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

1
Better relationships mean better outcomes?
Adventure therapy and Therapeutic Alliance.

• Matt Liddle
• Pressley Ridge
• Central and Eastern Europe

2
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).

3
Why am I getting so excited?

• Gap Gass (1993), Russell (1999, 2002)
• Bridging construct
• Outcome-bound
• Quantitative, reliable valid measures
• Process Variable

4
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

5
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

6
Show me some pictures, dang it!I dont read the
papers!
Source Lambert and Barley, 2001
7
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

8
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.

9
Hypothesized Model
Within Day Treatment Setting
Therapeutic Wilderness Trip
Teacher/ Counselor
Teacher/ Counselor
Student
T
TA
A
Student
10
The Study
11
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)

12
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?

13
Design
N O X O O N O
O X O
X wilderness trip O TA measurement N
non-randomized

• Modified switching replications NEGD
• 6 Classrooms participating in a Fall/Winter trip
• 3 research dyads
• 1 gets early trip the other gets later trip

14
But..
N O X O O N O
O X O
I had a methodological flaw in design.
N O X O N O X O
15
Analyses

• Data cleaned, coded and entered into SPSS
• One-way repeated measures within subjects ANOVAs
• Independent samples t-tests

16
Results

• No significant differences for youth
• Wilkss ? .99, F(1,59) 0.78, p .781, ?2
  .001.
• Likewise for clinical/demographic sub-groupings
• Significant improvements in TA for
  teacher/counselors
• Wilkss ? .60, F(1,83) 56, p lt .001, ?2
  .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

17
Histogram Youth
18
Histogram Teacher/Counselors
19
Mean Youth and T/C ratings
20
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 doesnt effect youth TA!

21
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)

22
Limitations

• Sample size -gt statistics
• Selection Bias
• Non-independence of UOA
• Non-randomization
• Reactive effect of testing
• Measurement of DV
• External Validity

23
Where can we go with this?

• Further research
• Intentional Programming
• Programming in the window
• Family Programming
• Mandated Families
• Adjunct Interventions

24
Matt Liddle Pressley Ridge CEE mliddle_at_pressleyrid
ge.org 36 1 785 4242