The alliance in motivational enhancement therapy and counseling as usual for substance use problems.
Crits-Christoph P., Gallop R., Temes C.M. et al. Journal of Consulting and Clinical Psychology: 2009, 77(6), p. 1125–1135.

Rarely has counselling been so deeply analysed as in this US study of mainly alcohol and cocaine dependent patients. The far-reaching implications are that some counsellors generate relationships with clients which feed through to better outcomes – but also that the 'best' relationship builders are not on average the most effective.

Summary
A working relationship or 'therapeutic alliance' between patient and counsellor is expected to be particularly for motivational interviewing, which seeks to engender change built on empathy, listening, respect and other features of a collaborative and supportive relationship. The featured report sought to determine whether this was the case in comparison to usual US substance use counselling. It carefully teased out variation between therapists in the extent to which they fostered an alliance across all their patients, versus variation between patients seeing the same therapist. If the former was substantial it would mean some therapists were better at generating collaborative working in their patients, which might be related to how well those patients did in controlling their substance use. One reason alliance might vary is the extent to which therapists embodied the supposedly relationship-building motivational style, another issue investigated by the report. First this account summarises the earlier findings (small text) from the study which set the context for the analysis made in the featured report.

The report drew its data from a study conducted in 2001–2004 at five US treatment centres offering outpatient counselling. In all 35 therapists at the centres who volunteered to join the study were allocated at random to implement two forms of individual counselling, an addition to the group counselling at the centres. Both individual approaches occupied three sessions over the first four weeks of what was on average a 10-week treatment episode. One simply replicated usual one-to-one counselling at the centres, for which the counsellors received no special training or supervision as part of the study. The other replaced this with sessions based on a manualised form of motivational interviewing, for which the counsellors had been specially trained, tested to ensure at least adequate/average delivery of the approach, and supervised via taped sessions to ensure they remained on track.

Of the 461 patients in the trial, about 60% each were assessed as problem (mainly dependent) drinkers or cocaine users. Typically they were single men in their 30s and half were in full time employment. The severity of their substance use was assessed during the 16 weeks after they started treatment.

A report on the main outcomes found that while seeing the counsellors, both sets of patients substantially reduced use of their main problem substance, but this was sustained over the next 12 weeks only after motivational counselling – an effect due to the 40% of patients with a primary alcohol problem; others did about as well regardless of the approach used for individual counselling. The report also found clinics differed in how well their patients did and how much was gained or not by implementing motivational interviewing, but after this had been taken in to account no significant differences could be attributed to individual therapists. Another report on the same study found that patients of motivational counsellors who more often and more skilfully implemented the approach expressed greater increases in motivation to change during counselling sessions and were less likely to test positive for illegal drugs during the four weeks they were individually counselled. However, other measures of substance use were not related to the counsellor behaviours assessed by the study.

The featured report assessed how much of these impacts could be attributed to the therapeutic alliance. It drew its data from 30 of the 35 therapists and 319 of the 461 patients, the ones who had attended their first counselling session and who after the second reported how they saw their alliance with their counsellor. In respect of substance use, the analysis further narrowed down to 257 patients who completed at least one of the required research interviews.