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Published paper
Meier, P.S., Barrowclough, C. and Donmall, M.C. (2005) The role of the
therapeutic alliance in the treatment of substance misuse: a critical review of the
literature. Addiction, 100 (3). pp. 304-316. http://dx.doi.org/10.1111/j.1360-
0443.2004.00935.x
eprints@whiterose.ac.uk
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The role of the therapeutic alliance in the treatment of substance misuse: A critical review of the
literature
Short title: Alliance in drug treatment
Page count: 16 (22 with Tables)
Word Count: 5,028 (excl references & Tables)
Authors:
Petra S. Meier, National Drug Evidence Centre, School of Epidemiology and Health Sciences, University
of Manchester, UK
Christine Barrowclough, Academic Division of Clinical Psychology, School of Psychiatry & Behavioural
Sciences, University of Manchester, UK
Michael C. Donmall, National Drug Evidence Centre, School of Epidemiology and Health Sciences,
University of Manchester, UK
Correspondence to:
Petra Meier, email: petra.meier@man.ac.uk
Drug Misuse Research Unit
School of Epidemiology and Health Sciences
University of Manchester
Bury New Road
Prestwich, M25 3BL, UK
Acknowledgements
This study forms part of the Counselling Project, which is funded through a Research and Training
Fellowship by the NHS North West Regional Office, UK.
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Abstract
Background: In the past two decades, a number of studies investigating the role of the therapeutic
alliance in drug treatment have been published and it is timely that their findings are brought together in a
comprehensive review.
Aims: This paper has two principal aims: 1) to assess the degree to which the relationship between drug
user and counsellor predicts treatment outcome and 2) to critically examine the evidence on determinants
of the quality of the alliance.
Method: Peer reviewed research located using the literature databases Medline, PsycInfo and Ovid Full
Text Mental Health Journals using predefined search-terms and published in the past 20 years is
considered. Further papers were identified from the bibliographies of relevant publications.
Findings: A key finding is that the early therapeutic alliance appears to be a consistent predictor of
engagement and retention in drug treatment. With regard to other treatment outcomes, the early alliance
appears to influence early improvements during treatment, but it is an inconsistent predictor of post-
treatment outcomes. There is relatively little research on the determinants of the alliance. In studies that
are available, clients’ demographic or diagnostic pre-treatment characteristics did not appear to predict
the therapeutic alliance, whereas modest but consistent relationships were reported for motivation,
treatment readiness and positive previous treatment experiences.
Conclusions: The therapeutic alliance plays an important role in predicting drug treatment process
outcomes, but too little is known about what determines the quality of the relationship between drug users
and counsellors.
Keywords: Review, alliance, retention, treatment outcomes
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Introduction
The quality of the therapeutic relationship is a significant predictor of psychotherapy and counselling
outcomes in clients presenting with a variety of non-psychotic disorders across different treatment
modalities (Horvath and Symonds 1991; Martin et al. 2000) and the therapeutic alliance is seen as an
essential ingredient of any psychotherapy and counselling (Gaston 1990) Several reviews on the
therapeutic alliance in generic psychotherapy or counselling settings have already been carried out
covering a range of issues including the historical and conceptual dimensions of the alliance (Horvath and
Luborsky 1993), definition of the concept, measurement issues and the relationship between the alliance
and psychotherapy outcomes (Horvath and Symonds 1991; Marziali and Alexander 1991; Martin, Garske
et al. 2000), therapy characteristics and techniques (Ackerman and Hilsenroth 2003), the impact of the
alliance on outcomes in short term dynamic therapy (Crits-Christoph and Connolly 1999), as well as the
role of the alliance in behaviour therapy (Sweet 1984) and cognitive therapy (Waddington 2002). No such
reviews have been undertaken in the field of drug treatment research, although there are a number of
factors which argue for the particular importance of the therapeutic relationship for substance using
clients.
Perhaps the most important of these factors is the difficulty engaging and retaining drug using clients in
treatment (Simpson, Joe, Rowan-Szal et al. 1997; Stanton 1997; Gossop et al. 1999; Joe, Simpson and
Broome 1999). As discussed later, there are now first indications that a supportive therapeutic
relationship may enhance such engagement and retention (Broome et al. 1999; Joe et al. 2001).
Moreover, it has been suggested that the therapeutic relationship may serve as a model for improved
relationships outside therapy (Greenson 1965; Henry and Strupp 1994) which in turn may improve
outcomes. This is important since many drug using clients report unsatisfactory relationships with their
social environment and a history of poor social and family relationships has been strongly implicated in
the aetiology of drug use (Bell et al. 1996). Furthermore, the presence of a strong social network during
and after treatment has been linked consistently to sustained improvements in drug use after treatment
(Hser et al. 1999; Simpson et al. 2000; Broome et al. 2002).
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It has been suggested that the nature of some drug treatment approaches which require the therapist to
take an active educational and confrontational role may present challenges to developing a working
therapeutic relationship (Millman 1986). Added to this, further relationship challenges arise since many
clients deny the extent of the problem, are hostile towards the therapist or other clients, do not want to be
in treatment and have a history of treatment failures (Joe et al. 1998).
Aim of the review
In the past two decades, a number of studies investigating the role of the therapeutic alliance in drug
treatment have been published and thus it is timely that the findings of these studies are brought together
in a comprehensive review. This paper has two principal aims: 1) to assess the degree to which the
relationship between drug user and counsellor predicts the progress and outcomes of treatment and 2) to
critically examine the evidence on which variables contribute to the development of a successful alliance.
Method
The review critically appraises the extent to which research efforts have identified predictors of successful
therapeutic alliances and have evaluated the impact of the therapeutic alliance on drug treatment
outcome. All peer reviewed research published in English during the past 20 years on these topics is
considered. However, case studies and studies investigating the alliance in group or family treatment
rather than individual treatment were excluded. The electronic databases Medline, PsycInfo and Ovid Full
Text Mental Health Journals were searched using a list of relevant terms (see Table 1). Each search
contained a minimum of one term from Area 1 and one term from Area 2. The bibliographies of relevant
publications were studied to locate further literature. A meta-analytic approach was not adopted because
the eighteen identified studies falling within the remit of this review varied widely with regard to
therapeutic approach, methodological approach, definition of study outcomes, and the timing of
assessments. Moreover, many studies did not include a quantifiable relationship between the alliance and
outcome necessary for meta-analysis and this would have led to the exclusion of some of the most
relevant studies. The purpose of the current review is to present a broad picture of the available evidence
and also to highlight gaps in the knowledge that need to be addressed.
