Working alliance and treatment fidelity as predictors of externalizing problem behaviors in parent management training.

Objective: The study investigated treatment fidelity and working alliance in the Parent Management Training-Oregon model (PMTO) and investigated how these relate to children's externalizing problem behaviors, as reported by parents and teachers.

Method: Participants were 331 Norwegian parents who rated the client-therapist working alliance at 3 time points (Sessions 3, 12, and 20). Competent adherence to the PMTO treatment protocol was assessed by PMTO specialists from evaluations of videotaped therapy sessions using the Fidelity of Implementation (FIMP) system (Knutson, Forgatch, & Rains, 2003). Parents and teachers reported children's problem behaviors at baseline and at the end of therapy. Structural equation modeling was used to analyze the repeated measures data.

Results: Parents reported high and stable levels of alliance and fidelity from Time 1 to Time 3, with no correlational or direct relations between the 2. Treatment fidelity predicted reductions in parent-reported externalizing behavior, whereas working alliance was related to less change in problem behavior. Alliance and fidelity were unrelated to teacher-reported behavior problems.

Conclusions: The findings point to treatment fidelity as an active ingredient in PMTO and working alliance as a negative predictor of postassessment parent-reported externalizing behavior. More research is needed to investigate whether these findings can be replicated and extended beyond PMTO.