The Therapeutic Alliance and Personality Dysfunction in Offending Behaviour Programs

393 Pages·2015·2.47 MB·English

by  Andrew Day

The Therapeutic Alliance and Personality Dysfunction
in Offending Behaviour Programs

By

Christina J. Kozar

BSc (Hons); MPsych (Forensic)

Submitted in fulfilment of the requirements for the degree of

Doctor of Philosophy

Deakin University

December, 2014

4

Acknowledgements

Many thanks to my supervisor, Professor Andrew Day, for his unrelenting support and
advice. Thanks also to my PhD buddies – Elle and Clark, as well as family and friends. Special
thanks also to participants and corrections organisations who participated in this research.

Research Outputs Arising From This Thesis

Publications
Day, A., Kozar, C., & Davey, L. (2013). Treatment approaches and offending behavior
programs: some critical issues. Aggression and Violent Behavior, 18, 630–635.
Kozar, C., & Day, A. (2012). The therapeutic alliance in offending behavior programs: A
necessary and sufficient condition for change? Aggression and Violent Behavior, 17, 482-
487.
Kozar, C. (2010). Treatment readiness and the therapeutic alliance. In Day, A., Casey,
S., Ward, T., Howells, K., & Vess, J. (Eds.), Transitions to Better Lives: Offender Readiness and
Rehabilitation. Cullompton, UK: Willan Press.

Presentations
Kozar, C. (2013). The therapeutic alliance and offending behaviour programs: A
workshop for forensic psychologists. Workshop for the South Australian College of Forensic
Psychologists, Adelaide, South Australia.
Kozar, C., & Day, A. (2013). Treatment integrity and therapeutic alliance. Conference
workshop, Australian Psychological Society’s National Forensic College Conference, Perth.
Kozar, C., & Day, A. (2012). The therapeutic alliance in offending behaviour program
for personality disordered clients: A preliminary model. 32nd ANZAPPL Annual Congress, 25
November 2012, Melbourne, Victoria.
Kozar, C., & Day, A. (2011). The therapeutic alliance and offending behaviour
programs. Paper presented at the APS Forensic Psychology National Conference. 6 Aug
2011, Noosa, Australia.
Kozar, C., & Day, A. (2010). The process of rupture repair in offending behaviour
programs: If I care, will it make a difference? International Congress of Applied Psychology,
July 2010, Melbourne, Australia.
Kozar, C., & Day, A. (2009). Developing the therapeutic alliance in offending behaviour
programs: A qualitative study of its perceived impact on treatment outcomes. APS College of
Forensic Psychologists Conference, Feb 27-March 2, Melbourne, Australia.
Kozar, C., & Day, A. (2007). The working alliance and offending behavior programs.
Paper presented at the 3rd International Congress of Psychology and Law in conjunction with
the 27th Annual Congress of the Australian and New Zealand Association of Psychiatry,
Psychology and Law. 3-8 July 2007, Adelaide, Australia.
5

Contents
Acknowledgements ............................................................................................................... 4
Research Outputs Arising From This Thesis .......................................................................... 4
List of Tables .......................................................................................................................... 9
Thesis Overview ....................................................................................................................... 11
A Note on Terminology ....................................................................................................... 15
CHAPTER ONE – Introduction .................................................................................................. 16
Overview .............................................................................................................................. 16
Australasian Jurisdictions: An Overview .............................................................................. 16
Offender Rehabilitation: Service Delivery Frameworks ...................................................... 17
Personality Disorder as a Key Responsivity Factor .............................................................. 19
Therapist Characteristics ..................................................................................................... 21
Conclusion ........................................................................................................................... 26
CHAPTER TWO – Psychological Treatment ............................................................................. 27
Overview .............................................................................................................................. 27
The Therapeutic Alliance ..................................................................................................... 28
Alliance Formation .......................................................................................................... 31
Rupture Repair ................................................................................................................ 34
Conclusion ........................................................................................................................... 37
CHAPTER THREE – The Therapeutic Alliance and Outcome in Offending Behaviour Programs
................................................................................................................................................. 38
Overview .............................................................................................................................. 38
The Role of the Alliance in Offending Behaviour Programs ................................................ 38
The Therapeutic Alliance and Outcome in Offending Behaviour Programs ....................... 44
Conclusion ........................................................................................................................... 58
CHAPTER FOUR – Personality Disorder and the Therapeutic Alliance .................................... 60
Overview .............................................................................................................................. 60
Categorical and Dimensional Models of Personality Disorder ............................................ 61
The Treatment of Personality Disorder ............................................................................... 62
The Treatment of Psychopathy (and Severe Personality Disorder) ................................ 68
Ruptures to the Therapeutic Alliance in the Treatment of Personality Disorders .............. 72
The Therapeutic Alliance and Outcome for Personality Disordered Clients ....................... 76
6

Conclusion ........................................................................................................................... 81
CHAPTER FIVE – What Correctional Therapists Say about the Therapeutic Alliance .............. 83
Overview .............................................................................................................................. 83
Rationale for Study One ...................................................................................................... 83
Methodology ....................................................................................................................... 84
Positioning Statement ..................................................................................................... 84
Procedure ........................................................................................................................ 85
Participants ...................................................................................................................... 87
Analysis ................................................................................................................................ 88
Importance of the Therapeutic Alliance .............................................................................. 90
Experiences of Developing the Therapeutic Alliance .......................................................... 92
Ruptures ............................................................................................................................ 104
Rupture Repair Responses ................................................................................................ 114
Enforcing Boundaries and Managing the Delivery of Group Content ........................... 115
Engagement Strategies .................................................................................................. 118
Ruptures as Opportunities for Therapeutic Change...................................................... 122
Working within Correctional Environments ...................................................................... 126
Negative Therapist Experiences .................................................................................... 127
Organisational Challenges ............................................................................................. 132
Supervision and Organisational Support ....................................................................... 135
Summary and Conclusion .................................................................................................. 138
CHAPTER SIX – What Clients Say ........................................................................................... 139
Overview ............................................................................................................................ 139
Rationale for Study Two .................................................................................................... 139
Methodology ..................................................................................................................... 140
Procedure ...................................................................................................................... 140
Participants .................................................................................................................... 142
Analysis .............................................................................................................................. 142
Views on the Therapeutic Alliance .................................................................................... 144
Therapist Strategies to Develop the Therapeutic Alliance ................................................ 146
Ruptures ............................................................................................................................ 149
What Rupture Repair Responses Occurred? ..................................................................... 158
Enforcing Boundaries and Managing the Delivery of Group Content ........................... 160
Engagement Strategies .................................................................................................. 162
Ruptures as Opportunities for Therapeutic Change...................................................... 163
Summary and Conclusion .................................................................................................. 164
7

CHAPTER SEVEN - A Model of the Therapeutic Alliance in Offending Behaviour Programs . 166
Overview ............................................................................................................................ 166
Summary and Integration of Qualitative Studies .............................................................. 166
The Educative Mode .......................................................................................................... 169
The Engagement Mode ..................................................................................................... 172
The Therapeutic Mode ...................................................................................................... 176
CHAPTER EIGHT – Alliance Modes and Rupture Repair in Offending Behaviour Programs . 180
Overview ............................................................................................................................ 180
Rationale for Study Three .................................................................................................. 180
Method .............................................................................................................................. 182
The Offending Behaviour Treatment Program .............................................................. 182
Participants .................................................................................................................... 183
Materials ........................................................................................................................ 184
Procedure ...................................................................................................................... 193
Results ............................................................................................................................... 195
To What Extent do Therapists Demonstrate Behaviours Consistent with the Educative,
Engagement and Therapeutic Modes? ......................................................................... 195
What Types of Ruptures to the Alliance Occur in Offending Behaviour Programs? ..... 197
What Modes are Used to Repair Ruptures and How Effectual are They? .................... 199
Discussion .......................................................................................................................... 202
CHAPTER NINE – Contribution and Implications ................................................................... 205
Overview ............................................................................................................................ 205
The Importance of the Therapeutic Alliance to Offending Behaviour Programs .............. 206
Personality Disorder Traits as Significant Rupture Triggers .............................................. 208
Varying Approaches to Developing and Repairing Ruptures in the Therapeutic Alliance 210
Implications for Practice .................................................................................................... 217
Selecting and Supporting Therapists ............................................................................. 217
Therapeutic Skill ............................................................................................................ 219
Co-working Strategies ................................................................................................... 223
Supervision Practices ..................................................................................................... 225
Conclusion ......................................................................................................................... 228
References ............................................................................................................................. 229
Appendix 1 – Summary of Therapeutic Alliance Measures ................................................... 245
Appendix 2 – Study One Human Research Ethics Committee Approval ............................... 247
Appendix 3 – Study One Plain Language Statement and Informed Consent Form ............... 251
Appendix 4 – Study One Semi-structured Interview Schedule ............................................. 254
8

Appendix 5 – Study One Focus Group Memos ...................................................................... 257
Appendix 6 – Study Two Human Research Ethics Committee Approval ............................... 306
Appendix 7 – Study Two Information Sheet for Program Facilitators .................................. 311
Appendix 8 – Study Two Participant Information Sheet ....................................................... 313
Appendix 9 – Study Two Plain Language Statement and Informed Consent Form .............. 315
Appendix 10 – Study Two Semi-structured Interview Schedule ........................................... 320
Appendix 11 – Study Two Interview Memos......................................................................... 323
Appendix 12 – Study Three Alliance Modes in Offending Behaviour Programs: Coding Manual
and Checklists ........................................................................................................................ 339
Appendix 13 – Study Three Group Rupture Rating System (GRRS) ...................................... 353
Appendix 14 – Study Three Human Research Ethics Committee Approval .......................... 369
Appendix 15 – Study Three Therapist and Observer Participant Plain Language Statement
and Consent Form ................................................................................................................. 374
Appendix 16 – Study Three Therapist Demographics Form .................................................. 381
Appendix 17 - Study Three Client Participant Plain Language Statement and Consent Form
............................................................................................................................................... 382
Appendix 18 – Therapeutic Experiences in Offending Behaviour Programs Draft Measure 388
9

List of Tables

Table 1: Research studies on the relationship between the therapeutic alliance, program
retention and treatment outcomes in offending behaviour programs .................................. 44

Table 2: Overview of participant characteristics from Study One .......................................... 87

Table 3: Parent and child nodes created for subject areas discussed in Study One and the
number of focus groups and references made by participants in relation to each of these .. 89

Table 4: Parent and child nodes created for subject areas discussed in Study Two ............. 143

Table 5: Ideal aims, therapist variables, and factors relevant for personality disordered
clients for the educative mode .............................................................................................. 171

Table 6: Ideal aims, therapist variables, and factors relevant for personality disordered
clients for the engagement mode ......................................................................................... 175

Table 7: Ideal aims, therapist variables, and factors relevant for personality disordered
clients for the therapeutic mode........................................................................................... 178

Table 8: Number of sessions, therapists and clients per treatment group included in Study 3
............................................................................................................................................... 184

Table 9: Alliance Modes checklists sub-scales and items ...................................................... 185

Table 10: Table outlining sub-categories of rupture repair strategies contained in the GRRS
............................................................................................................................................... 189

Table 11: Frequency ratings of alliance mode checklist items comparing two independent
raters at pilot stage ............................................................................................................... 192

Table 12: Frequency scores for each alliance mode, the proportion (in parentheses) each
mode was scored across checklists, and the overall alliance coding for each session ......... 196

Table 13: Frequency of confrontation, withdrawal and mixed ruptures and identified
personality factors ................................................................................................................. 198

Table 14: Frequencies, mean initial alliance ratings (standard deviations are in parentheses),
mean final alliance ratings (standard deviations are in parentheses), and change scores for
10

rupture repair strategies in response to confrontation, withdrawal, and mixed ruptures
(N=104) .................................................................................................................................. 201

Table 15: The number of resolved and unresolved ruptures when educative, engagement,
therapeutic, and no strategies were implemented .............................................................. 202

Table 16: Therapist stance towards the therapeutic alliance, what therapist, program and
client (personality disorder trait) factors impact on mode implementation, and costs,
benefits and opportunities associated with each alliance mode .......................................... 214

Table 17: Summary of the major scales developed to measure aspects of the therapeutic
alliance ................................................................................................................................... 245