Is the association of therapeutic alliance with days of use always negative?

1. Is the association of therapeutic alliance with days of use always negative? A.A. Forcehimes1, O. Silva 1, A. S. Kosinski2, M. Nakazawa1, K. Burlew3, L. Montgomery3 1University of New Mexico Center on Alcoholism, Substance Abuse and Addictions (CASAA) University of New Mexico, Albuquerque, NM 2Duke Clinical Research Institute 3 University of Cincinnati Procedure: All participants completed the Helping Alliance Questionnaire (HAQ-II), Addiction Severity Index-Lite, and other identical measures as part of a larger assessment battery. Therapists also completed a parallel version of the HAQ form as a measure of the level of alliance they perceived with a particular patient. We focused on patient (N=656) and therapist (N=105) HAQ-II scores at 4 weeks and outcome defined as patients’ self-reported substance use at week 4 of treatment. The three different studies were compared using linear regression analysis and analysis of covariance (ANCOVA). The primary outcome variable was patient substance use assessed with ASI (e.g., self-reported days of illicit substance use at week 4), The predictor variables were HAQ-II patient and therapist scores, and the fixed variable was the treatment patients received (Standard Treatment vs. MI/MET). Log transformation was applied to the outcome variable to reduce its skewness. Hypotheses: Therapeutic alliance, as defined by patient as well as therapist scores on the Helping Alliance (HAQ-II) at the end of 4 weeks of treatment, would predict patient outcomes on total days of substance use. This relationship between HAQ-II and days of substance use would be moderated by the treatment to which patients had been assigned (i.e., testing the interaction effect between HAQ-II and Treatment). INTRODUCTION DISCUSSION Evidence-based treatment has become a strong emphasis in the addiction field. From results of trials comparing one treatment to another, we now have many treatment methods that are science based. The science base also includes many studies showing that relationship matters; it makes a difference not just what treatment is delivered, but who provides it and how. One of the strongest determinants of addiction treatment outcome is the provider with whom the patient works (McLellan, Woody et al. 1988; Leake & King, 1977). Therapeutic alliance , describing the quality of the relationship between the patient and provider, appears to be a strong contributing factor defining the quality of the relationship between the patient and provider. Several components between the patient and therapist are thought to comprise therapeutic alliance, including sharing common goals, completing tasks, building trust, non-judgment, empathy, and having positive feelings towards one another (Summers & Barber, 2003). Across different psychotherapies, the quality of therapeutic alliance has been correlated with treatment entry, adherence, retention and outcome (Horvath & Symonds, 1991; Project MATCH Research Group 1998), particularly when alliance is judged by the patient (DiClemente, Carroll, Miller, Connors, & Donovan, 2003; Horvath & Symonds, 1991). Both motivational interviewing (MI) and motivational enhancement therapy (MET) are rooted in a belief that change is facilitated through a strengthening of a collaborative therapeutic relationship. The strengthening of the therapeutic relationship, through accurate empathy for example, is viewed as a salient relationship factor that directly influences outcome. The successful use of MI may depend on therapist’s ability to develop strong alliance. Building on an examination of alliance tested in one of the Clinical Trials Network MI trials (Crits-Christoph, Gallop et al. 2009) this study examined the impact of therapeutic alliance across three multi-site CTN MI/MET trials to determine whether participants’ and therapists’ perceptions of therapeutic alliance were associated with self reported days of use. • Summary • The aim of this study was to test whether participants’ and therapists’ perceptions of therapeutic alliance were associated with total days of substance use across participants in three MET/MI trials in the CTN. • Overall, there were significant relationships between therapeutic alliance and outcome, though they were not always in the direction we hypothesized. • Therapists’ ratings of therapeutic alliance, but not patients’ ratings, significantly predicted patient outcomes on total days of substance use across treatment conditions. This counters previous research (e.g., DiClemente, Carroll, Miller, Connors, & Donovan, 2003) that patient ratings of therapeutic alliance are strongly associated with treatment outcome. Instead, it appears that it is the therapists’ judgments of alliance that are useful in predicting patient outcomes. Even more unexpected was that the outcomes were not in the direction hypothesized. Higher therapist ratings of alliance actually predicted more days of patient substance use. • As hypothesized, for patients assigned to MI/MET conditions, higher patient ratings of therapeutic alliance predicted fewer days of self-reported substance use across the three trials. This suggests that in the context of motivational interviewing approaches, alliance remains a critical mechanism of change. Therapists using this approach should demonstrate skill in expressing accurate empathy, which is central to relationship building. • These findings counter previous research describing a clear relationship between therapeutic alliance and positive treatment outcomes. This study opens to question the consensus that alliance consistently predicts outcome regardless of treatment modality. • Future Studies • It is possible that the effect of specific therapeutic behaviors (e.g., MI-consistent behaviors) on outcome could vary depending on client ethnicity, gender and age. Therefore, future studies should include measures of demographic characteristics such as gender and ethnicity matching between therapist and patients. • It would also be important to examine longer term outcomes to determine whether these relationships between therapeutic alliance and substance use remain significant. RESULTS • Hypothesis 1 • HAQ-II patient scores were not a significant predictor of log-transformed days of substance use (B = -0.01, t(654) = -1.61, r = -0.06, p = 0.108, Fig.1 Left). • On the other hand, HAQ-II therapist scores were a significant positive predictor of log-transformed days of substance use (B = 0.03, t(654) = 2.65, r = 0.10, p = 0.008, Fig.1 Right). • Hypothesis 2 • The relationship between HAQ-II patient and log(days of substance use) was significantly moderated by Treatment (B = -0.05, t(652) = -3.33, d = -0.26, p = 0.001). Specifically, while HAQ-II patient scores were not a significant predictor of log(days of substance use) in the Treatment as Usual Group (B = 0.01, t(333) = 1.37, r = 0.07, p = 0.173, Fig. 2 Left), the scores were a significant negative predictor in the MI/MET Group (B = -0.03, t(319) = -3.41, r = -0.18, p = 0.001, Fig. 2 Right). • The relationship between HAQ-II therapist scores and log(days of substance use) was not significantly moderated by Treatment (B = -0.01, t(652) = -0.30, d = -0.02, p = 0.763). METHOD • Identical measures were obtained in three CTN trials of MI/MET: • 3 sessions of individual MET vs. Treatment as Usual (TAU) (CTN 0004) • a single 2 hour intake session integrating MI techniques followed by ongoing group treatment vs. standard intake followed by group treatment (CTN 0005) • 3 sessions of individual MET delivered in Spanish vs. TAU delivered in Spanish (CTN 0021) • Participants • Participants were (ns=67, 310 & 279) and therapists (ns=36, 41, & 28) participating in 0004, 0005, 0021, respectively, who had completed the HAQ-II and who had at least 4 weeks of self reported substance use data. The mean ± SD for age was 33.7 ± 9.9, and the three studies included 192 females and 464 males. • Measures • The Helping Alliance Questionnaire-II (HAQ-II) Levels of perceived therapeutic alliance for both therapists and clients was assessed using total scores on the HAQ-II. There are 19 items on the HAQ-II that are rated on a scale of 1-6 from “strongly disagree” to “strongly agree”. An example is the statement “I feel I can depend upon the therapist” (Luborsky, Barber, Siqueland, & Johnson, 1996). Higher scores on the HAQ indicate a stronger alliance between the therapist and patient. According to Luborsky et al. (1996), scores below 86 are considered poor alliance (range from 19 to 114). • The Addiction Severity Index-LiteSeverity of substance use and substance-related problems were be measured by composite scores of the Addiction Severity Index Lite (McLellan, Kushner et al., 1992). The ASI is the most widely-used instrument for assessment of substance use and related problems and its psychometric properties are well established (Cacciola, Alterman et al. 2007). Fig. 1 REFERENCES Crits-Christoph, P., R. Gallop, et al. (2009). "The alliance in motivational enhancement therapy and counseling as usual for substance use problems." 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