Jouraal of Consulting and Clinical Psychology1997. Vol. 65, No. 4, 388-598

Copyright 1997 by the American Psychological Association, Inc.0022-006)09743.00

The Therapeutic Alliance and Its Relationship to AlcoholismTreatment Participation and Outcome

Gerard J. ConnorsResearch Institute on Addictions

Kathleen M. CarrollYale University School of Medicine

Carlo C. DiClementeUniversity of Maryland—Baltimore County

Richard LongabaughBrown University

Dennis M. DonovanUniversity of Washington

The relationship between the therapeutic alliance and treatment participation and drinking outcomes

during and after treatment was evaluated among alcoholic outpatient and aftercare clients. In the

outpatient sample, ratings of the working alliance, whether provided by the client or therapist, were

significant predictors of treatment participation and drinking behavior during the treatment and 12-

month posttreatment periods, after a variety of other sources of variance were controlled. Ratings

of the alliance by the aftercare clients did not predict treatment participation or drinking outcomes.

Therapists ratings of the alliance in the aftercare sample predicted only percentage of days abstinent

during treatment and follow-up. The results document the independent contribution of the therapeutic

alliance to treatment participation and outcomes among alcoholic outpatients.

Research conducted over the recent decades has supported

the proposition that psychotherapy process variables are related

to treatment outcomes (Orlinsky, Grawe, & Parks, 1994). An

important focus of these empirical efforts has been the nature

and quality of the therapeutic (or working) alliance and its

relationship to treatment outcome. Although defined in a number

of ways over the years, most definitions of the therapeutic alli-

ance overlap in emphasizing a collaborative relationship be-

tween the client and therapist that consists of an emotional bond

and a shared presumption regarding the tasks and goals of the

treatment endeavor (e.g., Bordin, 1979; Greenson, 1967).

Research on the therapeutic alliance has been systematic and

Gerard J. Connors, Research Institute on Addictions, Buffalo, New

York; Kathleen M. Carroll, Substance Abuse Center, Yale University

School of Medicine; Carlo C. DiClemente, Department of Psychology,

University of Maryland—Baltimore County; Richard Longabaugh, Cen-

ter for Alcohol and Addiction Studies, Brown University; Dennis M.

Donovan, Alcohol and Drug Abuse Institute, and Department of Psychia-

try and Behavioral Sciences, University of Washington.

This research was supported by a series of grants from the National

Institute on Alcohol Abuse and Alcoholism. We gratefully acknowledge

the collaboration of the Project MATCH Research Group and especially

our fellow members of the Project MATCH Process Committee (Ned

Cooney, Ronald Kadden, William Miller, Philip Wirtz, and Allen

Zweben) in this research. We give special thanks to Kurt H. Dermen

and James R. Koutsky for their major contributions to the preparation

of this article.

Correspondence concerning this article should be addressed to Gerard

J. Connors, Research Institute on Addictions, 1021 Main Street, Buffalo,

New York 14203.

productive. The research to date, first and foremost, has reflected

an appreciation of the need to develop and evaluate tools for

measuring the therapeutic alliance (Horvath, 1994; Tichenor &

Hill, 1989). Subsequent research has provided several reason-

ably robust indications regarding the therapeutic alliance. Per-

haps the most important finding is that a positive therapeutic

relationship predicts treatment outcome. In reviewing this litera-

ture, Horvath and Symonds (1991) found a moderate but consis-

tent positive relationship between the therapeutic alliance and

outcome. The relationship was not related to the study sample

size or the length of treatment.

It also appears that ratings of the therapeutic alliance at early

stages of treatment are more predictive of outcome than are

ratings taken later in the treatment process (Gomes-Schwartz,

1978; Hartley & Strupp, 1983; Luborsky, Crits-Christoph, Alex-

ander, Margolis, & Cohen, 1983; Luborsky, McLellan, Woody,

O'Brien, & Auerbach, 1985). Furthermore, ratings of the alli-

ance provided by the client have been stronger predictors of

treatment outcome than ratings provided by the therapists (Hor-

vath, 1994; Horvath & Symonds, 1991). Finally, the available

research suggests that the relationship of the therapeutic alliance

to outcome is evident across therapeutic modalities. Horvath

and Symonds (1991) investigated this question in their review

and found that the relationship between alliance and outcome

appears robust across several types of psychotherapy (e.g., psy-

chodynamic, cognitive, eclectic).

There are limitations in the research accumulated to date on

the therapeutic alliance. First, the majority of research has been

conducted using relatively small sample sizes. The meta-analysis

reported by Horvath and Symonds (1991) included 20 studies

588

THERAPEUTIC ALLIANCE IN ALCOHOLISM TREATMENT 589

with an average sample size of 49 (range 8-144). In a more

recent study, a larger sample size of 225 was included (Krupnick

et al., 1996). Second, there has been variability in the extent to

which the treatments studied have been standardized, introduc-

ing a potential confound to the interpretation of results. Third,

past studies on therapeutic alliance often have not controlled

for client and therapist variables that might predict outcomes

independent of the therapeutic alliance.

The present report was designed to build on and extend past

work on the therapeutic alliance. The data were gathered as part

of Project MATCH (Matching Alcoholism Treatments to Client

Heterogeneity), a national multisite study of the matching of

patients to alcoholism treatments (Project MATCH Research

Group, 1993). Strengths of this study in the context of evaluat-

ing therapeutic alliance were the use of three highly distinguish-

able standardized treatments, the use of a large group of thera-

pists (N - 80) trained and certified to administer the respective

treatments, a large clinical sample (N = 1,726), the collection

of data at sites located across the country, and extensive assess-

ments before, during, and after treatment, including therapist

and client ratings of the treatment process.

The specific focus of this report is on the contribution of

the therapeutic alliance in alcoholism treatment to treatment

participation (weeks in treatment), drinking during treatment,

and posttreatment drinking. On the basis of past research, it was

expected that the therapeutic alliance, as rated by both the client

and therapist, would be linearly related to treatment participation

and positive drinking-related outcomes. It was further expected

that client ratings would be stronger predictors than therapist

ratings and that the predictive capability of the client and thera-

pist ratings would operate across the three treatments and across

treatment sites included in the study. Finally, the analysis plan

included procedures to control for the potentially confounding

influence of client characteristics, therapist characteristics, and

client pretreatment drinking history variables.

Method

Overview of Project MATCH

Project MATCH is a national multisite clinical trial designed to evalu-

ate hypotheses relating to patient-treatment matching. Two independent

but parallel matching studies were conducted, one with clients recruited

from outpatient settings (n = 952), the other with clients receiving

aftercare treatment after inpatient care (« = 774). After baseline assess-

ments, clients were randomly assigned to one of three 12-week treat-

ments: 12-step facilitation (TSF), cognitive-behavioral coping skills

treatment (CBT), or motivational enhancement therapy (MET). The

clients were followed at 3-month periods for the year after the treatment

period. At the 12-month posttreatment follow-up, 92% of the living

outpatients and 93% of the living aftercare clients were interviewed, hi

addition, several within-treatment process assessments were conducted.

The trial has been described in greater detail by the Project MATCH

Research Group (1993), and tests of the primary a priori matching

hypotheses have been reported (Project MATCH Research Group,

1997).

Participants

The present analyses included 698 outpatient (71% men) and 498

aftercare (80% men) clients. All met the criteria of the Diagnostic and

Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-IH-R;

American Psychiatric Association, 1987) for a current diagnosis of alco-

hol abuse or dependence (for aftercare clients on the basis of drinking

during the period before admission to their inpatient or day hospital

admission), as assessed using the alcohol section of the Structured

Clinical Interview for the DSM-IH-R (SCID; Spitzer & Williams,

1985). The vast majority in each arm (> 95%) met the criteria for

alcohol dependence, as opposed to alcohol abuse. Descriptive informa-

tion is provided in Table 1 for clients in each arm of the trial.

The present sample represents 73% of the original population of

Project MATCH outpatients and 64% of the original population of Proj-

ect MATCH aftercare clients. The main reasons for deletion of cases

from the original population of 1,726 were missing Working Alliance

Inventory (WAI; Horvath & Greenberg, 1986) ratings (approximately

19%), mostly reflecting treatment dropouts, and missing therapist demo-

graphic information (approximately 11%). Comparisons of clients in

the present sample with those excluded for any reason (by outpatient

or aftercare arm and correcting alpha for tests within arm) revealed only

one difference in each arm. In both cases, the variable was marital

status. Chi-square tests showed in each case that clients included were

more often married, relative to those excluded.

Procedure

Every effort was taken to maintain comparability of procedures across

the two arms of the investigation (the outpatient and aftercare arms).

Outpatient clients were recruited from the community and from outpa-

tient treatment centers, whereas aftercare clients participated after com-

pletion of inpatient or intensive day hospital treatment. The clients were

recruited through nine clinical research units (CRUs) across the country

(five outpatient and four aftercare CRUs); outpatients were recruited

from five clinical sites, and aftercare clients were recruited from six

clinical sites (one outpatient CRU contributed to both outpatient and

aftercare recruitment and one aftercare CRU comprised two distinct

aftercare recruitment sites) associated with these CRUs.

Inclusion criteria for the outpatient sample were a current DSM-II1-

R (American Psychiatric Association, 1987) diagnosis of alcohol abuse

or dependence, alcohol as the principal drug of abuse, active drinking

during the 3 months before entrance to the study, a minimum age of 18,

and minimum sixth-grade reading level. Inclusion criteria for the after-

care arm were identical, except that symptoms of alcohol abuse or

dependence and requisite drinking behavior were assessed for the 3-

month period before the inpatient or day hospital admission, clients

completed a program of at least 7 days of inpatient or intensive day

hospital treatment (not simply detoxification), and clients were referred

for aftercare treatment by the inpatient or day hospital staff. Exclusion

criteria included a DSM-1I1—R diagnosis of current dependence on

sedative-hypnotic drugs, stimulants, cocaine, or opiates; any intrave-

nous drug use in the past 6 months; currently a danger to self or others;

probation-parole requirements that might interfere with protocol partici-

pation; acute psychosis or severe organic impairment; and current or

planned involvement in alternative treatments for alcohol problems other

than mat provided by Project MATCH (defined as greater than 6 hr of

nonstudy treatment, except for self-help groups, during the 3 months of

study treatment).

After an initial screen to evaluate the inclusion-exclusion criteria,

clients provided informed consent and participated in three intake ses-

sions that comprised personal interviews, computer-assisted assessment,

and completion of self-administered questionnaires (a description of the

full battery is provided by Connors et al., 1994). Where possible, an

interview was conducted with an individual familiar with the client's

drinking (i.e., a collateral). We assigned clients to treatment using a

computerized urn-balancing program designed to minimize differences

590 CONNORS, CARROLL, DlCLEMENTE, LONGABAUGH, AND DONOVAN

Table 1

Descriptive Information on Clients in the Outpatient and Aftercare Samples

Outpatient

Demographic

GenderAge (years)

MSD

Ethnicity (%)WhiteAfrican AmericanHispanic

OtherEducation (no. of years)

MSD

Relationship status (%)"Married

SingleEmployment (%)"

EmployedNot employed

Prior alcohol treatment (%)YesNo

Alcohol dependence symptoms0

MSD

Men

494 (71%)

39.210.7

814

131

13.52.2

4258

5842

46

54

5.91.9

Women

204 (29%)

39.311.3

787

113

13.61.9

2971

4060

3862

5.71.9

Total

698

39.310.8

805

132

13.52.1

3862

5347

4456

5.81.9

Men

396 (80%)

42.710.8

811432

13.12.1

4060

4951

6238

6.91.8

Aftercare

Women

102 (20%)

42.512.0

841321

13.22.1

2575

4456

5446

6.52.0

Total

498

42.611.0

821432

13.12.1

3763

4852

6040

6.81.9

a Married = married and living with spouse at least 1 year; single = all others. b Employed = employedfull time in same job continuously for past 6 months; not employed = all others. c Measured by theStructured Clinical Inventory for the DSM-HI-R for the 90-day baseline period (range = 1-9).

on variables such as critical demographic characteristics among clients

across the three study treatments in each arm (Stout, Wirtz, Carbonari, &

Del Boca, 1994).

After treatment assignment, treatment lasted 12 weeks. Therapy ses-

sions were videotaped to assure quality delivery of treatment and to

provide the data needed for a detailed investigation of treatment process

(Carroll, Kadden, Donovan, Zweben, & Rounsaville, 1994; DiClemente,

Carroll, Connors, & Kadden, 1994). In this regard, assessments in a

variety of process domains were incorporated into the protocol (DiCle-

mente et al,, 1994). Consistent with conceptual domains in psychother-

apy process research identified by Orlinsky and Howard (1986), these

included dose of treatment, within-session treatment interventions, the

therapeutic relationship, and extrasession activities. Directly relevant to

the purposes of the present report, the process assessment component

included ratings of the therapeutic alliance.

Follow-up assessments were scheduled at posttreatment and at follow-

ups 3, 6, 9, and 12 months after the end of treatment. The posttreatment,

6-month, and 12-month follow-ups were major evaluation points, involv-

ing the collection of blood and urine specimens and collateral interviews.

A more complete description of the trial protocol has been provided by

the Project MATCH Research Group (1993).

Treatments

Three treatment modalities were chosen for study in Project MATCH

because of their potential relevance to matching, the evidence for their

clinical efficacy, their distinctiveness from each other, feasibility of im-

plementation, and their application within existing treatment systems.

TSF was based on the concept of alcoholism as a spiritual and medical

disease with stated objectives of fostering acceptance of the disease

of alcoholism, developing a commitment to participate in Alcoholics

Anonymous, and beginning to work through the 12 steps. CBT was

grounded in social learning theory and on the view of drinking behavior

as functionally related to major problems in an individual's life, with

emphasis placed on overcoming skills deficits and increasing the ability

to cope with situations that commonly precipitate relapse. MET was

based on principles of motivational psychology and focused on produc-

ing internally motivated change. This treatment was not designed to guide

the client step by step through recovery; instead, it utilized motivational

strategies to mobilize the individual's own resources. TSF and CBT

both involved weekly treatment sessions, and MET consisted of four

sessions, occurring during the 1st, 2nd, 6th, and 12th weeks. The therapy

protocol for each modality is described in detailed treatment manuals

(Kadden et al., 1992; Miller, Zweben, DiClemente, & Rychtarik, 1992;

Nowinski, Baker, & Carroll, 1992).

A training protocol and standards for therapist certification and monitor-

ing were developed. Eighty therapists were certified to administer the

diree treatments in the trial. All sessions were videotaped, and supervisors

monitored 25% of all Project MATCH therapy sessions (over 2,500) to

ensure dierapist adherence to treatment manuals and to prevent therapist

variation from the protocol (Project MATCH Research Group, 1993).

Subsequent independent and masked videotape ratings have indicated the

discriminability and integrity of the treatments (Carroll et al., in press).

Therapists

Seventy-five therapists (40 in the outpatient study, 35 in the aftercare

study) for whom sufficient data were available are included in these

THERAPEUTIC ALLIANCE IN ALCOHOLISM TREATMENT 591

analyses (24 in TSF, 28 in CBT, and 23 in MET). The outpatient

therapists had a mean age of 39.3 years (SD = 7.8), and 65% were

women; the aftercare therapists averaged 37.7 years of age (SD = 7.1),

and 60% were women. The outpatient therapists treated an average of

17.3 clients (SD = 9.5), whereas the aftercare therapists treated an

average of 14.2 clients (5D = 7.8).

Measures

Client and therapist background characteristics. A variety of basic

background information (e.g., demographics, education, current marital

and employment status) was gathered from participants as part of the

initial screening and a formal diagnostic evaluation interview session.

All therapists completed a questionnaire that yielded comparable

information.

Treatment alliance and participation. The WAI (Horvath &

Greenberg, 1986) was used to assess the therapeutic alliance. The WAI

is a 36-item measure that consists of three subscales that address the

goals of therapy (Goal), agreement about the tasks of therapy (Task),

and the bond between the client and therapist (Bond). Ratings are made

on a 7-point Likert-type scale ranging from 1 (never) to 7 (always) on

the extent to which the respondent agrees with the statement, and a

global score is calculated by taking the sum of the 36 items (after

accounting for reverse-scored items). The WAI was selected for use in

this project for several reasons. First, the orientation of the WAI system

is eclectic and, thus, well-suited to the three treatments being evaluated.

Second, the psychometric properties of the WAI are well established,

with estimates of internal consistency and interrater reliability and valid-

ity at .85 and above on all subscales (Horvath & Greenberg, 1986;

Safran & Wallner, 1991; Tracey & Kokotovic, 1989). Third, there are

parallel forms of the WAI for rating by both the client and the therapist.

In this project, clients completed the WAI after the 2nd treatment session,

and therapists completed the measure after the 2nd, 6th, and 10th treat-

ment sessions (after Sessions 2 and 3 in the MET condition). Because

the WAI was completed by both the client and therapist after the second

session only, those ratings have been selected for use in this report.

There were isolated cases in which the client and therapist did not

complete the WAI at the second session. In these cases, several decision

rules were applied. First, if the WAI was completed at the first session,

these data were excluded (n = 3). Cases in which the WAI was com-

pleted at Session 4 or later (Session 3 in the case of the MET treatment)

similarly were deleted (n = 33). WAI data that were collected at Session

3 for TSF and CBT (which met weekly) were included and treated as

Session 2 reports (n = 28). Thus, all ratings of the therapeutic alliance

followed at least two treatment sessions but occurred no later than the

third treatment session in TSF and CBT and the second treatment session

in MET.

In the present report, the results are based on analyses incorporating

WAI total scores. This determination was made after evaluation of the

intercorrelations among the WAI subscales. The intercorrelations among

the subscales ranged from .69 to .91 (across client and therapist scores

and the two samples). The correlations between the subscales and the

total score ranged from .87 to .96. Further justification for the use of

the WAI total scores is provided by the structural analysis of the WM

reported by Tracey and Kokotovic (1989), who found support for the

use of the WAI to assess one general alliance dimension.

Drinking history and alcohol consumption. Several questionnaire

and interview measures were used to gather information on clients'

pretreatment drinking histories, including the alcohol section of the

SCID (Spitzer & Williams, 1985) and the Alcohol Use Inventory (AUI;

Wanberg, Horn, & Foster, 1977).

We obtained estimates of alcohol consumption for the 90-day pretreat-

ment period (for aftercare clients, the 90 days before inpatient or day

hospital treatment), the 12-week treatment period, and throughout the

12-month posttreatment follow-up period using the Form 90 (Miller,

1996). This interview procedure, which combined calendar memory

cues from the time-line follow-back methodology (Sobell & Sobell,

1992) and drinking pattern estimation procedures (Miller & Marian,

1984), provides estimates of alcohol consumption for each day of the

respective periods. A telephone interview version of the Form 90 and a

quick follow-up interview version were used for clients who were unable

to participate in in-person follow-up interviews and for uncooperative

clients.

Given the use of self-reports to assess drinking behavior, special atten-

tion was given to the evaluation of reliability and validity of these

measures. A comprehensive test-retest reliability study has shown the

Form 90 procedure to be highly reliable for the two main drinking

measures evaluated in Project MATCH (percentage of days abstinent

and drinks per drinking day; Tbnigan, Miller, & Brown, in press). Fur-

thermore, self-reports of drinking were examined in relation to gamma

glutamyl transpeptidase (GGTP) values at the 12-month posttreatment

follow-up (Project MATCH Research Group, 1997). Comparing clients

on the basis of their GGTP status (normal vs. abnormal) and gender on

percentage of days abstinent and drinks per drinking day during the 30-

day period preceding the blood draw showed that, in each study, self-

reported alcohol use was consistently higher for clients with abnormal

GGTP test results, as would be expected. Comparable indications were

provided in evaluating self-reports in relation to levels of carbohydrate-

deficient transferrin, another indicant of heavy alcohol consumption.

Taken together, the self-reports of drinking collected appear to have at

least acceptable levels of reliability and validity.

Analysis Plan

We evaluated the contribution of therapeutic alliance to treatment

participation and drinking behavior using a series of parallel hierarchical

multiple regression analyses, each comprising eight blocks of variables.

The eight blocks reflected, in order, client characteristics, therapist char-

acteristics, client drinking history, treatment site, treatment modality

received, the WAI total score, three two-way interactions, and a three-

way interaction.' The first five blocks served as covariates to eliminate

potential "third variable" explanations for the results. The variables

associated with each of the eight blocks are identified in Table 2. Cate-

gorical predictors were represented as sets of dummy-coded variables.

Five dependent variables were predicted, once each using the client

WAI total score data and once each using the therapist WAI total score

data, separately for each sample (outpatient and aftercare). The five

dependent variables were treatment participation, percentage of days

abstinent and drinks per drinking day during the treatment period, and

percentage of days abstinent and drinks per drinking day during the 12-

month posttreatment period. The percentage of days abstinent variable

was selected to provide an indication of drinking frequency, and the

drinks per drinking day was selected to provide a measure of drinking

severity or intensity. Treatment participation was operationalized as the

number of weeks involved in treatment during the 12-week treatment

period (i.e., number of weeks spanning the first and last treatment session

attended). This measure, rather than number of sessions or percentage

1 It may be argued that, because of its greater theoretical relevance,

the WAI X Treatment Modality interaction should be evaluated separately

and not within the block of three two-way interactions. Although includ-

ing this interaction within the block of two-way interactions is more

conservative, analyses entering the WAI X Treatment Modality interac-

tion term as a separate step (after the WAI score and before the block

of the remaining two-way interactions) also were performed. None of

the WW X Treatment Modality interactions were significant.

592 CONNORS, CARROLL, DlCLEMENTE, LONGABAUGH, AND DONOVAN

Table 2

Blocks and Associated Variables for the Hierarchical Multiple Regression Analyses

Block Variables

Client characteristics

Therapist characteristicsClient drinking history

Treatment siteTreatment modality

Working allianceTwo-way interactionsThree-way interaction

Gender, age, ethnicity (African American, Hispanic, White), education

Gender, age, educationPrevious alcoholism treatment (number of previous outpatient and inpatient treatment episodes), baseline percentage

of days abstinent (for 90-day pretreatment period before the client's last drink), baseline drinks per drinking day(for same pretreatment period), AUI (Wanberg, Horn, & Foster, 1977) Alcohol Involvement score, SCID

(Spitzer & Williams, 1985) alcohol dependence symptom count (range = 1-9) for the 90-day pretreatmentperiod, number of years since onset of problem drinking

Five outpatient sites and 6 aftercare sitesTSF, CBT, MET

WAI total score (for client or therapist, depending on the analyses, gathered after Treatment Session 2)WAI X Treatment Modality, WAI X Treatment Site, Treatment Modality X Treatment Site

WAI X Treatment Modality X Treatment Site

Note. Ethnicity, treatment site, and treatment modality were dummy coded. The 90-day pretreatment period ran backward from the day of the lastdrink before enrollment in the trial. The baseline period for the clients in the aftercare study was the period before entry to then* inpatient or dayhospital treatment episode. AUI = Alcohol Use Inventory; SCID = Structured Clinical Inventory for the DSM-III-R; TSF = 12-step facilitation;CBT = cognitive-behavioral coping skills therapy; MET = motivational enhancement therapy; WAI = Working Alliance Inventory.

of sessions attended, was chosen because it provided a more comparable

assessment of participation across these three treatments differing in the

number of sessions offered. Variables such as percentage of days absti-

nent and drinks per drinking day often depart from normality because

of skewness and floor-ceiling effects. In response, the percentage of

days abstinent variable was subjected to an arcsin transformation, and

the drinks per drinking day variable was subjected to a square root

transformation, in each case to improve the distribution. All clients had

nonmissing outcome scores for these drinking measures for at least

two thirds of the weeks or months, respectively, of the treatment and

posttreatment periods. The means and standard deviations for the WAI

raw scores and for the dependent variables are provided in Table 3, and

the correlations between the WAI therapist and client total scores with

the dependent variables, broken down by treatment condition, are pro-

vided in Table 4.

Results

Outpatient Study

The results of the multiple regression analyses for the client

and the therapist data, respectively, are shown in Table 5; the

results for the first five blocks of covariates are shown first,

followed by the WAI total scores and the interaction terms for

the client (top panel) and therapist (bottom panel) data.

The most consistent finding to emerge among the five blocks

of covariates in each set of analyses was the contribution of

client's drinking history, whereby variables reflecting greater

degrees of recent alcohol involvement predicted less treatment

participation and predicted lower percentage of days abstinent

and more drinks per drinking day during treatment and follow-

up. For example, treatment participation was negatively related

to AUI General Alcohol Involvement scale scores, and drinks

per drinking day during treatment and follow-up were predicted

by pretreatment drinks per drinking day and the number of

previous treatment experiences. Treatment modality was a pre-

dictor of three dependent variables in the client WAI analyses.2

Clients in CBT (M = 10.05) participated longer in treatment

than those in MET (M = 9.47) or TSF (M = 9.34). MET

clients (M = 79%) had a lower rate of percentage of days

abstinent during treatment than did the CBT (M = 84%) or

TSF (M = 83%) clients. The MET clients (M = 7.55) also had

more drinks per drinking day during follow-up than clients in

CBT (M = 6.89) or TSF (M = 6.60). Treatment modality

predicted only percentage of days abstinent when the therapist

WAI data were studied.

WAI total scores, whether provided by the client or therapist,

were significant predictors of each dependent variable. As pre-

dicted, ratings on the WAI were positively related to treatment

participation and percentage of days abstinent (during treatment

and posttreatment) and negatively related to drinks per drinking

day (during treatment and posttreatment). The ranges of /?2

change across the dependent variables were .008- .015 for client

WAI scores and .013- .034 for therapist WAI scores.

No interactions involving client WAI scores emerged. Two

interactions involved therapist WAI ratings, in each case op-

erating during the treatment period. Examination of the Treat-

ment Site X WAI therapist score interaction for treatment partici-

pation revealed a strong positive relationship between WAI

scores and weeks in treatment at two of the outpatient sites,

whereas, at the other sites, little relationship was observed. For

percentage of days abstinent during treatment, the Treatment Site

X WAI therapist score interaction generally revealed a positive

relationship between WAI scores and percentage of days absti-

nent, with the relationship more pronounced at three of the sites.

A third interaction, Treatment Site X Treatment Modality for

percentage of days abstinent during treatment, showed that, after

2 It is important to remember that the treatment main effects described

in this report need to be interpreted with caution, as the present sample

includes only clients attending two or more treatment sessions. Analyses

evaluating treatment main effects in the entire outpatient and aftercare

samples, controlling for baseline drinking and site differences, revealed

no significant main effects of treatment on posttreatment percentage of

days abstinent and drinks per drinking day (Project MATCH Research

Group, 1997).

THERAPEUTIC ALLIANCE IN ALCOHOLISM TREATMENT 593

Table 3

Means, Standard Deviations, Skewness, and Kurtosis for Working Alliance Inventory (WAI) Scores

and the Dependent Variables for Outpatient and Aftercare Studies

Variable M(SD)

Outpatient study

Skewness

Aftercare study

Kurtosis M(SD) Skewness Kurtosis

WAI scores and dependent variables

Client WAI total scoreTherapist WAI total scoreTreatment participation (weeks)During treatment

% days abstinent

Drinks per drinking dayPosttreatment

% days abstinentDrinks per drinking day

211.6(24.1)193.2 (24.8)

9.7 (3.3)

83 (25)6.63 (7.15)

75 (28)6.95 (5.96)

-0.88-0.43-1.38

-1.781.94

-1.051.35

0.72-0.14

0.67

2.306.95

-0.082.89

214.8 (23.2)

192.6 (26.5)9.6 (3.5)

92 (19)5.14 (8.86)

83 (25)8.32 (9.59)

-1.05

-0.49-1.32

-2.962.24

-1.67.1.73

1.85-0.05

0.40

8.445.72

1.764.40

Transformed variables3

During treatment% days abstinent

Drinks per drinking dayPosttreatment

% days abstinentDrinks per drinking day

1.12 (0.43)2.07 (1.53)

0.97 (0.46)2.29 (1.31)

-0.93

0.11

-0.37-0.27

-0.04

-0.61

-0.98-0.28

1.35 (0.37)1.35 (1.82)

1.15 (0.45)2.22 (1.84)

-1.931.04

-0.900.22

3.02-0.13

-0.32-0.86

" The drinking variables were transformed before conducting the regression analyses. The percentage of days abstinent variables were subjected to

an arcsin transformation, and the drinks per drinking day variable to a square root transformation.

adjusting for covariates (e.g., demographics, drinking history,

and W\I scores), treatment assignment had relatively little im-

pact on percentage of days abstinent at two sites, whereas at

the remaining three sites, MET clients appeared to have a lower

percentage of days abstinent than TSF and CBT clients.

Aftercare Study

The results of the multiple regression analyses for the after-

care clients are detailed in Table 6. Looking first at the five

blocks of variables preceding entry of the working alliance vari-

ables, we found that the strongest predictions of drinking vari-

ables were again in the context of the client's pretreatment

drinking history. Drinks per drinking day during treatment and

during posttreatment were predicted by pretreatment drinks per

drinking day and AUI scores. Drinks per drinking day posttreat-

ment also was predicted by the number of previous episodes

of alcoholism treatment. Several client and therapist variables

predicted drinks per drinking day outcomes. Client ethnicity,

for example, predicted both drinks per drinking day variables,

with higher rates of drinks per drinking day reported by White

clients. Drinks per drinking day during treatment was also pre-

dicted by client age (negatively) and client gender (higher drinks

per drinking day among men). In terms of therapist characteris-

tics, having a male therapist was associated with higher reports

of drinks per drinking day during treatment and during follow-

up. Therapist age also negatively predicted drinks per drinking

day during posttreatment. Finally, several treatment effects were

found for the posttreatment drinking variables. Overall, MET

clients had lower rates of percentages of days abstinent and

higher rates of drinks per drinking day (Ms — 79% and 8.72,

respectively), whereas TSF clients had higher rates of percent-

ages of days abstinent and lower rates of drinks per drinking

day (Ms = 87% and 7.42, respectively). The means for the

CBT clients were 84% and 8.52, respectively.

In terms of aftercare clients' ratings of the therapeutic alli-

ance, the client WAI scores block was not significant across the

five dependent variables, and no significant two-way interactions

emerged. Therapist ratings of the therapeutic alliance were, how-

ever, significant positive predictors of percentage of days absti-

nent during treatment and posttreatment.

The regression equations evaluating aftercare therapist ratings

produced significant two-way interactions for three of the five

dependent variables. The W\I X Treatment Site interaction was

significant for drinks per drinking day during treatment, percent-

age of days abstinent posttreatment, and drinks per drinking day

posttreatment. Drinks per drinking day posttreatment also was

predicted by the WAI X Treatment Modality interaction, and

percentage of days abstinent posttreatment also was predicted

by the Treatment Modality X Treatment Site interaction. Exami-

nation of the variables used to represent the WAI X Treatment

Site interactions allowed for an assessment of the relationship

between therapist WAI scores and drinking at each aftercare

site. In this regard, the WAI X Treatment Site interaction for

drinks per drinking day during treatment showed a negative

relationship between WAI therapist scores and drinks per drink-

ing day at four sites but a positive relationship at the other two

sites. The interaction for percentage of days abstinent posttreat-

ment showed a modest positive relationship between W\I thera-

594 CONNORS, CARROLL, DiCLEMENTE, LONGABAUGH, AND DONOVAN

Table 4

Correlations Between Client and Therapist Working Alliance Inventory (WAI) Total Scores

and Treatment Participation and Drinking Behavior During Treatment and Posttreatment

Dependent variable

During treatment

WAI total score

Outpatient-client ratingsCBTMETTSFTotal sample

Outpatient-therapist ratingsCBTMETTSFTotal sample

Aftercare-client ratingsCBTMETTSFTotal sample

Aftercare-therapist ratingsCBTMETTSFTotal sample

Treatmentparticipation

.076

.132*

.126

.107**

.024

.077

.196**

.102**

.082-.048-.001

.021

.095

.061

.025

.072

% daysabstinent

.143*

.106

.123

.116**

.193**

.175**

.167*

.162***

-.040.069

-.117-.023

.070

.134

.143

.103*

Drinks perdrinking day

-.105-.114-.075-.092*

-.125-.111-.123-.106**

-.069-.049

.005

.038

.001-.122-.110-.063

Posttreatment

% daysabstinent

.202**

.084

.109

.134**

.148*

.122

.240***

.169***

.111

.127-.112

.040

.212**

.192*

.121

.150**

Drinks perdrinking day

-.180**-.152*-.001-.106**

-.165*-.058-.110-.102**

-.040-.116

.020-.034

.022-.157*

.034-.018

Note. Percentage of days abstinent and drinks per drinking day were transformed using arcsin and square-root transformations, respectively. The sample sizes associated with the above correlations vary slightlybecause of missing data. The ranges for the five dependent variables for the outpatient and aftercare armsby treatment were as follows: For client ratings in the outpatient study, cognitive-behavioral therapy (CBT)= 232-241, motivational enhancement treatment (MET) = 214-233, 12-step facilitation treatment (TSF)= 217-224, total sample = 663-698; for therapist ratings, CBT = 233-244, MET = 207-226, TSF =216-223, total sample = 656-693. For client ratings in the aftercare study, CBT = 178-188, MET =175-185, TSF= 112-117, total sample = 465-490; for therapist ratings, CBT = 179-189, MET = 174-186, TSF = 117-123, total sample = 470-498.*p < .05. **p<m. ***p < .001 (two-tailed).

pist ratings and percentage of days abstinent at four sites, a

markedly stronger positive relationship at a fifth site, and a

modest negative relationship at the sixth site. The relationship

between drinks per drinking day posttreatment and therapist

WAI scores was negative at four sites and positive at two sites.

The Treatment Modality X WAI therapist score interaction for

drinks per drinking day posttreatment showed a strong negative

relationship between therapist WAI scores and drinks per drink-

ing day in the MET condition and a modest positive relationship

in the CBT and TSF conditions. The final interaction, between

treatment site and treatment modality for posttreatment percent-

age of days abstinent, showed generally comparable rates of

posttreatment abstinence across sites, with the exception that

one site's outcomes reflected lower rates of percentage of days

abstinent for CBT and MET and significantly higher rates for

TSF.

Three three-way interactions, two involving client WAI scores

and one involving therapist WAI scores, also emerged. The inter-

action for percentage of days abstinent during treatment ap-

peared to be carried by one site for the TSF condition, where

high client WAI ratings were associated with a lower percentage

of days abstinent during treatment. The interaction for drinks

per drinking day posttreatment was predominantly carried

through the TSF treatment at this same site, where high WAI

ratings by the client were associated with high rates of drinks per

drinking day. In addition, at a second site there was a particularly

strong negative relationship between client WAI scores and

drinks per drinking day for TSF clients. The third interaction,

involving therapist WAI ratings, emerged in the analysis pre-

dicting treatment participation. It appeared that MET therapist

WAI ratings at one site and TSF therapist ratings at two sites

showed a particularly strong positive relationship between WAI

scores and treatment participation, relative to the other treat-

ments at the remaining sites.

Discussion

The main finding regarding the therapeutic alliance in the

present study was its consistent prediction among outpatient

alcoholic clients of treatment participation and positive drinking-

related outcomes, whether the alliance was rated from the client

or therapist perspective. We found this effect even after control-

THERAPEUTIC ALLIANCE IN ALCOHOLISM TREATMENT 595

Table 5

Multiple Regression Analyses Predicting Treatment Participation and Drinking Behavior During the Treatment and

Posttreatment Periods for Outpatient Sample Using Client and Therapist Ratings

Predictor

AR2 during treatmentAR2

treatment % days Drinks perparticipation abstinent drinking day

(n = 698) (n = 689) (n = 689)

A/?2 posttrealment

% days Drinks perabstinent drinking day

(n = 663) (n = 663)

Client WAI

Block 1 : client characteristicsBlock 2: therapist characteristicsBlock 3: client drinking historyBlock 4: treatment siteBlock 5: treatment modalityBlock 6: working alliance

Client WAI total scoreBlock 7: two-way interactions

WAI X Treatment ModalityWAI X Treatment SiteTreatment Modality X Treatment Site

Block 8: three-way interactionWAI X Treatment Modality x Treatment Site

.013

.006

.019*

.011

.011*

.014**(B = .016)

.018

.012

.010

.002

.051***

.008

.014**

.012**(B = .002)

.013

.009

.009

.001

.082***

.005

.007

.008*(B = -.006)

.010

.007

.027**

.002

.100***

.017*

.003

.015***(B = .002)

.011

.015

.015

.010

.114***

.006

.009*

.013**(fl = -.006)

.015

.003

Therapist WAI

Block 1: client characteristicsBlock 2: therapist characteristicsBlock 3: client drinking historyBlock 4: treatment siteBlock 5: treatment modalityBlock 6: working alliance

Therapist WAI total scoreBlock 7: two-way interactions

WAI X Treatment ModalityWAI X Treatment SiteTreatment Modality X Treatment Site

Block 8: three-way interactionWAI X Treatment Modality X Treatment Site

.012

.005

.026**

.010

.008

.013**(B = .016)

.056***

.005

.032***

.014

.009

.010

.001

.053***

.007

.011*

.034***(B = .003)

.034*

.002

.013*

.022*

.013

.014

.001

.080***

.005

.007

.016***(B = -.008)

.017

.007

.031**

.001

.105***

.015*

.002

.032***(B = .004)

.021

.014

.020*

.008

.107***

.006

.007

.015***(fl = -.007)

.022

.008

Note. The change in R2 for each of the two-way interactions represents the increment in variance for that interaction after the remaining twointeractions have been entered. For Block 1, the percentage of variance accounted for by individual interaction terms is presented only if the overallblock was significant. WAI = Working Alliance Inventory.*p<.05. **p<.01. ***p<.001.

ling for a number of covariates, including the client's pretreat-

ment drinking history. Consistent with our hypotheses, the effect

was generally consistent across treatment sites and, to a large

extent, across treatment modalities as well. This finding among

the outpatient sample is consistent with a larger body of litera-

ture indicating the contribution of the therapeutic alliance to

psychotherapy treatment outcome (Horvath, 1994; Horvatn &

Symonds, 1991). The present findings extend this literature to

include alcoholic clients, a population not previously studied in

detail in the context of therapeutic alliance. This endeavor in-

cluded a large sample size, and the fact that its design controlled

for a number of other variables suggests that these findings are

likely to be robust.

Although the data show a consistent indication among outpa-

tients that the therapeutic relationship is an important, indepen-

dent contributor to treatment participation and drinking out-

comes, the proportion of variance in the various outpatient out-

comes explained by the therapeutic alliance was modest (never

exceeding 3.5% across the client and therapist ratings for the

WAI main effects). This may come as a surprise to those who

would have expected the proportion of variance accounted for

to be higher. However, one should note that the present study

included procedures to control for a variety of other sources of

variance, some of which may have effects mediated by therapist

alliance, before evaluating the unique contribution of WAI rat-

ings. Thus, the estimates derived for these data regarding the

therapeutic alliance's contribution to outcome are probably con-

servative. Furthermore, as noted by Bourgeois, Sabourin, and

Wright (1990), the process of behavior change is multidimen-

sional, and it is not likely that any one factor operating as part

of this process will account for a large amount of variance (see

also Orlinsky & Howard, 1986). In fact, the use of multiple

determinants to predict outcomes places an upper limit on the

amount of variance that can be accounted for by any one pre-

dictor (Ahadi & Diener, 1989; Strube, 1991). Nevertheless,

given the methodological strengths of this large multisite clinical

596 CONNORS, CARROLL, DCLEMENTE, LONGABAUGH, AND DONOVAN

Table 6

Multiple Regression Analyses Predicting Treatment Participation and Drinking Behavior During the Treatment and

Posttreattnent Periods for Aftercare Sample Using Client and Therapist Ratings

Predictor

Art2

treatmentparticipation

(n = 490)

Afl2 during treatment AR2 posttreatment

% daysabstinent

(re = 479)

Drinks perdrinking day

(n = 479)

% daysabstinent(n = 465)

Drinks perdrinking day

(n = 465)

Client WAI

Block 1: client characteristics .018 .012Block 2: therapist characteristics .013 .005Block 3: client drinking history .011 .010Block 4: treatment site .029* .018Block 5: treatment modality .001 .004Block 6: working alliance .000 .002

Client WAI total score (B = .001) (B = -.001)Block 7: two-way interactions .037 .021

WAI X Treatment ModalityWAI X Treatment SiteTreatment Modality X Treatment Site

Block 8: three-way interaction ,024 .043*WAI X Treatment Modality X Treatment Site

(B-.

.032**

.019*

.040**

.004

.002

.000-.001)

.034

.036

.022

.015

.056***

.019

.023**

.001

.001)

.038

.024

.041**

.025**

.211**

.008

.012*

.000(B = -.001)

.024

.031»

Therapist WAI

Block 1 : client characteristicsBlock 2: therapist characteristicsBlock 3: client drinking historyBlock 4: treatment siteBlock 5: treatment modalityBlock 6: working alliance

Therapist WAI total scoreBlock 7: two-way interactions

WAI X Treatment ModalityWAI X Treatment SiteTreatment Modality x Treatment Site

Block 8: three-way interactionWAI x Treatment Modality X Treatment Site

.020

.012

.011

.038**

.001

.000(B = .001)

.047

.035*

.009

.005

.007

.016

.002

.013*(B = .002)

.028

.026

.032**

.016*

.046***

.005

.002

.004(8 = -.005)

.054*

.004

.028*

.024

.028

.020

.013

.057***

.022*

.022**

.022***(B = .003)

.066**

.010

.033**

.048**

.012

.039**

.024**

.212***

.009

.010*

.000(B = -.000)

.047*

.013*

.022*

.025

.017

Note. The change in R2 for each of the two-way interactions represents the increment in variance for that interaction after the remaining twointeractions have been entered. For Block 7, the percentage of variance accounted for by individual interaction terms is presented only if the overallblock was significant. WAI = Working Alliance Inventory.*p< .05 . **p<.01. ***p<.001.

trial and the sample size involved, the findings suggest that the

therapeutic alliance, among outpatient alcoholics at least, is a

factor that has an impact on treatment participation and

outcome.

The results in the aftercare study did not mirror the pattern

found in the outpatient study. In fact, client ratings were not

significant predictors of treatment participation or any of the

drinking outcome measures. Therapist ratings were consistent

significant predictors only of the percentage of days abstinent

variable (during both treatment and posttreatment). The reasons

that ratings of the therapeutic alliance among the aftercare cli-

ents did not predict outcomes to the extent found among the

outpatients, especially in terms of client ratings, are not clear.

Relative to the outpatients, the aftercare clients did have a greater

degree of previous alcoholism involvement (e.g., slightly higher

alcohol dependence SC1D counts, greater history of previous

alcoholism treatment), which may have overshadowed the im-

pact of the working alliance or its development. Perhaps more

likely is that the aftercare clients had already completed a course

of intensive alcoholism treatment (either as inpatiems or as part

of a day hospital treatment) in which some degree of abstinence

likely was achieved. This treatment completion may have re-

sulted in the aftercare sample being preselected for compliance

or motivation, among other variables. It may also be that these

clients did not view or value the working alliance as critically as

the outpatients, given their more intensive treatment experience

immediately before the study. However, it should be noted that

the outpatients and aftercare clients had similar rates of treat-

ment participation (Ms = 9.7 and 9.6 weeks, respectively) and

that the client WAI total scores were similarly comparable (Ms

= 211.6 and 214.8, respectively).

Several interactions (mostly within the aftercare sample) indi-

cated that the impact of therapeutic alliance on treatment partici-

pation and outcome was moderated by site or treatment assign-

ment. For example, in the outpatient sample, the interaction

between site and therapist alliance ratings showed a strong linear

THERAPEUTIC ALLIANCE IN ALCOHOLISM TREATMENT 597

relationship between alliance and treatment participation at two

sites, a slight relationship at a third, and no relationship at two

others. In the aftercare arm, the WAI X Treatment Site therapist

score interactions for drinks per drinking day during treatment

and during follow-up showed various magnitudes" of a negative

relationship between the alliance and drinks per drinking day,

except for two sites in each case where this pattern was inexpli-

cably reversed. It is possible that WAI X Treatment Site interac-

tions in the aftercare sample were influenced by the nature of

the relationships that these clients had with treatment personnel

on the inpatient or day hospital units. However, these (as well as

the other two-way interactions) need to be interpreted cautiously

because the values used to evaluate these interactions have been

adjusted for covariation with the blocks of variables entered in

the earlier steps of the equation. Nevertheless, these interactions

do suggest that findings reported at one treatment site may not

necessarily be fully replicated at other treatment sites, even in

the context of the same treatment protocol.

There are limits on the generalizability of these findings that

warrant comment. First, the present data were collected in a

clinical trial including alcoholic clients who agreed to partici-

pate in a clinical research protocol and who received one of

three structured, manual-guided, time-limited interventions. The

extent to which these findings would be replicated in similar

treatments that are less structured or in other treatment modal-

ities is not clear. Second, the samples included individuals who

stayed in treatment at least through the second session and, thus,

do not include those individuals who dropped out of treatment

before the second session. The aftercare sample does not include

individuals who did not complete a more intensive treatment for

alcoholism immediately before the study. Thus, these findings

cannot be immediately generalized to all clients who seek alco-

holism treatment. Finally, it needs to be acknowledged that in-

flation of alpha exists as a concern whenever multiple analyses

are performed. The finding that the WAI scores operated in the

predicted direction across a range of dependent measures argues

against these results being spurious. The findings involving WAI

scores in interaction with other variables were less consistent,

which suggests that they should be viewed more cautiously.

Taken together, these data indicate the important independent

contribution of the therapeutic relationship to treatment partici-

pation and positive treatment outcomes among alcoholic clients

in outpatient treatment. Accordingly, it will be useful to study

and to understand further the factors that contribute to the estab-

lishment and maintenance of a productive therapeutic alliance

and to evaluate the extent to which these findings generalize to

other populations of alcohol abusers.

References

Ahadi, S., & Diener, E. (1989). Multiple determinants and effect size.

Journal of Personality and Social Psychology, 56, 398-406.

American Psychiatric Association. (1987). Diagnostic and statistical

manual of mental disorders (3rd ed., rev.). Washington, DC: Author.

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept

of the working alliance. Psychotherapy: Theory, Research, and Prac-

tice, 16, 252-260.

Bourgeois, L., Sabourin, S., & Wright, J. (1990). Predictive validity of

therapeutic alliance in group marital therapy. Journal of Consulting

and Clinical Psychology, 58, 608-613.

Carroll, K. M., Connors, G. J., Cooney, N., DiClemente, C. C, Donovan,

D. M., Kadden, R. R., Longabaugh, R. L., Rounsaville, B. J., &

Zweben, A. (in press). Discriminability and integrity of treatments

for alcoholism: Findings from Project MATCH. Journal of Consulting

and Clinical Psychology.

Carroll, K. M., Kadden, R. M., Donovan, D. M., Zweben, A., & Rounsa-

ville, B.J. (1994). Journal of Studies on Alcohol, 55(Suppl. No.

12), 149-155.

Connors, G. J., Allen, J. P., Cooney, N. L., DiClemente, C. C., Tonigan,

J. S., & Allen, R. F. (1994). Assessment issues and strategies in alco-

holism treatment matching research. Journal of Studies on Alcohol,

55(Suppl. No. 12), 92-100.

DiClemente, C. C., Carroll, K. M., Connors, G. J., & Kadden, R. M.

(1994). Process assessment in treatment matching research. Journal

of Studies on Alcohol, 55(Suppl. No. 12), 156-162.

Gomes-Schwartz, B. (1978). Effective ingredients in psychotherapy:

Prediction of outcome from process variables. Journal of Consulting

and Clinical Psychology, 46, 1023-1035.

Greenson, R. R. (1967). Technique andpractice of psychoanalysis. New

\brk: International University Press.

Hartley, D. E., & Strupp, H. H. (1983). The therapeutic alliance: Its

relationship to outcome in brief psychotherapy. In J. Masling (Ed.),

Empirical studies in analytic theories (pp. 1-37). Hillsdale, NJ:

Erlbaum.

Horvath, A. O. (1994). Research on the alliance. In A. O. Horvath &

L. S. Greenberg (Eds.), The working alliance: Theory, research, and

practice (pp. 259-286). New \brk: Wiley.

Horvath, A. O., & Greenberg, L. S. (1986). The development of the

Working Alliance Inventory. In L. S. Greenberg & W. M. Pinsof

(Eds.), The psychotherapeutlc process: A research handbook (pp.

529-556). New York: Guilford Press.

Horvath, A. O., & Symonds, B. D. (1991). Relation between working

alliance and outcome in psychotherapy: A meta-analysis. Journal of

Counseling Psychology, 38, 139-149.

Kadden, R., Carroll, K., Donovan, D., Cooney, N., Monti, P., Abrams,

D., Lilt, M., & Hester, R. (1992). Cognitive-behavioral coping skills

therapy manual (Project MATCH Monograph Series No. 3). Rock-

ville, MD: National Institute on Alcohol Abuse and Alcoholism.

Krupnick, J. L., Sotsky. S. M., Simmens, S., Mover, J., Elkin, L. Watkins,

J., & Pilkonis, P. A. (1996). The role of the therapeutic alliance in

psychotherapy and pharmacotherapy outcome: Findings in the Na-

tional Institute of Mental Health Treatment of Depression Collabora-

tive Research Program. Journal of Consulting and Clinical Psychol-

ogy, 64, 532-539.

Luborsky, L., Crits-Christoph, P., Alexander, L., Margolis, M., & Cohen,

M. (1983). Two helping alliance methods for predicting outcomes of

psychotherapy: A counting signs vs. a global rating method. Journal

of Nervous and Mental Disease, 171, 480-491.

Luborsky, L., McLellan, A. X, Woody, G. E., O'Brien, C. P., & Auerbach,

A. (1985). Therapist success and its determinants. Archives of Gen-

eral Psychiatry, 42, 602-611.

Miller, W. R. (1996). Manual for Form 90: A structured assessment

interview for drinking and related behaviors (Project MATCH Mono-

graph Series No. 5). Rockville, MD: National Institute on Alcohol

Abuse and Alcoholism.

Miller, W. R., & Marian, G. A. (1984). The comprehensive drinker

profile. Odessa, FL: Psychological Assessment Resources.

Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G.

(1992). Motivational enhancement therapy manual (Project MATCH

Monograph Series No. 2). Rockville, MD: National Institute on Alco-

hol Abuse and Alcoholism.

598 CONNORS, CARROLL, DiCLEMENTE, LONGABAUGH, AND DONOVAN

Nowinski, J., Baker, S., & Carroll, K. (1992). Twelve-step facilitation

therapy manual (Project MATCH Monograph Series No. 1). Rock-

ville, MD: National Institute on Alcohol Abuse and Alcoholism.

Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome

in psychotherapy. In A. E. Bergin & S. L. Garneld (Eds.), Handbook

of psychotherapy and behavior change (4th ed., pp. 270-376). New

York: Wiley.

Orlinsky, D. E., & Howard, K. I. (1986). Process and outcome in psy-

chotherapy. In S. L. Garneld & A. E. Bergin (Eds.), Handbook of

psychotherapy and behavior change (3rd ed., pp. 311-381). New

York: Wiley.

Project MATCH Research Group. (1993). Project MATCH: Rationale

and methods for a multisite clinical trial matching patients to alcohol-

ism treatment. Alcoholism: Clinical and Experimental Research, 17,

1130-1145.

Project MATCH Research Group. (1997). Matching alcoholism treat-

ments to client heterogeneity: Project MATCH posttreatment drinking

outcomes. Journal of Studies on Alcohol, 58, 7-29.

Safrau, J. D., & Wallner, L. K. (1991). The relative predictive validity of

two therapeutic alliance measures in cognitive therapy. Psychological

Assessment, 3, 188-195.

Sobell, L. C, & Sobell, M. B. (1992). Time-line follow-back: A tech-

nique for assessing self-reported alcohol consumption. In R. Z. Lit-

ten & J. P. Allen (Eds.), Measuring alcohol consumption: Psychoso-

cial and biochemical methods (pp. 41-72). Totowa, NJ: Humana

Press.

Spitzer, R. L., & Williams, J. B. W. (1985). Structured Clinical Inter-

view for DSM-III-R, patient version. New York: New York State

Psychiatric Institute, Biometric Research Department.

Stout, R. L., Winz, P. W., Carbonari, J. P., & Del Boca, F. K. (1994).

Ensuring balanced distribution of prognostic factors in treatment out-

come research. Journal of Studies on Alcohol, J5(Suppl. No. 12),

70-75.

Strube, M. J. (1991). Multiple determinants and effect size: A more

general method of discourse. Journal of Personality and Social Psy-

chology, 61, 1024-1027.

Tbnigan, I. S., Miller, W. R., & Brown, J. (in press). Reliability of the

Form 90. Journal of Studies on Alcohol,

Tichenor, V, & Hill, C. E. (1989). A comparison of six measures of

working alliance. Psychotherapy, 26, 195-199.

Tracey.T J., & Kokotovic, A. M. (1989). Factor structure of the Work-

ing Alliance Inventory. Psychological Assessment, 1, 207-210.

Wanberg, K. W., Horn, J. L., & Foster, F. M. (1977). A differential as-

sessment model for alcoholism: The scales of the Alcohol Use Inven-

tory. Journal of Studies on Alcohol, 38, 512-543.

Received August 27, 1996

Revision received January 9, 1997

Accepted January 23, 1997 •