The role of therapeutic alliance in individual and couples cognitive-behavioral therapy for women with alcohol dependence

The construct of therapeutic alliance has yet to be investigated among women participating in treatment for alcohol dependence. The current study examined predictors of the formation of alliance and its relationship with treatment outcome within individual and couples cognitive-behavioral therapy. It also developed a new, observer-rated measure of alliance and tested the psychometric properties of this instrument (Treatment Integrity Rating Scale Alliance-Related Items [TIRS-ARI]). Participants were 158 women with an alcohol use disorder (98% alcohol dependence) treated in a 12-session randomized clinical trial either with or without their male partner. Participants were not randomized to study arm (i.e., Individual/Couples), therefore all analyses were conducted separately for the Full, Individual Arm, and Couples Arm Samples. Data were collected at baseline and 3-, 9-, and 15-months post-baseline (003, 009, 015), and relevant variables included: motivation (SOCRATES [SOC], choice of abstinence goal), alliance (Working Alliance Inventory [WAI], TIRS-ARI), alcohol consumption (percent days abstinent [PDA]), and relationship functioning (Dyadic Adjustment Scale [DAS]). Results indicated that the new measure of alliance created for the current study (TIRS-ARI) exhibited adequate psychometric properties and was appropriate for use in conjunction with the WAI. Predictor analyses indicated that greater motivation was associated the formation of stronger alliances in individual, but not couples, therapy; women who chose an abstinence goal (an index of motivation) formed stronger alliances as measured by the WAI and TIRS-ARI in the Full Sample and by the WAI in the Individual Sample than those who chose a non-abstinence goal. In multiple regression predictor analyses, motivation (SOC Problem Recognition subscale) was found to be significantly associated with WAI among participants in the Individual Arm Sample. Additional treatment modalities differences indicated that women in the Individual Arm of the clinical trial formed significantly stronger alliances as measured by the WAI than women in the Couples Arm. Treatment outcome analyses found that alliance was predictive of both alcohol consumption and relationship functioning during follow up when controlling for baseline values of outcome variables. Higher scores on the WAI were associated with greater PDA at 009 in the Full and Individual Arm Samples and at 015 in the Individual Arm Sample. Among Couples Arm participants, higher scores on the WAI and TIRS-ARI were associated with greater relationship functioning (DAS) at 009 and 015, respectively. Overall, patterns of alliance formation and predictive utility differed between the Individual and Couples Arms, and the current study concludes with a discussion of the clinical implications of these identified patterns.