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Therapeutic alliance and the relationship between motivation and treatment outcomes in patients with alcohol use disorder
Journal of Substance Abuse Treatment 31 (2006) 157 – 162
Regular article
Therapeutic alliance and the relationship between motivation and treatment outcomes in patients with alcohol use disorder Mark A. Ilgen, (Ph.D.)4, John McKellar, (Ph.D.), Rudolf Moos, (Ph.D.), John W. Finney, (Ph.D.) Center for Health Care Evaluation, Department of Veterans Affairs Palo Alto Health Care System, Menlo Park, CA 94025, USA Stanford University School of Medicine, Stanford, CA, USA Received 12 December 2005; received in revised form 11 April 2006; accepted 17 April 2006
Abstract Although motivational readiness to change predicts alcohol use disorder (AUD) treatment outcomes, little is known about treatment aspects that are helpful for patients with low motivation. We examined whether a positive therapeutic alliance is particularly beneficial for patients entering AUD treatment with low motivation. Among Project MATCH outpatients (n = 753), we tested the influence of motivation, therapeutic alliance, and their interaction on 6-month and 1-year alcohol use. The impact of motivation on alcohol use varied depending on therapists’ perceptions of alliance. Interactions involving treatment compliance did not mediate the Motivation Alliance interaction. Thus, a positive therapeutic relationship may be particularly important for patients with low motivation, but mechanisms underlying this possible patient–treatment bmatchQ remain to be determined. D 2006 Elsevier Inc. All rights reserved. Keywords: Motivation; Alcohol use disorder; Therapeutic alliance; Treatment
1. Introduction Motivational readiness to change is theorized to be an important determinant of treatment outcome for patients with alcohol use disorders (AUDs; Miller & Rollnick, 2002; Prochaska, DiClemente, & Norcross, 1992). High motivation prior to treatment is a strong predictor of treatment outcomes and foreshadows a better course for several years following treatment (Carbonari & DiClemente, 2000; DiClemente, Carbonari, Zweben, Morrel, & Lee, 2001; McKay & Weiss, 2001). The consistency of these findings has led researchers to examine how psychosocial interventions can strengthen motivation in patients with AUDs,
4 Corresponding author. Center for Health Care Evaluation, Department of Veterans Affairs Palo Alto Health Care System, 795 Willow Road (MPD 152), Menlo Park, CA 94025, USA. Tel.: +1 650 493 5000x27575. E-mail address: [email protected] (M.A. Ilgen). 0740-5472/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2006.04.001
particularly in patients who report low motivation at the beginning of treatment. Project MATCH tested whether any of three psychosocial treatments for AUDs was particularly well suited to treat patients with low motivation (Project MATCH Research Group, 1993). Specifically, it was hypothesized that patients with low motivation who were randomized to Motivational Enhancement Therapy (MET) would do better than those randomized to either Cognitive Behavioral Treatment (CBT) or 12-Step Facilitation (TSF). Further, it was hypothesized that this advantage would occur because the bmatchQ between MET and patients with low motivation would produce a better therapeutic alliance and better adherence to treatment than would be true for patients with low motivation in either of the other two treatment conditions. However, there was little or no support for the hypothesis that states that any of the three treatments used in Project MATCH was particularly well suited to the challenge of treating patients with AUD who have low motivation (Babor & Del Boca, 2003; DiClemente et al., 2001).
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Rather than focusing on specific treatments or modalities, an alternative approach for examining patient–treatment interactions is to focus on common factors across treatments. One common aspect of treatment, the quality of the therapeutic alliance, predicts treatment outcomes in a number of different domains (Lebow, Kelly, Knobloch-Fedders, & Moos, 2006; Meier, Barrowclough, & Donmall, 2005). Within Project MATCH, Connors, Carroll, DiClemente, Longabaugh, and Donovan (1997) found that stronger therapeutic alliance predicted better AUD treatment compliance and outcomes. Patients with low motivation are particularly sensitive to aspects of the therapeutic relationship (e.g., Miller & Rollnick, 2002) and, consequently, may be especially responsive to a strong, positive therapeutic alliance. Thus, it is likely that therapeutic alliance may influence the relationship between patient motivation and outcome. As far as we know, no prior study has examined the interaction between motivation and therapeutic alliance as a predictor of AUD treatment outcomes. We hypothesize that a positive therapeutic alliance can overcome the consequences of low motivation on drinking outcomes in patients treated for AUDs. We also examine the role of treatment compliance (treatment sessions attended) as a potential mediator of a Motivation Alliance interaction following steps described in Finney (1995). In these analyses, we test whether patients with low motivation who have a strong therapeutic alliance are more likely to achieve positive outcomes because they are more compliant with treatment compared with those who have a weak alliance. We hypothesize that the expected interaction between patient motivation and therapeutic alliance in predicting drinking outcomes may be due to increased treatment compliance among b matchedQ patients with low motivation, the interaction between compliance and therapeutic alliance on patient outcomes, or both.
2. Materials and methods Within Project MATCH, independent samples of outpatient and aftercare patients were randomly assigned to CBT (Kadden, Carroll, & Donovan, 1992), MET (Miller, Zweben, DiClemente, & Rychtarik, 1992), or TSF (Nowinski, Baker, & Carroll, 1992). We focus on outpatients because of our interest in the role of motivation at the beginning of treatment and because previous analyses in Project MATCH found the strongest predictive relationships for motivation, treatment type, and therapeutic alliance within the outpatient sample (Connors et al., 2000; DiClemente et al., 2001; Project MATCH Research Group, 1997). Patients were assessed at multiple time points before, during, and following treatment (see below). Informed consent was obtained from all participants, and the procedures used were in accordance with the standards of the Committee on Human Experimentation from the Helsinki Declaration of 1975 (Project MATCH Research Group,
1993). The Stanford University Human Research Protection Program provided human subjects approval for this specific set of secondary analyses of Project MATCH data. Detailed information on sample, eligibility criteria, assessments, and treatments has been reported previously (see Babor & Del Boca, 2003). 2.1. Participants This study included patients in the outpatient sample who provided usable data on measures of alcohol consumption at baseline, 6 months, and 1 year after treatment completion. Data on therapeutic alliance were available for 785 (82.5%) participants. Prior research on therapeutic alliance in Project MATCH indicates that outpatients with complete data on measures of therapeutic alliance are representative of the overall outpatient Project MATCH sample, with the exception that they were more likely to be married than were those without complete data (Connors et al., 1997). 2.2. Measures 2.2.1. Alcohol stages of change version of the University of Rhode Island Change Assessment (URICA-A; DiClemente & Hughes, 1990) This measure contains four 7-item subscales that were combined to develop a single scale of motivation to change. This method for scoring the URICA-A has been described previously in Kadden, Longabaugh, and Wirtz (2003). Reliability estimates for the four subscales range from .68 to .85 in the Project MATCH data set (Carbonari & DiClemente, 2000). 2.2.2. Working Alliance Inventory (WAI; Horvath & Greenberg, 1986) The WAI is a 36-item measure of the patient’s capacity to engage actively in treatment and the patient’s experience of the therapeutic relationship as helpful. Both the therapist and the patient completed the WAI. The WAI demonstrated good internal consistency (Connors et al., 1997), and, consistent with past research with the WAI on this sample, the total scores for therapists and patients reported after the second session of therapy were used here. 2.2.3. Drinking behavior Drinking behavior (percentage of days abstinent [PDA] and drinks per drinking day [DDD]) was measured via interview at all time points using the Form 90 (Miller, 1996). The Form 90 asks patients to provide retrospective data on the quantity and frequency of alcohol consumed per day in the prior 3 months. Consistent with other published reports from Project MATCH, we used transformed versions of these variables (i.e., arcsin transformation for PDA and square root transformation for DDD) in all analyses (for more information, see Project MATCH Research Group, 1997).
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159
To decrease family-wise error, we generated factor scores, combining PDA and DDD for each time point. The two outcomes converged well, producing a unitary factor (68% of variance in a single factor for 6-month outcomes and 70% of variance in a single factor for 1-year outcomes) on which each variable loaded .83 at both time points. 2.2.4. Type of treatment and number of sessions Treatment providers reported information about the number of treatment sessions attended by each patient. Treatment type (MET, CBT, and TSF) was coded using orthogonal contrasts (Kraemer & Blasey, 2004). To measure treatment compliance, we calculated the ratio of number of treatment sessions attended over number available (i.e., the number of sessions actually attended was divided by 12 for CBT and TSF and was divided by 4 for MET).
Fig. 1. Therapists’ ratings of alliance are more closely related to less alcohol use at 6 months in patients with low motivation than in those with high motivation.
treatment outcome. All variables were median centered (see Kraemer & Blasey, 2004).
2.3. Analysis plan Two regression analyses were conducted, in which the predictors were baseline motivation, therapeutic alliance, and the interaction of motivation and therapeutic alliance and the outcomes were alcohol use at either 6 months or 1 year. Baseline alcohol use and treatment type were included as covariates. Separate analyses were conducted for patients’ and therapists’ rating of therapeutic alliance. A series of regression analyses was conducted to test whether either of the two interactions involving the ratio of treatment sessions attended over number of available sessions (as a measure of treatment compliance) mediated the interaction between motivation and alliance in relation to alcohol use
Table 1 Predictors of alcohol use at 6 months and at 1 year Predictors Analyses of patient ratings of alliancea Motivation Patient rating of alliance Motivation Patient rating of alliance Constant R2 Analyses of therapist ratings of alliancea Motivation Therapist rating of alliance Motivation Therapist rating of alliance Constant R2
Alcohol use at 6 months (b)
Alcohol use at 1 year (b)
.06344 .00344 .000
.07544 .001 .000
.031 .055
.027 .053
.06744 .00544 .0024
.07244 .00444 .0024
.042 .071
.040 .072
3. Results Results from the primary regression analyses are presented in Table 1. With patient-rated therapeutic alliance in the model, a significant main effect was found, showing that stronger patient motivation at baseline was linked to less alcohol use at both 6 months and 1 year. Patients who perceived a stronger alliance had better alcohol outcomes at 6 months but not at 1 year. However, no significant interaction effect between motivation and patient-rated alliance was found at either time point. In analyses involving therapists’ ratings of the therapeutic alliance, higher motivation and more positive perception of the alliance by the therapist both independently predicted less alcohol use at the 6-month and 1-year follow-ups. Additionally, there was a significant interaction between motivation and therapists’ ratings of alliance at each follow-up. The form of these interactions is presented in Figs. 1 and 2, which show low, medium, and high groups F1 SD from the mean for motivation and therapists’ reports of therapeutic alliance. The effects of therapeutic alliance were strongest for patients
a
All analyses included baseline alcohol use and treatment type as covariates. 4 p = .05. 44 p b .01.
Fig. 2. Therapists’ ratings of alliance are more closely related to less alcohol use at 1 year in patients with low motivation than in those with high motivation.
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with low motivation. A good therapeutic alliance ameliorated the negative effects of low baseline motivation in predicting drinking at the 6-month and 1-year follow-up. In contrast, variation in the quality of the therapeutic alliance made relatively little difference in alcohol use outcomes for individuals with high motivation at treatment entry. Analyses were conducted to test whether interactions involving treatment compliance (operationalized as number of sessions attended over the maximum number of available sessions) might mediate the significant interaction between motivation and therapists’ ratings of alliance in relation to alcohol use outcome. All analyses predicting alcohol use utilized data from the 1-year follow-up. The first set of analyses indicated that compliance did not mediate the outcomes. Specifically, although compliance did predict 1-year alcohol use, the interaction between motivation and therapists’ ratings of alliance did not predict compliance, and the inclusion of compliance in the original model did not decrease the magnitude of the interaction of motivation and alliance in relation to alcohol use at 1 year. The other set of regression analyses provided further evidence that show that another interaction involving compliance did not mediate the effect of the interaction between motivation and alliance on alcohol use. Specifically, we found that motivation did not predict compliance, that the interaction between alliance and compliance did not predict alcohol use, and that the addition of the interaction of alliance and compliance to the original equation did not decrease the magnitude of the interaction between motivation and alliance predicting alcohol use.
4. Discussion Similar to earlier published reports from Project MATCH (Carbonari & DiClemente, 2000; DiClemente et al., 2001), motivation at treatment entry predicted a reduction in alcohol use 6 months and 1 year after AUD treatment. However, the relationship between low motivation and treatment outcomes depended on the therapist’s perception of the therapeutic alliance. Specifically, even after controlling for baseline alcohol use and treatment type, a high-quality therapeutic relationship was more strongly associated with reductions in alcohol use among patients with low motivation than among those with high motivation. These findings suggest that a strong positive therapeutic relationship may be able to overcome much of the negative effect of low motivation on posttreatment alcohol use. Although it seems plausible that interactions involving treatment compliance might explain this overall interaction effect, we found no support for such mediating effects. Our findings support the growing body of literature indicating that motivational readiness to change is important in influencing treatment outcomes for AUDs (Carbonari & DiClemente, 2000). As evidence builds for the importance of motivation as a determinant of treatment outcome, it becomes
increasingly vital to discover aspects of treatment that are especially beneficial for patients with low motivation. Past investigations of the role of treatment type may have underestimated the degree of variability across treatments in therapists’ abilities to employ diverse treatment strategies to engage patients with low motivation in the therapeutic process (Connors et al., 1997, 2000). Consistent with prior results from Project MATCH, the present findings indicate that the quality of the relationship between treatment provider and patient is important irrespective of the type of treatment provided (Connors et al., 1997). Providers espousing different orientations to treatment must attempt to establish rapport and a strong therapeutic relationship (Lambert & Barley, 2001; Lebow et al., 2006), and, according to our results, the quality of the relationship, especially as seen by the therapist, may be particularly important in patients with low motivation. However, it is important to note that these findings are preliminary and more research is needed before concluding that increased alliance caused the improvements seen in patients with low motivation. There are several reasons why patients with low motivation may be uniquely responsive to the therapeutic relationship. Such patients tend to be ambivalent about treatment (Miller & Rollnick, 2002), which may make them more attuned to contextual influences such as the quality of the therapeutic relationship (Lebow et al., 2006). Moreover, responsive therapists are likely to be aware of patients’ low motivation and change their behavior to fit these patients’ needs. Thus, therapists’ estimates of alliance may reflect their general sensitivity to the needs of patients with low motivation. This conceptualization is consistent with the finding that therapists’ perceptions of the relationship, rather than patients’ perceptions, were more closely tied with improvements in patients with low motivation. Additionally, such patients may be less attentive to the relationship and, consequently, provide less accurate ratings of therapeutic alliance. Others have suggested that ratings of alliance provided by either therapists or third-party observers may be more closely related to treatment outcomes in patients with substance use disorder than patients’ ratings of alliance (Fenton, Cecero, Nich, Frankforter, & Carroll, 2001; Shelef, Diamond, Diamond, & Liddle, 2005). More research is needed to understand how patients’ baseline motivation affects the development of the treatment alliance and why it is associated with outcomes. A closely related direction for future research is to examine alternative causal chains such as whether a positive therapeutic alliance with patients with low motivation leads to proximal changes (e.g., increases in approach coping) that foreshadow positive outcome. In this study, interactions involving treatment compliance did not mediate the effect of the interaction between therapists’ ratings of alliance and motivation on patients’ outcome. Our findings have implications for clinicians and researchers. Clearly, because of the association between motivation and prognosis, therapists need to attend to patients’ levels of
M.A. Ilgen et al. / Journal of Substance Abuse Treatment 31 (2006) 157–162
motivation. Additionally, the finding that the relationship between low motivation and poorer alcohol use outcomes is not uniform highlights the potential positive influence therapists can have with patients with low motivation. Although prior literature on motivation and AUD treatment has focused primarily on treatment techniques (Miller & Rollnick, 2002), our findings indicate that the quality of the relationship may be more important than the therapists’ treatment orientation or specific techniques. These implications notwithstanding, this study has several limitations. The selection criteria for participants and the close monitoring of treatment providers in Project MATCH may have raised patients’ levels of motivation and enhanced therapeutic alliances, thus decreasing the generalizability of our findings. Additionally, the lack of consistent findings between patient and therapist ratings of alliance raises the possibility that the findings may have been due to factors other than the quality of the therapeutic relationship. The fact that motivation was measured at baseline and alliance was measured after two sessions of treatment leaves open the possibility that, in addition to alliance, therapists may have been rating patients’ motivation or performance in treatment. Our findings suggest that treatment providers can work effectively with patients with low motivation when they are able to establish a strong alliance with their patient. Better identification of the mechanisms of action underlying the interaction between motivation and therapeutic alliance may help to identify ways in which therapists can enhance their relationships with patients who are initially hesitant to engage in treatment, thereby improving patients’ outcomes.
Acknowledgment Preparation of this article was supported by the Department of Veterans Affairs Health Services Research and Development Service. The views expressed here are the authors’ and do not necessarily represent the views of the Department of Veterans Affairs. Additionally, the authors acknowledge that the reported results are based on analyses of the Project MATCH Public Data Set. These data were collected as part of a multisite clinical trial of alcoholism treatments supported by a series of grants from the National Institute on Alcohol Abuse and Alcoholism and made available to the authors by the Project MATCH Research Group. This article has not been reviewed or endorsed by the Project MATCH Research Group and does not necessarily represent the opinions of its members, who are not responsible for the contents.
References Babor, T. F., & Del Boca, F. K. (Eds.). (2003). Treatment matching in alcoholism. New York, NY7 Cambridge University Press.
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Carbonari, J. P., & DiClemente, C. C. (2000). Using transtheoretical model profiles to differentiate levels of alcohol abstinence success. Journal of Consulting and Clinical Psychology, 68, 810 – 817. Connors, G. J., Carroll, K. M., DiClemente, C. C., Longabaugh, R., & Donovan, D. M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal of Consulting and Clinical Psychology, 65, 588 – 598. Connors, G. J., DiClemente, C. C., Dermen, K. H., Kadden, R., Carroll, K. M., & Frone, M. R. (2000). Predicting the therapeutic alliance in alcoholism treatment. Journal of Studies on Alcohol, 61, 139 – 149. DiClemente, C. C., Carbonari, J. P., Zweben, A., Morrel, T., & Lee, R. E. (2001). Motivation hypothesis causal chain analysis. In R. Longabaugh, & P. W. Wirtz (Eds.), Project match hypotheses: Results and causal chain analyses, (Vol. 8, pp. 206 – 222). Bethesda, MD: Project MATCH Monograph Series NIH Pub No. 01-4238. DiClemente, C. C., & Hughes, S. O. (1990). Stages of change profiles in outpatient alcoholism treatment. Journal of Substance Abuse, 2, 217 – 235. Fenton, L. R., Cecero, J. J., Nich, C., Frankforter, T. L., & Carroll, K. M. (2001). Perspective is everything: The predictive validity of six working alliance instruments. Journal of Psychotherapy Practice and Research, 10, 262 – 268. Finney, J. W. (1995). Enhancing substance abuse treatment evaluations: Examining mediators and moderators of treatment effects. Journal of Substance Abuse, 7, 135 – 150. Horvath, A. O., & Greenberg, L. S. (1986). The development of the working alliance inventory. In L. S. Greenberg, & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 529 – 556). New York, NY7 Guilford. Kadden, R. M., Carroll, K., & Donovan, D. M. (1992). Cognitive– behavioral coping skills therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse or dependence. Rockville, MD7 National Institute on Alcohol Abuse and Alcoholism. Kadden, R. M., Longabaugh, R., & Wirtz, P. W. (2003). The matching hypotheses: Rationale and predictions. In F. Babor (Ed.), Treatment matching in alcoholism. International research monographs in the addictions (pp. 81 – 102). New York, NY7 Cambridge University Press. Kraemer, H. C., & Blasey, C. M. (2004). Centering in regression analyses: A strategy to prevent errors in statistical inference. International Journal of Methods in Psychiatric Research, 13, 141 – 151. Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38, 357 – 361. Lebow, J., Kelly, J. F., Knobloch-Fedders, L. M., & Moos, R. (2006). Relationship factors in treating substance use disorders. In L. B. Castonguay, & L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 293 – 317). New York, NY7 Oxford University Press. McKay, J. R., & Weiss, R. V. (2001). A review of temporal effects and outcome predictors in substance abuse treatment studies with long-term follow-ups: Preliminary results and methodological issues. Evaluation Review, 25, 113 – 161. Meier, P. S., Barrowclough, C., & Donmall, M. C. (2005). The role of the therapeutic alliance in the treatment of substance misuse: A critical review of the literature. Addiction, 100, 304 – 316. Miller, W. R. (1996). Manual for form 90: A structural assessment interview for drinking and related behaviors (project match monograph series no. 5). Rockville, MD7 National Institute on Alcohol Abuse and Alcoholism. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York, NY7 US: Guilford Press. Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational-enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse or dependence. Rockville, MD7 National Institute on Alcohol Abuse and Alcoholism. Nowinski, J., Baker, S., & Carroll, K. (1992). The twelve-step facilitation therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse or dependence. Rockville, MD7 National Institute on Alcohol Abuse and Alcoholism.
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Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102 – 1114. Project MATCH Research Group. (1993). Project match: Rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcoholism: Clinical & Experimental Research, 17, 1130 – 1145.
Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project match posttreatment drinking outcomes. Journal of Studies on Alcohol, 58, 7 – 29. Shelef, K., Diamond, G. M., Diamond, G. S., & Liddle, H. A. (2005). Adolescent and parent alliance and treatment outcome in multidimensional family therapy. Journal of Consulting and Clinical Psychology, 73, 689 – 698.
Regular article
Therapeutic alliance and the relationship between motivation and treatment outcomes in patients with alcohol use disorder Mark A. Ilgen, (Ph.D.)4, John McKellar, (Ph.D.), Rudolf Moos, (Ph.D.), John W. Finney, (Ph.D.) Center for Health Care Evaluation, Department of Veterans Affairs Palo Alto Health Care System, Menlo Park, CA 94025, USA Stanford University School of Medicine, Stanford, CA, USA Received 12 December 2005; received in revised form 11 April 2006; accepted 17 April 2006
Abstract Although motivational readiness to change predicts alcohol use disorder (AUD) treatment outcomes, little is known about treatment aspects that are helpful for patients with low motivation. We examined whether a positive therapeutic alliance is particularly beneficial for patients entering AUD treatment with low motivation. Among Project MATCH outpatients (n = 753), we tested the influence of motivation, therapeutic alliance, and their interaction on 6-month and 1-year alcohol use. The impact of motivation on alcohol use varied depending on therapists’ perceptions of alliance. Interactions involving treatment compliance did not mediate the Motivation Alliance interaction. Thus, a positive therapeutic relationship may be particularly important for patients with low motivation, but mechanisms underlying this possible patient–treatment bmatchQ remain to be determined. D 2006 Elsevier Inc. All rights reserved. Keywords: Motivation; Alcohol use disorder; Therapeutic alliance; Treatment
1. Introduction Motivational readiness to change is theorized to be an important determinant of treatment outcome for patients with alcohol use disorders (AUDs; Miller & Rollnick, 2002; Prochaska, DiClemente, & Norcross, 1992). High motivation prior to treatment is a strong predictor of treatment outcomes and foreshadows a better course for several years following treatment (Carbonari & DiClemente, 2000; DiClemente, Carbonari, Zweben, Morrel, & Lee, 2001; McKay & Weiss, 2001). The consistency of these findings has led researchers to examine how psychosocial interventions can strengthen motivation in patients with AUDs,
4 Corresponding author. Center for Health Care Evaluation, Department of Veterans Affairs Palo Alto Health Care System, 795 Willow Road (MPD 152), Menlo Park, CA 94025, USA. Tel.: +1 650 493 5000x27575. E-mail address: [email protected] (M.A. Ilgen). 0740-5472/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2006.04.001
particularly in patients who report low motivation at the beginning of treatment. Project MATCH tested whether any of three psychosocial treatments for AUDs was particularly well suited to treat patients with low motivation (Project MATCH Research Group, 1993). Specifically, it was hypothesized that patients with low motivation who were randomized to Motivational Enhancement Therapy (MET) would do better than those randomized to either Cognitive Behavioral Treatment (CBT) or 12-Step Facilitation (TSF). Further, it was hypothesized that this advantage would occur because the bmatchQ between MET and patients with low motivation would produce a better therapeutic alliance and better adherence to treatment than would be true for patients with low motivation in either of the other two treatment conditions. However, there was little or no support for the hypothesis that states that any of the three treatments used in Project MATCH was particularly well suited to the challenge of treating patients with AUD who have low motivation (Babor & Del Boca, 2003; DiClemente et al., 2001).
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Rather than focusing on specific treatments or modalities, an alternative approach for examining patient–treatment interactions is to focus on common factors across treatments. One common aspect of treatment, the quality of the therapeutic alliance, predicts treatment outcomes in a number of different domains (Lebow, Kelly, Knobloch-Fedders, & Moos, 2006; Meier, Barrowclough, & Donmall, 2005). Within Project MATCH, Connors, Carroll, DiClemente, Longabaugh, and Donovan (1997) found that stronger therapeutic alliance predicted better AUD treatment compliance and outcomes. Patients with low motivation are particularly sensitive to aspects of the therapeutic relationship (e.g., Miller & Rollnick, 2002) and, consequently, may be especially responsive to a strong, positive therapeutic alliance. Thus, it is likely that therapeutic alliance may influence the relationship between patient motivation and outcome. As far as we know, no prior study has examined the interaction between motivation and therapeutic alliance as a predictor of AUD treatment outcomes. We hypothesize that a positive therapeutic alliance can overcome the consequences of low motivation on drinking outcomes in patients treated for AUDs. We also examine the role of treatment compliance (treatment sessions attended) as a potential mediator of a Motivation Alliance interaction following steps described in Finney (1995). In these analyses, we test whether patients with low motivation who have a strong therapeutic alliance are more likely to achieve positive outcomes because they are more compliant with treatment compared with those who have a weak alliance. We hypothesize that the expected interaction between patient motivation and therapeutic alliance in predicting drinking outcomes may be due to increased treatment compliance among b matchedQ patients with low motivation, the interaction between compliance and therapeutic alliance on patient outcomes, or both.
2. Materials and methods Within Project MATCH, independent samples of outpatient and aftercare patients were randomly assigned to CBT (Kadden, Carroll, & Donovan, 1992), MET (Miller, Zweben, DiClemente, & Rychtarik, 1992), or TSF (Nowinski, Baker, & Carroll, 1992). We focus on outpatients because of our interest in the role of motivation at the beginning of treatment and because previous analyses in Project MATCH found the strongest predictive relationships for motivation, treatment type, and therapeutic alliance within the outpatient sample (Connors et al., 2000; DiClemente et al., 2001; Project MATCH Research Group, 1997). Patients were assessed at multiple time points before, during, and following treatment (see below). Informed consent was obtained from all participants, and the procedures used were in accordance with the standards of the Committee on Human Experimentation from the Helsinki Declaration of 1975 (Project MATCH Research Group,
1993). The Stanford University Human Research Protection Program provided human subjects approval for this specific set of secondary analyses of Project MATCH data. Detailed information on sample, eligibility criteria, assessments, and treatments has been reported previously (see Babor & Del Boca, 2003). 2.1. Participants This study included patients in the outpatient sample who provided usable data on measures of alcohol consumption at baseline, 6 months, and 1 year after treatment completion. Data on therapeutic alliance were available for 785 (82.5%) participants. Prior research on therapeutic alliance in Project MATCH indicates that outpatients with complete data on measures of therapeutic alliance are representative of the overall outpatient Project MATCH sample, with the exception that they were more likely to be married than were those without complete data (Connors et al., 1997). 2.2. Measures 2.2.1. Alcohol stages of change version of the University of Rhode Island Change Assessment (URICA-A; DiClemente & Hughes, 1990) This measure contains four 7-item subscales that were combined to develop a single scale of motivation to change. This method for scoring the URICA-A has been described previously in Kadden, Longabaugh, and Wirtz (2003). Reliability estimates for the four subscales range from .68 to .85 in the Project MATCH data set (Carbonari & DiClemente, 2000). 2.2.2. Working Alliance Inventory (WAI; Horvath & Greenberg, 1986) The WAI is a 36-item measure of the patient’s capacity to engage actively in treatment and the patient’s experience of the therapeutic relationship as helpful. Both the therapist and the patient completed the WAI. The WAI demonstrated good internal consistency (Connors et al., 1997), and, consistent with past research with the WAI on this sample, the total scores for therapists and patients reported after the second session of therapy were used here. 2.2.3. Drinking behavior Drinking behavior (percentage of days abstinent [PDA] and drinks per drinking day [DDD]) was measured via interview at all time points using the Form 90 (Miller, 1996). The Form 90 asks patients to provide retrospective data on the quantity and frequency of alcohol consumed per day in the prior 3 months. Consistent with other published reports from Project MATCH, we used transformed versions of these variables (i.e., arcsin transformation for PDA and square root transformation for DDD) in all analyses (for more information, see Project MATCH Research Group, 1997).
M.A. Ilgen et al. / Journal of Substance Abuse Treatment 31 (2006) 157–162
159
To decrease family-wise error, we generated factor scores, combining PDA and DDD for each time point. The two outcomes converged well, producing a unitary factor (68% of variance in a single factor for 6-month outcomes and 70% of variance in a single factor for 1-year outcomes) on which each variable loaded .83 at both time points. 2.2.4. Type of treatment and number of sessions Treatment providers reported information about the number of treatment sessions attended by each patient. Treatment type (MET, CBT, and TSF) was coded using orthogonal contrasts (Kraemer & Blasey, 2004). To measure treatment compliance, we calculated the ratio of number of treatment sessions attended over number available (i.e., the number of sessions actually attended was divided by 12 for CBT and TSF and was divided by 4 for MET).
Fig. 1. Therapists’ ratings of alliance are more closely related to less alcohol use at 6 months in patients with low motivation than in those with high motivation.
treatment outcome. All variables were median centered (see Kraemer & Blasey, 2004).
2.3. Analysis plan Two regression analyses were conducted, in which the predictors were baseline motivation, therapeutic alliance, and the interaction of motivation and therapeutic alliance and the outcomes were alcohol use at either 6 months or 1 year. Baseline alcohol use and treatment type were included as covariates. Separate analyses were conducted for patients’ and therapists’ rating of therapeutic alliance. A series of regression analyses was conducted to test whether either of the two interactions involving the ratio of treatment sessions attended over number of available sessions (as a measure of treatment compliance) mediated the interaction between motivation and alliance in relation to alcohol use
Table 1 Predictors of alcohol use at 6 months and at 1 year Predictors Analyses of patient ratings of alliancea Motivation Patient rating of alliance Motivation Patient rating of alliance Constant R2 Analyses of therapist ratings of alliancea Motivation Therapist rating of alliance Motivation Therapist rating of alliance Constant R2
Alcohol use at 6 months (b)
Alcohol use at 1 year (b)
.06344 .00344 .000
.07544 .001 .000
.031 .055
.027 .053
.06744 .00544 .0024
.07244 .00444 .0024
.042 .071
.040 .072
3. Results Results from the primary regression analyses are presented in Table 1. With patient-rated therapeutic alliance in the model, a significant main effect was found, showing that stronger patient motivation at baseline was linked to less alcohol use at both 6 months and 1 year. Patients who perceived a stronger alliance had better alcohol outcomes at 6 months but not at 1 year. However, no significant interaction effect between motivation and patient-rated alliance was found at either time point. In analyses involving therapists’ ratings of the therapeutic alliance, higher motivation and more positive perception of the alliance by the therapist both independently predicted less alcohol use at the 6-month and 1-year follow-ups. Additionally, there was a significant interaction between motivation and therapists’ ratings of alliance at each follow-up. The form of these interactions is presented in Figs. 1 and 2, which show low, medium, and high groups F1 SD from the mean for motivation and therapists’ reports of therapeutic alliance. The effects of therapeutic alliance were strongest for patients
a
All analyses included baseline alcohol use and treatment type as covariates. 4 p = .05. 44 p b .01.
Fig. 2. Therapists’ ratings of alliance are more closely related to less alcohol use at 1 year in patients with low motivation than in those with high motivation.
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with low motivation. A good therapeutic alliance ameliorated the negative effects of low baseline motivation in predicting drinking at the 6-month and 1-year follow-up. In contrast, variation in the quality of the therapeutic alliance made relatively little difference in alcohol use outcomes for individuals with high motivation at treatment entry. Analyses were conducted to test whether interactions involving treatment compliance (operationalized as number of sessions attended over the maximum number of available sessions) might mediate the significant interaction between motivation and therapists’ ratings of alliance in relation to alcohol use outcome. All analyses predicting alcohol use utilized data from the 1-year follow-up. The first set of analyses indicated that compliance did not mediate the outcomes. Specifically, although compliance did predict 1-year alcohol use, the interaction between motivation and therapists’ ratings of alliance did not predict compliance, and the inclusion of compliance in the original model did not decrease the magnitude of the interaction of motivation and alliance in relation to alcohol use at 1 year. The other set of regression analyses provided further evidence that show that another interaction involving compliance did not mediate the effect of the interaction between motivation and alliance on alcohol use. Specifically, we found that motivation did not predict compliance, that the interaction between alliance and compliance did not predict alcohol use, and that the addition of the interaction of alliance and compliance to the original equation did not decrease the magnitude of the interaction between motivation and alliance predicting alcohol use.
4. Discussion Similar to earlier published reports from Project MATCH (Carbonari & DiClemente, 2000; DiClemente et al., 2001), motivation at treatment entry predicted a reduction in alcohol use 6 months and 1 year after AUD treatment. However, the relationship between low motivation and treatment outcomes depended on the therapist’s perception of the therapeutic alliance. Specifically, even after controlling for baseline alcohol use and treatment type, a high-quality therapeutic relationship was more strongly associated with reductions in alcohol use among patients with low motivation than among those with high motivation. These findings suggest that a strong positive therapeutic relationship may be able to overcome much of the negative effect of low motivation on posttreatment alcohol use. Although it seems plausible that interactions involving treatment compliance might explain this overall interaction effect, we found no support for such mediating effects. Our findings support the growing body of literature indicating that motivational readiness to change is important in influencing treatment outcomes for AUDs (Carbonari & DiClemente, 2000). As evidence builds for the importance of motivation as a determinant of treatment outcome, it becomes
increasingly vital to discover aspects of treatment that are especially beneficial for patients with low motivation. Past investigations of the role of treatment type may have underestimated the degree of variability across treatments in therapists’ abilities to employ diverse treatment strategies to engage patients with low motivation in the therapeutic process (Connors et al., 1997, 2000). Consistent with prior results from Project MATCH, the present findings indicate that the quality of the relationship between treatment provider and patient is important irrespective of the type of treatment provided (Connors et al., 1997). Providers espousing different orientations to treatment must attempt to establish rapport and a strong therapeutic relationship (Lambert & Barley, 2001; Lebow et al., 2006), and, according to our results, the quality of the relationship, especially as seen by the therapist, may be particularly important in patients with low motivation. However, it is important to note that these findings are preliminary and more research is needed before concluding that increased alliance caused the improvements seen in patients with low motivation. There are several reasons why patients with low motivation may be uniquely responsive to the therapeutic relationship. Such patients tend to be ambivalent about treatment (Miller & Rollnick, 2002), which may make them more attuned to contextual influences such as the quality of the therapeutic relationship (Lebow et al., 2006). Moreover, responsive therapists are likely to be aware of patients’ low motivation and change their behavior to fit these patients’ needs. Thus, therapists’ estimates of alliance may reflect their general sensitivity to the needs of patients with low motivation. This conceptualization is consistent with the finding that therapists’ perceptions of the relationship, rather than patients’ perceptions, were more closely tied with improvements in patients with low motivation. Additionally, such patients may be less attentive to the relationship and, consequently, provide less accurate ratings of therapeutic alliance. Others have suggested that ratings of alliance provided by either therapists or third-party observers may be more closely related to treatment outcomes in patients with substance use disorder than patients’ ratings of alliance (Fenton, Cecero, Nich, Frankforter, & Carroll, 2001; Shelef, Diamond, Diamond, & Liddle, 2005). More research is needed to understand how patients’ baseline motivation affects the development of the treatment alliance and why it is associated with outcomes. A closely related direction for future research is to examine alternative causal chains such as whether a positive therapeutic alliance with patients with low motivation leads to proximal changes (e.g., increases in approach coping) that foreshadow positive outcome. In this study, interactions involving treatment compliance did not mediate the effect of the interaction between therapists’ ratings of alliance and motivation on patients’ outcome. Our findings have implications for clinicians and researchers. Clearly, because of the association between motivation and prognosis, therapists need to attend to patients’ levels of
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motivation. Additionally, the finding that the relationship between low motivation and poorer alcohol use outcomes is not uniform highlights the potential positive influence therapists can have with patients with low motivation. Although prior literature on motivation and AUD treatment has focused primarily on treatment techniques (Miller & Rollnick, 2002), our findings indicate that the quality of the relationship may be more important than the therapists’ treatment orientation or specific techniques. These implications notwithstanding, this study has several limitations. The selection criteria for participants and the close monitoring of treatment providers in Project MATCH may have raised patients’ levels of motivation and enhanced therapeutic alliances, thus decreasing the generalizability of our findings. Additionally, the lack of consistent findings between patient and therapist ratings of alliance raises the possibility that the findings may have been due to factors other than the quality of the therapeutic relationship. The fact that motivation was measured at baseline and alliance was measured after two sessions of treatment leaves open the possibility that, in addition to alliance, therapists may have been rating patients’ motivation or performance in treatment. Our findings suggest that treatment providers can work effectively with patients with low motivation when they are able to establish a strong alliance with their patient. Better identification of the mechanisms of action underlying the interaction between motivation and therapeutic alliance may help to identify ways in which therapists can enhance their relationships with patients who are initially hesitant to engage in treatment, thereby improving patients’ outcomes.
Acknowledgment Preparation of this article was supported by the Department of Veterans Affairs Health Services Research and Development Service. The views expressed here are the authors’ and do not necessarily represent the views of the Department of Veterans Affairs. Additionally, the authors acknowledge that the reported results are based on analyses of the Project MATCH Public Data Set. These data were collected as part of a multisite clinical trial of alcoholism treatments supported by a series of grants from the National Institute on Alcohol Abuse and Alcoholism and made available to the authors by the Project MATCH Research Group. This article has not been reviewed or endorsed by the Project MATCH Research Group and does not necessarily represent the opinions of its members, who are not responsible for the contents.
References Babor, T. F., & Del Boca, F. K. (Eds.). (2003). Treatment matching in alcoholism. New York, NY7 Cambridge University Press.
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Carbonari, J. P., & DiClemente, C. C. (2000). Using transtheoretical model profiles to differentiate levels of alcohol abstinence success. Journal of Consulting and Clinical Psychology, 68, 810 – 817. Connors, G. J., Carroll, K. M., DiClemente, C. C., Longabaugh, R., & Donovan, D. M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal of Consulting and Clinical Psychology, 65, 588 – 598. Connors, G. J., DiClemente, C. C., Dermen, K. H., Kadden, R., Carroll, K. M., & Frone, M. R. (2000). Predicting the therapeutic alliance in alcoholism treatment. Journal of Studies on Alcohol, 61, 139 – 149. DiClemente, C. C., Carbonari, J. P., Zweben, A., Morrel, T., & Lee, R. E. (2001). Motivation hypothesis causal chain analysis. In R. Longabaugh, & P. W. Wirtz (Eds.), Project match hypotheses: Results and causal chain analyses, (Vol. 8, pp. 206 – 222). Bethesda, MD: Project MATCH Monograph Series NIH Pub No. 01-4238. DiClemente, C. C., & Hughes, S. O. (1990). Stages of change profiles in outpatient alcoholism treatment. Journal of Substance Abuse, 2, 217 – 235. Fenton, L. R., Cecero, J. J., Nich, C., Frankforter, T. L., & Carroll, K. M. (2001). Perspective is everything: The predictive validity of six working alliance instruments. Journal of Psychotherapy Practice and Research, 10, 262 – 268. Finney, J. W. (1995). Enhancing substance abuse treatment evaluations: Examining mediators and moderators of treatment effects. Journal of Substance Abuse, 7, 135 – 150. Horvath, A. O., & Greenberg, L. S. (1986). The development of the working alliance inventory. In L. S. Greenberg, & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 529 – 556). New York, NY7 Guilford. Kadden, R. M., Carroll, K., & Donovan, D. M. (1992). Cognitive– behavioral coping skills therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse or dependence. Rockville, MD7 National Institute on Alcohol Abuse and Alcoholism. Kadden, R. M., Longabaugh, R., & Wirtz, P. W. (2003). The matching hypotheses: Rationale and predictions. In F. Babor (Ed.), Treatment matching in alcoholism. International research monographs in the addictions (pp. 81 – 102). New York, NY7 Cambridge University Press. Kraemer, H. C., & Blasey, C. M. (2004). Centering in regression analyses: A strategy to prevent errors in statistical inference. International Journal of Methods in Psychiatric Research, 13, 141 – 151. Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38, 357 – 361. Lebow, J., Kelly, J. F., Knobloch-Fedders, L. M., & Moos, R. (2006). Relationship factors in treating substance use disorders. In L. B. Castonguay, & L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 293 – 317). New York, NY7 Oxford University Press. McKay, J. R., & Weiss, R. V. (2001). A review of temporal effects and outcome predictors in substance abuse treatment studies with long-term follow-ups: Preliminary results and methodological issues. Evaluation Review, 25, 113 – 161. Meier, P. S., Barrowclough, C., & Donmall, M. C. (2005). The role of the therapeutic alliance in the treatment of substance misuse: A critical review of the literature. Addiction, 100, 304 – 316. Miller, W. R. (1996). Manual for form 90: A structural assessment interview for drinking and related behaviors (project match monograph series no. 5). Rockville, MD7 National Institute on Alcohol Abuse and Alcoholism. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York, NY7 US: Guilford Press. Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational-enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse or dependence. Rockville, MD7 National Institute on Alcohol Abuse and Alcoholism. Nowinski, J., Baker, S., & Carroll, K. (1992). The twelve-step facilitation therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse or dependence. Rockville, MD7 National Institute on Alcohol Abuse and Alcoholism.
162
M.A. Ilgen et al. / Journal of Substance Abuse Treatment 31 (2006) 157–162
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102 – 1114. Project MATCH Research Group. (1993). Project match: Rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcoholism: Clinical & Experimental Research, 17, 1130 – 1145.
Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project match posttreatment drinking outcomes. Journal of Studies on Alcohol, 58, 7 – 29. Shelef, K., Diamond, G. M., Diamond, G. S., & Liddle, H. A. (2005). Adolescent and parent alliance and treatment outcome in multidimensional family therapy. Journal of Consulting and Clinical Psychology, 73, 689 – 698.