Alliance and therapist adherence: bidirectional associations in systemic therapy for antisocial adolescents in the Netherlands

Objectives: The current presentation will describe the conjoint role of the client-therapist working alliance and therapist adherence. Alliance is a key contributor to effective adult psychotherapy and may also be essential... [ view full abstract ]

Objectives: The current presentation will describe the conjoint role of the client-therapist working alliance and therapist adherence. Alliance is a key contributor to effective adult psychotherapy and may also be essential for effective family- and system therapy. However, the process through which alliance plays a role in therapy remains largely unknown. Alliance is usually conceptualised as consisting of personal alliance (the affective bond) and task-related alliance (addressing the goals of the treatment and the tasks required to achieve those goals). Most studies have measured alliance on only one occasion, thus failing to take into account the longitudinal and developmental nature of alliance during therapy. Yet, alliance is likely to fluctuate over time and the development of alliance during therapy may be a more consistent predictor of treatment outcome than the alliance at a single point in time.
Another limitation of many previous alliance-studies is that alliance has often been investigated in isolation. Available evidence, however, suggests that alliance is likely to interact with other process variables, such as therapist adherence. Therapist adherence is the extent to which the therapist delivers the technical elements of a treatment as designed. Monitoring therapist adherence allows evaluation of the quality of the delivered intervention and helps identifying potential problems if the intervention is not achieving the desired outcomes.
Although theoretical models posit that alliance and therapist adherence work together to initiate and facilitate therapeutic change, few studies have investigated their interaction so far. Knowledge regarding the conjoint role of alliance and therapist adherence may be used to monitor and improve treatment, leading to better treatment outcomes. The current study assessed alliance and therapist adherence on a monthly basis during therapy and investigated how alliance in one month predicted adherence in a subsequent month and vice versa.
Method: We used routinely collected data of a sample of 1,970 adolescents and their families participating in Multisystemic Therapy (MST). The bidirectional associations of alliance and adherence were investigated using a cross-lagged panel analysis with five fixed time points. Alliance and therapist adherence were scored at monthly intervals through telephone interviews with the primary caregiver. A number of client characteristics were included as moderators, namely demographic characteristics, type and severity of adolescent problem behaviour, and whether or not the MST treatment was court-ordered.
Results: Alliance in one month predicted therapist adherence in a subsequent month. Adherence only predicted subsequent alliance during the middle part of the treatment process. The results were not moderated by any of the client factors.
Conclusions: The results suggest that alliance and therapist adherence may reinforce one another during therapy. Whereas alliance may facilitate the development of therapist adherence, adherence may subsequently deepen and consolidate the client-therapist alliance. Our results suggest that it is important to build a strong alliance at the start of therapy. Adherence to the therapy protocol may further strengthen the working alliance.