the role of the therapeutic alliance and its relationship to treatment

195 Pages·2011·0.68 MB·English

THE ROLE OF THE THERAPEUTIC ALLIANCE AND ITS RELATIONSHIP TO
TREATMENT OUTCOME AND CLIENT MOTIVATION IN AN ADOLESCENT
SUBSTANCE ABUSE TREATMENT SETTING

A dissertation presented to
the faculty of
the College of Arts and Sciences of Ohio University

In partial fulfillment
of the requirements for the degree
Doctor of Philosophy

Andrew J. Darchuk
June 2007
This dissertation titled
THE ROLE OF THE THERAPEUTIC ALLIANCE AND ITS RELATIONSHIP TO
TREATMENT OUTCOME AND CLIENT MOTIVATION IN AN ADOLESCENT
SUBSTANCE ABUSE TREATMENT SETTING

by
ANDREW J. DARCHUK

has been approved for
the Department of Psychology
and the College of Arts and Sciences by

Timothy M. Anderson
Associate Professor of Psychology

Benjamin M. Ogles
Dean, College of Arts and Sciences
Abstract
DARCHUK, ANDREW J., Ph.D., June 2007, Clinical Psychology
THE ROLE OF THE THERAPEUTIC ALLIANCE AND ITS RELATIONSHIP TO
TREATMENT OUTCOME AND CLIENT MOTIVATION IN AN ADOLESCENT
SUBSTANCE ABUSE TREATMENT SETTING (195 pp.)
Director of Dissertation: Timothy M. Anderson
While motivation and therapeutic alliance have been found to be influential
factors in the outcome of substance abuse treatment for adult populations, comparatively
little is known about the potential impact of these variables on outcomes in adolescent
substance abuse treatment. The present study examined the relationships between
motivation and readiness for treatment, therapeutic alliance, treatment compliance, and
outcome variables in a sample of adolescents in residential substance abuse treatment.
Eighty-one adolescents participated in the study, in which they completed self-report
measures of motivation and readiness prior to treatment, therapeutic alliance measures
during treatment, and ratings of psychiatric problem severity and depressive
symptomatology before and after their treatment episodes.
Results indicated that initial alliance, as rated by clients or counselors on an
adapted form of the Working Alliance Inventory (Horvath, 1981), was not associated
with measures of treatment outcome, including discharge status, change in psychiatric
symptoms, and clinician ratings of progress at discharge. Higher initial client-rated
alliances were associated with fewer instances of severely inappropriate behavior over
the course of treatment. However, positive counselor-rated alliance ratings obtained after
session six of individual therapy significantly predicted greater progress in the treatment
program and reductions in psychiatric problem severity as measured by the Ohio Youth
Problem, Functioning, and Satisfaction Scale (Ogles, et al., 2000).
Client-reported pre-treatment levels of problem recognition were negatively
associated with client-rated alliance after session six of individual therapy, while high
levels of treatment readiness predicted client ratings of the alliance at the same time
point. In addition, high levels of problem recognition were associated with clients’ poor
compliance with program rules over the course of treatment.
Despite mixed findings, these results provide preliminary evidence that high
levels of treatment readiness and positively-rated alliances are likely important factors in
the successful treatment of adolescent substance abusers. The implications of the present
findings and suggestions for future research are discussed.
Approved:
Timothy M. Anderson
Associate Professor of Psychology
Acknowledgments
The author wishes to thank Tim Anderson, chair of the dissertation committee, for
his guidance, patience, and support during the completion of this project. The author also
wishes to thank the other members of the committee, whose expertise and guidance
served to improve the quality of this project. The author thanks his parents for their
continued support of his professional and personal development. Most of all, the author
thanks his wife, Kathleen Darchuk, for everything.
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Table of Contents
Page
Abstract...............................................................................................................................3
Acknowledgments...............................................................................................................5
List of Tables......................................................................................................................8
CHAPTER ONE.................................................................................................................9
INTRODUCTION..............................................................................................................9
CHAPTER TWO..............................................................................................................15
THE LITERATURE REVIEW.........................................................................................15
PART I: ADOLESCENT SUBSTANCE ABUSE, TREATMENT, AND OUTCOME
.......................................................................................................................................15
PART II: THEORETICAL FOUNDATIONS OF THE THERAPEUTIC ALLIANCE
AND RESEARCH FINDINGS....................................................................................34
PART III: MOTIVATION FOR TREATMENT: THEORETICAL FOUNDATIONS
AND RELEVANT RESEARCH..................................................................................60
PART IV: RATIONALE FOR THE PRESENT STUDY............................................78
CHAPTER THREE..........................................................................................................81
THE PRESENT STUDY..................................................................................................81
METHOD.....................................................................................................................84
RESULTS...................................................................................................................100
CHAPTER FOUR...........................................................................................................114
DISCUSSION.................................................................................................................114
References.......................................................................................................................139
7
Appendix A--Working Alliance Inventory-Short Form, Client and Counselor Versions
(Horvath, 1981; Tracey & Kokotovic, 1989)..................................................................169
Appendix B—Ohio Youth Problem, Functioning, and Satisfaction Scale: Youth Rating—
Short Form (Ohio Scales; Ogles, Melendez, Davis, & Lunnen, 2000)..........................171
Appendix C— Beck Depression Inventory II (BDI-II; Beck, Ward, Mendelsohn, Mock,
& Erbaugh, 1961)............................................................................................................172
Appendix D—Treatment Expectations Questionnaire (Meier, Donmall, McElduff,
Barrowclough, & Heller, 2006)......................................................................................176
Appendix E—Texas Christian University (TCU) Treatment Motivation Scale (Simpson,
1992)...............................................................................................................................177
Appendix F—University of Rhode Island Change Assessment (URICA; McConnaughy,
Prochaska, & Velicer, 1983; Greenstein, Franklin, & McGuffin, 1999)........................179
Appendix G—Demographics Questionnaire and Medical Records Review Form........181
Appendix H--Appropriate/Inappropriate Behavior Log Codes......................................183
Appendix I--Description of Goals, Objectives, and Interventions Guidelines...............184
Appendix J—Informed consent form.............................................................................193
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List of Tables
Table Page
1 Description of Adolescent Addictions Treatment Outcome Studies 158
2 Client Sample Characteristics……………………………………….. 159
3 Substance Use Diagnoses for Current Sample………………………. 160
4 Psychiatric Diagnoses for Current Sample………………………….. 161
5 Counselor Sample Characteristics…………………………………… 162
6 Descriptive Statistics for All Scales and Subscales…………………. 163
7 Correlations Between Motivation/Readiness, Alliance, and Outcome
Measures…………………………………………………………….. 164
8 Correlations Between Alliance and Compliance/Outcome Variables. 165
9 Correlations Between Treatment Compliance and Outcome Variables. 166
10 Correlations Between Client Treatment Expectations and
Key Variables……………………………………………………….. 167
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CHAPTER ONE
INTRODUCTION
Over the past 40 years, adolescent substance use and abuse has become a
significant public health concern and a costly financial burden in this country. As recently
as 1999, it was estimated that the total cost of alcohol use by youth—including traffic
crashes, violent crime, burns, drowning, suicide attempts, fetal alcohol syndrome, alcohol
poisonings, and treatment—was more than $58 billion per year (Levy, Miller, & Cox,
1999). Drug- and alcohol-related car crashes are the number one cause of death for teens.
In addition, alcohol use is also significantly correlated with homicides, suicides, and
drownings—the next three leading causes of death among youth (Levy, et al, 1999).
Recent prevalence data regarding substance use by adolescents confirms that
substance abuse is a significant problem in society. As of 2004, it was estimated that
nearly 40% of high school seniors had used an illicit drug in the past year and 15% of 8th
graders had used an illicit drug in the past year (Johnston, O’Malley, Bachman, &
Schulenberg, 2005). In 2005, it was estimated that 4.7% of all adolescents between 12
and 17 years of age met diagnostic criteria for a substance use disorder. In raw form, this
figure corresponds to approximately 1.2 million adolescent substance abusers in the
United States (Substance Abuse and Mental Health Services Administration [SAMHSA],
2005). While these data may be startling, what is even more alarming is that observers in
the field estimate that fewer than 10% of adolescents with past-year symptoms of
substance abuse or dependence receive appropriate treatment (Dennis & McGeary, 1999).
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Adolescent-onset substance abuse behavior is associated with declining academic
performance, increased incidences of disruptive behavior, mental health problems, legal
difficulties, and increased likelihood of subsequent substance abuse/dependence in
adulthood (Kuperman, et al, 2001; Grant & Dawson, 1997; Wilens, Biederman, Abrantes,
& Spencer, 1997). Governing bodies overseeing the provision of mental healthcare
services, such as the Joint Commission (JC; formerly known as Joint Commission on
Accreditation of Healthcare Organizations), have mandated empirically-sound methods
of measuring treatment outcome in a number of domains of functioning, thus providing
an urgent need to evaluate outcomes in treatment settings. While there is evidence that
substance abuse treatment effectively reduces problem substance use in a subset of
adolescents (Winters, Stinchfield, Opland, Weller, & Latimer, 2000), researchers in the
field report high levels of relapse shortly following treatment (Cornelius, et al., 2003).
In order to improve treatment outcomes and gain a better understanding of the
variables that contribute to positive outcome in adolescent populations, it appears useful
to identify and investigate treatment processes that have been demonstrated to improve
outcomes in other treatment domains, such as general psychotherapy. The therapeutic
alliance, by virtue of its importance in adult psychotherapy, preliminary findings in
adolescent populations, and existing data suggesting that child/adolescent therapists view
the therapeutic alliance as extremely important to their work, is an interesting avenue of
study.
The therapeutic alliance has long been viewed as an important aspect of
psychotherapy process. Over the past 30 years, psychotherapy researchers have
investigated how the therapeutic alliance develops, how it is maintained, and how the