The Role of Alliance in Treatment Outcome for People with Alcohol Dependence and Depression

Abstract

Introduction: The pantheoretical variable of alliance has consistently been reported to have a moderate yet robust effect on treatment outcome. However, the relationship is less clear in the addiction field where research is more limited.

To contextualise the current research, the history and development of the alliance concept and the identification of key methodological issues are provided. Alliance research is then reviewed in two parts: that relating to the concept of alliance, followed by research concerned with the alliance-outcome relationship. This review focuses on the treatment populations under investigation in the current dissertation, those with alcohol dependence and depression, and shows how alliance differs in substance-using treatment populations. Specific areas warranting further investigation are identified. These shape the hypotheses used in the current dissertation. Method: There were three separate components of research: the first study investigated alliance with 69 subjects who received treatment as part of the Brief Treatment Programme (BTP) which had investigated the effectiveness of Motivational Enhancement Therapy (MET) in treating mild to moderate alcohol dependence. The relationship between alliance, based on therapists’ ratings of the therapy, was examined for its association with drinking outcomes, e.g. percent days abstinent (PDA), drinks per drinking day (DDD), level of dependence and alcohol-related problems. The second larger part of the investigation was conducted as part of the Treatment Evaluation of Alcohol and Mood (TEAM) study, a randomized controlled pharmacotherapy trial with supportive clinical case management. Therapist and client ratings were assessed using the Working Alliance Inventory (WAI) for 123 alcohol dependent and depressed client-therapist dyads at 3 weeks. Outcome data was obtained at 3 and 12 weeks (end of treatment). Drinking-related measures included PDA and DDD. Mood outcomes were scores on the Montgomery Asberg Depression Rating Scale (MADRS) and Symptom Checklist-90-item-Revised (SCL-90-R) depression subscale. Alongside this TEAM research, a small qualitative investigation was conducted to assist in giving insight and illumination to interpretations of the quantitative data. Twelve clients were interviewed regarding their perspective of the therapeutic relationship, and what they perceived had assisted in the changes that had occurred in their mood and drinking. Results: The BTP investigation found that the older the client, the greater their level of education and the later the onset of alcohol dependence, the higher the therapist-rated alliance. With regards to outcomes, alliance was positively associated with early change in drinking frequency, alcohol-related problems and the number of sessions attended. In contrast, alliance was not associated with drinking intensity, level of dependence or treatment modality. The findings suggest that when examining the alliance-outcome relationship further attention should be given to clients’ drinking profile. The TEAM investigation found that clients rated alliance significantly higher than therapists, but client and therapist ratings were not associated with each other. Baseline motivation was the only pre-treatment client variable associated with alliance, the higher the client’s RCQ-TV score, the higher the therapist-rated alliance. In terms of the alliance-outcome relationship, higher therapists’ ratings of alliance were significantly associated with improved mood outcomes at the end of treatment but, with one minor exception, were not related to drinking outcomes. Higher therapist-rated alliance was also significantly associated with treatment completion. In contrast, client-rated alliance was not related to mood or drinking outcomes, possibly due to a ceiling effect. Subscale analysis found that of the different components that comprise the alliance concept, the task component was most important for drinking outcomes whereas the task and goal components were equally important for mood outcomes. Controlling for early symptom change did not meaningfully alter associations between therapist alliance and mood. In contrast, the strength of associations between therapist alliance and drinking outcomes was reduced for PDA and DDD 12 week change scores, whereas the association between the therapist alliance and 12 week PDA became significant when previously this had not been the case. Qualitative results highlighted factors that were central to the client construct of the therapeutic relationship: the therapeutic bond and engagement, advocacy and competence. Factors that clients associated with changes in their mood or drinking included within treatment factors such as therapeutic qualities, changed thinking and behaviour, and factors external to the TEAM treatment such as external supports and alternative treatments. Conclusions: Therapeutic alliance is associated with improved mood outcomes. However, alliance, as measured by the WAI, and drinking outcomes, are not related. Findings from these investigations signal the need to re-examine the concept and measurement of alliance in substance-using treatment populations, particularly with regard to drinking outcomes. Within this re-examination, findings support greater focus being given to the therapists’ role in the alliance-outcome relationship.