Abstract
Little research has been done on the role of the therapeutic working alliance in treatment for alcohol problems. This longitudinal study’s objectives were (a) to identify predictors of working alliance and (b) to investigate whether client and/or therapist reports of the working alliance predicted posttreatment motivation and then later treatment outcome. Client and therapist perceptions of the working alliance were assessed after the first treatment session using a short form of the Working Alliance Inventory (WAI) among 173 clients taking part in the United Kingdom Alcohol Treatment Trial (UKATT) and randomized to motivational enhancement therapy (MET) or social behavior and network therapy (SBNT) with complete data on all measures of interest. Structural equation models were fitted to identify predictors of WAI scores and investigate the relationships between WAI and measures of drinking during treatment, posttreatment motivation, and successful treatment outcome (abstinent or nonproblem drinker), and measures of drinks per drinking day and nondrinking days, assessed 9 months after the conclusion of treatment. Motivation to change drinking when treatment began was a strong predictor of client—adjusted coefficient = 2.21 (95% confidence interval [CI] [0.36, 4.06]—but not therapist WAI. Client WAI predicted successful treatment outcome—adjusted odds ratios (OR) = 1.09 (95% CI [1.02, 1.17])—and had effects on drinking during treatment, and on posttreatment motivation to change. There was evidence for effect modification by treatment, with strong associations between WAI and posttreatment motivation, and evidence of WAI prediction of treatment outcomes in the MET group, but no evidence of associations for SBNT. Therapist WAI was not strongly associated with treatment outcome (adjusted OR = 1.05; 95% CI [0.99, 1.10]). The working alliance is important to treatment outcomes for alcohol problems, with client evaluation of the alliance strongly related to motivation to change drinking throughout treatment for MET. It was also much more important than therapist-rated alliance in this study.
Highlights
Therapist-reported Working Alliance Inventory (WAI) was lower in the 81 excluded clients (44.9 vs. 47.0, p ϭ .03) but there was no evidence of a difference in client-assessed WAI (47.9 vs. 48.6, p ϭ .30)
Consistent with the larger United Kingdom Alcohol Treatment Trial (UKATT) sample that saw both greater numbers randomized to MET (UKATT Research Team, 2005) and higher levels of initial treatment engagement in clients randomized to MET (Dale et al, 2011), the current sample included a greater proportion of MET to SBNT clients than the 569 clients who were excluded due to missing data: 76% (131/173) MET in study sample versus 51% (291/569) MET in those excluded (p Ͻ .001)
Despite evidence of its importance in treatment for other psychological problems, little is known about the role of the working alliance in treatment for alcohol problems
Summary
The United Kingdom Alcohol Treatment Trial (UKATT) was a multicenter randomized controlled trial carried out in five treatment centers in the United Kingdom, comparing two different treatments for alcohol problems (Motivational Enhancement Therapy [MET] and Social Behavior and Network Therapy [SBNT]) delivered over a 3-month period, after which treatment was terminated (UKATT Research Team, 2005). Form 90 and APQ data were used to construct a binary measure of successful treatment outcome at 9 months after treatment ended: abstinent or nonproblem drinker (no alcohol consumption in the past 90 days or some drinking with a score of zero on the APQ, indicating no evidence of any problems) versus the remainder of the sample This binary outcome measure was derived from the composite categorical variable developed by Heather and Tebbutt (1989) for treatment outcome evaluation purposes, and has been used in earlier UKATT analyses (Heather, McCambridge, & the UKATT Research Team 2013). Hypotheses about the direction of relationships were based on temporality, that is, pretreatment variables must necessarily influence working alliance rather than the other way round Using this explicitly longitudinal perspective to organize the assessment of relationships between variables, we included indirect pathways from WAI to treatment outcome via drinking behaviors during treatment and posttreatment motivation to change drinking immediately posttreatment. This pathway represents the effects on WAI on drinking outcome at 9 months due to unmeasured factors not captured by changes in drinking during treatment or posttreat-
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