The role of the working alliance in psychological treatment of substance use disorder outpatients

Abstract

The main objective of this study was to explore the relationship between alliance and treatment outcome of substance use disorder (SUD) outpatients in routine care. Attachment, type of substance use, and treatment orientation were analyzed as potential moderators of this relationship. Method: Ninety-nine SUD outpatients rated their psychological distress before every session. Patients and therapists rated the alliance after every session. At treatment start and end, the patient completed the Alcohol Use Disorders Identification Test (AUDIT), the Drug Use Disorders Identification Test (DUDIT), and the Experiences in Close Relationships (ECR-S). Data were analyzed using multilevel growth curve modeling and Dynamic Structural Equation Modeling (DSEM). Results: The associations between alliance and outcome on psychological distress and substance use were, on average, weak. Within-patient associations between patient-rated alliance and outcome were moderated by self-rated attachment. Type of abuse moderated associations between therapist-rated alliance and psychological distress. No moderating effect was found for treatment orientation. Conclusions: Patients' attachment style and type of abuse may have influenced the association between alliance and problem reduction. A larger sample size is needed to confirm these findings.

Attachment and Therapeutic Alliance in Substance Use Disorders: Initial Findings for Treatment in the Therapeutic Community

“…In this study we focused on the examination of alliances between SUD clients, but further research is needed to investigate within-patient therapeutic alliance. This might contribute to more knowledge regarding the specific direction of the association between therapeutic alliance and symptomatic improvement, as previously pointed out by Gidhagen et al ( 14 ). Does a stronger therapeutic alliance lead to symptomatic improvement or does the decrease of symptoms increase therapeutic alliance?…”

“…Nevertheless, comparisons of participants with mood disorders and patients suffering from SUD might be a particularly interesting research topic, as mood disorders pose a significant vulnerability to develop addictions (64). Finally, literature suggests the associations between therapeutic alliance and attachment to be more complex with various intervariable connections [e.g., (14,27)]. In order to gain an enhanced understanding of the relationship between working alliance dimensions and attachment, as well as personality, mood pathology and therapy motivation, future research might focus on more complex research designs in SUD samples.…”

“…This is consistent with the findings from therapy outcome research focusing on SUD treatments ( 12 , 13 ). Nevertheless, recent studies suggest the relationship between therapeutic alliance and positive outcomes to be lower in SUD patients, by reporting weak correlations of around r = 0.14 ( 9 , 14 ). What is more, various client characteristics have been observed to play an important role for the relationship between therapeutic alliance and the course of SUD treatment.…”

“…Despite of conflicting results [e.g., (26)] attachment organization might have a huge impact regarding an increased alliance, as securely attached individuals were observed to exhibit stronger alliance values than insecurely attached ones (27)(28)(29)(30). Correspondingly, Gidhagen et al (14) reported attachment styles as to be a significant moderator variable between higher working alliance and positive therapy outcome in a sample of SUD patients. Furthermore, there is significant evidence for the substantial connection of attachment organization and personality structure (31).…”

Securing Participant Engagement in Longitudinal Substance Use Disorder Recovery Research: A Qualitative Exploration of Key Retention Factors

“…Professional SUD treatments have developed methods to meet retention challenges in clinical services [26,32]. Therapeutic alliances and relationships between patients and clinicians are commonly considered important tools to retain patients and improve outcomes [51], and attachment style and type of substance use may also influence the association between alliances and problem reduction for individuals with SUD [17]. Continuity in care, availability of services, flexible approaches to keeping in touch, and timing of treatment episodes are often described as essential factors in SUD treatments [10,31,44].…”