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 don’t 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 Therapeutic Wilderness Trip Within Day Treatment Setting 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 • Wilks’s λ = .99, F(1,59) = 0.78, p = .781, η2 = .001. • Likewise for clinical/demographic sub-groupings • Significant improvements in TA for teacher/counselors • Wilks’s λ = .60, F(1,83) = 56, p < .001, η2 = .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 doesn’t 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 -> 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@pressleyridge.org +36 1 785 4242