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Chiropractic Journal of Australia : CJA March 2013
26 Chiropractic Journal of Australia Volume 43 Number 1 March 2013 TA has been shown to be a signifcant factor in determining outcomes in adolescent eating disorders. These reviews evaluated psychological treatments for Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder and were conducted in a primary care setting. High attrition and non-compliance rates are common among participants with these syndromes. However the studies reviewed indicated the importance of a strong therapeutic alliance between provider and patient as a central determining factor in improved outcomes.9,10 Similar results have also been found in children with poorly controlled diabetes11 and with speech dysfuency.12 The results of interventions to enhance patient adherence to medication have been inconsistent. A recent study chose to explore the nature of the TA as a possible factor. Forty-six clinicians were trained in 'medication alliance'. The quality of the therapeutic relationship was also enhanced. It was concluded that clinician training to support improved patient adherence should include strategies that also enhance the therapeutic alliance.13 Although cognitive-behavioural therapy for paediatric obsessive-compulsive disorder is considered a frst-line treatment, not all youth have a positive treatment response, suggesting the need for investigating factors that may enhance or reduce treatment effects. Findings in this study indicated that stronger child-rated, parent-rated and therapist-rated TA's were predictive of better treatment outcome. Second that larger and more positive early alliance shifts were predictive of better treatment outcome.14 Strength of the TA may reduce the likelihood of the relapse of depression. Psychoeducation has proven to be an effective treatment method for the prevention of relapse in recurrent depression. However, little is known about the processes which could account for the effects of psychoeducational treatment. These were investigated as predictors of reducing the recurrence risk in depression. One year after treatment, no associations were found between therapist adherence or competence and the risk of relapse. The patients' view of the therapeutic alliance was moderately associated with the time to relapse. The latter was the most important predictor of time to relapse, explaining 15% of variance.15 Therapeutic Alliance and Outcomes TA appears to be established early on and its impact at this stage has its greatest power for predicting positive outcomes. Early alliance has been found to be a better predictor of outcome than when averaged across sessions or measured in the middle or late phase of treatment.16 Two recently published reviews have sought to measure its impact in psychotherapy. Included were over 200 research reports based on 190 independent data sources, covering more than 14,000 treatments. The overall aggregate relation between the alliance and treatment outcome was r = .275 (k = 190).17,18 A substantial and signifcant fgure. Dropping Out of Therapy A meta-analytic review of 11 studies (1,301 participants) examined the relationship between psychotherapy dropout and therapeutic alliance in adult individual psychotherapy.19 Results of the meta-analysis demonstrated a moderately strong relationship between psychotherapy dropout and therapeutic alliance (d = .55). Findings indicate that clients with weaker therapeutic alliance are more likely to drop out of psychotherapy. Exploratory analyses were conducted to determine the influence of variables moderating the relationship between alliance and dropout. Client educational history, treatment length, and treatment setting were found to moderate the relationship between alliance and dropout. Studies with a larger percentage of clients who completed high school or higher demonstrated weaker relationships between alliance and dropout. Studies with lengthier treatments demonstrated stronger relationships between alliance and dropout. Inpatient settings demonstrated signifcantly larger effects than both counselling centres and research clinics. These fndings have been recently replicated.20 Implications for Therapy? Researchers have provided evidence that client ratings of the alliance are stronger predictors of treatment outcome than are counsellor ratings.21,22 Thus it is the eyes of the recipient of therapy not the administrator of the intervention. It is client focused. The impact of the TA is not a sign of psychopathology or psychological vulnerability in the client. Psychiatric symptoms do not predict alliance formation.23 It is a normal and natural part of a therapeutic interaction. The therapist’s level of experience appears to have a relationship to the quality of the TA. In a review of 12 studies, a small positive relationship between the therapists' experience and the quality of the therapeutic relationship early in treatment was found.24 A more recent study explored the therapists’ level of experience and was not found to be predictive of patients' alliance ratings.25 Evidence from the attachment literature suggests that the quality of a client’s early relational or family experiences may infuence his or her ability to form an alliance early in individual psychotherapy. Researchers have linked insecure attachment styles with poor initial alliances in individual psychotherapy.26,27 How to Foster TA Sue et al suggest that the presence of warmth, friendliness, genuineness, open posture, good eye contact, empathy, and Active Listening by the therapist are hall marks of the TA.28 This is further enhanced by frequently repeating back what client has said for clarifcation. This demonstrates a respect for the patient. It should be borne in mind that the impact of a clinical encounter resonates well beyond the treatment room. It does not only happen in offce contact time. During the days-long or week-long intervals between therapy sessions, patients typically recollect, refect on, practice, and imaginatively elaborate on experiences they had during sessions with their therapists. These intersession experiences have been studied for some time with the Intersession Experience Questionnaire (IEQ) in Germany and the United States. Signifcant associations were found between certain IE factors and therapeutic alliance, varying in strength by treatment duration and country.29 THERAPEUTIC ALLIANCE INNES • CAMERON
CJA December 2012
CJA June 2013