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Therapeutic alliance is a factor of change in arts therapies and psychomotor therapy with adults who have mental health problems
Accepted Manuscript Title: The therapeutic alliance as a factor of change in arts therapies and psychomotor therapy among adults with mental health problems Authors: Evelyn Heynen, Jesse Roest, Gemmy Willemars, Susan van Hooren PII: DOI: Reference:
S0197-4556(16)30185-X http://dx.doi.org/doi:10.1016/j.aip.2017.05.006 AIP 1457
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The Arts in Psychotherapy
Received date: Revised date: Accepted date:
19-10-2016 8-5-2017 28-5-2017
Please cite this article as: Heynen, Evelyn., Roest, Jesse., Willemars, Gemmy., & Hooren, Susan van., The therapeutic alliance as a factor of change in arts therapies and psychomotor therapy among adults with mental health problems.The Arts in Psychotherapy http://dx.doi.org/10.1016/j.aip.2017.05.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
THERAPEUTIC ALLIANCE IN ARTS THERAPIES The role of the therapeutic alliance in arts-therapies among adult mental health patients Running Head: THERAPEUTIC ALLIANCE IN ARTS THERAPIES Evelyn Heynen1,2,3 Jesse Roest 5 Gemmy Willemars 2,4 Susan van Hooren1,2,6 Zuyd University of Applied Sciences, Faculty of Healthcare, Heerlen, The Netherlands 1 KenVaK, Research Centre for the Arts Therapies, Heerlen, The Netherlands 2 Maastricht University, Department of Clinical Psychological Sciences, Maastricht, The Netherlands 3 Utrecht University of Applied Sciences, Utrecht, The Netherlands 4 Leiden University of Applied Social Sciences, Faculty of Social Work and Applied Psychology, Leiden, The Netherlands 5 Open University, Faculty of Psychology and Educational Sciences, Heerlen, The Netherlands 6
The therapeutic alliance as a factor of change in arts therapies and psychomotor therapy among adults with mental health needsproblems?
THERAPEUTIC ALLIANCE IN ARTS THERAPIES
Highlights
Arts-therapies related to positive therapeutic alliance, especially task collaboration. Positive alliance was associated with higher decrease in depressive symptoms in early phase of therapy. Positive alliance in later phase was associated with higher decrease in anxiety symptoms.
Abstract Research has established that outcomes of psychotherapeutic therapies depend on the ability to create an open and cooperative alliance (task, bond, goal) between client and therapist. The present research investigated the influences of 17 weeks of arts therapies on the therapeutic alliance and symptom change among 164 adults with mental health problems using the Working Alliance Inventory-12 and the Brief Symptom Inventory. Results show that alliance scores increased over time there was an increased perception of the therapeutic alliance during artstherapies, and psychomotor therapy and more specifically for the task subscale. Furthermore, results show that there was a significant effect of the therapeutic alliance on symptom reduction (depression and anxiety) during time of arts therapy treatment. Results indicate that participants persons who experienced the alliance as positive showed a higher decrease in depressive symptoms in the early phase and for anxiety symptoms in the later phase of the therapy. The present results give first implications of the role of the therapeutic alliance in arts-therapies and psychomotor therapy within adults with mental health needs. Keywords: therapeutic alliance; arts therapies; mental health services
THERAPEUTIC ALLIANCE IN ARTS THERAPIES The therapeutic alliance as a factor of change in arts therapies and psychomotor therapy among adults with mental health needsproblems? It is well established that the outcomes of psychotherapeutic therapies depend on the client’s ability to create an open and cooperative alliance between client and therapist (Bachelor, 2013; Horvath, Del Re, Flückiger, & Symonds, 2011; Horvath & Symonds, 1991; Luborsky & Auerbach, 1985; Orlinsky, Grawe, & Parks, 1994; Svensson & Hansson, 1999). OverNearly hundred years ago, therapeutic alliance was defined as ‘transference from the patient to the therapist’ (Freud, 1913). Today, it is more described as a conscious and active collaboration between client and therapist and is distinguished by three main concepts: the client-therapist bond or relationship, agreement on goals, and collaboration on tasks (Bordin, 1979; see also Martin, Garske, & Davis, 2000). The client-therapist bond is defined as the active bond between therapist and client, and is made up of reciprocal positive feelings, based on mutual trust and acceptance. Agreement on treatment goals is based on the degree of commitment to the shared goals of the therapy; whereas the collaboration on tasks refers to consensus on the methods used in therapy (Ardito & Rabellino, 2011; Munder, Wilmers, Leonhart, Linster, & Barth, 2010; Taber, Leibert, & Agaskar, 2011). Results of several studies now indicate that the quality of the therapeutic alliance has a significant impact on treatment outcomes (Ardito & Rabellino, 2011; Flückiger, Del Re, Wampold, Symonds, & Horvath, 2012; Martin et al., 2000), therapy drop-out, recidivism reduction, positive treatment results, and treatment motivation (Bordin, 1979; Constantino, Castonguay, Zack, & DeGeorge, 2010; Flückiger et al., 2012; Kennealy, Skeem, Manchak, & Louden, 2012; Martin et al., 2000; Shirk, Karver, & Brown, 2011; Wampold, 2001), and may even be more predictive of positive therapy results than the type of the intervention (Lambert & Barley, 2001). Actually, research found evidence that a poor therapeutic alliance is even actively detrimental in psychotherapy (Goldsmith, Lewis, Dunn, & Bentall, 2015). Recently, evidence-based research on essential elements to create an optimal
THERAPEUTIC ALLIANCE IN ARTS THERAPIES therapeutic alliance is a growing topic (Norcross & Lambert, 2014; Norcross & Wampold, 2011). This evidence suggests that in creating a positive therapeutic alliance, therapists have to be flexible, honest, warm and reliable (Nocross & Wampold, 2011; Van Yperen, Van der Steege, Addink, & Boendermaker, 2010). Therapist’s efforts, such as creating a safe environment, and encouraging the client to express his emotions, have shown to be of great influence in order to form a strong therapeutic alliance in different kinds of therapies (Van Yperen et al., 2010). Research has shown that a therapist needs to be aware of creating a positive alliance from the first moment. Therapists who fail to build a positive alliance in the first six months of treatment hardly ever succeed in doing so during therapy (Kvrgic, Cavelti, Beck, Rüsch, & Vauth, 2013). A weak alliance in the early phase of treatment can be improved, but is not obvious and requires an accurate interpretation of the patient’s personal needs (Sharf, Primavera, & Diener, 2010). Arts therapies and also psychomotor therapy are therapies are expected to increase the quality of the therapeutic alliance. Arts therapies and psychomotor therapy are grouped together in the Dutch mental health care system. In this system, arts therapies refer to the creative arts therapies, i.e. art-, dance-, music-, drama therapy, and psychomotor therapy (PMT). PMT is a method of treatment that uses body awareness and physical activity (sporting activities, games, of body experiences) as means to achieve treatment goals (Probst e.a., 2010). Both are believed to rely on an experiential orientation, apply a holistic view of the human being with a unity of body and mind, and stress the ‘non verbal’ aspects in therapy. In addition, through acting within working methods, both arts therapies and psychomotor therapy appeal to senses, movement and play. The therapeutic alliance of these therapies is based on personal characteristics (therapists and client), the working methods (Lambert & Barley, 2001), but and also by using arts materials or physical activities to influence the interaction (Penzes, Van Hooren, Dokter, Smeijsters, & Hutschemaekers, 2015; Smeijsters, Kil, Kurstjens, Welten, & Willemars, 2010). The use of materials and physical activities in
THERAPEUTIC ALLIANCE IN ARTS THERAPIES addition to and the focus on the material interaction with the creative materials or during the physical activities can influence the therapeutic alliance (Carey, 2006). In addition, through a working method that is based on experiences within arts, clients experience arts therapies as a more direct way to access less conscious emotions (Haeyen, Van Hooren, & Hutschemaekers, 2015). With regard to the therapeutic alliance, arts therapists and psychomotor therapists need to focus on the three aspects of the therapeutic alliance; the bond between the therapist and the client, the agreement on goals and the collaboration on tasks. However, because of the focus on working with arts materials and the active process during treatment, it is expected that in these arts therapies, the collaboration on tasks is more important in order to reach a positive therapeutic alliance, compared to the client-therapist bond and agreement on goals. Unfortunately, to our best knowledge, there is currently sparse empirical research available on the elements of the therapeutic alliance in arts therapies and psychomotor therapy is sparse. Previous empirical studies on arts therapies and alliance show that arts therapies have a beneficial effect on therapeutic alliance, for example the alliance increased after art therapy as an adjunct to academic assistance for children with learning abilities (Freilich & Shechtman, 2010) or after a single music therapy session among clients who are in detoxification (Silverman, 2009) or among psychiatric patients (Silverman, 2011). More knowledge about the subcomponents of the therapeutic alliance can provide therapists information on what to focus on during their interaction with the client in arts therapies or psychomotor therapy. The aim of the present study is to examine the subcomponents of the therapeutic alliance in arts therapies or psychomotor therapy. First, we investigated the development of the therapeutic alliance subcomponents during arts therapies or psychomotor therapy. It is expected that due to the focus on (material) interaction and acting working methods in thesearts- therapies, there is more development of task collaboration compared to the client-therapist bond and agreement on goals. Second, we examined whether the therapeutic alliance is related to change in psychiatric symptoms, both in the early phase of
THERAPEUTIC ALLIANCE IN ARTS THERAPIES the treatment as well as in a later phase of the treatment. It is hypothesized that a positive therapeutic alliance in arts therapies or psychomotor therapy will be related to a decrease in psychiatric symptoms and that the effect of therapeutic alliance on symptom reduction will be more pronounced in the early phase of the therapy, than in a later phase. Method Participants and procedure The present study was conducted with 164 adult participants (68 male, 55 female, 41 without registration of gender) who were all inpatient clients in a mental health care clinic in the Netherlands. Inpatient clients who started psychomotor therapy, music therapy or art therapy were informed on the aim and procedure of this study and were asked to participate. This was done by a therapist, preferably not involved in the treatment of the client. When a client agreed, she/he signed an informed consent declaration form. Participants were randomly selected in the institution. Patients were diagnosed with one or more different mental health problems as for example, anxiety disorders, depression, substance abuse or personality disorders. There were no exclusion criteria due to DSM-IV-TR diagnosis. Response rate was 92%. Participants were told that their answers would be treated confidentially and anonymously and would be accessed only by the researchers. Ethical approval was obtained from the ethics committee of the faculty of Psychology, Open University. Respondents were aged between 16 and 66 years (mean = 38.53, SD =13.03). Participants received psychomotor therapy (n = 91), music therapy (n = 3), or art therapy (n = 33). For 61 participants there is no information regarding the kind of therapies they received during this study. Eighty-four clients participants received other types of treatment, such as psychological treatment or psychiatric treatment in addition to psychomotor therapy, music therapy, or art therapy an additional kind of therapy (psychological treatment or psychiatric treatment). The psychomotor therapy, music therapy, and art therapy were delivered by a
THERAPEUTIC ALLIANCE IN ARTS THERAPIES professional psychomotor therapist, music therapist, or art therapist respectively.
Study Design The present study consisted of three measurements. The baseline measurement (T0) was one week before the start of art therapy. The second measurement (T1) was 8-10 weeks and the third measurement (T2) 17 weeks from baseline. Participants completed the Brief Symptom Inventory at baseline. During T1 and T2 participants completed the Working Alliance Inventory-12 and the Brief Symptom Inventory. Instruments Working Alliance Inventory-12 (WAI-12) The Working Alliance Inventory – Short version (Stinckens, Ulburghs, & Claes, 2009), based on the WAI of Horvath & Greenberg (1989), is a 12-item instrument scored on a 5-point Likert scale from 1 (never) to 5 (always). The scale assesses one general scale (general alliance) and three subscales; tasks (i.e. the level of agreement between the provider and client on what should be done in treatment); bond (i.e. the strength of the relationship or connection between the provider and client); and goals (i.e. the level of agreement on the desired outcome of the treatment). The total score utilizes all 12 items, while the three subscales are assessed with 4 items each. The total score for the WAI-12 ranges from 12 (low working alliance) to 84 (high working alliance), and subscale scores range from 4 to 28. The WAI-12 has shown to have strong internal consistencies, ranging from .70 to .91 for the subscales and .90 to .95 for the total score (Busseri & Tyler, 2003; Dunkle & Friedlander, 1996; Ligiero & Gelso, 2002; Tracey & Kokotovic, 1989) and predictive and concurrent validity (Busseri & Tyler, 2003; Ligiero & Gelso, 2002; Parish & Eagle, 2003). In the present study the subscales demonstrated satisfactory to good reliabilities for the subscales bond (α = .78), task (α = .86), goals (α = .80) and the total scale (α = .92).
THERAPEUTIC ALLIANCE IN ARTS THERAPIES Brief Symptom Inventory (BSI) The brief symptom inventory is a client self-report measurement consisting of 53 questions about psychopathology and psychological distress (Derogatis, 1993). The questions are divided into 9 dimensions of psychopathology (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobia, paranoid ideas, and psychoticism) and two global scores. During the present research we only used the subscales for depression and anxiety, due to the fact that this were the most common problems in the Dutch mental health population (Graaf, Have, & Dorsselaer, 2010). The severity of each symptom has to be scored on a 5-point Likert-scale ranging from 0 (symptom not present) to 4 (extreme severity). The BSI has shown good reliabilities in the American general population (internal consistency Cronbach’s α = .71-.85 and test-retest reliability intraclass correlation coefficient r ICC = .68 - .91). Reliability coefficients in the present study were good (α = .84 .92). Statistical Analysis A general linear model (ANOVA) with repeated measures was examined to investigate the development of the therapeutic alliance over time (i.e. within subject factor). Additionally, in order to investigate the influences of the therapeutic alliance during arts therapies and psychomotor therapy on symptom reduction, general linear models with repeated measures were used. This was performed for the early phase (T0-T1) and the late phase of the treatment (T1-T2) separately. For these analyses, time was the within subject factor (two levels; T0 and T1 (early phase analyses) or T1 and T2 (late phase analyses) and therapeutic alliance (highmedium-low) as between subject factor. All analysis were conducted in SPSS 21.0. Results Table 1 presents the means, standard deviations, main effects, and interaction effects of the WAI-12 and the BSI during the three measurements. Using a general linear model with
THERAPEUTIC ALLIANCE IN ARTS THERAPIES repeated measures, it was shown that there was an increase of the total score of the WAI-12 during AT [F(71) = 6.924; p = .010]. This increase was also seen in the WAI subscale ‘task’ [F(76) = 10.723, p = .002]. For the WAI subscales ‘goals’ and ‘bond’ only a trend was observed (p = .08; respectively p = .056). Next, we investigated whether a positive therapeutic alliance in terms of the WAI subscales during arts therapies and psychomotor therapy had a positive influence on symptom reduction. For all models, there was a main effect of AT indicating that all clients had a decrease of symptoms in time. Regarding the depression symptoms in the early phase of the treatment, results showed that there was an interaction effect of time x WAI subscale ‘goal’ [F(2,91) = 3.33, p = 0.04,
2
= 0.07]. This interaction effect was in the
expected direction, indicating that participant’s persons who experienced the alliance as positive showed a higher decrease in depressive symptoms compared to the participants persons who experience the alliance as less positive. A trend was found for the interaction effects of time x WAI subscale ‘Task’ [F(2,90) = 2.78, p = 0.07,
2
= 0.06].
Concerning the late phase of the treatment, no interaction effects were found regarding the scores on BSI depression subscale.
Examining the interaction
effects of the BSI anxiety scores in both the early and late phase showed only one interaction effect, i.e. in the late phase, of time x WAI subscale ‘bond’ [F(2,70) = 3.45, p = .04,
2
= 0.09]. Trends were shown for time x WAI total scores in the early phase
[F(2,85) = 2,86, p = 0.06, 0.07,
2
2
=0.06] and the late phase [F(2,68) = 2,73, p =
= 0.07]. Discussion
The present study was conducted to investigate the development of the therapeutic alliance, (i.e., the client-therapist bond, agreement on goals and collaboration on task) in arts therapies and psychomotor therapy over time. Furthermore, we examined whether a good
THERAPEUTIC ALLIANCE IN ARTS THERAPIES therapeutic alliance was related to symptom change (depression and anxiety) among adults in mental health care. To our knowledge, this was the first study on arts therapies and psychomotor therapy to investigate whether symptom change was related to the therapeutic alliance.
As expected, results showed that during arts-therapies there was a positive development of the therapeutic alliance during arts therapies and psychomotor therapy, which is mostly, explained by higher scores an increased perception of the collaboration on tasks. Findings indicate that participants had an increased perception of the task collaboration. The stronger improvement of task collaboration during therapy can be explained by the focus on the interaction and agreement with materials and methods used in arts therapies and psychomotor therapy. Measurement instruments of the present study only investigated the therapeutic alliance in general terms. It is recommended that future studies should focus on the development of an arts therapy specific instruments to focus on this material interaction. In arts-therapies, methods, tasks, and interaction with the materials seem to play an important role in promoting the therapeutic alliance (Smeijsters et al., 2011). Contrary to our the expectations based on the and results of previous research (Martin et al., 2000; Webb et al., 2012) overall results in the present study indicate that the relation between therapeutic alliance and symptom change was rather weak and effects in the early phase equal the effects in the late phase. Despite these weak effects of the therapeutic alliance, the effects were in the expected direction, for example i.e. patients who experienced the therapeutic alliance as positive show more improvements of their anxiety and depressive symptoms compared to patients who experience the alliance as less positive. Results weare preliminary and show different considerations that need further explanation; first, the present study did not investigate the therapeutic alliance directly after the beginning of the therapy sessions. Approximately pPrevious research has shown that one-third of symptom change occurres prior to the early session (session 3; Webb et al., 2011), and thus
THERAPEUTIC ALLIANCE IN ARTS THERAPIES before alliance was assessed in the present study. As building a therapeutic alliance is a dynamic process that is started during the first meeting, one would expect that there is also a kind of some alliance after the first therapy session (Ardito & Rabellino, 2011; Barber, Connolly, CritsChristoph, Gladis, & Siqueland, 2000; Horvath & Greenberg, 1989). Future research should focus on the therapeutic alliance TA in an early phase of treatment and to examine the relation between therapeutic alliance and to well establish symptom change in relation to the number of therapy sessions. This would be in line with findings of Barber et al. (2000) who examined the relations among therapeutic alliance, outcome, and early-in-treatment symptomatic improvements in a group of patients with generalized anxiety disorders, chronic depression and avoidant or obsessive–compulsive personality disorder, after receiving supportive–expressive dynamic psychotherapy. Results indicated that alliance at in later sessions, but not in first sessions, was associated with changes in depression. Alliance at all sessions significantly predicted subsequent changes in depression in all sessions (Barber et al., 2000). We recommend to examine in Thus, future studies the development of the alliance using should focus on a more frequent measurement of the therapeutic alliance during therapy to investigate changes in therapeutic alliance during the therapy. A second point to discuss is the fact that during the present study only the client’s view on alliance was investigated. In previous research, client’s assessments have shown to be a positive outcome predictor of positive outcome of psychotherapy (Castonguay et al., 2006). Furthermore, rating scales were usually validated on the basis of clinical data only (Hovrvath, 2000). HoweverBut, research has shown that client’s experiences of the alliance tend to be more subjective, a-theoretical and based on past experiences, whereas the view of the therapist is more used as a theoretical perspective (Ardito & Rabellino, 2011). As alliance is a reciprocal process, future studies should focus on clients’ and therapists’ perception of alliance. Research has indicated that client’s and therapist’s perspectives in general show a moderate correlation, and that clients rate the alliance to be more positively than their therapist (Tryon, Blackwell, &
THERAPEUTIC ALLIANCE IN ARTS THERAPIES Hammel, 2007). Comparing client and therapist versions of existing alliance scales, Bachelor (2013) found that client and therapist perspectives might have a different underlying factor structure, which limits the valid comparison of client and therapist ratings. Therefore, the client and therapist perspectives should be recognized as distinct perspectives. In order to gain more insight into the development of subcomponents of the therapeutic alliance throughout treatment, and their relation to outcomes, it is important for future research to include both perspectives. A final point of attention is the fact that different types of therapies were involved in the present study. Because of the limited number of participants, it was not possible to investigate the influence of the therapeutic alliance for each therapy. We need to question whether there is a difference in the development of the therapeutic alliance during arts therapies (using creative arts and expression) versus the psychomotor therapies (using sporting activities). Future research should therefore focus on the role of the therapeutic alliance in specific therapies. The present study was one of the first to investigate the relationship between artstherapies and therapeutic alliance and their relation with symptom change in a group of mental health patients. The present study was Results were explorative and future research in arts therapies should focus on more frequent measurement of alliance and symptom change even as the measurement of alliance in client and therapists and their reciprocal effects on therapy outcomes. Due to the present findings, in future research there should be specific attention on the role of the task collaboration. Although the results of the present research were preliminary, they give a first implication of the therapeutic alliance in arts therapies and show the importance of the task collaboration within a strong therapeutic alliance.
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THERAPEUTIC ALLIANCE IN ARTS THERAPIES APPENDIX
Table 1: means, standard deviations, main effects and interaction effects of WAI and BSI scores T0 (N = 164)
T1 (N = 108)
T2 (N = 84)
Main effect
Mean (SD)
Mean (SD)
Mean (SD)
F-value
WAI subscale ‘Bond’
-
3.55 (0.83)
3.98 (2.54)
WAI subscale ‘Goal’
-
3.49 (0.75)
3.91 (2.64)
3.15**
WAI subscale ‘Task’
-
3.44 (0.82)
3.87 (2.60)
10.72**
WAI total score
-
42.5 (8.09)
44.01 (7.77)
6.92**
BSI anxiety BSI depression ** p<0.1 ** p<0.05
9.96 (6.36) 10.31 (6.92)
9.00 (5.86) 9.02 (5.93)
8.40 (5.89) 8.38 (5.90)
8.76** 7.85**
3.78**
S0197-4556(16)30185-X http://dx.doi.org/doi:10.1016/j.aip.2017.05.006 AIP 1457
To appear in:
The Arts in Psychotherapy
Received date: Revised date: Accepted date:
19-10-2016 8-5-2017 28-5-2017
Please cite this article as: Heynen, Evelyn., Roest, Jesse., Willemars, Gemmy., & Hooren, Susan van., The therapeutic alliance as a factor of change in arts therapies and psychomotor therapy among adults with mental health problems.The Arts in Psychotherapy http://dx.doi.org/10.1016/j.aip.2017.05.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
THERAPEUTIC ALLIANCE IN ARTS THERAPIES The role of the therapeutic alliance in arts-therapies among adult mental health patients Running Head: THERAPEUTIC ALLIANCE IN ARTS THERAPIES Evelyn Heynen1,2,3 Jesse Roest 5 Gemmy Willemars 2,4 Susan van Hooren1,2,6 Zuyd University of Applied Sciences, Faculty of Healthcare, Heerlen, The Netherlands 1 KenVaK, Research Centre for the Arts Therapies, Heerlen, The Netherlands 2 Maastricht University, Department of Clinical Psychological Sciences, Maastricht, The Netherlands 3 Utrecht University of Applied Sciences, Utrecht, The Netherlands 4 Leiden University of Applied Social Sciences, Faculty of Social Work and Applied Psychology, Leiden, The Netherlands 5 Open University, Faculty of Psychology and Educational Sciences, Heerlen, The Netherlands 6
The therapeutic alliance as a factor of change in arts therapies and psychomotor therapy among adults with mental health needsproblems?
THERAPEUTIC ALLIANCE IN ARTS THERAPIES
Highlights
Arts-therapies related to positive therapeutic alliance, especially task collaboration. Positive alliance was associated with higher decrease in depressive symptoms in early phase of therapy. Positive alliance in later phase was associated with higher decrease in anxiety symptoms.
Abstract Research has established that outcomes of psychotherapeutic therapies depend on the ability to create an open and cooperative alliance (task, bond, goal) between client and therapist. The present research investigated the influences of 17 weeks of arts therapies on the therapeutic alliance and symptom change among 164 adults with mental health problems using the Working Alliance Inventory-12 and the Brief Symptom Inventory. Results show that alliance scores increased over time there was an increased perception of the therapeutic alliance during artstherapies, and psychomotor therapy and more specifically for the task subscale. Furthermore, results show that there was a significant effect of the therapeutic alliance on symptom reduction (depression and anxiety) during time of arts therapy treatment. Results indicate that participants persons who experienced the alliance as positive showed a higher decrease in depressive symptoms in the early phase and for anxiety symptoms in the later phase of the therapy. The present results give first implications of the role of the therapeutic alliance in arts-therapies and psychomotor therapy within adults with mental health needs. Keywords: therapeutic alliance; arts therapies; mental health services
THERAPEUTIC ALLIANCE IN ARTS THERAPIES The therapeutic alliance as a factor of change in arts therapies and psychomotor therapy among adults with mental health needsproblems? It is well established that the outcomes of psychotherapeutic therapies depend on the client’s ability to create an open and cooperative alliance between client and therapist (Bachelor, 2013; Horvath, Del Re, Flückiger, & Symonds, 2011; Horvath & Symonds, 1991; Luborsky & Auerbach, 1985; Orlinsky, Grawe, & Parks, 1994; Svensson & Hansson, 1999). OverNearly hundred years ago, therapeutic alliance was defined as ‘transference from the patient to the therapist’ (Freud, 1913). Today, it is more described as a conscious and active collaboration between client and therapist and is distinguished by three main concepts: the client-therapist bond or relationship, agreement on goals, and collaboration on tasks (Bordin, 1979; see also Martin, Garske, & Davis, 2000). The client-therapist bond is defined as the active bond between therapist and client, and is made up of reciprocal positive feelings, based on mutual trust and acceptance. Agreement on treatment goals is based on the degree of commitment to the shared goals of the therapy; whereas the collaboration on tasks refers to consensus on the methods used in therapy (Ardito & Rabellino, 2011; Munder, Wilmers, Leonhart, Linster, & Barth, 2010; Taber, Leibert, & Agaskar, 2011). Results of several studies now indicate that the quality of the therapeutic alliance has a significant impact on treatment outcomes (Ardito & Rabellino, 2011; Flückiger, Del Re, Wampold, Symonds, & Horvath, 2012; Martin et al., 2000), therapy drop-out, recidivism reduction, positive treatment results, and treatment motivation (Bordin, 1979; Constantino, Castonguay, Zack, & DeGeorge, 2010; Flückiger et al., 2012; Kennealy, Skeem, Manchak, & Louden, 2012; Martin et al., 2000; Shirk, Karver, & Brown, 2011; Wampold, 2001), and may even be more predictive of positive therapy results than the type of the intervention (Lambert & Barley, 2001). Actually, research found evidence that a poor therapeutic alliance is even actively detrimental in psychotherapy (Goldsmith, Lewis, Dunn, & Bentall, 2015). Recently, evidence-based research on essential elements to create an optimal
THERAPEUTIC ALLIANCE IN ARTS THERAPIES therapeutic alliance is a growing topic (Norcross & Lambert, 2014; Norcross & Wampold, 2011). This evidence suggests that in creating a positive therapeutic alliance, therapists have to be flexible, honest, warm and reliable (Nocross & Wampold, 2011; Van Yperen, Van der Steege, Addink, & Boendermaker, 2010). Therapist’s efforts, such as creating a safe environment, and encouraging the client to express his emotions, have shown to be of great influence in order to form a strong therapeutic alliance in different kinds of therapies (Van Yperen et al., 2010). Research has shown that a therapist needs to be aware of creating a positive alliance from the first moment. Therapists who fail to build a positive alliance in the first six months of treatment hardly ever succeed in doing so during therapy (Kvrgic, Cavelti, Beck, Rüsch, & Vauth, 2013). A weak alliance in the early phase of treatment can be improved, but is not obvious and requires an accurate interpretation of the patient’s personal needs (Sharf, Primavera, & Diener, 2010). Arts therapies and also psychomotor therapy are therapies are expected to increase the quality of the therapeutic alliance. Arts therapies and psychomotor therapy are grouped together in the Dutch mental health care system. In this system, arts therapies refer to the creative arts therapies, i.e. art-, dance-, music-, drama therapy, and psychomotor therapy (PMT). PMT is a method of treatment that uses body awareness and physical activity (sporting activities, games, of body experiences) as means to achieve treatment goals (Probst e.a., 2010). Both are believed to rely on an experiential orientation, apply a holistic view of the human being with a unity of body and mind, and stress the ‘non verbal’ aspects in therapy. In addition, through acting within working methods, both arts therapies and psychomotor therapy appeal to senses, movement and play. The therapeutic alliance of these therapies is based on personal characteristics (therapists and client), the working methods (Lambert & Barley, 2001), but and also by using arts materials or physical activities to influence the interaction (Penzes, Van Hooren, Dokter, Smeijsters, & Hutschemaekers, 2015; Smeijsters, Kil, Kurstjens, Welten, & Willemars, 2010). The use of materials and physical activities in
THERAPEUTIC ALLIANCE IN ARTS THERAPIES addition to and the focus on the material interaction with the creative materials or during the physical activities can influence the therapeutic alliance (Carey, 2006). In addition, through a working method that is based on experiences within arts, clients experience arts therapies as a more direct way to access less conscious emotions (Haeyen, Van Hooren, & Hutschemaekers, 2015). With regard to the therapeutic alliance, arts therapists and psychomotor therapists need to focus on the three aspects of the therapeutic alliance; the bond between the therapist and the client, the agreement on goals and the collaboration on tasks. However, because of the focus on working with arts materials and the active process during treatment, it is expected that in these arts therapies, the collaboration on tasks is more important in order to reach a positive therapeutic alliance, compared to the client-therapist bond and agreement on goals. Unfortunately, to our best knowledge, there is currently sparse empirical research available on the elements of the therapeutic alliance in arts therapies and psychomotor therapy is sparse. Previous empirical studies on arts therapies and alliance show that arts therapies have a beneficial effect on therapeutic alliance, for example the alliance increased after art therapy as an adjunct to academic assistance for children with learning abilities (Freilich & Shechtman, 2010) or after a single music therapy session among clients who are in detoxification (Silverman, 2009) or among psychiatric patients (Silverman, 2011). More knowledge about the subcomponents of the therapeutic alliance can provide therapists information on what to focus on during their interaction with the client in arts therapies or psychomotor therapy. The aim of the present study is to examine the subcomponents of the therapeutic alliance in arts therapies or psychomotor therapy. First, we investigated the development of the therapeutic alliance subcomponents during arts therapies or psychomotor therapy. It is expected that due to the focus on (material) interaction and acting working methods in thesearts- therapies, there is more development of task collaboration compared to the client-therapist bond and agreement on goals. Second, we examined whether the therapeutic alliance is related to change in psychiatric symptoms, both in the early phase of
THERAPEUTIC ALLIANCE IN ARTS THERAPIES the treatment as well as in a later phase of the treatment. It is hypothesized that a positive therapeutic alliance in arts therapies or psychomotor therapy will be related to a decrease in psychiatric symptoms and that the effect of therapeutic alliance on symptom reduction will be more pronounced in the early phase of the therapy, than in a later phase. Method Participants and procedure The present study was conducted with 164 adult participants (68 male, 55 female, 41 without registration of gender) who were all inpatient clients in a mental health care clinic in the Netherlands. Inpatient clients who started psychomotor therapy, music therapy or art therapy were informed on the aim and procedure of this study and were asked to participate. This was done by a therapist, preferably not involved in the treatment of the client. When a client agreed, she/he signed an informed consent declaration form. Participants were randomly selected in the institution. Patients were diagnosed with one or more different mental health problems as for example, anxiety disorders, depression, substance abuse or personality disorders. There were no exclusion criteria due to DSM-IV-TR diagnosis. Response rate was 92%. Participants were told that their answers would be treated confidentially and anonymously and would be accessed only by the researchers. Ethical approval was obtained from the ethics committee of the faculty of Psychology, Open University. Respondents were aged between 16 and 66 years (mean = 38.53, SD =13.03). Participants received psychomotor therapy (n = 91), music therapy (n = 3), or art therapy (n = 33). For 61 participants there is no information regarding the kind of therapies they received during this study. Eighty-four clients participants received other types of treatment, such as psychological treatment or psychiatric treatment in addition to psychomotor therapy, music therapy, or art therapy an additional kind of therapy (psychological treatment or psychiatric treatment). The psychomotor therapy, music therapy, and art therapy were delivered by a
THERAPEUTIC ALLIANCE IN ARTS THERAPIES professional psychomotor therapist, music therapist, or art therapist respectively.
Study Design The present study consisted of three measurements. The baseline measurement (T0) was one week before the start of art therapy. The second measurement (T1) was 8-10 weeks and the third measurement (T2) 17 weeks from baseline. Participants completed the Brief Symptom Inventory at baseline. During T1 and T2 participants completed the Working Alliance Inventory-12 and the Brief Symptom Inventory. Instruments Working Alliance Inventory-12 (WAI-12) The Working Alliance Inventory – Short version (Stinckens, Ulburghs, & Claes, 2009), based on the WAI of Horvath & Greenberg (1989), is a 12-item instrument scored on a 5-point Likert scale from 1 (never) to 5 (always). The scale assesses one general scale (general alliance) and three subscales; tasks (i.e. the level of agreement between the provider and client on what should be done in treatment); bond (i.e. the strength of the relationship or connection between the provider and client); and goals (i.e. the level of agreement on the desired outcome of the treatment). The total score utilizes all 12 items, while the three subscales are assessed with 4 items each. The total score for the WAI-12 ranges from 12 (low working alliance) to 84 (high working alliance), and subscale scores range from 4 to 28. The WAI-12 has shown to have strong internal consistencies, ranging from .70 to .91 for the subscales and .90 to .95 for the total score (Busseri & Tyler, 2003; Dunkle & Friedlander, 1996; Ligiero & Gelso, 2002; Tracey & Kokotovic, 1989) and predictive and concurrent validity (Busseri & Tyler, 2003; Ligiero & Gelso, 2002; Parish & Eagle, 2003). In the present study the subscales demonstrated satisfactory to good reliabilities for the subscales bond (α = .78), task (α = .86), goals (α = .80) and the total scale (α = .92).
THERAPEUTIC ALLIANCE IN ARTS THERAPIES Brief Symptom Inventory (BSI) The brief symptom inventory is a client self-report measurement consisting of 53 questions about psychopathology and psychological distress (Derogatis, 1993). The questions are divided into 9 dimensions of psychopathology (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobia, paranoid ideas, and psychoticism) and two global scores. During the present research we only used the subscales for depression and anxiety, due to the fact that this were the most common problems in the Dutch mental health population (Graaf, Have, & Dorsselaer, 2010). The severity of each symptom has to be scored on a 5-point Likert-scale ranging from 0 (symptom not present) to 4 (extreme severity). The BSI has shown good reliabilities in the American general population (internal consistency Cronbach’s α = .71-.85 and test-retest reliability intraclass correlation coefficient r ICC = .68 - .91). Reliability coefficients in the present study were good (α = .84 .92). Statistical Analysis A general linear model (ANOVA) with repeated measures was examined to investigate the development of the therapeutic alliance over time (i.e. within subject factor). Additionally, in order to investigate the influences of the therapeutic alliance during arts therapies and psychomotor therapy on symptom reduction, general linear models with repeated measures were used. This was performed for the early phase (T0-T1) and the late phase of the treatment (T1-T2) separately. For these analyses, time was the within subject factor (two levels; T0 and T1 (early phase analyses) or T1 and T2 (late phase analyses) and therapeutic alliance (highmedium-low) as between subject factor. All analysis were conducted in SPSS 21.0. Results Table 1 presents the means, standard deviations, main effects, and interaction effects of the WAI-12 and the BSI during the three measurements. Using a general linear model with
THERAPEUTIC ALLIANCE IN ARTS THERAPIES repeated measures, it was shown that there was an increase of the total score of the WAI-12 during AT [F(71) = 6.924; p = .010]. This increase was also seen in the WAI subscale ‘task’ [F(76) = 10.723, p = .002]. For the WAI subscales ‘goals’ and ‘bond’ only a trend was observed (p = .08; respectively p = .056). Next, we investigated whether a positive therapeutic alliance in terms of the WAI subscales during arts therapies and psychomotor therapy had a positive influence on symptom reduction. For all models, there was a main effect of AT indicating that all clients had a decrease of symptoms in time. Regarding the depression symptoms in the early phase of the treatment, results showed that there was an interaction effect of time x WAI subscale ‘goal’ [F(2,91) = 3.33, p = 0.04,
2
= 0.07]. This interaction effect was in the
expected direction, indicating that participant’s persons who experienced the alliance as positive showed a higher decrease in depressive symptoms compared to the participants persons who experience the alliance as less positive. A trend was found for the interaction effects of time x WAI subscale ‘Task’ [F(2,90) = 2.78, p = 0.07,
2
= 0.06].
Concerning the late phase of the treatment, no interaction effects were found regarding the scores on BSI depression subscale.
Examining the interaction
effects of the BSI anxiety scores in both the early and late phase showed only one interaction effect, i.e. in the late phase, of time x WAI subscale ‘bond’ [F(2,70) = 3.45, p = .04,
2
= 0.09]. Trends were shown for time x WAI total scores in the early phase
[F(2,85) = 2,86, p = 0.06,
2
2
=0.06] and the late phase [F(2,68) = 2,73, p =
= 0.07]. Discussion
The present study was conducted to investigate the development of the therapeutic alliance, (i.e., the client-therapist bond, agreement on goals and collaboration on task) in arts therapies and psychomotor therapy over time. Furthermore, we examined whether a good
THERAPEUTIC ALLIANCE IN ARTS THERAPIES therapeutic alliance was related to symptom change (depression and anxiety) among adults in mental health care. To our knowledge, this was the first study on arts therapies and psychomotor therapy to investigate whether symptom change was related to the therapeutic alliance.
As expected, results showed that during arts-therapies there was a positive development of the therapeutic alliance during arts therapies and psychomotor therapy, which is mostly, explained by higher scores an increased perception of the collaboration on tasks. Findings indicate that participants had an increased perception of the task collaboration. The stronger improvement of task collaboration during therapy can be explained by the focus on the interaction and agreement with materials and methods used in arts therapies and psychomotor therapy. Measurement instruments of the present study only investigated the therapeutic alliance in general terms. It is recommended that future studies should focus on the development of an arts therapy specific instruments to focus on this material interaction. In arts-therapies, methods, tasks, and interaction with the materials seem to play an important role in promoting the therapeutic alliance (Smeijsters et al., 2011). Contrary to our the expectations based on the and results of previous research (Martin et al., 2000; Webb et al., 2012) overall results in the present study indicate that the relation between therapeutic alliance and symptom change was rather weak and effects in the early phase equal the effects in the late phase. Despite these weak effects of the therapeutic alliance, the effects were in the expected direction, for example i.e. patients who experienced the therapeutic alliance as positive show more improvements of their anxiety and depressive symptoms compared to patients who experience the alliance as less positive. Results weare preliminary and show different considerations that need further explanation; first, the present study did not investigate the therapeutic alliance directly after the beginning of the therapy sessions. Approximately pPrevious research has shown that one-third of symptom change occurres prior to the early session (session 3; Webb et al., 2011), and thus
THERAPEUTIC ALLIANCE IN ARTS THERAPIES before alliance was assessed in the present study. As building a therapeutic alliance is a dynamic process that is started during the first meeting, one would expect that there is also a kind of some alliance after the first therapy session (Ardito & Rabellino, 2011; Barber, Connolly, CritsChristoph, Gladis, & Siqueland, 2000; Horvath & Greenberg, 1989). Future research should focus on the therapeutic alliance TA in an early phase of treatment and to examine the relation between therapeutic alliance and to well establish symptom change in relation to the number of therapy sessions. This would be in line with findings of Barber et al. (2000) who examined the relations among therapeutic alliance, outcome, and early-in-treatment symptomatic improvements in a group of patients with generalized anxiety disorders, chronic depression and avoidant or obsessive–compulsive personality disorder, after receiving supportive–expressive dynamic psychotherapy. Results indicated that alliance at in later sessions, but not in first sessions, was associated with changes in depression. Alliance at all sessions significantly predicted subsequent changes in depression in all sessions (Barber et al., 2000). We recommend to examine in Thus, future studies the development of the alliance using should focus on a more frequent measurement of the therapeutic alliance during therapy to investigate changes in therapeutic alliance during the therapy. A second point to discuss is the fact that during the present study only the client’s view on alliance was investigated. In previous research, client’s assessments have shown to be a positive outcome predictor of positive outcome of psychotherapy (Castonguay et al., 2006). Furthermore, rating scales were usually validated on the basis of clinical data only (Hovrvath, 2000). HoweverBut, research has shown that client’s experiences of the alliance tend to be more subjective, a-theoretical and based on past experiences, whereas the view of the therapist is more used as a theoretical perspective (Ardito & Rabellino, 2011). As alliance is a reciprocal process, future studies should focus on clients’ and therapists’ perception of alliance. Research has indicated that client’s and therapist’s perspectives in general show a moderate correlation, and that clients rate the alliance to be more positively than their therapist (Tryon, Blackwell, &
THERAPEUTIC ALLIANCE IN ARTS THERAPIES Hammel, 2007). Comparing client and therapist versions of existing alliance scales, Bachelor (2013) found that client and therapist perspectives might have a different underlying factor structure, which limits the valid comparison of client and therapist ratings. Therefore, the client and therapist perspectives should be recognized as distinct perspectives. In order to gain more insight into the development of subcomponents of the therapeutic alliance throughout treatment, and their relation to outcomes, it is important for future research to include both perspectives. A final point of attention is the fact that different types of therapies were involved in the present study. Because of the limited number of participants, it was not possible to investigate the influence of the therapeutic alliance for each therapy. We need to question whether there is a difference in the development of the therapeutic alliance during arts therapies (using creative arts and expression) versus the psychomotor therapies (using sporting activities). Future research should therefore focus on the role of the therapeutic alliance in specific therapies. The present study was one of the first to investigate the relationship between artstherapies and therapeutic alliance and their relation with symptom change in a group of mental health patients. The present study was Results were explorative and future research in arts therapies should focus on more frequent measurement of alliance and symptom change even as the measurement of alliance in client and therapists and their reciprocal effects on therapy outcomes. Due to the present findings, in future research there should be specific attention on the role of the task collaboration. Although the results of the present research were preliminary, they give a first implication of the therapeutic alliance in arts therapies and show the importance of the task collaboration within a strong therapeutic alliance.
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THERAPEUTIC ALLIANCE IN ARTS THERAPIES APPENDIX
Table 1: means, standard deviations, main effects and interaction effects of WAI and BSI scores T0 (N = 164)
T1 (N = 108)
T2 (N = 84)
Main effect
Mean (SD)
Mean (SD)
Mean (SD)
F-value
WAI subscale ‘Bond’
-
3.55 (0.83)
3.98 (2.54)
WAI subscale ‘Goal’
-
3.49 (0.75)
3.91 (2.64)
3.15**
WAI subscale ‘Task’
-
3.44 (0.82)
3.87 (2.60)
10.72**
WAI total score
-
42.5 (8.09)
44.01 (7.77)
6.92**
BSI anxiety BSI depression ** p<0.1 ** p<0.05
9.96 (6.36) 10.31 (6.92)
9.00 (5.86) 9.02 (5.93)
8.40 (5.89) 8.38 (5.90)
8.76** 7.85**
3.78**