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Supervisory Alliance as a Moderator of the Effects of Behavioral Rehearsal on TF-CBT Fidelity: Results from a Randomized Trial of Supervision Strategies

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Abstract

Exposure is an important element of treatment for many evidence-based treatments but can be challenging to implement. Supervision strategies to support exposure delivery may be an important tool to facilitate the use of exposure techniques; however, they must be considered and used in the context of the supervisory alliance. The present study examined relations between supervisory alliance and fidelity to the trauma narrative (TN; i.e., imaginal exposure) component of Trauma-Focused Cognitive Behavioral Therapy. We also examined how supervisory alliance moderated the effect of behavioral rehearsal use in supervision on TN fidelity. We analyzed data from a randomized controlled trial, in which forty-two supervisors and their clinicians (N = 124) from 28 Washington State community-based mental health offices participated. Clinicians were randomized to receive one of two supervision conditions—symptom and fidelity monitoring (SFM) or SFM with behavioral rehearsal (SFM + BR). Supervisory alliance alone did not predict delivery (i.e., occurrence) or extensiveness of delivery of the trauma narrative. Client-focused supervisory alliance moderated the effectiveness of behavioral rehearsal—as client-focused alliance increased, the odds of delivering the TN also increased significantly. Future research should further investigate how to appropriately match supervision techniques with supervisory dyads and explore the interplay of alliance with supervision techniques a supervisor might employ.

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Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code Availability

All code for data cleaning and analysis associated with the current submission is available from the corresponding author on reasonable request.

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Funding

This study was funded by the National Institute of Mental Health (R01 MH095749 [PI: Dorsey]). Manuscript preparation was also supported in part the Health Policy Research Scholars, a program of the Robert Wood Johnson Foundation (Fellow: Triplett), a National Institute of Mental Health grant (F31 MH124328 [PI: Triplett]) that supported the time of Mr. Triplett, a National Institute of Mental Health grant (F31 MH130041 [PI: Johnson]) that supported the time of Ms. Johnson, two National Institutes on Alcohol Abuse and Alcoholism grants that supported the time of Dr. McCabe (T32AA013525 [PI: Larimer]; K99AA030052 [PI: McCabe]), and a National Institute of Mental Health grant (P50 MH126219 [MPI: Dorsey & Lewis]) that supported the time of Dr. Dorsey.

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  1. Department of Psychology, University of Washington, Box 351525, 119A Guthrie Hall, Seattle, WA, 98195, USA

    Noah S. Triplett, Rashed AlRasheed, Clara Johnson & Shannon Dorsey

  2. Department of Psychiatry and Behavioral Medicine, University of Washington, Box 356560, 1959 NE Pacific Street, Seattle, WA, 98195, USA

    Connor J. McCabe

  3. UW School Mental Health Assessment, Research, and Training (SMART) Center, University of Washington, 6200 74th Street, Building 29, Seattle, WA, 98115, USA

    Michael D. Pullmann

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  1. Noah S. Triplett
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Contributions

Conceptualization: Noah Triplett, Shannon Dorsey; Methodology: Noah S. Triplett, Michael Pullmann, Shannon Dorsey; Formal analysis and investigation: Noah S. Triplett, Connor McCabe; Writing - original draft preparation: Noah S. Triplett; Writing - review and editing: Noah S. Triplett, Rashed AlRasheed, Clara Johnson, Connor McCabe, Michael Pullmann, Shannon Dorsey; Funding acquisition: Michael Pullmann, Shannon Dorsey; Supervision: Shannon Dorsey.

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Correspondence to Noah S. Triplett.

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Dr. Dorsey has received honorariums for providing TF-CBT training. Authors Triplett, AlRasheed, Johnson, McCabe, and Pullmann declare no conflicts of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the University of Washington Institutional Review Board (STUDY00000428).

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Triplett, N.S., AlRasheed, R., Johnson, C. et al. Supervisory Alliance as a Moderator of the Effects of Behavioral Rehearsal on TF-CBT Fidelity: Results from a Randomized Trial of Supervision Strategies. Adm Policy Ment Health 51, 254–267 (2024). https://doi.org/10.1007/s10488-023-01334-2

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