Self-efficacy change as a mediator of associations between therapeutic bond and one-year outcomes in treatments for alcohol dependence.

Abstract

Empirically-supported treatments for alcohol dependence exist, yet understanding of influences contributing to the intended behavior change is limited. The current study, a secondary analysis of the recent multi-site COMBINE trial (The COMBINE Study Research Group, 2003), tested a mediational model wherein change in client self-efficacy for abstinence was examined as a potential mediator of associations between client-report of the therapeutic bond and one-year outcomes of drinking frequency, drinking consequences, and psychiatric functioning. For analyses, the 1383 COMBINE trial participants were grouped as follows: 1) those receiving study medications (Naltrexone, Acamprosate, Naltrexone + Acamprosate, Placebo) and enrolled in medication management (MM) only (n=607), 2) those receiving study medications/MM and also enrolled in a combination behavioral intervention (CBI) as well (n=619), and 3) those enrolled in CBI only (n=157). Mediation analyses using the product-of-coefficients approach indicated self-efficacy change during treatment significantly mediated associations between the therapeutic bond with the CBI therapist and each of the three one-year outcomes among those exclusively receiving CBI, but failed to do so among those receiving pills/MM (with or without CBI). Effect sizes were small, but indicated that variance in bond-outcome associations was partially mediated by self-efficacy change for trial participants. Findings advance understanding of proximal client change processes during delivery of treatments for alcohol dependence.

The Indirect Effect of the Therapeutic Alliance and Alcohol Abstinence Self-Efficacy on Alcohol Use and Alcohol-Related Problems in Project MATCH

“…In the current study, 2 planned contrasts comparing respective pairs of treatment conditions were tested. Third, both Hartzler and colleagues (2011) and Connors and colleagues (1997) tested 1-year outcomes, whereas in the current study, all of the longitudinal data were including in the model, as represented in our testing for the significance of the slope of self-efficacy and alcohol-related outcomes, respectively, over time.…”

“…Hartzler and colleagues (2011) showed in the COMBINE data set that alcohol abstinence self-efficacy is a potentially important statistical mediator of the relationship between the alliance and client outcomes. …”

“…For example, Hartzler and colleagues (2011) used data from the COMBINE study (COMBINE Study Research Group, 2003) to test whether changes in alcohol abstinence self-efficacy mediated the relationship between client ratings of the therapeutic bond (1 component of the therapeutic alliance as measured by the WAI) and client outcomes. Results indicated that changes in self-efficacy significantly mediated the association between client ratings of therapeutic bond and percentage drinking days, alcohol consequences, and psychiatric functioning at 12-month follow-up, but only for those who received only the “combination behavioral intervention” (no medical management and no medications, including placebo).…”

“…These initial findings concerning self-efficacy have important implications for advancing the understanding of the alliance–AUD patient outcomes relationship, as well as for clinical practice in demonstrating that the negative relationship between client self-efficacy and treatment outcome may be compensated for to some degree by a strong therapeutic alliance, at least as the therapist perceives it. Accordingly, the purpose of this study was to investigate further the alcohol abstinence self-efficacy statistical mediation effect by replicating and extending the Hartzler and colleagues (2011) study in the Project MATCH outpatient sample. In the study reported here, a multivariate parallel process growth model was derived from the studies cited in this paper as well as in the general literature on AUD clinical course and outcome (McKay, 2009), and this model was tested on each of 3 outcome variables: PDD, DDD, and negative alcohol-related consequences.…”

“…However, the treatment alliance–self-efficacy outcomes statistical mediation effect was also tested. It is important to note that this study provides an extension of Connors and colleagues (1997) and Hartzler and colleagues (2011) in 3 main ways. First, we examined a new drinking outcome while retaining 2 of 3 drinking outcomes identical to those of Hartzler and colleagues (percent days drinking [PDD] and alcohol-related negative consequences).…”