The Parent-Group Worker Therapeutic Alliance in Residential Youth Care: The Internal Structure of a Dutch Questionnaire and the Effects of Professional’s and Work Characteristics
Masterscriptie Forensische Orthopedagogiek Graduate School of Child Development and Education Universiteit van Amsterdam R.R.G. Nieuwenweg 11029722 Begeleiding: Mw. dr. A. L. van den Akker & Dhr. dr. P. J. Hoffenaar Amsterdam, (april 2017)
Abstract
The therapeutic alliance has shown to predict treatment outcomes for adults as well as children. Therefore it is important to have valid and reliable scales available to measure the therapeutic alliance during the therapy process and to know more about the factors that influence the therapeutic alliance in order to improve this relationship. This study first
examined the internal structure of the Dutch Therapeutic Alliance Scale for Parents (DTASP) and the Dutch Therapeutic Alliance Scale for Group Workers (DTASG). Second, this study examined to what extent the therapeutic alliance can be explained by the group workers’ characteristics and their work climate. The data consisted of N = 186 parents and N = 293 group workers who are involved in the treatment of youth taking residence in treatment settings for psychosocial and behaviour problems. Parents were asked to fill out the DTASP, group workers were asked to fill out the DTASG and questions about gender, age, work years, work commitment, positive team functioning, shared vision, work pressure and work
surroundings. Results show that the DTASP measures one component, the overall therapeutic alliance. Reliability is proven high. The DTASG measures the overall therapeutic alliance and the negative personal alliance. Reliability is proven good and moderate respectively. Results show that shared vision and work pressure are positively associated with the overall alliance between parents and group workers as perceived by group workers. Suggestions for further improvement of both questionnaires are made as well as recommendations for further research on parent-group worker therapeutic alliance predictors.
For youth with severe psychiatric or behavioural problems, residential youth care is perceived as a last chance for improvement after other methods have not been able to
contribute to a positive and safe development (Knorth, Harder, Zandberg, & Kendrick, 2007). The efficacy of all treatment methods, including residential care can be ascribed to multiple factors. A distinction can be made between non-specific factors and specific factors (Lambert, 1992). Non-specific factors are common to all therapeutic treatments, whereas specific factors are unique to a specific treatment.
Studies have shown that non-specific factors are more strongly correlated with treatment outcomes than specific factors (Van Yperen, Van der Steege, Addink, &
Boendermaker, 2010; Lambert & Barley, 2001). This phenomenon is known as the Dodo bird effect. Meta-analyses have shown that despite the differences in specific therapeutic factors, no true differences in effect-sizes among different therapeutic treatments exist (Luborsky, Rosenthal, Diguer, Andrusyna, Berman, Levitt, Seligman, & Krause, 2002; Wampold, Mondin, Moody, Stich, Benson, & Ahn, 1997) Therefore: “Everybody has won, and all must have prizes” (Carroll, 1962).
In this study the focus will be on the therapeutic relationship. The therapeutic
relationship is a non-specific factor that is common to all therapeutic interventions. Research on the effectiveness of therapeutic interventions has shown that the therapeutic relationship between therapist and client plays a central role in determining treatment outcome (Accurso, Hawley, & Garland, 2013; Brent & Kolko, 1998; Wampold, Mondin, Moody, Stich, Benson, & Ahn, 1997). The therapeutic relationship, or therapeutic alliance can be divided in two parts. It consists of a personal relationship and a collaborative relationship between therapist and client (Hougaard, 1994). The personal relationship, the affective bond, is based on empathy and trust. The collaborative relationship is based on agreement on tasks and goals (Bordin, 1997).
Research on the therapeutic alliance has shown that it predicts treatment outcomes for adults as well as children (Martin, Garske, & Davis, 2000; Karver, Handelsman, Fields, & Bickman, 2006). Compared to the therapeutic alliance in adult psychotherapy, the therapeutic alliance for children is far more complex (Accurso & Garland, 2015). In child psychotherapy, not only the child, but also their caregivers are involved in the therapy process. Caregivers are for instance the ones who decide that their children are in need of help and seek services that can offer this (Hawley & Garland, 2008). This results in a triangular therapeutic relationship, with each alliance and each individual contributing to different aspects of the therapy process (Accurso, Hawley, & Garland, 2013). However, so far, it is the therapeutic alliance between
child and therapist that has received most attention, even though the parent-therapist alliance might be of great importance in determining children’s treatment outcomes as well.
Recently, studies have started to focus on the parent-therapist alliance in clinical care. Diamond, Diamond, and Liddl (2000) described how the parent-therapist relationship might influence treatment outcomes. They hypothesize that the parent-therapist relationship contributes to the therapy process and its outcomes in two ways. First, a strong parent-therapist relationship might increase the involvement of the whole family in the therapy process. Second, the therapist-parent relationship is crucial in reattaching parents and their children, because the therapist offers parents the support and understanding they need to be responsive to their children’s feelings. Hawley and Garland (2008) found that even though the child-therapist relationship is more strongly related to treatment outcomes of outpatient therapy than the parent-therapist relationship, the parent-therapist relationship itself correlates with decreases in children’s externalizing behaviour problems as well. These results show the importance of the therapeutic relationship with parents.
Because the parent-therapist alliance is proven to contribute to children’s treatment outcomes, it is important to have valid and reliable scales available to measure the therapeutic alliance during the therapy process. In the Netherlands, to date there appears to be only one instrument available to measure the alliance between parents and the therapeutic team surrounding a child. This inventory is based on The Working Alliance Inventory-Short version, which is an inventory used in mental adult health settings across different countries (Lamers, Delsing, Van Widenfelt, & Vermeiren, 2015). This inventory was translated into Dutch and later adapted to be used in the Dutch youth residential psychiatry. This resulted in the WAV-12R: a twelve question inventory with a team version and a parent version with slight differences in their formulations. Research on the psychometric properties of the WAV-12R showed strong reliability for both versions. Internal consistency was proven good with Cronbach’s alphas ranging between .78 and .97. Concurrent validity was established for both versions as well. Subscale scores of the parent version were correlated with parents’ total scores on the Empathy and Understanding Questionnaire, resulting in Pearson’s correlations ranging between .50 and .78. Subscale scores of the team version were correlated with the Parental Alliance scale of the Family Engagement Questionnaire and resulted in Pearson’s correlation ranging between .48 and .57 (Lamers, Delsing, Van Widenfelt, & Vermeiren, 2015).
Because WAV-12R was developed for youth in residential psychiatry, the results described above could not be generalized to other populations. The researchers suggested that
this study should be replicated with different patient groups in other residential settings. However, professionals working in the residential care for youth with psychosocial and/or behavioral problems, in their opinion, did not reckon the formulation of questions of the WAV-12R suitable for their target group. They found that, on average, the level of education of parents of youth with psychosocial and/or behavioral problems in residential settings did not correspond with the level of language used in the WAV-12R: question formulations were judged to be too complicated.
Because the WAV-12R could not be used in residential youth care settings for
psychosocial and/or behavioral problems, a new inventory was created in order to measure the caregiver-therapist alliance of this specific target group. This new alliance scale was based on The Therapeutic Alliance Scale for Caregivers and Parents (TASCP). The TASCP consists of twelve short questions that cover the affective bond (“I like my child’s therapist”) as well as the collaborative bond (“I work with my child’s therapist to work on our problems”) between caregiver and therapist. Two parallel scales are available, one for the parent-therapist alliance and one for the therapist-parent alliance (Accurso, Hawley, & Garland, 2013). Research on the psychometric properties of the TASCP showed high reliability for both versions. Internal consistency was proven good with Cronbach’s alphas ranging between .85 and .88. Temporal consistency was measured using autoregressive regression models. The model of fit indicated moderate temporal consistency for both versions (X2 = .24, p = .62, and X2 = .21, p = .65 respectively). Convergent and divergent validity were measured using intraclass correlations (ICC) between the parent and the therapist version and between each version and the child alliance as reported by both the child and the therapist. The TASCP showed convergent and divergent validity with significant ICC’s ranging from .40 to .67 (Accurso & Hawley, 2013). Questions of the TASCP were translated and adapted for Dutch use in residential settings for youth with psychosocial and/or behavioural problems, resulting in the Dutch Therapeutic Alliance Scale for Parents and the Dutch Therapeutic Alliance Scale for Group workers. This study will examine the internal structure and reliability of both newly developed Dutch inventories.
Effects of Professionals’ and Work Characteristics on Overall Therapeutic Alliance In addition to having valid and reliable scales to measure the therapeutic alliance, it is also important to know more about the factors that influence the therapeutic alliance in order to improve this relationship. Hougaard (1994) reported that the therapeutic alliance is
influenced by therapist characteristics. Several personal characteristics, and competences of the professional have been identified as meaningful in determining treatment outcomes in
residential youth care. For example personal childhood attachment, resilience, flexibility and communication competences (Barnhoorn et al., 2013; Schuengel & Van IJzendoorn, 2001). However, studies have either looked at the direct relationship between therapists’
characteristics and treatment outcomes, or they used the therapeutic alliance between client and therapist as a mediating variable. The relationship between group workers’ characteristics and the parent-group worker therapeutic alliance has yet to be identified. This study will make a start in doing so. It will further explore the relationship between group workers’ personal characteristics and the parent-group worker alliance. Positive relationships between personal characteristics and the parent-group worker alliance are expected, except for work pressure which is expected to be negatively related to the parent-group worker alliance.
Because professionals in residential youth care do not act alone but in a broader team of group workers, one could argue that team functioning might influence the therapeutic alliance as well. Positive team functioning has shown to enhance group workers’ work
performance (Knort, Harder, Huyghen, Kalverboer, & Zandberg, 2010), which might result in more positive therapeutic alliances. Research on this subject has yet to be conducted and will be included in this study. The same goes for characteristics at an even broader level: the work climate. Van der Ploeg (1984) showed that a negative work climate results in group workers being less successful in contributing to a positive child development (Knort, Harder,
Huyghen, Kalverboer, & Zandberg, 2010). It can be hypothesized that the parent-group worker alliance plays a mediating role between work climate and treatment outcomes in residential youth care. Therefore, a positive relationship between work climate and parent-group worker alliance would be expected.
The effects of these factors may be of special interest to child welfare services since these factors can be taken into account when recruiting a competent workforce (DePanfilis & Zlotnik, 2008).
In sum, first this study will focus on the development of a suitable therapeutic alliance scale for Dutch use. It will be examined what components underlie the Dutch Therapeutic Alliance Scale for Parents (DTASP) and the Dutch Therapeutic Alliance Scale for Group Workers (DTASG). Based on the distinction made by Hougaard (1994) it is expected that both questionnaires will consist of two components: the personal and collaborative
relationship. Second, this study aims to examine to what extent the therapeutic alliance can be explained by the group workers’ characteristics and their work climate. It is hypothesized that all characteristics show a positive relationship with the parent-group worker alliance, except
work pressure which is expected to show a negative relationship with the parent-group worker alliance.
Method Sample
Two organizations offering residential care to youth with psychosocial and/or behavioural problems took part in this study: Juzt and Maashorst. Both organizations are mainly active in the Dutch county Noord-Brabant.
The data consisted of N = 186 parents and N = 293 group workers who are involved in the treatment of youth taking residence in treatment settings for psychosocial and behaviour problems. In April n = 84 parents and n = 132 group workers took part. In November n = 72 parents and n = 129 group workers took part. In August n = 68 parents and n = 95 group workers took part. Data from all three periods was combined. In case of a client taking residence over the period of two or three measurements, only the answers his/her parents and primary group worker gave on the first measurement were used, resulting in n = 84 parents and n = 132 group workers in April, n = 52 parents and n = 96 group workers in November and n = 50 parents and n = 65 group workers in August. There were n = 87 parents and group workers who reported on the same alliance in the same time period. There was no background information available of the parents that participated in this research. Of the group workers 72% was female. Ages ranged from 21 to 60 (M = 34.81, SD = 8.67).
Procedures
Parents and group workers were invited to participate in this research through mail. Along with the questionnaires, parents and group workers received an additional letter, explaining that answers were to be used to conduct research.
Parents and group workers were asked to fill out the therapeutic alliance scale and a few additional questions. Data was collected in three different time periods. First in April 2014, second in November 2014 and third in August 2015.
Measures
Therapeutic alliance. The Dutch Therapeutic Alliance Scale for Parents and Group Workers (DTASP and DTASG) that are subject of this research were based on the American Therapeutic Alliance Scales for Caregivers and Parents (TASCP). The TASCP itself is a parallel version of the Therapeutic Alliance Scale for Children –Revised (TASC-R), which distinguished between the affective and collaborative bond. In order to create the Therapeutic Alliance Scale for Caregivers and Parents, Accurso, Hawley and Garland (2013) copied the TASC-R and changed “my therapist” to “my child’s therapist”. Research
conducted on the psychometric properties of the TASCP showed high reliability. Internal consistency of the TASCP was measured across four time points and showed high reliability with Cronbach’s alphas ranging between .85 and .88. Temporal consistency was proven moderate and the TASCP showed convergent and divergent validity (Accurso, Hawley, & Garland, 2013).
The newly developed inventories for Dutch use were based on the TASCP.
Formulation of questions were altered, because the TASCP focuses on one-on-one therapeutic relations, whereas, in residential settings, there is a team of group workers involved. After these initial changes, the DTASP and DTASG were presented to a group of eight
professionals, who were asked their opinion on how the questionnaires could be improved. By consulting these professionals, the ecological validity of both questionnaires was enhanced (Araújo, Davids, & Passos, 2007). They commented that in their opinion the questionnaires did not pay enough attention to the parents their situation. Therefore questions about
respecting the role of the parents, and the engagement and understanding of group workers towards the parents’ situation were added. For example: “The primary group worker of my child shows involvement in my/our situation”. After a first trial and analysis of both questionnaires, the DTSCP was brought back to eight questions (For example: “I can work well together with my child’s primary group worker on dealing with problems”), while the DTSCG remained the same, with thirteen questions (For example: “I find it important to talk to the parents of my pupil”). Questions could be answered on a 5-point Likert-type scale ranging from 1 (not true) to 5 (very much true).
Group worker’s characteristics and work climate. In the present study the personal characteristics, team characteristics and work environment were topics of interest. Group workers’ personal characteristics included information about gender, age, work years for the current organization and commitment. Commitment was measured using the commitment scale of the Living Group Work Climate Inventory (LGWCI; Dekker, Van Miert, Van der Helm, & Stams, 2015). This scale consists of seven questions that could be answered on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree) and has a Cronbach’s alpha of .78. Team characteristics consisted of group worker’s personal scorings of positive team functioning and shared vision. Positive team functioning was measured using the eight positive team functioning items of the team functioning scale of the LGWCI, with a Cronbach’s alpha of .88. Work climate consisted of group workers’ scores on work pressure and work surroundings, which were measured using the work pressure and work surroundings scales of the LGWCI. These scales consists of respectively eight and seven questions, which
again could be answered on a 5-point Likert-type scale. Cronbach’s alphas are .71 and .60 respectively.
Data analyses
First a principal component analysis was conducted in order to identify which
components underlie the questionnaires about therapeutic alliance. Varimax rotation was used in order to maximize convergent and divergent validity for each variable (Bijleveld &
Commandeur, 2012) resulting in a better distinction between components. Internal consistency for each component was examined using Cronbach’s alphas. Based on the convergent and divergent validity and reliability, decisions were made on improving both questionnaires. Second, stepwise multiple regression analyses were conducted of the
components that were outcome of the PCA. Group workers’ personal characteristics (gender, age, work years and commitment), team characteristics (positive team functioning and shared vision) and work characteristics (work pressure and work surroundings) were entered as sets of independent variables using the standard method. Therefore assumptions for multiple regression analysis were checked first. Assumptions for independency, homoscedasticity and normality of the residuals were checked using the Durbin-Watson test, the plot with the standardized residuals against the standardized predicted value and the probability plot respectively. Assumptions are met with a Durbin-Watson value close to 2, an evenly spread scatterplot and the residuals in the probability plot following the diagonal (Bijleveld & Commandeur, 2012). Because the aim of this study is to find the contribution of each individual variable to the therapeutic alliance instead of finding the most suitable model, the enter method was used. This method includes all variables in the final model, regardless of their significance.
Results Dutch Therapeutic Alliance Scale for Parents
The explorative principal component analysis (PCA) of the Dutch Therapeutic Alliance Scale for Parents resulted in a one component solution. First, the scree-plot (Figure 1) clearly showed one component above the scree. Second, results showed one component with an Eigenvalue >1 (5.72) , which explained 71.47% of the total variance.
Convergent validity of each item was determined based on the component loadings in the component matrix. The results are shown in table 1. Convergent validity was proven high for all items, with component loadings above .40, ranging from .77 to .89. Since only one component could be extracted, divergent validity was automatically established.
Because only one component could be extracted this component measures the overall therapeutic alliance between parent and group worker.
Reliability was measured using Cronbach’s Alpha. The DTASP shows high reliability with a Cronbach’s Alpha of .94. Table 1 shows that deletion of any of the items would not result in an increase of the level of reliability.
Dutch Therapeutic Alliance Scale for Group Workers
The explorative PCA of the Dutch Therapeutic Alliance Scale for Group Workers initially resulted in a two component solution. The scree-plot (Figure 2) showed two or three components above the scree. Only two components had an Eigenvalue > 1 (6.39 and 1.17) and respectively explained 49.15% and 9.02% of the total explained variance, which was 58.17%.
The results of the PCA were rotated using Varimax with Kaiser normalization in order to determine the convergent and divergent validity. Divergent validity is reached when an item unambiguously fits one component (loading > .40 for one component and at least .20 higher or lower for other components). This method increases high component loadings and lowers low component loadings to the maximum extent possible, resulting in high divergent validity and clear definitions of each component (Bijleveld & Commandeur, 2012).
Component loadings are shown in Table 2. The results show moderate convergent validity for items 2, 3 and 13, with factor loadings ranging between .40 - .60, and high
convergent validity for all other items, with factor loadings above .60. The results showed that divergent validity was not reached for items 2, 3, 4, 8, 9 and 13, because the discrepancy between the component loadings of these items was below .2. Item 3 “The parents and I work on goals we both agree on” had the smallest discrepancy and was therefore excluded from the scale before PCA was run again. This process was repeated until divergent validity was reached for all items. As can be seen in Table 3, this was the case after items 3, 4 and 13 were removed from the scale. The final PCA resulted in a two component solution. The scree-plot (Figure 3) showed two components above the scree, which had an Eigenvalue of 4.81 and 1.14. These components respectively explained 48.01% and 11.41% of the total explained variance, which was 59.49%. With respect to the content of these components there seems to be one component that measures the overall therapeutic alliance and one component that measures the negative personal alliance.
Reliability for each component was measured using Cronbach’s Alpha. The overall therapeutic alliance scale showed good reliability with a Cronbach’s Alpha of .88. The negative personal alliance scale showed moderate reliability with a Cronbach’s Alpha of .65.
As shown in Table 3, deletion of any one of the items from the overall therapeutic alliance scale would not result in an increase of the reliability coefficient. Because the negative personal alliance scale consists of only two questions and shows moderate reliability, this scale was excluded from further analyses.
Since both the DTASP and DTASG were meant to measure the same construct, it could be expected that the scores on the DTASP and the scores on the positive personal relationship scale of the DTASG would show a strong positive relationship. The correlation between both scores was measured using Pearson’s r and showed a significant positive relationship (r = .28, N = 85, p = 0.005). The strength of this correlation is considered moderate (Brace, Kemp, & Snelgar, 2012).
The association between group workers’ characteristics, work climate and the therapeutic alliance
Assumption tests showed that with parents’ overall therapeutic alliance scores as a dependent variable, the regression model did not meet the assumptions of independent residuals (Durbin-Watson = .711), homoscedasticity (the plot with the standardized residuals against the standardized predicted value showed abnormalities) and normality (the P-P plot did not follow the diagonal). Therefore this study will only focus on the effects of said predictors on the overall therapeutic alliance scores as perceived by the group workers.
The regression model with group workers’ overall therapeutic alliance scores as dependent variable met the assumptions of independent residuals (Durbin-Watson = 2.02), homoscedasticity (the plot with the standardized residuals against the standardized predicted value did not show abnormalities) and normality (the P-P plot showed all points near the diagonal). A stepwise regression analysis with three steps was conducted for group workers’ overall therapeutic alliance scores. Group workers’ personal characteristics, team
characteristics and work environment characteristics were added sequentially using the standard method.
Regression analysis showed that step 1, with personal characteristics (gender, age, work years and commitment) as the only predictors explained 3.1% of the variance in group worker’s overall therapeutic alliance scores (Adjusted R2 = .031). This model was significant (F(4,288) = 3.325, p = .011). Commitment showed have a significant positive association with the group workers’ overall therapeutic alliance scores at a significance level of p = .05. Gender, age and work years did not. Table 4 gives information about the models and
Step 2, in which team characteristics (positive team functioning and shared vision) were added, did not significantly explain more variance in group workers’ overall therapeutic alliance scores than group workers’ personal characteristics did in model 1 (R2 change = .011, F change(2,286) = 1.740, p = .177). In this model, there were no significant predictors at a significance level of p = .05.
Step 3, in which work characteristics (work pressure and work surroundings) were added, did not significantly explain more variance in group workers’ overall therapeutic alliance scores than group workers’ personal characteristics and team characteristics did in model 2 (R2 change = .019, F change(2,284) = 2.828, p = .060). In this model commitment was no longer a significant predictor. Shared vision and work pressure were significant predictors of the variance in group workers’ overall therapeutic alliance scores at a
significance level of p = .05. Gender, age, work years, commitment, team functioning and work surroundings did not have a significant effect on the variance in group workers’ overall therapeutic alliance scores.
Discussion
This study first aimed to examine the components that underlie the DTASP and the DTASG. The DTASP consists of one component which measures the overall therapeutic alliance between parent and group worker. The DTASG consists of two components, which measure the overall therapeutic alliance and the negative personal alliance between group worker and parent. There is a moderate, positive relationship between parents’ overall
therapeutic alliance scores and group workers’ overall alliance scores. The second aim of this study was to elaborate on the knowledge of variables that could predict the parent-group worker therapeutic alliance. Results of this study show that shared vision and work pressure are positively associated with the overall therapeutic alliance between parents and group workers as perceived by group workers.
Based on the distinction made by Hougaard (1994) it was expected that both
questionnaires would consist of two scales that would measure the personal relationship and the collaborative relationship between parent and group worker. Results show that the eight questions of the Dutch Therapeutic Alliance Scale for Parents (DTASP), form one
component; it measures the parent-group worker alliance as a whole. Reliability of this scale is proven high. Even though the content of this scale does contain questions that address both the personal as well as the collaborative bond, these constructs could not be distinguished with the principal component analysis. This raises questions about Hougaard’s
to the therapist relationship. However, the WAV-12R, which also measures the parent-therapist relationship, did find this distinction. The parent version of the WAV-12R
distinguishes between insight, bond and work alliance (Lamers, Delsing, Van Widenfelt, & Vermeiren, 2015), suggesting that a distinction between the personal and collaborative relationship of the parent-therapists alliance exist.
The reason to develop the DTASP was that the WAV-12R could only be used in residential settings for youth with psychiatric problems, and there was a need for a similar questionnaire that could be used in residential settings for youth with psychosocial and/or behavioral problems. The difference between both clinical settings might hold an explanation for the fact that the WAV-12R is able to distinguish between the personal and the
collaborative relationship, and the DTASP is not. In both residential settings a
multidisciplinary team is involved. The WAV-12R is based on the relationship between parents and the psychiatrist or psychologist who is connected to the youth as a case manager (Lamers, Delsing, Van Widenfelt, & Vermeiren, 2015). The DTASP is based on the
relationship between parents and the primary group worker of their child. In the residential settings that took part in the current study, the therapist responsible for the treatment
procedure is more on a side line and parents have most contact with the primary group worker of their child. Perhaps there is a difference in the amount of contact that parents have with the case manager of their child in the psychiatric setting and the primary group worker in the psychosocial and/or behavioral setting. This might result in closer relationships between parents and primary group workers than between parents and case managers. It might be possible that the relationships that parents and group workers build are too intense for parents to distinguish between the personal and collaborative relationship. It is likely for parents to work well together with a group worker they feel a personal connection with and vice versa.
It might also be possible that the questions themselves make it difficult to distinguish between the personal and the collaborative relationship. Adding a few additional questions and/or changing their current formulations might result in a clearer distinction between questions about the personal relationship and questions about the collaborative relationship. For instance, question 1: “I have the feeling that the group worker is on our side and helps” contains elements of both constructs. It addresses the personal relationship by asking about the engagement of the group worker and the collaborative relationship by asking whether the group worker helps the parent. Separating both questions would make it more likely to find two underlying constructs that fit Hougaard’s conceptualization of the therapeutic alliance.
Results show that the 10 questions of the Dutch Therapeutic Alliance Scale for Group Workers (DTASG), distinguishes between the overall therapeutic alliance and the negative personal alliance. Reliability coefficients show good and moderate reliability respectively. The DTASG seems to be slightly better in distinguishing between the personal and
collaborative relationship. It would seem likely that group workers, from a professional point of view, can better distinguish between the personal and collaborative relationship than parents, because they learn to not let their personal relationship with parents influence their collaborative relationship. However, not a clear distinction between the collaborative relationship and personal relationship was found. Again, this does not correspond with the results of the study to the WAV-12R, which showed that the team version was able to distinguish between the bond, tasks and goals.
Like the DTASP, improvements on the DTASG could be made to make it easier for group workers to distinguish between the collaborative and personal relationship. Questions about the collaborative relationship should be added, since this aspect is insufficiently
addressed at the moment. Finally, questions of the DTASP and DTASG should correspond on a higher level, to make them more comparable.
Variance in Group workers’ Overall Therapeutic Alliance Scores Explained The second part of this study focused on characteristics that might influence the parent-group worker relationship. Group workers’ personal characteristics (gender, age, work years and commitment) team characteristics (positive team functioning and shared vision) and work environment (work pressure and work surroundings) were subject of this study. It was hypothesized that all, but work pressure would have a positive effect on the therapeutic alliance. Regression analysis was conducted with group workers’ positive personal alliance as the dependent variable, and shows small, positive effects for shared vision and work pressure.
The positive association between shared vision and group workers’ overall therapeutic alliance scores means that when group workers experience commonality in their work vision, they experience better overall therapeutic alliances with parents than group workers who do not feel they have a shared vision. Shared vision possibly makes it easier for team members to work together. Positive team functioning has shown to enhance group workers’ work
performance (Knort, Harder, Huyghen, Kalverboer, & Zandberg, 2010). This might explain the positive effect of shared vision on group workers’ overall therapeutic alliance scores.
The positive association between work pressure and group workers’ overall therapeutic alliance scores is remarkable. This means that group workers who experience more work pressure, experience better overall therapeutic alliances with parents. A possible
explanation might lie in the relationship between commitment and work pressure. It might be that group workers who experience high work pressure are more committed to their job than group workers who experience low work pressure. This study showed that, when only taking into account group worker’s personal characteristics, commitment had a small but significant effect on group workers’ overall therapeutic alliance scores. This association disappeared when team- and work characteristics were added. This reduction demonstrates that
commitment shares explained variance with at least one of the other predictors, possibly work pressure.
Even though the effects of shared vision and work pressure are small, this knowledge can be used to improve parent-group worker alliances and furthermore, the treatment
outcomes of youth with psychosocial and/or behavioural problems in residential care. Group workers who are aware of their shared vision and work pressure can actively work on
maximizing these characteristics in order to establish optimal parent-group worker alliances. This study was limited by the fact that regression analysis could not be conducted for parents’ alliance scores, because assumptions of independent residuals, homoscedasticity and normality were not met. Also, effects of parent characteristics on group workers’ positive personal relationship scores could not be researched because there was no background information available for the parents. As research has shown that besides therapist
characteristics, client characteristics are also of importance in determining the therapeutic alliance (Hougaard, 1994), it would be interesting to see whether parent characteristics would influence the parent-group worker alliance as well. Finally, results of this study are
exclusively applicable to similar residential youth care centres for youth with psychosocial and behavioural problems. Results cannot be generalized to settings that differ in target group and the way they carry out the therapeutic process.
Further improvement and research on the DTASP and DTASG is recommended in order to have both questionnaires measure the personal and collaborative relationship. This is necessary in order to provide useful information about the therapeutic alliance. Also, further research with larger sample sizes is recommended to elaborate on the knowledge of parent-group worker alliance predictors. It would be interesting to see whether shared vision and work motivation could mediate the relationship between parent-group worker/therapist alliance and treatment outcomes.
In sum, this study has shown that the Dutch Therapeutic Alliance Scale for Parents measures the overall therapeutic alliance between parent and group worker and that the Dutch Therapeutic Alliance Scale for Group workers measures the overall therapeutic alliance and
the negative personal alliance between group worker and parent. It also found indications that commitment, shared vision and work pressure have a small effect on group worker’s overall therapeutic alliance scores.
References
Accurso, E. C., & Garland, A. F. (2015). Child, caregiver, and therapist perspectives on therapeutic alliance in usual care child psychotherapy. Psychological Assessment, 27, 347-352.
Accurso, E. C., Hawley, K. M., & Garland, A. F. (2013). Psychometric properties of the therapeutic alliance scale for caregivers and parents. Psychological Assessment, 25, 244-252.
Araújo, D., Davids, K., & Passos, P. (2007). Ecological validity, representative design, and correspondence between experimental task constraints and behavioural setting: Comments on Rogers, Kadar, and Costall (2005). Ecological Psychology, 19, 69-78. Barnhoorn, J., Broeren, S., Distelbrink, M., De Greef, M., Van Grieken, A., Jansen, W., Pels,
T., Pijnenburg, H., & Raat, H. (2013). Cliënt-, professional- en alliantiefactoren: hun relatie met het effect van zorg voor de jeugd. (ZonMw, augustus 2013). Retrieved from:
https://blackboard.ru.nl/bbcswebdav/pid-2096643-dt-content-rid-
5662759_4/institution/SOW/SOW-PW/Courses/SOW-PWB2220/Kennisinventarisatie_client_professional_alliantiefactoren%20Onderdelen. pdf
Bijleveld, C. C. J. H., & Commandeur, J. J. F. (2012). Multivariate analyse: een inleiding voor criminologen en andere sociale wetenschappers. Den Haag: Boom Lemma uitgevers.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252-260.
Brace, N., Snelgar, R., & Kemp, R. (2012). SPSS for Psychologists. Palgrave Macmillan. Brent, A. & Kolko, D. J. (1998). Psychotherapy: definitions, mechanisms of action, and
relationship to etiological models. Journal of Abnormal Child Psychology, 26, 17-25. Carroll, L. (1962). Alice’s adventures in wonderland. Harmondsworth, Middlesex, England:
Penguin Books.
Creed, T. A., & Kendall, P. C. (2005). Therapist alliance-building behavior within a cognitive-behavioral treatment for anxiety in youth. Journal of Consulting and Clinical Psychology, 73, 498-505.
Dekker, A. L., Van Miert, V. S. L., Van der Helm, G. H. P., & Stams, G. J. J. M. (2015). Handleiding Living Group Working Climate Inventory (LGWCI), inclusief referentiegroepen voor jeugd- en volwassensetting. Retrieved from:
https://www.hsleiden.nl/binaries/content/assets/hsl/lectoraten/residentiele-jeugdzorg/handleidingen/handleiding-lgwci-incl.-referentiegroepen.pdf
DePanfilis, D., & Zlotnik, J. L. (2008). Retention of front-line staff in child welfare: A systematic review of research. Children and Youth Services Review, 30, 995-1008. Diamond, G. M., Diamond, G. S., & Liddle, H. A. (2000). The therapist-parent alliance in
family based therapy for adolescents. Journal of Clinical Psychology, 56, 1037-1050. Hawley, K. M., & Garland, A. F. (2008). Working alliance in adolescent outpatient therapy:
youth, parent and therapist reports and associations with therapy outcomes. Child Youth Care Forum, 37, 59-74.
Hougaard, E. (1994). The therapeutic alliance – a conceptual analysis. Scandinavian Journal of Psychology, 35, 67-85.
Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L. (2006). Meta-analysis of therapeutic relationship variables in youth and family therapy: The evidence for different relationship variables in the child and adolescent treatment outcome literature. Clinical Psychology Review, 26, 50-65.
Knort, E. J., Harder, A. T., Huyghen, A. N., Kalverboer, M. E., & Zandberg, T. (2010). Residential Youth Care and Treatment Research: Care Workers as Key Factor in Outcomes? International Journal of Child & Family Welfare, 1, 49-67.
Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In: J.C. Norcross & M.R. Goldfield (Eds.). Handbook of psychotherapy integration, p. 94-129. New York: Basic Books.
Lambert, M. J., & Barley, D. E. (2001). Research summary of the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38, 357-361.
Lamers, A., Delsing, M. J. M. H., Van Widenfelt, B. M., & Vermeiren, R. R. J. M. (2015). A measure of the parent-team alliance in youth residential psychiatry: the revised short working alliance inventory. Child Youth Care Forum, 44, 801-817.
Luborsky, L., Rosenthal, R., Diguer, L., Andrusyna, T. P., Berman, J. S., Levitt, J. T., Seligman, D. A., & Krause, E. D. (2002). The dodo bird verdict is alive and well— mostly. Clinical Psychology: Science and Practice, 9, 2-12.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438-450.
critical review of assumptions, clinical implications, and research strategies. Attachement & Human Development, 3, 304-323.
Shirk, S. R., & Saiz, C. C. (1992). Clinical, empirical, and developmental perspectives on the therapeutic relationship in child psychotherapy. Development and Psychopathology, 4, 713-728.
Tabachnick, B. G. & Fidell, L. S. (2007). Using Multivariate Statistics, 5th edn. Boston, MA: Allyn & Bacon/Pearson Education.
Van Yperen, T., Van der Steege, M., Addink, A., & Boendermaker, L. (2010). Algemeen en specifiek werkzame factoren in de jeugdzorg. (Nederlands Jeugdinstituut, januari 2010). Retrieved from http://www.jeugdzorg.nl/nl/Download-NJi/Publicatie-NJi/Rapport-AlgemeenWerkzameFactoren.pdf
Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: empirically, “All must have prizes”. Psychological Bulletin, 122, 203-215.
Table 1. Component Loadings of the DTASP
Item Therapeutic
Alliance
Cronbach’s Alpha if item deleted 1. Primary group worker is on our
side and helps
.860 .929
2. Working together on problems .815 .934
3. Understanding for me .885 .927
4. There is a click .869 .929
5. Work well together to solve problems
.859 .929
6. Primary group worker shows commitment
.856 .932
7. Primary group worker lives up to agreements
.771 .936
8. Primary group worker involves me in the therapeutic process
.843 .931
Table 2. Initial Component Loadings of the DTASG
Item Component
1
Component 2 1. Important to talk with parents .714
2. Parents trust me .578 .522
3. Work together on goals .558 .582
4. Working on problems with parents .510 .613 5. I feel uncomfortable with the parents (R) * .799 6. Don’t like talking to these parents as much
(R)
* .685
7. We use our conversation time to make progress
.667 .401
8. There is a connection between me and the parents
.621 .504
9. We work well together on solving problems .546 .618 10. I feel involved with the parents .725 .254 11. I acknowledge the parents in their role .671 .153 12. I invest in a good collaboration .733 .123 13. The parents don’t want to work with me (R) .432 .561
Note. Bolded values indicate an item loading on the corresponding component. The “*” indicates that item loadings were below .10. Scores of items followed by (R) were reversed before analysis.
Table 3. Component Loadings of the DTASG after Excluding Items One by One that did not meet Divergent Validity
Item Overall therapeutic alliance Negative personal alliance Cronbach’s Alpha if item deleted
1. Important to talk with parents .707 * .877
2. Parents trust me .662 .414 .860
5. I feel uncomfortable with the parents (R) .106 .841 - 6. Don’t like talking to these parents as much (R) .163 .783 - 7. We use our conversation time to make progress .720 .290 .860 8. There is a connection between me and the
parents
.698 .427 .855
9. We work well together on solving problems .636 .435 .863
10. I feel involved with the parents .759 .183 .861
11. I acknowledge the parents in their role .670 .120 .875
12. I invest in a good collaboration .730 .120 .871
Note. Bolded values indicate an item loading on the corresponding component. The “*” indicates that item loadings were below .10. Scores of items followed by (R) were reversed before analysis.
Table 4. Outcomes of the Regression Analysis with Group Workers’ Alliance Scores as Dependent Variable (N = 293)
Model Variable B S.E. β P
1 Gender* .148 .084 .104 .079 Age .001 .005 .021 .763 Work years -.028 .043 -.043 .521 Commitment .262 .094 .164 .006 2 Gender .124 .086 .087 .150 Age < -.000 .005 -.001 .988 Work years -.014 .044 -.022 .754 Commitment .188 .103 .117 .070 Positive team functioning -.017 .068 -.016 .803 Shared vision .132 .073 .126 .070 3 Gender .126 .085 .088 .139 Age .001 .005 .010 .890 Work years -.028 .045 -.044 .531 Commitment .197 .108 .123 .071 Positive team functioning -.017 .068 -.017 .799 Shared vision .167 .075 .160 .027 Work surroundings -.030 .069 -.031 .664 Work pressure .133 .062 .130 .032 Note. “*”: Gender was coded as 1 = male and 2 = female.
Fig ure 3. Sce e-plot of the fina l two -co mp one nt solution of the DTASG
