nzps elizabeth ross
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Examining the relationship between client factors,
therapeutic alliance, and treatment outcome in high-risk
violent offender treatment
Dr Elizabeth Ross, Dr Devon Polaschek, Dr Marc Wilson
Victoria University of Wellington
What we know
• Therapeutic alliance is a collaborative relationship between therapist and client that can facilitate positive change for the client (Ross, Polaschek & Ward, 2008)
• Therapeutic alliance accounts for 25% variance in outcome in therapy (Horvath & Symonds, 1991)
• A client’s motivation to change linked to both a positive alliance and positive treatment gains
What we know
• Therapeutic alliance and other process factors overlooked in offender rehabilitation
• Despite compelling reasons for salience of these factors
• No studies with incarcerated high-risk violent offenders but partner-violent community treatment studies promising (Taft et al., 2003, 2004, 2007)
Research Question
• What is the relationship between motivation to change, therapeutic alliance and treatment outcome for high-risk incarcerated violent offenders in treatment?
Method: Setting
• Rimutaka Violence Prevention Unit• 30-bed low-medium security Special
Treatment Unit at Rimutaka Prison, Wellington, New Zealand
• 36-week CBT based programme• Aim is to reduce violent re-offending• Voluntary but heavily influenced by parole
(external motivation)
Method: Participants
• Cohort of 70 men across seven treatment groups
• 31 yrs, 54% indigenous Maori, 52 % psychopathic, estimated risk over 5 years = .65, 8.7 years average sentence
• 11 therapists (2 per group)• 2 clinical supervisor observers
Method: Measures
• Therapeutic Alliance = Working Alliance Inventory (WAI) - Short version, 12 items, Goals, Tasks and Bond
• Motivation to Change (MTC) = item 13 of Client Attributes Scale therapist-rated
• Outcome = Violence Risk Scale Change (VRS), Treatment Completion/Time in Programme
Method: Procedure
• Therapeutic alliance and motivation measured at four time points Week 2, 10, 18, 30
• WAI by observer and MTC by therapist• VRS by trained consultant pre and post-
programme• Treatment completion and time in the
programme recorded
Results: Can therapists and offenders form an alliance?
• Yes
• The average score for the WAI was 65/80
• All raters scored the alliance highly and it only increased over time
Results: Is motivation to change related to alliance?
• Yes• At time 1 motivation and alliance correlated
r =.53, p < .01• In multiple regression motivation to change
was the only significant client variable accounts for 29% variance in WAI total scores at Week 2 of the programme
Results: Is therapeutic alliance related to outcome?
• Mixed Results• Chose to use Hierarchical Linear
Modeling - good for “nested” data and mediation
• In Hierarchical Linear Models, no significant relationship between alliance at any time point and change in the VRS
Results: Is therapeutic alliance related to outcome?
• In order to look at predicting the outcome of treatment completion need to assess the “odds” using Logistic Regression
• The alliance at specific time points did not predict in HLM so looked at the change in alliance scores across time
• In Logistic Regression Change in WAI scores predicted odds of client completing (Odds ratio = .08, 83% versus 70% chance)
Results: Is motivation to change related to outcome?
• Yes
• In a logistic regression, MTC predicted the odds of client completion better than the therapeutic alliance (Odds ratio = 1.19, 90% versus 70% chance)
Results: What is the relationship between motivation, therapeutic
alliance and treatment outcome? • Structural Equation Modeling allows us to
build models of mediation relationships• Conceptual pathways were tested using: • Motivation (MTC) at time 1, therapeutic
alliance (WAI) at time 2, change in risk of violence (VRS), treatment completion and time in programme
Mediation Model 1:Motivation-Alliance-Change
.28* .44*
MOTIVATIONTime 1
ALLIANCETime 2
CHANGE
Mediation Model 2:Motivation-Alliance-Completion
.30* .39*
MOTIVATIONTime 1
ALLIANCETime 2
COMPLETION
Mediation Model 3:Motivation-Alliance-Prog Time
.34* .60*
MOTIVATIONTime 1
ALLIANCETime 2
PROG TIME
Results: Comparing models
FIT INDICES
2
df
p
CFI
RMSEA
Results: Comparing models
FIT INDICES CHANGE
2 .04
df 1
p .83
CFI 1
RMSEA .00
Results: Comparing models
FIT INDICES CHANGE COMPLETE
2 .04 4.17
df 1 1
p .83 .04
CFI 1 .68
RMSEA .00 .18
Results: Comparing models
FIT INDICES CHANGE COMPLETE TIME
2 .04 4.17 2.47
df 1 1 1
p .83 .04 .12
CFI 1 .68 .87
RMSEA .00 .18 .13
What if motivation is the mediator?
.47* .28*
FIT INDICES MOTIVATION MED ALLIANCE MED
2 .98 .04
df 1 1
p .32 .83
CFI 1 1
RMSEA .00 .00
ALLIANCETime 1
MOTIVATIONTime 2
CHANGE
Results Summary
• Strong alliances formed • Motivation to change at time 1 most
strongly related to time 1 alliance • Alliance not explaining variance in
outcome in HLM’s• Change in alliance across time predicts
odds of treatment completion but not as well as average motivation across time
Results Summary
• Motivation to change at time 1 strongly related to VRS change and time in programme mediated by alliance at time 2
• However support for bi-directional relationship with motivation also acting as a mediator between alliance and outcome
Implications: Forensic work
• Alliance is high despite these offenders being “challenging” psychopaths
• Motivation to change is vital
• Clients may form motivation in treatment
• Therapeutic alliance is important but may be more facilitative of change rather than directly related to change
• May work through motivation, protection
Implications: Future Research
• Next step of current research is to look at recidivism: Are alliance and motivation related to recidivism?
• Important to continue research in this challenging area
Acknowledgements
• Dr Devon Polaschek and Dr Marc Wilson
• Victoria University of Wellington
• Department of Corrections
• Staff and inmates of RVPU
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