Document Type



Doctor of Philosophy (PhD)



First Advisor's Name

Jeremy Pettit

First Advisor's Committee Title

Committee chair

Second Advisor's Name

Jonathan Comer

Second Advisor's Committee Title

Committee Member

Third Advisor's Name

Dana McMakin

Third Advisor's Committee Title

Committee Member

Fourth Advisor's Name

Mark Macgowan

Fourth Advisor's Committee Title

Committee Member


therapeutic alliance, child/adolescent, anxiety, depression

Date of Defense



Suboptimal treatment response rates in interventions for youth internalizing disorders (anxiety, depression, OCD) highlight a critical need to enhance intervention outcomes. My dissertation project addresses this need by identifying therapeutic process variables that predict intervention outcomes, and examining how, for whom, and under what circumstances they contribute to outcomes. In a series of three manuscripts, I present findings on a systematic review and meta-analysis of alliance-outcome associations in youths receiving intervention for internalizing disorders (Chapter II) and examine variables that may explain or influence alliance-outcome associations in interventions for internalizing problems in university-based (Chapter III) and usual care settings (Chapter IV). Findings across studies revealed that (1) findings on alliance-outcome associations are mixed and may be explained by clinical and methodological heterogeneity between studies; (2) age influences the association between therapeutic alliance and outcome, with stronger effects in older youths compared to younger youths; (3) session attendance is important to outcome; and (4) associations between early provider perceptions of alliance and outcomes may be more complex than previously believed. Findings from the three manuscripts provide a more nuanced understanding of alliance-outcome associations in interventions for youth internalizing disorders. Future research should consider the role of additional engagement variables on outcomes, evaluate why early provider perceptions of alliance might predict worse youth outcomes in cognitive behavioral therapy, and incorporate developmental considerations into models of youth engagement and outcomes.



Previously Published In

Bose, D., Proenza, D.A., Costales, G., Viswesvaran, C., Bickman, L. & Pettit, J.W. (2021). Therapeutic alliance in psychosocial interventions for youth internalizing disorders: A systematic review and preliminary meta-analysis. Clinical Psychology: Science and Practice.



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