Replication of relations among working alliance, distress and attendance variables

Introduction

Recent reports from the World Health Organization and the American Psychological Association have highlighted the gap between the growing need for mental health services and available resources. Even with additional funding, however, the high proportion of clients who drop out after only a few sessions presents a significant obstacle to providing effective help.

Methods

Using archival data from the Research Consortium of Counseling and Psychological Services in Higher Education, this study examined relations between client attendance and two constructs of the early therapeutic environment model, working alliance and client distress.

Results

Session count evidenced a floor effect, with the mean of the distribution (4.45) <1 standard deviation (SD; 4.11) from the lowest possible score. In contrast, clients' alliance scores (measured with the Working Alliance Inventory) displayed a ceiling effect, with the mean 1.48 SD units from the highest possible score. Analyses indicated that alliance and distress (measured via the Outcome Questionnaire—45) scores exhibit different nonlinear relations with session count. Working alliance scores exhibited a power function indicating that rapid increases in alliance scores during initial sessions were associated with larger session counts. In contrast, distress scores formed a funnel shape with session count such that moderate initial distress was associated with greater attendance. Clients whose alliance scores evidenced a ceiling effect accounted for most of the observed change on the distress measure.

Conclusion

To enhance attendance, study findings suggest that, as early as possible, therapists should maximise the client–therapist alliance and moderate the level of client distress.