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Regular article

Therapeutic alliance and the relationship between motivation and

treatment outcomes in patients with alcohol use disorder

Mark A. Ilgen, (Ph.D.)4, John McKellar, (Ph.D.), Rudolf Moos, (Ph.D.), John W. Finney, (Ph.D.)

Center for Health Care Evaluation, Department of Veterans Affairs Palo Alto Health Care System, Menlo Park, CA 94025, USA

Stanford University School of Medicine, Stanford, CA, USA

Received 12 December 2005; received in revised form 11 April 2006; accepted 17 April 2006

Abstract

Although motivational readiness to change predicts alcohol use disorder (AUD) treatment outcomes, little is known about treatment

aspects that are helpful for patients with low motivation. We examined whether a positive therapeutic alliance is particularly beneficial for

patients entering AUD treatment with low motivation. Among Project MATCH outpatients (n = 753), we tested the influence of motivation,

therapeutic alliance, and their interaction on 6-month and 1-year alcohol use. The impact of motivation on alcohol use varied depending on

therapists perceptions of alliance. Interactions involving treatment compliance did not mediate the Motivation Alliance interaction. Thus,

a positive therapeutic relationship may be particularly important for patients with low motivation, but mechanisms underlying this possible

patienttreatment bmatchQremain to be determined. D 2006 Elsevier Inc. All rights reserved.

Keywords:Motivation; Alcohol use disorder; Therapeutic alliance; Treatment

1. Introduction

Motivational readiness to change is theorized to be an

important determinant of treatment outcome for patients

with alcohol use disorders (AUDs;Miller & Rollnick, 2002;

Prochaska, DiClemente, & Norcross, 1992). High motiva-

tion prior to treatment is a strong predictor of treatment

outcomes and foreshadows a better course for several years

following treatment (Carbonari & DiClemente, 2000;

DiClemente, Carbonari, Zweben, Morrel, & Lee, 2001;

McKay & Weiss, 2001). The consistency of these findingshas led researchers to examine how psychosocial interven-

tions can strengthen motivation in patients with AUDs,

particularly in patients who report low motivation at the

beginning of treatment.

Project MATCH tested whether any of three psychosocial

treatments for AUDs was particularly well suited to treat

patients with low motivation (Project MATCH Research

Group, 1993). Specifically, it was hypothesized that patients

with low motivation who were randomized to Motivational

Enhancement Therapy (MET) would do better than those

randomized to either Cognitive Behavioral Treatment (CBT)

or 12-Step Facilitation (TSF). Further, it was hypothesized

that this advantage would occur because the bmatchQ

between MET and patients with low motivation would

produce a better therapeutic alliance and better adherence to

treatment than would be true for patients with low moti-

vation in either of the other two treatment conditions.

However, there was little or no support for the hypothesis

that states that any of the three treatments used in Project

MATCH was particularly well suited to the challenge of

treating patients with AUD who have low motivation

(Babor & Del Boca, 2003; DiClemente et al., 2001).

0740-5472/06/$ see front matterD 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.jsat.2006.04.001

4 Corresponding author. Center for Health Care Evaluation, Depart-

ment of Veterans Affairs Palo Alto Health Care System, 795 Willow Road

(MPD 152), Menlo Park, CA 94025, USA. Tel.: +1 650 493 5000x27575.

E-mail address: [email protected] (M.A. Ilgen).

Journal of Substance Abuse Treatment 31 (2006) 157162


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Rather than focusing on specific treatments or modalities,

an alternative approach for examining patienttreatment

interactions is to focus on common factors across treatments.

One common aspect of treatment, the quality of the thera-

peutic alliance, predicts treatment outcomes in a number of

different domains (Lebow, Kelly, Knobloch-Fedders, &

Moos, 2006; Meier, Barrowclough, & Donmall, 2005).Within Project MATCH, Connors, Carroll, DiClemente,

Longabaugh, and Donovan (1997) found that stronger

therapeutic alliance predicted better AUD treatment com-

pliance and outcomes. Patients with low motivation are

particularlysensitive to aspects ofthe therapeutic relation-

ship (e.g.,Miller & Rollnick, 2002) and, consequently, may

be especially responsive to a strong, positive therapeutic

alliance. Thus, it is likely that therapeutic alliance may

influence the relationship between patient motivation and

outcome. As far as we know, no prior study has examined the

interaction between motivation and therapeutic alliance as a

predictor of AUD treatment outcomes.We hypothesize that a positive therapeutic alliance can

overcome the consequences of low motivation on drinking

outcomes in patients treated for AUDs. We also examine the

role of treatment compliance (treatment sessions attended)

as a potential mediator of a Motivation Alliance inter-

action following steps described in Finney (1995). In these

analyses, we test whether patients with low motivation who

have a strong therapeutic alliance are more likely to achieve

positive outcomes because they are more compliant with

treatment compared with those who have a weak alliance.

We hypothesize that the expected interaction between

patient motivation and therapeutic alliance in predicting

drinking outcomes may be due to increased treatmentcompliance among bmatched Qpatients with low motivation,

the interaction between compliance and therapeutic alliance

on patient outcomes, or both.

2. Materials and methods

Within Project MATCH, independent samples of out-

patient and aftercare patients were randomly assigned to

CBT (Kadden, Carroll, & Donovan, 1992), MET (Miller,

Zweben, DiClemente, & Rychtarik, 1992) , or T SF

(Nowinski, Baker, & Carroll, 1992). We focus on out-patients because of our interest in the role of motivation at

the beginning of treatment and because previous analyses in

Project MATCH found the strongest predictive relationships

for motivation, treatment type, and therapeutic alliance

within the outpatient sample (Connors et al., 2000;

DiClemente et al., 2001; Project MATCH Research Group,

1997). Patients were assessed at multiple time points before,

during, and following treatment (see below). Informed

consent was obtained from all participants, and the pro-

cedures used were in accordance with the standards of the

Committee on Human Experimentation from the Helsinki

Declaration of 1975 (Project MATCH Research Group,

1993). The Stanford University Human Research Protection

Program provided human subjects approval for this specific

set of secondary analyses of Project MATCH data. Detailed

information on sample, eligibility criteria, assessments, and

treatments has been reported previously (see Babor &

Del Boca, 2003).

2.1. Participants

This study included patients in the outpatient sample who

provided usable data on measures of alcohol consumption at

baseline, 6 months, and 1 year after treatment completion.

Data on therapeutic alliance were available for 785 (82.5%)

participants. Prior research on therapeutic alliance in Project

MATCH indicates that outpatients with complete data on

measures of therapeutic alliance are representative of the

overall outpatient Project MATCH sample, with the

exception that they were more likely to be married than

were those without complete data (Connors et al., 1997).

2.2. Measures

2.2.1. Alcohol stages of change version of the University of

Rhode Island Change Assessment (URICA-A; DiClemente

& Hughes, 1990)

This measure contains four 7-item subscales that were

combined to develop a single scale of motivation to change.

This method for scoring the URICA-A has been described

previously in Kadden, Longabaugh, and Wirtz (2003).

Reliability estimates for the four subscales range from .68

to .85 in the Project MATCH data set (Carbonari &

DiClemente, 2000).

2.2.2. Working Alliance Inventory (WAI; Horvath &

Greenberg, 1986)

The WAI is a 36-item measure of the patients capacity to

engage actively in treatment and the patients experience of

the therapeutic relationship as helpful. Both the therapist

and the patient completed theWAI. The WAI demonstrated

good internal consistency (Connors et al., 1997), and,

consistent with past research with the WAI on this sample,

the total scores for therapists and patients reported after the

second session of therapy were used here.

2.2.3. Drinking behavior

Drinking behavior (percentage of days abstinent [PDA]

and drinks per drinking day [DDD]) was measured via

interview at all time points using the Form 90 (Miller,

1996). The Form 90 asks patients to provide retrospective

data on the quantity and frequency of alcohol consumed

per day in the prior 3 months. Consistent with other pub-

lished reports from Project MATCH, we used transformed

versions of these variables (i.e., arcsin transformation for

PDA and square root transformation for DDD) in all

analyses (for more information, see Project MATCH Re-

search Group, 1997).

M.A. Ilgen et al. / Journal of Substance Abuse Treatment 31 (2006) 157162158


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To decrease family-wise error, we generated factor

scores, combining PDA and DDD for each time point.

The two outcomes converged well, producing a unitary

factor (68% of variance in a single factor for 6-month

outcomes and 70% of variance in a single factor for 1-year

outcomes) on which each variable loaded .83 at both

time points.

2.2.4. Type of treatment and number of sessions

Treatment providers reported information about the

number of treatment sessions attended by each patient.

Treatment type (MET, CBT, and TSF) was coded using

orthogonal contrasts (Kraemer & Blasey, 2004). To measure

treatment compliance, we calculated the ratio of number

of treatment sessions attended over number available

(i.e., the number of sessions actually attended was divided

by 12 for CBT and TSF and was divided by 4 for MET).

2.3. Analysis plan

Two regression analyses were conducted, in which the

predictors were baseline motivation, therapeutic alliance,

and the interaction of motivation and therapeutic alliance

and the outcomes were alcohol use at either 6 months or

1 year. Baseline alcohol use and treatment type were

included as covariates. Separate analyses were conducted

for patients and therapists rating of therapeutic alliance. A

series of regression analyses was conducted to test whether

either of the two interactions involving the ratio of treatment

sessions attended over number of available sessions (as a

measure of treatment compliance) mediated the interaction

between motivation and alliance in relation to alcohol use

treatment outcome. All variables were median centered (see

Kraemer & Blasey, 2004).

3. Results

Results from the primary regression analyses are

presented inTable 1. With patient-rated therapeutic alliance

in the model, a significant main effect was found, showing

that stronger patient motivation at baseline was linked to

less alcohol use at both 6 months and 1 year. Patients who

perceived a stronger alliance had better alcohol outcomes at

6 months but not at 1 year. However, no significant inter-

action effect between motivation and patient-rated alliance

was found at either time point.

In analyses involving therapists ratings of the therapeutic

alliance, higher motivation and more positive perception ofthe alliance by the therapist both independently predicted less

alcohol use at the 6-month and 1-year follow-ups. Addition-

ally, there was a significant interaction between motivation

and therapists ratings of alliance at each follow-up. The

form of these interactions is presented inFigs. 1 and 2, which

show low, medium, and high groups F1SD from the mean

for motivation and therapists reports of therapeutic alliance.

The effects of therapeutic alliance were strongest for patients

Fig. 1. Therapists ratings of alliance are more closely related to less

alcohol use at 6 months in patients with low motivation than in those

with high motivation.

Fig. 2. Therapists ratings of alliance are more closely related to less

alcohol use at 1 year in patients with low motivation than in those with

high motivation.

Table 1

Predictors of alcohol use at 6 months and at 1 year

Predictors

Alcohol use at

6 months (b)

Alcohol use at

1 year (b)

Analyses of patient

ratings of alliancea

Motivation .06344 .07544

Patient rating of alliance .00344 .001

Motivation Patient

rating of alliance

.000 .000

Constant .031 .027

R2 .055 .053

Analyses of therapist

ratings of alliancea

Motivation .06744 .07244

Therapist rating of alliance .00544 .00444

Motivation Therapist

rating of alliance

.0024 .0024

Constant .042 .040

R2 .071 .072

a All analyses included baseline alcohol use and treatment type

as covariates.

4 p = .05.

44 p b .01.

M.A. Ilgen et al. / Journal of Substance Abuse Treatment 31 (2006) 157162 159


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with low motivation. A good therapeutic alliance ameliorated

the negative effects of low baseline motivation in predicting

drinking at the 6-month and 1-year follow-up. In contrast,

variation in the quality of the therapeutic alliance made

relatively little difference in alcohol use outcomes for

individuals with high motivation at treatment entry.

Analyses were conducted to test whether interactionsinvolving treatment compliance (operationalized as number

of sessions attended over the maximum number of available

sessions) might mediate the significant interaction between

motivation and therapists ratings of alliance in relation to

alcohol use outcome. All analyses predicting alcohol use

utilized data from the 1-year follow-up. The first set of

analyses indicated that compliance did not mediate the

outcomes. Specifically, although compliance did predict

1-year alcohol use, the interaction between motivation and

therapists ratings of alliance did not predict compliance,

and the inclusion of compliance in the original model did

not decrease the magnitude of the interaction of motivationand alliance in relation to alcohol use at 1 year. The other set

of regression analyses provided further evidence that show

that another interaction involving compliance did not

mediate the effect of the interaction between motivation

and alliance on alcohol use. Specifically, we found that

motivation did not predict compliance, that the interaction

between alliance and compliance did not predict alcohol

use, and that the addition of the interaction of alliance and

compliance to the original equation did not decrease the

magnitude of the interaction between motivation and

alliance predicting alcohol use.

4. Discussion

Similar to earlier published reports from Project MATCH

(Carbonari & DiClemente, 2000; DiClemente et al., 2001),

motivation at treatment entry predicted a reduction in

alcohol use 6 months and 1 year after AUD treatment.

However, the relationship between low motivation and treat-

ment outcomes depended on the therapists perception of the

therapeutic alliance. Specifically, even after controlling for

baseline alcohol use and treatment type, a high-quality

therapeutic relationship was more strongly associated with

reductions in alcohol use among patients with low moti-vation than among those with high motivation. These

findings suggest that a strong positive therapeutic relation-

ship may be able to overcome much of the negative effect of

low motivation on posttreatment alcohol use. Although it

seems plausible that interactions involving treatment com-

pliance might explain this overall interaction effect, we

found no support for such mediating effects.

Our findings support the growing body of literature

indicating that motivational readiness to changeis important

in influencing treatment outcomes for AUDs (Carbonari &

DiClemente, 2000). As evidence builds for the importance of

motivation as a determinant of treatment outcome, it becomes

increasingly vital to discover aspects of treatment that are

especially beneficial for patients with low motivation. Past

investigations of the role of treatment type may have

underestimated the degree of variability across treatments

in therapists abilities to employ diverse treatment strategies

to engage patients with low motivation in the therapeutic

process (Connors et al., 1997, 2000). Consistent with priorresults from Project MATCH, the present findings indicate

that the quality of the relationship between treatment provider

and patientis important irrespective of the type of treatment

provided (Connors et al., 1997). Providers espousing differ-

ent orientations to treatment must attemptto establish rapport

and a strong therapeutic relationship (Lambert & Barley,

2001; Lebow et al., 2006), and, according to our results, the

quality of the relationship, especially as seen by the therapist,

may be particularly important in patients with low motiva-

tion. However, it is important to note that these findings are

preliminary and more research is needed before concluding

that increased alliance caused the improvements seen inpatients with low motivation.

There are several reasons why patients with low

motivation may be uniquely responsive to the therapeutic

relationship. Such patients tend to be ambivalent about

treatment (Miller & Rollnick, 2002), which may make them

more attuned to contextual influences such as the quality of

the therapeutic relationship (Lebow et al., 2006). Moreover,

responsive therapists are likely to be aware of patients low

motivation and change their behavior to fit these patients

needs. Thus, therapists estimates of alliance may reflect

their general sensitivity to the needs of patients with low

motivation. This conceptualization is consistent with the

finding that therapists perceptions of the relationship, ratherthan patients perceptions, were more closely tied with

improvements in patients with low motivation. Additionally,

such patients may be less attentive to the relationship and,

consequently, provide less accurate ratings of therapeutic

alliance. Others have suggested that ratings of alliance

provided by either therapists or third-party observers may be

more closely related to treatment outcomes in patients with

substance use disorder than patients ratings of alliance

(Fenton, Cecero, Nich, Frankforter, & Carroll, 2001; Shelef,

Diamond, Diamond, & Liddle, 2005).

More research is needed to understand how patients

baseline motivation affects the development of the treatmentalliance and why it is associated with outcomes. A closely

related direction for future research is to examine alternative

causal chains such as whether a positive therapeutic alliance

with patients with low motivation leads to proximal changes

(e.g., increases in approach coping) that foreshadow positive

outcome. In this study, interactions involving treatment

compliance did not mediate the effect of the interaction

between therapists ratings of alliance and motivation on

patients outcome.

Our findings have implications for clinicians and research-

ers. Clearly, because of the association between motivation

and prognosis, therapists need to attend to patients levels of



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motivation. Additionally, the finding that the relationship

between low motivation and poorer alcohol use outcomes is

not uniform highlights the potential positive influence

therapists can have with patients with low motivation.

Although prior literature on motivation and AUDtreatment

has focused primarily on treatment techniques (Miller &

Rollnick, 2002), our findings indicate that the quality of therelationship may be more important than the therapists

treatment orientation or specific techniques.

These implications notwithstanding, this study has

several limitations. The selection criteria for participants

and the close monitoring of treatment providers in Project

MATCH may have raised patients levels of motivation and

enhanced therapeutic alliances, thus decreasing the general-

izability of our findings. Additionally, the lack of consistent

findings between patient and therapist ratings of alliance

raises the possibility that the findings may have been due to

factors other than the quality of the therapeutic relationship.

The fact that motivation was measured at baseline andalliance was measured after two sessions of treatment leaves

open the possibility that, in addition to alliance, therapists

may have been rating patients motivation or performance

in treatment.

Our findings suggest that treatment providers can work

effectively with patients with low motivation when they are

able to establish a strong alliance with their patient. Better

identification of the mechanisms of action underlying the

interaction between motivation and therapeutic alliance may

help to identify ways in which therapists can enhance their

relationships with patients who are initially hesitant to

engage in treatment, thereby improving patients outcomes.

Acknowledgment

Preparation of this article was supported by the Depart-

ment of Veterans Affairs Health Services Research and

Development Service. The views expressed here are the

authors and do not necessarily represent the views of the

Department of Veterans Affairs. Additionally, the authors

acknowledge that the reported results are based on analyses

of the Project MATCH Public Data Set. These data were

collected as part of a multisite clinical trial of alcoholism

treatments supported by a series of grants from the NationalInstitute on Alcohol Abuse and Alcoholism and made

available to the authors by the Project MATCH Research

Group. This article has not been reviewed or endorsed by

the Project MATCH Research Group and does not

necessarily represent the opinions of its members, who are

not responsible for the contents.

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