Until recently it has been believed that positive treatment outcome is influenced by either patient variables, treatment variables or their interaction. Numerous studies have explored the impact of these variables on outcome hoping to find the magic key that would unlock the mystery of treatment success. Here’s what we have learned.
Matching studies investigated the notion that patients will have the best outcome if their personality or presenting problems were matched with a particular type of treatment or particular type of therapist. For example, I conducted a matching study at South Bay Hospital in Redondo Beach in the early 80s. I matched inpatients who were being treated for alcoholism according to a personality factor, their Health Related Locus of Control, with two counselors who had very different counseling styles – one was directive the other was non-directive. The hypothesis I tested was that the non-directive counselor would work better with patients who had an Internal Health Locus of Control while the directive counselor would work best with clients with an External Health Locus of Control. I found that while the directive counselor was somewhat more helpful in certain areas than the non-directive counselor, most patients benefited from treatment regardless of whether their therapist was directive or non-directive and regardless of whether they had an Internal of External Health Related Locus of Control. This finding is consistent with the results from other matching studies.
The results from studies that have focused exclusively on treatment variables like type of treatment or degree of counselor experience or theoretical orientation of the counselor have shown that these variables do not account for a substantial amount of variance of treatment outcome. Like the matching studies, these studies have also demonstrated that treatment works. People who received treatment were much better off than those who were untreated. This was surprising, not that treatment worked, but that treatment factors accounted for so little of the variance of treatment outcome.
What research has shown us is that there is a patient variable associated with better outcomes. Can you guess what it is? It is the client’s rating of the quality of the therapeutic alliance. Most of the variance of treatment outcome can be accounted for by this factor and this factor alone. One of the largest alcoholism treatment outcome studies ever conducted was Project Match (1997). These investigators found that the client’s rating of the therapeutic alliance was the best predictor for treatment participation, drinking behavior during treatment, and drinking at 12-month follow-up.
Please let this sink in. The quality of the therapeutic alliance, as perceived by the client, is a critical factor in treatment outcome and predicts participation in treatment and better outcomes than any other variable. Amazing isn’t it. But for the most part this finding has been ignored. What a shame! We could easily increase patient outcome across the board by focusing on the quality of the therapeutic alliance between counselor and client. It’s that simple. So where do we start?
The quality of the therapeutic alliance, as perceived by the client, is a critical factor in treatment outcome
The first thing we need to look at is the experience a person has during the initial phase of becoming a patient. Does the patient feel welcomed, do they feel cared for and safe? Is the patient oriented to treatment? Are the experiences that the patient is having increasing their confidence in the program and its staff? If the experience a person has in becoming a patient is not positive, it will make it hard for them to form a positive therapeutic alliance with the program.
Orienting patients to treatment has proven to be very important. Patients who are indoctrinated to treatment with a formal orientation are more likely to participate during treatment. The orientation process should include things like an introduction to the program rules, grievance procedures, staff expectations of patient responsibilities like adherence to the patient schedule or completing reading and writing assignments, an introduction to their primary counselor and to the weekend staff, when and how often they are expected to attend AA or NA meetings, and anything else that would help them understand and anticipate the experiences they are likely to have during treatment.
Patients who are educated about group therapy and how to participate in the group are also more likely to get more out of treatment. Given that group therapy is the heart of treatment, creating a special group therapy orientation is essential because it will increase patient participation in group therapy sessions. In 1990 Hazelden published a pamphlet I specifically created for this purpose. This pamphlet is currently being utilized in treatment programs to increase patient participation in group therapy. In the next couple of months, Serene Connections will be releasing a series of DVDs that are specifically designed to help patients understand the benefits of group therapy and how to get the most out of group therapy.
Taking time to insure that patients are indoctrinated to treatment and instructed as to the benefits of group therapy and how to participate in group sessions is well worth the effort and will help you increase positive treatment outcomes.
Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK.
Berger, A. (1987). Differential effectiveness of nondirective-directive alcoholism group counseling as a function of the patients’
health locus of control. Unpublished doctoral dissertation. University of California, Davis.
Berger, A. (1990, 2007). How to get the most out of group therapy. Mn: Hazledon.
Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome.
Journal of Consulting and Clinical Psychology, 65(4), 588-98
By Allen Berger, Ph.D.