. The therapeutic Alliance Scale for Children
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