Examining the Role of the Therapeutic Alliance in Treatment Efficacy by Mediating Client Engagement

Document Type : Research Paper

Authors

1 Ph.D. Student of Psychology, Department of Psychology, Tabriz Branch, Islamic Azad University, Tabriz, Iran.

2 Department of Psychology, Tabriz Branch, Islamic Azad University, Tabriz, Iran

3 Department of Psychology, University of Tabriz, Tabriz, Iran.

Abstract

The purpose of this study is to determine the role of the therapeutic alliance in treatment effectiveness through mediation of client engagement. Individuals who had approached counseling centers of welfare organization, oil company, and Tabriz municipality in 2019 were selected as the statistical population. The statistical sample of the present study consists of 324 participants (225 women and 99 men) who were selected through purposive sampling based on entry and exit criteria, after obtaining their consent. The Working Alliance Inventory-Short Revised (WAI-SR), Client Engagement (CES), Client Satisfaction (CSQ), and Client Outcome (COM) questionnaires were used to collect data, and the data were analyzed using structural equation modeling and Amos24 software. Results showed that therapeutic alliances with client engagement mediation were able to explain changes in treatment effectiveness. In addition, the results of the mediation test showed that client engagement partially mediated the relationship between the therapeutic alliance and treatment outcome, but fully mediated the relationship between the therapeutic alliance and client satisfaction. The results of the fit indices indicated that the measured model was in good agreement with the theoretical research model. In conclusion, this study showed that client engagement was a mediating variable in explaining treatment efficacy, so therapists should pay special attention to the role of client engagement in treatment efficacy in addition to selecting appropriate treatment approaches.

Keywords

References

ورمقانی، ح.، پورشریفی، ح.، زرانی، ف.، و اثباتی، م. (1396) رابطۀ مشاور-مراجع، پیروی از درمان و رضایت مراجعان از مراکز خدمات روان‌شناسی و مشاوره. فصلنامۀ روان‌شناسی معاصر. 12(ویژه‌نامه)، 1855-1852.
پروچاسکا، ج. ا.، و نورکراس، ج. س. (1397). نظریه‌های روان‌درمانی. ترجمۀ یحیی سیدمحمدی. تهران: انتشارات رشد.
فیست، ج.، فیست، گ. ج.، و رابرتس، ت. آ. (1395). نظریه‌های شخصیت (ویراست هشتم). ترجمۀ یحیی سیدمحمدی. تهران: نشر روان.
غلامی، ز.، و شاره، ح. (1394). اثربخشی گروه‌درمانی بر مبنای روش‌های هوشیاری فراگیر انفصالی در کاهش میل و احتمال مصرف افراد وابسته به مواد. مجلۀ اصول بهداشت روانی. 17(6)، 317-308.
غلامی، ح.، محمودی، ح.، سرابندی، ح.، و برجی، ع. (1396). بررسی میزان رضایتمندی مراجعین از مرکز بهداشتی درمانی شهری وابسته به یگان نظامی منتخب در سال 1394. مجلۀ طب نظامی. 19(3)، 305-299.
قاسمی، و. (1389). مدلسازی معادلۀ ساختاری در پژوهش‌های اجتماعی با کاربرد Amos Graphics. تهران: انتشارات جامعه‌شناسی.
 
Ahn, H.-N., & Wampold, B. E. (2001). Where oh where are the specific ingredients? A meta-analysis of component studies in counseling and psychotherapy. Journal of Counseling Psychology. 48(3), 251–257.
Allen, M. L., Cook, B. L., Carson, N., Interian, A., La Roche, M., & Alegría, M. (2017). Patient- provider therapeutic alliance contributes to patient activation in community mental health clinics. Administration and Policy in Mental Health. 44(4), 431–440.
Ammerman, R., Stevens, J., Putnam, F., Altaye, M., Hulsmann, J., Lehmkuhl, H., …, & Van Ginkel, J.. (2006). Predictors of early engagement in home visitation. Journal of Family Violence. 21(2), 105–115.
Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research. Frontiers in Psychology. 270(2), 1-11.
Bachelor, A. (2013). Clients' and therapists' views of the therapeutic alliance: Similarities, differences and relationship to therapy outcome. Clinical Psychology & Psychotherapy. 20(2), 118–135.
Baydar, N., Reid, M. J., &Webster-Stratton, C. (2003). The role of mental health factors and program engagement in the effectiveness of a preventive parenting program for head start mothers. Child Development. 74(5), 1433–1453.
Bedi, R. P. (2018). Racial, ethnic, cultural, and national disparities in counseling and psychotherapy outcome are inevitable but eliminating global mental health disparities with indigenous healing is not. Archives of Scientific Psychology. 6(1), 96–104.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice. 16(3), 252-260.
Byrd, K. R., Patterson, C. L., & Turchik, J. A. (2010). Working alliance as a mediator of client attachment dimensions and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training. 47(4), 631–636.
Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change that work. New York: Oxford University Press.
Cheng, T. C., & Lo, C. C. (2018). A longitudinal analysis of factors associated with therapeutic alliances. Community Mental Health Journal. 54(6), 782-792.
Cuijpers, P., van Straten, A., Andersson, G., & van Oppen, P. (2008). Psychotherapy for depression in adults: A meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology. 76(6), 909–922.
Fornell, C. & Larcker, D. (1981). Evaluating structural equation models with unobservable variables and measurement error. Journal of Marketing Research. 18(1), 39-50
Fuertes, J. N., Mislowack, A., Brown, S., Gur-Arie, S., Wilkinson, S., & Gelso, C. J. (2007). Correlates of the real relationship in psychotherapy: A study of dyads. Psychotherapy Research. 17(4), 423-430.
Gelso, C. J., & Johnson, D. H. (1983). Explorations in time-limited counseling and psychotherapy. New York, NY: Teachers College Press.
Gelso, C. J., Kivlighan, D. R., Busa-Knepp, J., Spiegel, E. B., Ain, S., Hummel, A. M., …, & Markin, R. D. (2012). The unfolding of the real relationship and the outcome of brief psychotherapy. Journal of Counseling Psychology. 59(4), 495-506.
Graff, F. S.,Morgan, T. J., Epstein, E. E., McCrady, B.S., Cook, S.M., Jensen, N. K., & Kelly, S.. (2009). Engagement and retention in outpatient alcoholism treatment for women. American Journal on Addictions. 18(4), 277–288
Graffigna, G. (2017). Is a transdisciplinary theory of engagement in organized settings possible? A concept analysis of the literature on employee engagement, consumer engagement and patient engagement. Frontiers in Psychology. 8, 872.
Hatcher, R. L., & Gillaspy, J. A. (2006) Development and validation of a revised short version of the working alliance inventory. Psychotherapy Research. 16(1), 12-25.
Hatchett, G. T. (2004). Reducing premature termination in university counseling centers. Journal of College Student Psychotherapy. 19(2), 13–27.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. New York: Guilford Press.
Higgins, T., Larson, E., & Schnall, R. (2017). Unraveling the meaning of patient engagement: A concept analysis. Patient Education and Counseling. 100(1), 30–36.
Holdsworth, E., Bowen, E., Brown, S., & Howat, D. (2014). Client engagement in psychotherapeutic treatment and associations with client characteristics, therapist characteristics, and treatment factors. Clinical Psychology Review. 34(5), 428–450.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapists contributions and responsiveness to patients (pp. 37-69). New York: Oxford University Press.
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology. 36(2), 223-233.
Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology. 61(4), 561–573.
Horvath, A. O., Re, A. C. D., Flückiger, C., & Symonds, D. (2011). In J. C. Norcross (Ed.), Alliance in individual psychotherapy (pp. 25–69). New York, NY, US: Oxford University Press.
Illing, V., Tasca, G. A., Balfour, L., & Bissada, H. (2011). Attachment dimensions and group climate growth in a sample of women seeking treatment for eating disorders. Psychiatry. 74(3), 255–269.
Johansson, H., & Jansson, J. (2010). Therapeutic alliance and outcome in routine psychiatric out-patient treatment: Patient factors and outcome. Psychology & Psychotherapy: Theory, Research & Practice. 83(2), 193–206.
Kietaibl, C. M. (2012). A review of attachment and its relationship to the working alliance. Canadian Journal of Counselling and Psychotherapy. 46(2), 122–140.
Kim, J. E., Park, S. S., La, A., Chang, J., & Zane, N. (2016). Counseling services for Asian, Latino/a, and White American students: Initial severity, session attendance, and outcome. Cultural Diversity and Ethnic Minority Psychology. 22(3), 299–310.
Kim, J. E., Zane, N. W., & Blozis, S. A. (2012). Client predictors of short-term psychotherapy outcomes among Asian and white American outpatients. Journal of Clinical Psychology. 68(12), 1287–1302.
Kirchmann, H., Mestel, R., Schreiber-Willnow, K., Mattke, D., Seidler, K., Daudert, E., …, & Strauss, B.,. (2009). Associations among attachment characteristics, patients' assessment of therapeutic factors, and treatment outcome following inpatient psychodynamic group psychotherapy. Psychotherapy Research. 19(2), 234–248.
Kirsh, B., & Tate, E. (2006). Developing a comprehensive understanding of the working alliance in community mental health. Qualitative Health Research. 16(8), 1054–1074.
Klag, S. M., Creed, P., & O'Callaghan, F. (2010). Early motivation, well-being, and treatment engagement of chronic substance users undergoing treatment in a therapeutic community setting. Substance Use & Misuse. 45(7), 1112–1130.
Kline, R. B. (2005). Principles and practice of structural equation modelling (2nd ed.). New York: The Guilford Press
Koole, S. L., & Tschacher, W. (2016). Synchrony in psychotherapy: A review and an integrative framework for the therapeutic alliance. Frontiers in Psychology. 7, 862.
Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., Nguyen, T. D. (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning: An International Journal. 2(3), 197-207.
Livesley, W. J. (2007). An integrated approach to the treatment of personality disorder. Journal of Mental Health. 16(1), 131-148.
Mackrill, T. (2011). Differentiating life goals and therapeutic goals: Expanding our understanding of the working alliance. British Journal of Guidance & Counselling. 39(1), 25–39.
Makoul, G. (2001). Essential Elements of Communication in Medical Encounters: The Kalamazoo Consensus Statement. Academic Medicine. 76(4), 390-342.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology. 68(3), 438–450.
McCarthy, L., & Duggan, C. (2010). Engagement in a medium secure personality disorder service: A comparative study of psychological functioning and offending outcomes. Criminal Behaviour and Mental Health. 20(2), 112–128.
McMurtry, S. L., Hudson, W. W. (2000). The client satisfaction inventory: Results of an initial validation study. Research on Social Work Practice. 5(10), 644-63.
Melville, K. M., Casey, L. M., & Kavanagh, D. J. (2007). Psychological treatment dropout among pathological gamblers. Clinical Psychology Review. 27(8), 944–958.
Miklowitz, D.J. (2008). Adjunctive psychotherapy for bipolar disorder: State of the evidence. American Journal of Psychiatry. 165, 1408-1419.
Norcross, J. C. (2011). In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd Ed.). New York, NY, US: Oxford University Press.
Nordheim, K., Walderhaug, E., Alstadius, S., Kern-Godal, A., Arnevik, E., & Duckert, F. (2018). Young adults’ reasons for dropout from residential substance use disorder treatment. Qualitative Social Work. 17(1), 24-40.
Rogers, C. (1951). Client-centered therapy: Its current practice, implications and theory. London: Constable.
Rahimian Boogar, I., Safarzade, S., & Talepasand, S. (2020). Premature termination of psychotherapy in outpatient clinic settings: structural effects of patients’ expectations, treatment tolerance, therapists’ competencies and therapeutic alliance. Iranian Journal of Health Psychology. 2(2), 33-44.
Scott, K., King, C., McGinn, H., & Hosseini, N. (2011). Effects of motivational enhancement on immediate outcomes of batterer intervention. Journal of Family Violence. 26(2), 139–149.
Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology. 80(4), 547-559.
Tetley, A., Jinks, M., Huband, N., & Howells, K. (2011). A systematic review of measures of therapeutic engagement in psychosocial and psychological treatment. Journal of Clinical Psychology. 67(9), 927–941.
Thompson, S., Bender, K., Lantry, J., & Flynn, P. (2007). Treatment engagement: Building therapeutic alliance in home-based treatment with adolescents and their families. Contemporary Family Therapy: An International Journal. 29(1), 39–55.
Tracey, T. J., & Kokotovic, A. M. (1989). Factor structure of the working alliance inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology. 1(3), 207-210.
Uckelstam, C. J., Holmqvist, R., Philips, B., & Falkenström, F. (2020). A relational perspective on the association between working alliance and treatment outcome. Psychotherapy Research. 30(1), 13-22.
Vermeersch, D. A., Whipple, J. L., Lambert, M. J., Hawkins, E. J., Burchfield, C. M., & Okiishi, J. C. (2004). Outcome questionnaire: Is it sensitive to changes in counseling center clients? Journal of Counseling Psychology. 51(1), 38–49.
Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice. 24(2), 190–195.
Yalom, I. D. (1975). The theory and practice of group psychotherapy (2nd Ed.). New York: Basic Books.
Yoskowitz, N. A. (2018). Client engagement in psychotherapy: The roles of client and beginning therapist attachment styles. PhD dissertation in Clinical Psychology. Columbia University, New York, United States.
 
Journal of Applied Psychological Research
Volume 12, Issue 3
December 2021
Pages 171-190

Files

History

  • Receive Date: 19 November 2020
  • Revise Date: 25 December 2020
  • Accept Date: 20 January 2021
  • First Publish Date: 07 November 2021
  • Publish Date: 22 November 2021

Share

How to cite

Statistics