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Investigating the Relationship Between the Therapeutic
Alliance and Treatment Outcome in Violent Offender
Treatment
By
Elizabeth C. Ross
A thesis submitted to the Victoria University of Wellington in fulfilment of the
requirements for the degree of Doctor of Philosophy in
Psychology
December 2008
The research studies in this thesis have been supported by the New Zealand Department of
Corrections.
2
Declaration
I hereby declare that this thesis has not been submitted, either in the same or
different form, to this or any other university for a degree:
Signature: _____________________________
3
Publications
Data and literature from this thesis have been reported in the following formats
and been published or submitted for publication:
Ross, E. C., Polaschek, D. L. L., & Ward, T. (2008). The Therapeutic Alliance:
A theoretical revision for offender rehabilitation. Aggression and Violent
Behavior, 13, 462-480.
Ross, E. C., Polaschek, D. L. L., & Wilson, M. (2008). Shifting perspectives:
A confirmatory factor analysis of the Working Alliance Inventory with high-risk
violent offenders. Journal of Offender Therapy and Comparative Criminology,
(under review).
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Acknowledgements
Writing a thesis is like riding a rollercoaster. There are dizzying highs,
frightening lows, and at times you feel like your life has been turned upside
down. And all this happens once every couple of minutes! There have been a lot
of people in my life along for this ride, to whom I owe my eternal gratitude.
Firstly, to my wonderful supervisors Devon Polaschek and Marc Wilson; I
have been so lucky to have the benefit of your wisdom and experience. Devon:
you were critical but gentle, encouraging but realistic, and you were always there
to ground me when I threatened to get carried away by my ideas. Marc: you were
always positive, always enthusiastic, always encouraging me to try new statistics
on my own, but you never left me feeling unsupported. Together, you were the
perfect supervisors, and I always left supervision feeling motivated and happy.
Tony Ward: I also owe you gratitude for setting me on this path with my honours
year project, which is now a published theory and a large part of this thesis.
Secondly, I am deeply grateful to the staff and clients at the Rimutaka
Violence Prevention Unit. Without all of you taking time out of your lives to fill
in my endless forms, I would not have a thesis. To the therapists: thank you for
allowing me in to what is usually a private and privileged relationship between a
therapist and client. To the clients: thank you so much for participating in
research that you may have found challenging and of little immediate benefit. To
the supervisors: I know I added in more work to your already hectic lives. To the
custodial and operational staff: thank you for accepting me as staff, and
arranging things for me, even if you had no idea who I was. I also owe many
5
thanks to the Department of Corrections, for supporting this research and
allowing me to access the evaluation data.
To my friends and family — who have had to put up with me all this time
being alternately wildly enthusiastic, despondent, and just plain crazy — thank
you for not disowning me. Mum and Dad: I know how proud and supportive you
are, mostly because you wouldn’t let me get married and become Mrs
Robertshaw unless I was going to be Dr Ross. Caroline and Anna: you may not
have always known exactly what I was studying and when, but you’ve always
been there as my sisters and best friends. To Emily and Cat: I enjoyed our
research debriefs over coffee or wine, it’s nice to know you’re not the only one
obsessing about something no-one else knows about! To Bec, my lovely office
mate: you have been a great source of help, information, and importantly gossip;
and I know you will produce a fantastic thesis. To the clinical girls: you have
been great company and classes with you were a welcome relief from endless
data and statistics.
Lastly, I owe huge thanks to my wonderful husband Kevin. It was you who
got the brunt of my emotional rollercoaster ride, consoling me with hugs when it
was all too hard, celebrating my achievements, and motivating me when I just
couldn’t face writing another word. You have been so supportive of me so far,
and never complained once, but I’m sure you’re glad the ride is almost over. I
know I am.
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Conventions Used in this Thesis
Numbering Studies
The four studies in this thesis are numbered independently from the chapters in
which they appear.
Numbering Tables and Figures
All tables and figures are numbered according to the chapter in which they
appear. They are numbered as figure or table x.y with x referring to the chapter
and y referring to the order in which they appear in the chapter.
Abbreviations
Although all abbreviations are explained in the text, the following list are the
common abbreviations used that may be helpful to refer to in reading this thesis:
TA Therapeutic Alliance
WAI Working Alliance Inventory
RVPU Rimutaka Violence Prevention Unit
CBT Cognitive Behavioural Therapy
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Abstract
The role of the therapeutic alliance (TA) has largely been ignored in the field
of high-risk violent offender treatment. The focus on effective manualised
treatment that reduces recidivism has led to improvements in treatment
programme delivery, but at the cost of examining the therapy process.
Considering previous research has consistently linked levels of alliance with
treatment outcome in clinical and community treatment settings, it is imperative
to investigate the role of the TA within high-risk violent offender treatment,
because of the particularly challenging group that they represent.
The aim of this thesis was to examine the relationship between the TA and
treatment outcome, and the various factors that influence this relationship, within
a violence prevention setting. To achieve this aim, a longitudinal study was
conducted at the Rimutaka Violence Prevention Unit (RVPU) in Wellington,
New Zealand, with a cohort of 70 men in treatment and their therapists,
examining the TA, treatment outcome and associated variables over four time
points throughout the eight month treatment programme. The results of this
research are reported as four related studies.
Study One explored the structure and patterns of the Working Alliance
Inventory (WAI). Study One Part A was a Confirmatory Factor Analysis of the
WAI, which tested the competing models of the factor structure of the WAI and
explored whether rater perspective (client, therapist, observer) had an effect on
the structure. It was found that a two-factor structure was the best fit for the
WAI, and that all rater perspectives shared this structure. Study One Part B
explored the pattern of the WAI over the four time periods of this study in order
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to understand how the WAI changes over time, and whether this pattern differed
by rater perspective. The results confirmed that changes in all rater perspectives
showed a linearly increasing pattern of alliance over time.
Study Two explored the client factors that affect the initial formation of the
TA and examined whether these factors were specific to an “offender” or
“general” client profile informed by previous research. Two client factors
specific to an offender profile — motivation to change and criminal attitudes —
were found to be significantly associated with the initial formation of the TA.
Study Three examined the relationship between the TA and treatment
outcome, and explored whether there were any factors that co-varied with or
moderated this relationship. A small but significant association between alliance
and outcome was found; however no significant co-varying or moderating factors
were discovered.
Lastly, Study Four drew together the data from Study Two and Study Three
and tested whether these results fit the Revised Theory of the Therapeutic
Alliance (RTTA) model (Ross, Polaschek, & Ward, 2008), or other models
previously reported in the literature. Several significant models were found that
partly supported the RTTA. The best of these models incorporated client
motivation to change, TA and treatment outcome as measured by change in risk
of violent reoffending.
Overall, the results of this study support the importance of the TA and client
motivation to change in violent offender treatment. The implications for these
results and the clinical applications are discussed, limitations are outlined, and
directions for future research are suggested.
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Contents
Declaration 2
Publications 3
Acknowledgments 4
Conventions Used in this Thesis 6
Abstract 7
Contents 9
List of Tables 17
List of Figures 20
Chapter One: The Therapeutic Alliance 22
Introduction 22
Process vs. content: The importance of process issues in 23
psychotherapy
The therapeutic alliance concept: Historical roots of the therapeutic 24
alliance
Defining the therapeutic alliance 26
The role of the therapeutic alliance in CBT 27
Chapter Two: Violence and Violence Prevention 31
Violence in New Zealand: Prevalence and proportions 31
Why should we care? The human and economic costs of violence 32
1 0
The global emergence of violence prevention programmes 32
The Rimutaka Violence Prevention Unit (RVPU) 34
Evaluating the RVPU 35
The role of the therapeutic alliance in violence prevention 36
programmes
A neglected area of research 36
Current research 37
Chapter Three: Current Research on Factors That Can Affect the 39
Therapeutic Alliance
Client factors that could affect the therapeutic alliance 39
Therapist factors that could affect the therapeutic alliance 41
Interactional factors that could affect the therapeutic alliance 45
Setting factors that could affect the therapeutic alliance 47
System factors 48
Role conflict and confusion 51
Programme factors 53
Group treatment settings 55
Immediate therapy environment 58
Chapter Four: A Proposed Model of the Therapeutic Alliance in 62
Offender Rehabilitation
Chapter Five: The Relationship Between Therapeutic Alliance and 73
Treatment Outcome
Description:Writing a thesis is like riding a rollercoaster. There are dizzying highs, frightening lows, and at times you feel like your life has been turned upside.
