Dear Jodie

I dont believe that we can measure or predict drop of client after first appointment with measure. Why? If clients are not willed,or able to continue after the first session, it did not fit. When it does not fit we cannot be sure that the relationship between therapist and client leads him to tell you the truth. Muran et al., (1994), were the first to raise the question whether patient-rated measures of the working alliance are rating compliance but not the working alliance (collaboration), because they could demonstrate that friendly submissive patients reported constantly a good early alliance.

I believe it ist a challenge to the competence of the therapist to realize, and to detect alliance ruptures.

Muran, J. C., Segal, Z. V., Samstag, L. W., & Crawford, C. E. (1994). Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy. J Consult Clin Psychol, 62(1), 185-190.

Greetings

Egon

Hi Jodie,

Leaving the therapeutic alliance aside, there are sometimes genuine barriers to client attending appointments, such as transportation, child care, working hours, are they mandated or voluntary etc., as well as the individual's stage of change. Our outpatient clinic conducts a survey at the first appointment about potential barriers, and they are then addressed during the first counseling session.

Minority populations, particularly African-Americans have highest rates of dropping out of counseling at very early stages.

I wonder how best to control for all these variables, to allow us to focus on the therapeutic alliance only?

Very good question Violeta.  The gap between research and the realities/complexities in practice can be quite challenging in capturing such potentially elusive constructs as Therapeutic alliance.  I am currently analysing a sample of 200 people on their rating of therapeutic alliance and how this relates to satisfaction ratings, dropout risk whilst trying to tease apart what it is about the first five appointments that provides practitioners who are aligned to therapeutic alliance principles a reduction in dropout rates within the first appointments.  The research was backed up with qualitative for greater context.  Early days of Analysis...will post on here some outcomes later this year.  

Kind regards

Flückiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A. O. (2012). How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology, 59(1), 10-17. doi: 10.1037/a0025749

Oh, oh, I see now!  I am familiar with the work of Wampold and also Luborsky on the therapeutic alliance.  I thought you are referring to the actual practicalities of the issue.  Very interesting research with a great deal of potential and perspectives.  Are you using any instruments, Jodie?

There was a really good review by elvins and green on the psychometric robustness of around 52 measures. Based on this review i selected working alliance inventory short form. I also asked participants to rate how important that each item occurred with their healthcare provider. I.e doctor, psychologist, counsellor. Etc The first rating was subtracted by the second rating to give a measure that we termed violation to expectation. It was really interesting to differentiate groups based on high risk of dropout versus low. There is a significant drop in violation after appointment five. There appears to be two items most violated overall. Cleaning up the data further before confirming that though. Very interesting stuff. But the research showed that mental healthcare providers are doing really good work.

That sounds really good!  I'd be interested to see the results!