Better relationships mean better outcomes? Adventure therapy and Therapeutic Alliance. Matt Liddle Pressley 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

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 Student TA Teacher/ Counselor Student T A

The Study

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

But….. N O X O O N O O X O I had a methodological flaw in design. N 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

Histogram: Teacher/Counselors

Mean Youth and T/C ratings

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 Liddle Pressley Ridge CEE