Better relationships mean better outcomes?

Adventure therapy and Therapeutic Alliance.

Matt LiddlePressley Ridge Central and Eastern Europe

Therapeutic Alliance?

• The helpful, working relationship between a client and therapist, defined in terms of the emotional bond between the client and the therapist, agreement on therapeutic tasks and the goals of treatment as well as the perceived openness and truthfulness of the relationship (Doucette and Bickman, 2001).

Why am I getting so excited?

• Gap: Gass (1993), Russell (1999, 2002)

• “Bridging” construct

• Outcome-bound

• Quantitative, reliable & valid measures

• Process Variable

Therapeutic Alliance: Theory• Freud (1913), Zetel (1956), Greenson (1965)

– Transference vs. independent, working relationship• Bordin (1976)

– Tasks, Goals, Bonds

• Luborsky (1976) – Dynamic process that changes throughout therapy

• Frieswyk (1986)– Client collaboration in therapy, not transference

• Horvath and Luborsky (1993)– Phase I and Phase II alliance

• Doucette and Bickman (2001) – Perceived openness and truthfulness of relationship

Therapeutic Alliance: Research

• Horvath (1993):– TA makes a positive contribution to outcome in a broad variety

of treatment modalities serving a spectrum of patient problems

• Luborsky (1985): – Therapeutic alliance ratings had a much stronger correlation with

outcome than did ratings of the purity of therapeutic delivery

• Horvath and Symonds (1991)– TA accounted for 26% of therapy outcome– Early measures of alliance more predictive than late or mean

• corroborated by Frieswyk, 1986; Barber, 2000; Klein, 2003

• Barber (2001):– Alliance still a predictor when symptom change partialled out– Alliance predictive of symptom change throughout therapy

15%

15%

40%

30%

Techniques

Expectancy

Extratherapeutic

Common Factors

Source: Lambert and Barley, 2001

Show me some pictures, dang it!

I don’t read the papers!

Why does TA matter in adolescent mental/behavioral

health care?• Adolescents:

• Resistant to adults/authority figures• Often enter treatment against their will• Referred to treatment because of difficulty

forming relationships

• Structure of mental health care programs:

• Partial Hospital/Day Treatment program

Why does TA matter to adventure programming?

I believe that certain forms of adventure- based programming can be positioned

as a direct intervention designed to spike therapeutic alliance – a construct based upon trust and collaboration –

and therefore a catalyst for total therapeutic outcome.

Hypothesized Model

Within Day Treatment SettingTherapeutic Wilderness Trip

Teacher/Counselor StudentTA

Teacher/Counselor

Student

T

A

The Study

Sample• Youth 11-18 in partial hospital/day treatment • Convenience NR sampling• Analytic sample: 45 students (40/5) and 10

(1/9) teacher counselors in 5 classrooms [down from 58/12]

Instrumentation

• PRY-TAS & PRC-TAS (Doucette & Bickman, 2001)

Research Questions

• Do youths participating in therapeutic wilderness camping trips report a significant change in therapeutic alliance, as measured by their overall PRY-TAS score?

• Are there differences in change in therapeutic alliance among youth by their a) gender, b) age, c) timing of their trip, d) category of axis I diagnosis, or e) their teacher/counselors’ number of years of experience in teaching?

• Do teacher/counselors participating in therapeutic wilderness camping trips report a significant change in therapeutic alliance, as measured by their overall PRC-TAS score?

• Are there differences in change in therapeutic alliance among teacher/counselors by the a) age of their students, b) timing of the trip, c) category of students’ axis I diagnoses, or d) the number of years they have been teaching?

• Do youth and teacher/counselors report agreement in their assessment of their therapeutic relationship?

Design

• Modified switching replications NEGD

• 6 Classrooms participating in a Fall/Winter trip

• 3 research dyads– 1 gets early trip; the other gets later trip

N O X O ON O O X O

X = wilderness trip O = TA measurement N = non-randomized

But…..

N O X O ON O O X O

I had a methodological flaw in design.

N O X ON O X O

Analyses

• Data cleaned, coded and entered into SPSS

• One-way repeated measures within subjects ANOVAs

• Independent samples t-tests

Results

• No significant differences for youth– Wilks’s λ = .99, F(1,59) = 0.78, p = .781, η2

= .001.• Likewise for clinical/demographic sub-groupings

• Significant improvements in TA for teacher/counselors– Wilks’s λ = .60, F(1,83) = 56, p < .001, η2 = .40.

• Significantly higher with younger students• Significantly higher with early groups

• Significant differences between youth and T/C ratings of TA at both time points

Histogram: Youth

0.900.600.300.00-0.30-0.60

ychngTA

20

15

10

5

0

Fre

qu

enc

y

Mean =0.0113Std. Dev. =0.31383N =60

ychngTA

Histogram: Teacher/Counselors

1.000.800.600.400.200.00-0.20-0.40

tchngTA

20

15

10

5

0

Fre

qu

ency

Mean =0.1713Std. Dev. =0.20981N =84

tchngTA

Mean Youth and T/C ratings

T/C Time 2Youth Time 2T/C Time 1Youth Time 1

3.00

2.90

2.80

2.70

2.60

2.50

2.40

2.30

2.20

2.10

2.00

Mea

n T

AS

Sco

res

Why no significant differences among youth?

• Power and/or Statistics

• Constancy of TA scores– Bickman et al. (2001), Bachelor and

Salame (2002)– “Window of opportunity” early in treatment

• Or….AT doesn’t effect youth TA!

Why are the T/C findings encouraging?

• Relationships• Teacher expectancy research• Higher T/C scores consistent with literature

– Rauktis, Doucette, Andrade (in press)– Bickman et al. (2004)

• Greater increase in TA among early semester groups– “Window of opportunity” (Bickman et al., 2004)

Limitations

• Sample size -> statistics

• Selection Bias

• Non-independence of UOA

• Non-randomization

• Reactive effect of testing

• Measurement of DV

• External Validity

Where can we go with this?

• Further research

• Intentional Programming

• Programming in the “window”

• Family Programming– Mandated Families

• Adjunct Interventions

Matt LiddlePressley Ridge CEEmliddle@pressleyridge.org+36 1 785 4242