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THERAPEUTIC ALLIANCE- FIELD STAFF AND CLIENTS
Therapeutic Alliance Between Field Staff and Clients
University of New Hampshire
Stefanie Biron
Therapeutic Alliance Between Field Staff and Clients
Research has shown that there are positive social and psychological gains for adolescents in Outdoor Behavioral Healthcare treatment (OBH). The mechanisms of change have been less explored, but some themes have emerged, including staff/therapist relationship to clients (Russell, 2005; Marchand & Russell, 2013). The therapeutic alliance is considered a significant predictor of positive outcomes in clinical work although there has been less research for clients in out of home care (Horvarth & Simmonds, 1991; Zegers, Schuengel, van IjzendoornJanssens, 2006). With clients in OBH programs spending significant amounts of time with field staff and therapists while in treatment, understanding what factors contribute to positive therapeutic alliances in the field and what role the therapeutic alliance plays in positive outcomes is valuable. The therapeutic alliance is rooted in attachment theory and research has shown that individuals attachment histories may be a moderating factor in the significance of the therapeutic alliance (Zack, Boswell, Adelman, Castonguay, McAleavey, Kraus & Pate, 2015). Maybe work on flow in the introduction
Attachment theory proposes that an individual’s fundamental relationships in childhood help to influence the relationship security over the course of one’s life (Bowlby, 1988). In the context of wilderness therapy, it requires adolescents to build new relationships with various types of people in a novel atmosphere to help secure emotional and physical needs as well as learn how to cope with changing staff and students. For some students with attachment injuries the therapeutic alliance may be more difficult to form but be more significantas a predictor of outcomes (Zacl et.al, 2015). The therapeutic alliance is typically defined as being a working relationship in which goals are mutually agreed upon and including an element of warmth and respect (BholaKapur, 2013). Building these types of relationships can help to deliver more effective clinical treatment. This can help individuals with insecure attachments to form a more functional internal working model of relationships that can be utilized in future relationships (Roisman, Padron, SroufeEgeland, 2002).
Wilderness therapy offers a unique opportunity for clients to develop earned security as relationship patterns are disrupted and developed in the field (BettmannJasperson, 2008). With clients spending the majority of their time with field staff and peers while in treatment, understanding the nature of these relationships and what aids in positive attachment is of benefit to the field and to further understanding what influences positive outcomes.
Attachment Theory
Bowbly’s theory on attachment identifies two primary categories of attachment styles, secure and insecure. Attachment styles form in early childhood and are based on one’s ability to develop trust with a primary caregiver (Bowlby, 1988). These early attachment styles can have a significant impact on life long relationship patterns. Adolescence remains a time where attachment patterns are still developing and creating internal working models (Holmes, 2014). Developing healthy internal working models depends on a number of factors from infancy but a primary thought is that it depends on the primary caregiver providing comfort and acting as a secure base. Even though adolescence is characterized by a search for autonomy and independence it is stillimportant for adolescents to have secure relationships with adult figures in order to aid in more positive acclimatization to adult life (Holmes, 2014).
When placed into the wilderness or treatment context the need for attachment remains present. Forming a connection with field staff, therapists and peers can help in reconstructing the current potentially unhealthy internal working models (Holmes, 2014). A study by Zack et. al, 2015, they found that attachment history was a significant indicator of not only the formation of the therapeutic alliance but with clients outcomes overall. One hundred adolescents participated in this study at a residential treatment center with a primary focus on substance abuse. For clients who had positive attachment histories the therapeutic alliance seemed to have less of an impact on outcomes over time.
For field staff this could potentially influence the way relationships are maintained and repaired overtime, requiring a greater emphasis on this process. The intersection of the many roles field staff have and the shared experience of being in the field together may necessitate opportunities for adolescents with insecure attachment styles to find more opportunities to connect and form the therapeutic alliance.
Social Climate and Staff
Understanding the social nature of groups and the instructor’s role creates a better understanding of the implications of appropriate training and leadership, particularly when working with higher risk clients and examining the role of the therapeutic alliance. In a mixed method study of 74 student’s common themes supported the importance of the instructor’s role in modeling behavior. Participants who averaged a higher level of group cohesion had more positive reflections on their instructor’s role (Mirkin & Middleton, 2014). Participants form perceptions of their instructors by assessing them in a variety of categories such as interpersonal effectiveness, skills ability and care for their students, ultimately informing the client on the instructor’s trust-worthiness (SibthorpJostad, 2014). Building trust helps instructors to create more cohesive groups and stronger relationships between staff and student. An instructor’s ability to maintain both strong connections to individuals in the group and the group as a whole may impact the therapeutic alliance formation.
With group work being a major component of wilderness therapy programs, understanding the effects instructors have within the group context and how this relates to group functioning could benefit the field in understanding how instructor’s relationship to the group impacts their connections with individuals.
Residential Treatment
Staff in residential treatment centers have similar demands as wilderness staff. Characterized by maintaining group and individual safety while incorporating the agencies policies and procedures with treatment goals and with significant amounts of time spent with clients. Research concerning the therapeutic alliance in residential settings may provide a glimpse into possible connections and implications for OBH programs. In a small qualitative study by Tally Moses (2000), a residential treatment center in California was usedto identify common themes around how staff connected with clients and formed meaningful attachments. Many themes were identified around paying more positive attention to clients they liked more, or had an easier time connecting with and also providing these individuals with more focused attention. This individualized time was also accounted for in a study by Harder, KnorthKalverboer (2013), as being an indicator of affective bonds. This study looked at 135 adolescents in a residential facility and the factors associated with positive relationships. Clients in residential settings who had greater social and emotional support were more likely to demonstrate a decrease in negative behaviors (Harder et al., 2013). Greater motivation to change or to cooperate is more likely to get clients positive staff attention and individualized time. Simliar findings were found in a study of a large residential treatment facility byHurley, Van Ryzin, Lambert & Stevens, 2015. They found that youth who identified as having a higher degree of externalizing behavior at intake were less likely to experience positive growth in their alliance.
These studies indicate that there could potentially be a lack of training or resources potentially interfering with staff’sability to build meaningful therapeutic relationships with more difficult individuals. More difficult client’s may also be dealing with more significant attachment histories, further intensifying the need to create more positive internal working models.
Working with staff to emphasize and cultivate qualities and characteristics that help build the therapeutic alliance may also be of benefit to clients and outcomes. A study of a therapeutic residential program for adolescent boys was done by Manso, Rauktis and Boyd (2008), that looked more specifically at the relationship between staff and clients through a mixed methods approach with the primary tactic being focus groups. The findings identified some key qualities that youth found to be important to building positive relationships with staff. The qualities that were highest valued were, caring, helpful, good judgment, trustworthy, genuineness, maturity, responsible and self-awareness (Manso et al., 2008). This has been one of the only studies found that looks specifically at the qualities of staff in relation to the therapeutic alliance in a residential setting. Residential programs may offer some insight into the therapeutic alliance in relation to field staff and what enhances this relationship. Continuing to research information about how the therapeutic alliance impacts client’s experiences in OBH programs will help to reveal what factors are influencing positive outcomes.
Implications
The therapeutic alliance is well-established factor in predicting treatment outcomes across many different treatment methodologies. Continuing to understand how the therapeutic alliance predicts or increases outcomes in OBH programs can provide insight into how influential it may be in programming. Understanding how attachment history may influence the relationships created in the field as well as the way these relationships are utilized could be valuable to treatment planning. For students who have insecure attachment histories, creating, maintain and repairing relationships could be a valuable and focused aspect of programming. Training field staff to better understand the nature of attachment in relation to behavior and the formation of future relationships may prove to help field staff focus more effort on these clients who may be difficult to connect with. More research examining the role the therapeutic alliance plays in OBH programs, could help to better inform training of field staff and program methods.
References
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Bettmann, J., Olson-Morrison, D., &Jasperson, R. (2011). Adolescents in wilderness therapy: A qualitative study of attachment relationships. Journal of Experiential Education, 34(2), 182–200.
Bhola, P., & Kapur, M. (2013). The development and role of the therapeutic alliance in supportive psychotherapy with adolescents. Psychological Studies, 58(3), 207–215.
Bowlby, J. (1988). A Secure Base: Clinical Applications of attachment Theroy. London: Routledge.
Harder, A., Knorth, E., & Kalverboer, M. (2013). A secure base? The adolescent-staff relationship in secure residential youth care. Child and Family Social Work, 18, 305–317.
Harper, N. (2009). The relationship of therapeutic alliance to outcome in wilderness treatment. Journal of Adventure Education & Outdoor Learning, 9(1), 45–59.
Holmes, J. (2014). John Bowlby and Attachment Theory. Routledge. Retrieved from
Manso, A., Rauktis, M. E., & Boyd, S. (2008). Youth expectations about therapeutic alliance in a residential setting. Residential Treatment for Children & Youth, 25(1), 55–72.
Marchand, G., & Russell, K. (2013). Examining the role of expectations and perceived job demand stressors for field instructors in outdoor behavioral healthcare. Residential Treatment for Children & Youth, 30, 55–71.
Marchand, G., Russell, K., & Cross, R. (2009). An empirical examination of outdoor behavioral healthcare field instructor job-related stress and retention. Journal of Experiential Education, 31(3), 359–375.
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Moses, T. (2000). Attachment theory and residential treatment: A study of staff-client relationships. American Journal of Orthopsychiatry, 70(4), 474–490.
Roisman, G., Padron, E., Sroufe, A., & Egeland, B. (2002). Earned-secure attachment status in retrospect and prospect. Child Development, 73(4), 1204–1219.
Russell, K. (2005). Two years later: A qualitative assessment of youth well-being and the role of aftercare in outdoor behavioral healthcare treatment. Child & Youth Care Forum, 34(3), 209–238.
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Sibthorp, J., Paisley, K., & Gookin, J. (2007). Exploring participant development through adventure-based programming: A model from the National Outdoor Leadership School. Leisure Sciences, 29, 1–18.
Zack, S., Boswell, J., Adelman, R., Castonguay, L., McAleavey, A., Kraus, D., & Pate, G. (2015). Attachment history as a moderator of the alliance outcome relationship in adolescents. Psychotherapy, 52(2), 258–267.