DRAFT: This module has unpublished changes.

Running head: THE THERAPEUTIC ALLIANCE AND ADDICTION                               1








                      The Therapeutic Alliance and its Effects on Addiction:
        Features that Promote Positive Change in Adult Substance Abuse Patients.

                        Darius Muniz, Eric D. Shafarman, Angelica Maciel
                                   & Malcolm S. Ranger-Murdock
                                         New York University











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The therapeutic alliance is an important factor in identifying specific aspects of the relationship between client and counselor that promote positive treatment outcomes. A counselor’s positive personality traits and nurturing therapy techniques along with a clients’ trust in their therapist, and willingness for change, are all determining factors in establishing the groundwork for developing a strong therapeutic alliance. Client expectancies along with the counselors’ expectations are required for guiding the therapeutic process towards specific treatment goals that will allow the client to view the therapy process as beneficial and promote program completion. Established measures to identify components of the therapeutic alliance and to measure positive or negative change will help to develop better treatments and techniques for both drug treatment therapy and the retention and completion rates of these programs.
Keywords: therapeutic alliance, expectancies, drug treatment, substance abuse, traits and techniques, retention and completion


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                     The Therapeutic Alliance and its Effects on Addiction:
       Features that Promote Positive Change in Adult Substance Abuse Patients.

Substance abuse in the United States is a major obstacle afflicting millions of Americans across different ages, ethnicities, gender, and leads to major disruptions in their lives often to the point of self-destruction. In the 2009 National Survey on Drug Use and Health (NSDUH), an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 21.8 million Americans aged 12 or older were current illicit drug users, meaning that they had used an illicit drug during the past month prior to the survey interview. This estimate represents 8.7 percent of the U.S. population aged 12 or older. Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used non-medically. The rate of current illicit drug use among persons aged 12 or older in 2009 (8.7 percent) was found to be higher than the rate in 2008 (8.0 percent).This review will detail the importance of the therapeutic alliance in establishing a positive relationship that will promote voluntary reciprocal involvement between counselor and client for controlling addiction in adult substance abuse patients. Implications for positive treatment outcomes involving the therapeutic alliance in substance abuse therapy will be discussed and outlined through relevant research articles with different features of the therapeutic alliance being highlighted as instrumental in assessing its effectiveness.

Counselor Traits and Techniques

Counselor traits are specific personal qualities of the therapist that promote strong ties between the client and themselves, while the techniques employed by the counselor are ways of bringing a working alliance to the point of complete trust and mutual teamwork in promoting positive outcomes for the client (Ackerman & Hilsenroth, 2003). According to Ackerman and Hilsenroth (2003) while examining a therapist’s personal attributes during in-session activities, a

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therapist’s personal qualities such as being flexible, honest, respectful, trustworthy, confident, warm, interested, and open were found to impact positively on the alliance. Also, a therapist’s technique such as exploration, reflection, noting past therapy success, accurate interpretation, and attending to the patient’s experience also positively impacted the therapeutic alliance. The integration of both a therapists positive personal qualities and an implementation of relevant and effective client tailored techniques allow the therapist to relay to the client a sense of genuine compassion and knowledgeability that clients take comfort in.

A counselors attributes are continually identified as a strong predictor of positive counseling outcomes according to a study by Duff and Bedi (2010). Participants rated and identified specific therapist behaviors that they felt are important factors for developing a strong relationship with their therapist. These behavioral features in which promoted a positive environment for trust, are aspects of a therapist that clients related to and held in most regard. This suggests that seemingly small strengths and attributes of a counselor’s behavior can play a key role in strengthening the therapeutic alliance and allows for an atmosphere that clients feel comfortable in and are more willing to adhere to during the therapy process. Given the role that these attributes play in promoting positive counseling outcomes, it is suggested that these specific behaviors be implemented and nurtured early on in the counseling process. Not only are a therapists attributes important for developing a strong bond, but the expectations of both the client and therapist are equally a determining factor for the development of a strong working alliance.

Client and Therapist Expectancies

Client expectancies are expectations by the client that determine if there will be a strong working alliance between client and counselor (Dew & Bickman, 2005; Joyce & Piper, 1998).

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Dew and Bickman (2005) point out that a clients expectancy about the therapy process are considered a crucial feature that is not specific to any particular technique or approach but is an important component in successful therapy. This research emphasized findings about the relationship between expectancies and factors such as client improvement and the role of the therapeutic alliance. Results of this study have found that client expectancies are positively related to both client improvement and strength of the alliance, and demonstrate that clients are more willing to participate in therapy when they have well defined expectations and these expectations are met by the therapist. When a client knows what to expect from their therapist during therapy sessions and the goals of treatment are well established and outlined throughout the treatment process, a client takes comfort in the counselors and therapy’s stability.

In contrast to the clients’ expectations, Joyce and Piper (1998) measured therapist expectancies about the “typical session” during a controlled trial of short term individual psychotherapy. Similar to the Dew and Bickman study, this research examined relationships between expectancy ratings and measures of the therapeutic alliance in regards to treatment outcomes. Relationships were tested in the presence of a competing predictor variable, either pre-therapy disturbance (depression) or the patient’s quality of object relations (QOR). A therapist’s expectations towards the client are shown to be associated strongly with the alliance but only moderately with treatment outcome. This study revealed that a patient’s capacity for mature relationships and expectancies for therapy appeared to be important determinants of the treatment process and also outcome. These expectancies can either strengthen the working alliance (if the expectations are met by the counselor) or weaken and prevent a strong working alliance (if expectations are not met creating a level of distrust and resentment). The stronger the bond between the counselor and client is, and the more expectations of both the client and

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counselor are well defined and met during therapy, a stronger chance for positive treatment goals to be obtained as a result of therapy. While a therapist’s attributes can nurture and strengthen the bond between themselves and their client and while both the client and therapists expectations are important driving forces toward treatment goals, the relationship between the therapeutic alliance and how it affects drug abuse treatment and program completion is an important question to explore.
Substance Abuse Treatment and Program Completion
Hoxmark and Wynn (2010) showed that patients with a dual diagnosis of substance abuse and severe psychiatric illness were often frequently interrelated, and the building of the therapeutic alliance with this group of patients seemed to be both important and difficult. Two focus groups included in this study were providers working in a Therapeutic Community (TC) and a Dual Diagnosis (DD) ward. Participants were given a short case history and asked to describe how they would approach the case. All providers indicated that a good relationship with their client was central to the treatment process, though providers in the DD ward had indicated greater importance in building close relationships with the patients, and described their relationship with the patients as more crucial to treatment. The providers that worked in the TC setting indicated a greater importance on the role of peers and to the structure of the program itself as opposed to emphasizing greater importance on the relationship. The providers agreed that a good therapeutic relationship is important to treatment, yet, they had differed in their opinion about how central this relationship was.
Schiff and Levit (2010) examined potential predictors such as attachment style and the frequency of therapeutic treatment sessions, in relation to how clients rated therapeutic alliance strength between their social worker and themselves. The relationship between the therapeutic
alliance and the client’s psychological outcome in regards to hope and posttraumatic stress symptoms (PTS’s) were also examined. During their research, clients that participated in this study had reported a strong therapeutic alliance with their social workers regardless of attachment style as long as the social worker was attentive and interested in their needs.
The frequency of treatment sessions that the client participated in rated higher therapeutic alliance strength when the sessions were more frequent then when they were more spaced out over time. This demonstrated that the more constant and direct influence the client received from their worker, the more positively a clients view of the therapeutic alliance was. The avoidance dimension of attachment was strongest when clients rated a weak therapeutic alliance between themselves and their worker and avoidance was also strongest when clients had less frequent therapy sessions. The therapeutic alliance is also a strong predictor of less frequent opiate use and is most effective when paired with both frequent therapy sessions and a high therapeutic alliance strength rating by clients. Hope is significantly predicted by a strong therapeutic alliance indicating that the stronger the bond is between the client and their worker the higher levels of hope the client would feel towards achieving positive change. The therapeutic alliance is effective in promoting a positive attitude towards treatment when treatments are more frequent, therapists are more attentive, and the clients’ view of the therapeutic alliance is strong. Not only does this alliance foster a strong relationship, but will most likely play an important role on a patient’s willingness to follow the therapeutic process till its completion.
Cournoyer, Brochu, Landry, and Bergeron (2007) stated that treatment dropout was an important concern for professionals working in mental health. While the problem is common, the highest attrition rates have been observed in drug rehabilitation programs. This study focused on the therapeutic alliance, a process variable that has been associated repeatedly with positive
treatment outcomes for substance abuse patients. Client behavior that is indicative of commitment or resistance to treatment was examined in combination with the therapists’ prognoses. Therapists rated the behavior of clients in treatment and made prognoses about perseverance and improvement. An increased risk of dropout was predicted when patients viewed themselves as less committed and perceived their therapist as less understanding and less involved. A client’s expectation of their therapist, a client’s personal view of their therapist’s attributes, and their view of themselves, play an important part in whether or not a client is willing to continually partake in drug treatment. The therapist prognosis of client determination was also predictive of dropout. Again expectations, this time by the therapist, is instrumental in determining how the client is going to react to the treatment process and is a deciding factor in eventual treatment completion. This study demonstrates that the ability to predict dropout was possible by measuring the strength of the therapeutic alliance, by the therapist expectations through their prognoses of the client, and the therapists’ appraisal of patient behavior as it relates to the strength of the therapeutic alliance and their subsequent determination to complete the treatment process. Clients are more willing to complete drug treatment programs when they have developed a strong therapeutic alliance with their therapist. Also, through positive attributes of the therapist that promotes this strong alliance, along with expectations that are met reciprocally, drug treatment completion can be predicted to a more positive conclusion.
Brochu, Cournoyer, Tremblay, Bergeron, Brunelle, and Landry (2006) examined variables that could predict treatment perseverance and impact for offenders admitted to rehabilitation centers for alcoholics/drug addicts in different regions of the province of Quebec. Factors like time spent in treatment, alcohol/drug use–related problems, motivation to change, criminal profile, subject’s perception of judicial pressure, quality of the therapeutic relationship,
assessment of client commitment to treatment, and social support, are important features of a client that impacted the retention rates and their subsequent completion of a drug program. The therapeutic alliance is a strong predictor of drug treatment retention when sessions are more frequent, and plays an important role in a client’s view of the treatment as beneficial. The higher the rating of the therapeutic alliance by clients, the higher a client’s level of motivation was towards treatment progression. Clients that are more motivated towards positive change predicted higher retention rates and also higher rates of drug treatment completion. Judicial pressure is a strong predictor of treatment retention, but is strongest when the client also rated a strong therapeutic alliance with their therapist. Criminal profile is weakly related to a client’s ability to form a strong therapeutic alliance but was a strong factor in predicting motivation for change, their view of judicial pressure, and the time spent in treatment. Regardless of the substance used, frequency, or severity of substance abuse, a strong therapeutic alliance promoted a more positive view of the treatment process and ultimately had a positive impact on the completion and retention rates of substance abusers in treatment programs. The therapeutic alliance has an important role in the treatment of substance abuse patients and established measures to identify components of the therapeutic alliance and to measure positive or negative change will help to develop better treatments and techniques for both drug treatment therapy and the retention and completion rates of clients that partake in these programs.
Measures of the Therapeutic Alliance
Current measures and inventories that assess components of the therapeutic alliance and specific aspects of a client or therapist that promote this alliance are evaluated and tested for effective results toward positive treatment outcomes (Elvins & Green, 2008; Jacobson &Truax, 1991; Lunnen & Olges, 1998). These measures range the gambit of assessing counselor and
client perceptions, therapist qualities, client expectations, and goal setting to name a few. Elvins and Green (2008) state that the therapeutic alliance constitutes a major variable in explaining the outcome of treatment and that valid measuring technique are instrumental in assessing its impact towards these treatment outcomes. Current alliance concepts and measures are reviewed with the aim of identifying the current status of methods and clarifying the conceptual needs of these measures for future use. A therapist’s personal qualities such as being flexible, respectful, trustworthy, confident, warm, interested, and open are strong predictors of a client’s motivation towards treatment goals, a client’s willingness for change, and their subsequent view of the therapeutic alliance between themselves and their counselor. A therapist’s technique such as exploration, reflection, noting past therapy success, accurate interpretation, and attending to the patient’s experience, provided the client with a sense of trust in their therapist that impacted on the strength of the therapeutic alliance and allowed the client to progress towards treatment goals. The range of concepts and measures available in identifying the therapeutic alliance is numerous; however there is no one current measure of alliance that meets all the predefined criteria in adult populations that encompass both the client and therapist attributes that strengthen the alliance, the client and therapist expectancies that define this therapeutic relationship, and client progress that is specifically enhanced and improved by establishing and nurturing this phenomenon during drug abuse therapy.
Lunnen and Ogles (1998) explore a measure created by Jacobson and Truax (1991), which is a method for evaluating the clinical significance of client change. This is a measure that gained, over the years, increasing prominence in psychotherapy outcome research. This study addressed the limitations of the measure by comparing the perceived level of change (as subjectively reported from 3 distinct perspectives) across outcome groupings based on Jacobson
and Truax's reliable change index (RCI) and subjective reports of therapeutic alliance and satisfaction across outcome groupings. The Jacobson and Truax (1991) measure is a common method of calculating clinical significance and involves calculating a Reliability Change Index or (RCI). The RCI equals the difference between a participant’s pre-test and post-test scores, divided by the standard error of the difference. Cutoff scores are established for placing participants into one of four categories- recovered, improved, unchanged, or deteriorated depending on the directionality of the RCI and whether the cutoff score was met. The results of these comparisons indicated that the RCI is effective in identifying those who make reliable improvement in therapy but is less effective in differentiating between clients with no change. It is evident that valid measures of the impact of the therapeutic alliance that relate to accurate progress change is needed to be able to assess the impact of the therapeutic alliance on measurable client change during drug therapy. The measurement of the therapeutic alliance as it impacts client willingness towards participation in therapy is crucial in determining affective techniques that will promote positive change for clients in substance abuse treatment.
The several most widely used scales that have been developed to assess the patient-counselor relationship in therapy, include, the Working Alliance Inventory (WAI), the Barrett-Lennard Relationship Inventory, and the California Psychotherapy Alliance Scales (CALPAS). The Scale To Assess Relationships (STAR) was specifically developed to measure the therapeutic relationship in community psychiatry, and within mental health care community settings. While much early work on the impact of the therapeutic alliance was generated from a psychodynamic perspective, researchers from other theoretical orientations have since investigated this area. It has been found to predict treatment adherence, compliance, and a willingness for positive change across a range of client/patient diagnoses and treatment settings.
Current Study
The therapeutic alliance is a crucial feature of the client-therapist relationship that promotes positive change for substance abusers and allows for continual treatment progress in drug therapies (Hoxmark & Wynn, 2010). Specific qualities of the therapist, from positive attributes, attentive therapy techniques, and clearly defined expectations towards their client in regards to goal setting (Joyce & Piper, 1998) , also prove to be an important factor in strengthening and promoting a strong therapeutic alliance (Ackerman & Hilsenroth, 2003). Duff and Bedi (2010) also identify a counselors attributes as being continually acknowledged by patients as an important feature of the therapy process as well as a strong predictor of positive counseling outcomes. Dew and Bickman (2005) indentify client factors which included willingness for change in their lives, well defined expectations of the treatment process, and respect and trust in their therapists, as contributing to a strong therapeutic alliance and allowing for beneficial treatment progress. A combination of these factors along with reliable and valid measures of the therapeutic alliance to assess change and solidarity, demonstrate that a strong relationship early in the therapy process produce more positive treatment outcomes than can be achieved without these defining features of counselors and clients that develop a strong therapeutic alliance.
Though a counselors’ traits and techniques are an important part of developing a strong alliance, studies on the identification of specific client traits and coping techniques that can either strengthen resistance to a strong alliance or allow for more beneficial and long lasting termination of drug seeking behavior has not been explored and documented and detailed studies on this feature would be recommended. Client and therapist expectancies have been taken into account in relation to promoting a strong alliance, but further exploration of these features that
define expectations for the process of change in progressing toward goals needs to be evaluated as a specific and unique aspect of expectations apart from its impact on the therapeutic alliance. Finally there are many measures indicating the importance of the therapeutic alliance, yet there is no one measurement that takes into account and encompasses all the crucial features of both the counselor and client that make the phenomenon of the therapeutic alliance such a strong predictor of positive treatment outcomes. Creation and utilization of such a measure can ensure that a therapists attempt at building rapport with their client can be achieved flawlessly and be eliminated as a potential inhibitor on positive treatment outcomes.
This current study will examine: 1. Will a strong therapeutic alliance achieve positive treatment outcomes for substance abusers? 2. Will a strong therapeutic alliance positively impact the retention and completion rates of substance abusers in drug treatment programs? We hypothesized that a strong therapeutic alliance between counselor and client will achieve positive treatment outcomes and also a strong therapeutic alliance will be the determining factor in establishing higher rates of treatment retention of patients and higher rates of subsequent drug therapy completion. Implications of this study emphasize the importance and beneficial outcomes of having a strong therapeutic alliance and demonstrate why this alliance should be a mandatory feature of all therapy sessions. For this technique to be beneficial and effective, it should always be implemented and nurtured right from the beginning of the client-therapist relationship and should be the foundation that different therapy approaches build off of. Due to the limited literature on measures assessing the different client and therapist features that create a strong therapeutic alliance, we would suggest that many more measures be developed to further assess and define the differing features of client and counselor that seem to be crucial in the implementation of this unique aspect of the therapy process.
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DRAFT: This module has unpublished changes.