The Role of Youth Trainee–Trainer Alliance and Involvement in School-Based Prevention: A Moderated-Mediation Model of Student Gatekeeper Suicide Prevention Training

  • Christine M. Wienke ToturaEmail author
  • Christa D. Labouliere
  • Kim Gryglewicz
  • Marc S. Karver
Original Article


This study examined the roles that youth involvement and youth trainee–trainer alliance play in school mental health prevention within the context of youth suicide gatekeeper training. Measures included youth involvement in programming, trainee–trainer alliance, and intentions to refer at-risk youth at pre- and post-training. A moderated-mediation design was used to examine associations among these factors. Results show alliance mediating pre- and post-training referral intentions, and involvement moderating the relationship between alliance and post-training intentions. On average, trainee intentions improved from pre- to post-training, but trainees reporting high alliance endorsed higher post-training referral intentions regardless of involvement level. Low alliance resulted in lower than average post-training referral intentions, even with active involvement in programming, and those with both low alliance and involvement showed the lowest post-training referral intentions. Given these findings, fostering the youth trainee–trainer relationship may be an avenue to optimize prevention program effectiveness.


Trainer alliance Youth trainee involvement Community prevention Suicide prevention School-based mental health 



Special thanks to Sarah Gunderson, Renee Brown Hangartner, Jason I. Chen, Sarah J. Tarquini, and Krista Kutash for their invaluable assistance.


This research was supported by Substance Abuse and Mental Health Administration Grants (#SM57442-01, 02–3) to Drs. Karver, Kutash, and Totura. Dr. Labouliere was supported as a post-doctoral fellow by Award #2T32 MH16434-34 from the National Institute of Mental Health (NIMH) at the National Institutes of Health (NIH). The contents of the manuscript are solely the responsibility of the authors and do not necessarily represent the official views of NIMH or SAMHSA.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical Approval

All procedures performed in this study 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.

Informed Consent

Informed consent was obtained from all participants included in the study via university Institutional Review Board approved waiver of parental signed informed consent.


  1. Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhl & J. Beckman (Eds.), Action-control: From cognition to behavior (pp. 11–39). Heidelberg: Springer.Google Scholar
  2. Ajzen, I. (2017). Constructing a Theory of Planned Behavior Questionnaire. Retrieved from:
  3. Berkel, C., Mauricio, A. M., Schoenfelder, E., & Sandler, I. N. (2011). Putting the pieces together: An integrated model of program implementation. Prevention Science, 12, 23–33.PubMedCentralGoogle Scholar
  4. Berry, K., Gregg, L., Lobban, F., & Barrowclough, C. (2016). Therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis. Comprehensive Psychiatry, 67, 73–80.Google Scholar
  5. Bickman, L., deAndrade, A. R. V., Athay, M. M., Chen, J. I., De Nadai, A. S., Jordan-Arthur, B. L., & Karver, M. S. (2012). The relationship between change in therapeutic alliance ratings and improvement in youth symptom severity: Whose ratings matter the most? Administration and Policy in Mental Health and Mental Health Services Research, 39, 78–89.Google Scholar
  6. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16, 252–260.Google Scholar
  7. Brown, C. H., Wyman, P. A., Brinales, J. A., & Gibbons, R. D. (2007). The role of randomized trial in testing interventions for the prevention of youth suicide. International Review of Psychiatry, 19, 617–631.Google Scholar
  8. Brown, H. R., Totura, C. M. W., Labouliere, C. D., Gryglewicz, K., & Karver, M. S. (2018). Benchmarking the Question, Persuade, Refer program against established suicide prevention gatekeeper trainings. Suicide and Life-Threatening Behavior. Scholar
  9. Bruffaerts, R., Demyttenaere, K., Hwang, I., Chiu, W. T., Sampson, N., Kessler, R. C., … Nock, M. K. (2011). Treatment of suicidal people around the world. British Journal of Psychiatry, 199, 64–70.Google Scholar
  10. Castro-Blanco, D., Karver, M. S., & Chiechi, J. (2010). Conclusions: Looking ahead—Future directions in treatment engagement with high risk adolescents. In D. Castro-Blanco & M. S. Karver (Eds.), Elusive alliance: Treatment engagement strategies with high-risk adolescents. Washington, D.C.: American Psychological Association.Google Scholar
  11. Centers for Disease Control and Prevention. (2016). Web-based Injury Statistics Query and Reporting System, Fatal Injury Data. Retrieved January 25, 2018 from fatal.html.
  12. Cummings, C., Caporino, N., Settipani, C., Read, K., Compton, S., March, J., … Kendall, P. (2013). The therapeutic relationship in cognitive-behavioral therapy and pharmacotherapy for anxious youth. Journal of Consulting and Clinical Psychology, 81, 859–864.Google Scholar
  13. Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. American Journal of Community Psychology, 41, 327–350.Google Scholar
  14. Fixsen, D. L., Naoom, S. F., Blase, K. A., & Friedman, R. M. (2005). Implementation research: Synthesis of the literature. Tampa: University of South Florida.Google Scholar
  15. Fluckiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A. O. (2012). How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology, 59, 10–17.Google Scholar
  16. Fredricks, J. A., Bohnert, A. M., & Burdette, K. (2014). Moving beyond attendance: Lessons learned from assessing engagement in afterschool contexts. New Directions for Student Leadership, 144, 45–58.Google Scholar
  17. Garvey, C., Julion, W., Fogg, L., Kratovil, A., & Gross, D. (2006). Measuring participation in a prevention trial with parents of young children. Research in Nursing & Health, 29, 212–222.Google Scholar
  18. Hagger, M. S., Chan, D. K., Protogerou, C., & Chatzisarantis, N. L. (2016). Using meta-analytic path analysis to test theoretical predictions in health behavior: An illustration based on meta-analyses of the theory of planned behavior. Preventive Medicine, 89, 154–161.Google Scholar
  19. Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Press.Google Scholar
  20. Hayes, A. F. (2018). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach (2nd edn.). New York: Guilford Press.Google Scholar
  21. Hogue, A., Dauber, S., Stambaugh, L. F., Cecero, J. J., & Liddle, H. A. (2006). Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems. Journal of Consulting and Clinical Psychology, 74, 121–129.PubMedCentralGoogle Scholar
  22. Horvath, A. O., Re, D., Flückiger, A. C., C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16.Google Scholar
  23. Johansson, P., & Høglend, P. (2007). Identifying mechanisms of change in psychotherapy: Mediators of treatment outcomes. Clinical Psychology & Psychotherapy, 14, 1–9.Google Scholar
  24. Kalafat, J., & Elias, M. (1994). An evaluation of a school-based suicide awareness intervention. Suicide and Life-Threatening Behavior, 24, 224–233.Google Scholar
  25. Karver, M., Shirk, S., Handelsman, J., Fields, S., Crisp, H., Gudmundsen, G., & McMakin, D. (2008). Relationship processes in youth psychotherapy: Measuring alliance, alliance-building behaviors, and client involvement. Journal of Emotional & Behavioral Disorders, 16, 15–28.Google Scholar
  26. Karver, M. S., De Nadai, A. S., Monahan, M., & Shirk, S. R. (2018). Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy, 55, 341–355.Google Scholar
  27. Kim, H. Y., & Cappella, E. (2016). Mapping the social world of classrooms: A multi-level, multi-reporter approach to social processes and behavioral engagement. American Journal of Community Psychology, 57, 20–35.Google Scholar
  28. Labouliere, C., Reyes, J. P., Shirk, S., & Karver, M. (2017). Therapeutic alliance with depressed adolescents: Predictor or outcome? Disentangling temporal confounds to understand early improvement. Journal of Clinical Child & Adolescent Psychology, 46, 600–610.Google Scholar
  29. Labouliere, C., Tarquini, S., Totura, C., Kutash, K., & Karver, M. (2015). How much is learned by students participating in suicide prevention gatekeeper training? Crisis, 36, 274–280.PubMedCentralGoogle Scholar
  30. Low, S., Van Ryzin, M. J., Brown, E. C., Smith, B. H., & Haggerty, K. P. (2014). Engagement matters: lessons from assessing classroom implementation of steps to respect: A bullying prevention program over a one-year period. Prevention Science, 15, 165–176.Google Scholar
  31. McCormick, M. P., O’Connor, E. E., Cappella, E., & McClowry, S. G. (2013). Teacher–child relationships and academic achievement: A multilevel propensity score model approach. Journal of School Psychology, 51, 611–624.Google Scholar
  32. McLeod, B. D., Islam, N. Y., Chiu, A., Smith, W., Chu, M. M., B. C., & Wood, J. J. (2014). The relationship between alliance and client involvement in CBT for child anxiety disorders. Journal of Clinical Child & Adolescent Psychology, 43, 735–741.Google Scholar
  33. Michie, S., van Stralen, M., & West, R. (2011). The behavior change wheel: A new method for characterizing and designing behavior change interventions. Implementation Science, 6, 1–11.Google Scholar
  34. Murphy, R., & Hutton, P. (2018). Practitioner review: Therapist variability, patient-reported therapeutic alliance, and clinical outcomes in adolescents undergoing mental health treatment—a systematic review and meta-analysis. The Journal of Child Psychology and Psychiatry, 59(1), 5–19.Google Scholar
  35. Nix, R. L., Bierman, K. L., McMahon, R. J., & The Conduct Problems Prevention Research Group (2009). How attendance and quality of participation affect treatment response to parent management training. Journal of Consulting and Clinical Psychology, 77, 429–438.PubMedCentralGoogle Scholar
  36. Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to the addictive behaviors. American Psychologist, 47, 1102–1114.Google Scholar
  37. Sandler, I., Wolchik, S. A., Cruden, G., Mahrer, N. E., Ahn, S., Brincks, A., & Brown, C. H. (2014). Overview of meta-analyses of the prevention of mental health, substance use, and conduct problems. Annual Review of Clinical Psychology, 10, 243–273.PubMedCentralGoogle Scholar
  38. Shirk, S. R., Karver, M. S., & Brown, R. (2011). Alliance in child and adolescent psychotherapy. Psychotherapy, 48, 17–24.Google Scholar
  39. Thompson, S. J., Bender, K., Lantry, J., & Flynn, P. M. (2007). Treatment engagement: Building therapeutic alliance in home-based treatment with adolescents and their families. Contemporary Family Therapy, 29(1–2), 39–55.PubMedCentralGoogle Scholar
  40. Totura, C. M. W., Figueroa, L., Wharton, H., C., & Marsiglia, F. F. (2015). Assessing implementation of evidence-based childhood obesity prevention strategies in schools. Preventive Medicine Reports, 2, 347–354.PubMedCentralGoogle Scholar
  41. Totura, C. M. W., Kutash, K., Labouliere, C. D., & Karver, M. (2017). Evaluating active parental consent procedures for school programming: Addressing the sensitive topic of suicide prevention. Journal of School Health, 87, 114–120.Google Scholar
  42. Totura, C. M. W., Tarquini, S., Naoom, S., Karver, M. S., & Kutash, K. (2008). Planned Behavior & Implementation Questionnaire. Unpublished. Tampa: University of South Florida.Google Scholar
  43. Wandersman, A., Duffy, J., Flaspohler, P., Noonan, R., Lubell, K., Stillman, L., … Saul, J. (2008). Bridging the gap between prevention research and practice: The interactive systems framework for dissemination and implementation. American Journal of Community Psychology, 41(3–4), 171–181.Google Scholar
  44. Weisz, J. R., Doss, A. J., & Hawley, K. M. (2005). Youth psychotherapy outcome research: A review and critique of the evidence base. Annual Review of Psychology, 56, 337–363.Google Scholar
  45. Whittaker, K. A., & Cowley, S. (2012). An effective programme is not enough: A review of factors associated with poor attendance and engagement with parenting support programmes. Children & Society, 26, 138–149.Google Scholar
  46. Xia, Y., Taylor, S., & de Guzman, M. R. T. (2017). Evaluation of the Health Rocks! Program: The association of youth engagement with program outcomes. Journal of Youth Development, 11, 95–104.Google Scholar
  47. Zhao, X., Lynch, J. G., & Chen, Q. (2010). Reconsidering Baron and Kenny: Myths and truths about mediation analysis. Journal of Consumer Research, 37, 197–206.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PsychologyAuburn UniversityAuburnUSA
  2. 2.Division of Behavioral Health Services and Policy Research, New York State Psychiatric InstituteColumbia UniversityNew YorkUSA
  3. 3.School of Social WorkUniversity of Central FloridaOrlandoUSA
  4. 4.Department of PsychologyUniversity of South FloridaTampaUSA

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