Patients` assessment of their therapeutic alliance affects drinking patterns

A strong therapeutic alliance between a patient and a clinician appears to predict positive alcohol use outcomes after a treatment session, and this seems to remain a pivotal factor throughout the course of treatment. A study published in the November 2016 Journal of Consulting and Clinical Psychology also noted that therapeutic alliances were not significantly associated with alcohol use for individuals who had been able to reduce their drinking substantially before entering treatment.

The study used the Working Alliance Inventory (WAI) instrument to capture patients' assessment of the alliance with their therapist. The WAI measures patient/therapist agreement on the goals of therapy, their agreement on the tasks of treatment, and the bond between the two individuals.

The findings of this study help to reinforce the often-cited observation, supported by research, that the therapeutic relationship between the substance use treatment patient and the treating clinician can be more important to outcome than the type of therapy that is used.

Details of study

The study involved 63 participants seeking outpatient treatment for an alcohol use disorder. The average age of participants was just over 48, and individuals with a psychotic disorder or severe neurocognitive impairment were excluded from eligibility.

Standard cognitive-behavioral therapy (CBT) sessions were delivered over a 12-week period, with the therapy administered by clinicians with at least five years of experience in working with patients with alcohol use disorders. At the end of each session, patients completed the WAI and offered information about their drinking levels since the last session.

The research team, led by Gerard Connors, PhD, senior research scientist at the University at Buffalo Research Institute on Addictions, found that higher therapeutic alliance scores in one week predicted a lower number of drinking days and heavy-drinking days in the following week. Heavy drinking days were defined as at least five drinks per occasion for men and at least four drinks for women.

The researchers also found that individuals who had significantly reduced their drinking before the start of the treatment period saw little in the way of additional progress during treatment.

Connors tells Addiction Professional that this study and other research using the WAI did not find any difference in influence among the three subscales of the instrument. He adds that the WAI subscales related to goals, tasks and bond “typically are very highly correlated.”

Asked what the results of this study might signal for effective treatment planning, Connors said that they may highlight “the need to attend not only to the establishment of strong therapeutic alliances at the beginning of treatment but as well to monitor alliances throughout the course of treatment. To the extent a fractured therapeutic alliance is detected, efforts could be promptly initiated to address it.”

Other considerations

This study did not explore treatment modalities other than CBT, but the researchers pointed out in their paper that findings on the therapeutic alliance generally are consistent across modalities.

The study did not find that changes in drinking between treatment sessions predicted patients' subsequent assessment of the therapeutic alliance. Connors says that might say something positive regarding treatment, in that “patients who might have a discouraging week in terms of drinking do not necessarily perceive poorer therapeutic alliances at the next treatment session.”