The Impact of Initial Factors on Therapeutic Alliance in Individual and Couples Therapy

Abstract

The study uses 457 clients to investigate the impact of initial client factors on the development of therapeutic alliance. Data were collected longitudinally over the early portion of treatment. Cases included both individual and couple clients, allowing for examination of differences by case type. The study used the Working Alliance Inventory-Shortened Version (Tracey & Kokotovic, 1989) to measure therapeutic alliance. Initial factors considered included age, differentiation levels, prior stress, and depression. Couple clients showed differences from individual clients, and the variability prompted further investigation into relationship satisfaction and commitment as factors influencing the development of therapeutic alliance. Results highlight the increased complexity of developing an alliance with couples, and recommendations are provided for clinicians.

The Intersection of Therapy Constructs: The Relationship Between Motivation to Change, Distress, Referral Source, and Pressure to Attend

“…Mandated clients often experience stressful and pressured referrals into therapy (Chamberlain et al, 1984), resulting in low levels of motivation (Begun et al, 2003) and lower levels of engagement and alliance formation (Conners et al, 2000;Rempel & Destefano, 2001). The clients preceding experience with their referral source may leave them on the offensive when they enter therapy, at which point they struggle to connect with their therapist and find motivation to change, resulting in premature termination of services (Begun et al, 2003;Chamberlain et al, 1984;Knerr et al, 2009). Dissimilarly, voluntary clients experience some intrinsic desire or awareness of a need for treatment (O'Hare, 1996;Prochaska, Johnson, & Lee, 2008), may have sought out a referral or utilized a referring agency to connect them to support services.…”

“…Further evidence of the relationship between distress and motivation is present in the relationship between distress and client engagement in therapy. Distress has been linked to low levels of engagement and trouble forming a strong individual and couple therapeutic alliances (Connors et al, 2000;Knerr et al, 2009) both of which likely influence the high rates of dropout in distressed couple populations (Tambling & Johnson, 2008). Further, clients who are poorly motivated are less likely to develop a strong alliances (Conners et al, 2000), suggesting that clients who are both poorly motivated and highly distressed will be among the most difficult to engage, retain, and form alliances with in therapy.…”

“…Some classic research suggests that high levels of distress are associated with increases in motivation (Wolff, 1968). Newer research has suggested that high levels of distress are negatively associated with motivation (Knerr et al, 2009). Yet, studies remain inconclusive.…”

“…The pressure placed on the client by the referral source increases the clients' perceptions of stigma related to therapy attendance and results in clients viewing therapy as a form of punishment (Knerr et al, 2009;Larke, 1985). Due to links between pressure and motivation, the manner in which a referral is made has the ability to impact the course of therapy (Knerr et al, 2009).…”

“…Referral Source and Experience of Pressure Motivation to change and distress levels are intertwined with many factors that pre-date the onset of the course of therapy. One such factor is the pressure placed on a client, often imposed by the referring party who mandates the client to attend therapy (Knerr et al, 2009), or face severe consequences, such as incarceration or loss of parental rights. Referring parties are often viewed as oppressive and authoritarian, limiting the client's autonomy (Ackerman et al, 1991).…”