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Sulaman I, Hartley S, Elvins R. Therapeutic alliance in the treatment of adolescent substance misuse: a systematic review. Child Adolesc Ment Health 2024; 29:226-241. [PMID: 37528449 DOI: 10.1111/camh.12671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Therapeutic alliance has been found to play an influential role in predicting outcomes for adults and adolescents in psychotherapy. However, thus far, the information concerning the impact of therapeutic alliance on outcomes for adolescents in treatment for substance misuse has not yet been critically synthesised. METHODS In accordance with PRISMA guidelines, the current review aimed to systematically collate published research investigating the association between alliance and outcomes for adolescents undergoing substance misuse treatment. Database searching produced 1083 records, with 16 studies meeting eligibility criteria. RESULTS Twelve out of the 16 studies (75%) reported significant alliance-outcome relationships, whereby higher alliance ratings predicted better treatment outcomes, as well as improved engagement and retention in treatment. In addition, the review explored the conditions whereby alliances better predict outcomes, with reference to the alliance rater, the timing of the alliance rating and comorbid diagnoses. These results, however, largely remain inconclusive. CONCLUSIONS The evidence as it stands demonstrates the importance of the therapeutic alliance in predicting outcomes for adolescents in substance misuse treatments. The implications of the review's findings and recommendations for future research are discussed.
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Affiliation(s)
- Iniyah Sulaman
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK
- GMMH NHS Foundation Trust, Manchester, UK
| | - Samantha Hartley
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK
- CAMHS at Pennine Care NHS Foundation Trust, Manchester, UK
| | - Rachel Elvins
- Royal Manchester Children's Hospital & Salford CAMHS, Manchester, UK
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Boson K, Anderberg M, Melander Hagborg J, Wennberg P, Dahlberg M. Adolescents with substance use problems in outpatient treatment: a one-year prospective follow-up study focusing on mental health and gender differences. Subst Abuse Treat Prev Policy 2022; 17:53. [PMID: 35840967 PMCID: PMC9284845 DOI: 10.1186/s13011-022-00482-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/22/2022] Open
Abstract
Background Although several studies have found a high incidence of coexisting mental health problems among adolescents with substance use problems, follow-up studies addressing how these conditions change over time are rare. The study will describe and analyze indications of mental health problems and how various risk factors predict outcomes 1 year after initial treatment contact. In addition, gender-specific risk factors are explored. Methods A clinical sample of 455 adolescents (29% girls, median age 17 years) answered a structural interview at baseline and were followed up using official records 1 year after initiated treatment. Bivariate associations and logistic regressions were conducted to analyse the links between risk factors at the individual, social, and structural levels as well as links between various mental illness symptoms at treatment start and indications of mental health problems 1 year later were analysed. Results The results show that mental health problems among adolescents largely persisted 1 year after start of outpatient care for substance use problems. Forty-two per cent of the sample displayed indications of mental health problems at follow-up, and registrations for both outpatient treatment and psychiatric medication were more common among the girls. Girls also reported more mental illness symptoms at treatment start than boys did, especially anxiety. Depression and suicidal thoughts had predictive values regarding indications of mental health problems and small cumulative effects were found for 6–10 co-occurring risk factors. Conclusions Adolescents with depression and suicidal thoughts at treatment start should yield attention among clinicians as these general risk factors could predict indication of mental health problems at 1 year follow-up effectively. Also, patients with more than six co-occurring risk factors seem more vulnerable for continued mental health problems. Generally, girls displayed a greater mental health and psychosocial burden at treatment initiation and were more likely to show indication of mental health problems at follow-up. These results suggests that girls are more likely to get psychiatric out-treatment parallel to, or after, substance abuse treatment. We recommend further investigation of gender differences and gender-specific needs in substance use treatment.
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Nairn SA, Audet M, Stewart SH, Hawke LD, Isaacs JY, Henderson J, Saah R, Knight R, Fast D, Khan F, Lam A, Conrod P. Interventions to Reduce Opioid Use in Youth At-Risk and in Treatment for Substance Use Disorders: A Scoping Review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2022; 67:881-898. [PMID: 35535396 PMCID: PMC9659799 DOI: 10.1177/07067437221089810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Youth and young adults have been significantly impacted by the opioid overdose and health crisis in North America. There is evidence of increasing morbidity and mortality due to opioids among those aged 15-29. Our review of key international reports indicates there are few youth-focused interventions and treatments for opioid use. Our scoping review sought to identify, characterize, and qualitatively evaluate the youth-specific clinical and pre-clinical interventions for opioid use among youth. METHOD We searched MedLine and PsycInfo for articles that were published between 2013 and 2021. Previous reports published in 2015 and 2016 did not identify opioid-specific interventions for youth and we thus focused on the time period following the periods covered by these prior reports. We input three groups of relevant keywords in the aforementioned search engines. Specifically, articles were included if they targeted a youth population (ages 15-25), studied an intervention, and measured impacts on opioid use. RESULTS We identified 21 studies that examined the impacts of heterogeneous interventions on youth opioid consumption. The studies were classified inductively as psycho-social-educational, pharmacological, or combined pharmacological-psycho-social-educational. Most studies focused on treatment of opioid use disorder among youth, with few studies focused on early or experimental stages of opioid use. A larger proportion of studies focused heavily on male participants (i.e., male gender and/or sex). Very few studies involved and/or included youth in treatment/program development, with one study premised on previous research about sexual minority youth. CONCLUSIONS Research on treatments and interventions for youth using or at-risk of opioids appears to be sparse. More youth involvement in research and program development is vital. The intersectional and multi-factorial nature of youth opioid use and the youth opioid crisis necessitates the development and evaluation of novel treatments that address youth-specific contexts and needs (i.e., those that address socio-economic, neurobiological, psychological, and environmental factors that promote opioid use among youth).
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Affiliation(s)
- Stephanie A Nairn
- Département de Psychiatrie, Faculté de Médecine, Université de Montréal, Montréal, Québec, H3T 1J4, Canada.,Centre de Recherche, CHU Ste-Justine, Montréal, Quebec, H3T 1C4, Canada.,Department of Sociology, 5620McGill University, Montreal, Quebec, H3A 2T7, Canada
| | - Marion Audet
- Département de Psychiatrie, Faculté de Médecine, Université de Montréal, Montréal, Québec, H3T 1J4, Canada.,Centre de Recherche, CHU Ste-Justine, Montréal, Quebec, H3T 1C4, Canada
| | - Sherry H Stewart
- Department of Psychiatry, 3688Dalhousie University, Halifax, Nova Scotia, B3H 2E2, Canada.,Department of Psychology & Neuroscience, 3688Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lisa D Hawke
- 7978Centre for Addiction and Mental Health, Toronto, Ontario, M6J 1H4, Canada
| | - Jason Y Isaacs
- Department of Psychiatry, 3688Dalhousie University, Halifax, Nova Scotia, B3H 2E2, Canada
| | - Joanna Henderson
- 7978Centre for Addiction and Mental Health, Toronto, Ontario, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, M5T 1R8, Canada
| | - Rebecca Saah
- Cumming School of Medicine, 70401University of Calgary, Calgary, Alberta, T2N 4N1, Canada.,Department of Community Health Sciences, 70401University of Calgary, Calgary, Alberta, T2N 4Z6, Canada
| | - Rod Knight
- British Columbia Centre on Substance Use, Vancouver, British Columbia, V6Z 2A9, Canada
| | - Danya Fast
- British Columbia Centre on Substance Use, Vancouver, British Columbia, V6Z 2A9, Canada
| | - Faria Khan
- Cumming School of Medicine, 70401University of Calgary, Calgary, Alberta, T2N 4N1, Canada.,Department of Community Health Sciences, 70401University of Calgary, Calgary, Alberta, T2N 4Z6, Canada
| | - Alice Lam
- Research Centre du Chum, Montreal, Quebec, H2X 0C1, Canada
| | - Patricia Conrod
- Département de Psychiatrie, Faculté de Médecine, Université de Montréal, Montréal, Québec, H3T 1J4, Canada.,Centre de Recherche, CHU Ste-Justine, Montréal, Quebec, H3T 1C4, Canada
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Anderberg M, Dahlberg M, Wennberg P. Adolescents with substance abuse problems in outpatient treatment: A one-year prospective follow-up study. NORDIC STUDIES ON ALCOHOL AND DRUGS 2022; 38:466-479. [PMID: 35308818 PMCID: PMC8900184 DOI: 10.1177/1455072521995611] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 01/29/2021] [Indexed: 11/17/2022] Open
Abstract
Aim: There is a lack of knowledge about how adolescents with substance abuse problems manage after taking part in treatment. It is also difficult to perform traditional follow-up studies with this group. This article presents the outcome of a prospective study of 455 adolescents who underwent outpatient treatment, based on data taken from official registers. It aims to describe and analyse indications of continued use of substance (CUS) and how various risk and protective factors predict outcomes after initiated treatment at a Maria clinic in Sweden. Design: The study is based on structured interviews at intake, and the data that indicated CUS were taken from several different national registers. The analyses included descriptive data and bivariate associations, logistic regressions and a CHAID analysis. Results: Almost two thirds of the adolescents have no indication of CUS at one-year follow-up. The ten studied risk factors independently were weak predictors of CUS and it was instead the accumulation of risk factors that were linked to a negative outcome. Conclusion: The majority of adolescents who start outpatient treatment for substance abuse problems return to a lesser extent in registers that may indicate a continued problem with alcohol and drugs one year later. A concentration of more than five risk factors appears to be associated with a registration. The study also provides an example of an alternative method for following up adolescents with alcohol and drug abuse problems.
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Gidhagen Y, Holmqvist R, Philips B, Falkenström F. The role of the working alliance in psychological treatment of substance use disorder outpatients. Psychother Res 2020; 31:557-572. [PMID: 32838697 DOI: 10.1080/10503307.2020.1807639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Objective: The main objective of this study was to explore the relationship between alliance and treatment outcome of substance use disorder (SUD) outpatients in routine care. Attachment, type of substance use, and treatment orientation were analyzed as potential moderators of this relationship.Method: Ninety-nine SUD outpatients rated their psychological distress before every session. Patients and therapists rated the alliance after every session. At treatment start and end, the patient completed the Alcohol Use Disorders Identification Test (AUDIT), the Drug Use Disorders Identification Test (DUDIT), and the Experiences in Close Relationships (ECR-S). Data were analyzed using multilevel growth curve modeling and Dynamic Structural Equation Modeling (DSEM).Results: The associations between alliance and outcome on psychological distress and substance use were, on average, weak. Within-patient associations between patient-rated alliance and outcome were moderated by self-rated attachment. Type of abuse moderated associations between therapist-rated alliance and psychological distress. No moderating effect was found for treatment orientation.Conclusions: Patients' attachment style and type of abuse may have influenced the association between alliance and problem reduction. A larger sample size is needed to confirm these findings.
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Affiliation(s)
- Ylva Gidhagen
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Rolf Holmqvist
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Björn Philips
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Fredrik Falkenström
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
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Richert T, Anderberg M, Dahlberg M. Mental health problems among young people in substance abuse treatment in Sweden. Subst Abuse Treat Prev Policy 2020; 15:43. [PMID: 32580732 PMCID: PMC7315521 DOI: 10.1186/s13011-020-00282-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/06/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Young people with substance use problems face a high risk of co-occurring mental health problems, something that may involve a more difficult life situation, social problems as well as worse treatment outcomes. The aim of this study is to analyse self-reported mental health problems among young people receiving outpatient treatment for substance use problems in Sweden. We explore what types of mental health problems are more or less predominant, and whether there are significant differences between boys and girls. In addition, we analyse how various mental health problems covary with indicators of substance abuse severity. METHODS The study is based on structured interviews with 1970 young people enrolled at outpatient clinics in 11 Swedish cities. The data was analysed through frequency- and averages-calculations, Chi-square tests and multivariate logistic regression analyses. RESULTS Self-reported mental health problems were common among the young people in the study. A relatively large percentage of the total group (34-54%) reported problems such as concentration difficulties, sleeping difficulties, anxiety and depression. At the same time, many of the young people did not report any symptoms and only a small group, about 20%, reported diagnosed mental health disorders. The results show substantial gender differences, with girls reporting significantly higher levels of mental health problems. Multivariate logistic regression analyses demonstrated significant associations between severity of drug use problems and anxiety, concentration difficulties, aggression, hallucinations and mental stress caused by experiences of trauma. CONCLUSIONS Treatment needs are diverse within this group of young people who use drugs. Since girls report higher levels of all mental health problems, and a larger burden of psychosocial risk factors than boys, they are likely to require more comprehensive treatment interventions. The link between more severe drug problems and mental health problems points to the importance of exploring this relationship in treatment. A multidisciplinary approach, in which co-occurring problems can be addressed simultaneously, may be the best treatment form for many young people with drug problems.
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Affiliation(s)
- Torkel Richert
- Department of Social Work, Malmö University, Citadellsvägen 7, 211 18 Malmö, Sweden
| | - Mats Anderberg
- Department of Pedagogy and Learning, Linnaeus University, Växjö, Sweden
| | - Mikael Dahlberg
- Department of Pedagogy and Learning, Linnaeus University, Växjö, Sweden
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Murphy R, Hutton P. Practitioner Review: Therapist variability, patient-reported therapeutic alliance, and clinical outcomes in adolescents undergoing mental health treatment - a systematic review and meta-analysis. J Child Psychol Psychiatry 2018; 59:5-19. [PMID: 28681928 DOI: 10.1111/jcpp.12767] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Previous meta-analyses have only found small correlations (r = .10 to r = .19) between therapeutic alliance and clinical outcomes in samples of adolescents receiving psychological therapy. Although study-level variables have been found to moderate this, little is known about the impact of therapist variability. The present meta-analysis aimed to address this gap by using patient-therapist ratio as a moderator variable. METHODS Contrary to previous reviews of adolescent alliance, individual effect sizes were extracted using a preregistered conceptual hierarchy. Controlling for treatment-level confounds, a random effects meta-analysis assessed the moderating effect of patient-therapist ratio on the alliance-outcome relationship in predefined single-predictor and multipredictor meta-regressions. RESULTS The alliance-outcome relationship was found to be larger than previously thought (k = 28, N = 2,911, r = .29, 95% Confidence Interval 0.21, 0.37; p < .0001, I2 = 80%). When study samples exceeding the adolescent 12-19 age range were removed, the correlation rose (k = 15, N = 1,797, r = .34, 95% Confidence Interval 0.23, 0.45; p < .0001, I2 = 83%). In contrast to research with adults, patient-therapist ratio did not moderate this relationship in either single-predictor (p = .26) or multi-predictor (p = .22) models. CONCLUSIONS The alliance-outcome relationship for adolescents was larger than previously thought, and comparable to estimates in adult samples. The failure of patient-therapist ratio to moderate its strength, however, challenges the hypothesis that variability in therapist characteristics is an important determinant of the alliance-outcome effect in this age group.
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Affiliation(s)
- Regina Murphy
- Child & Adolescent Mental Health Service, Kirkwall Health Centre, Kirkwall, UK
| | - Paul Hutton
- School of Health & Social Care, Edinburgh Napier University, Edinburgh, UK
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Labouliere CD, Reyes JP, Shirk S, Karver M. Therapeutic Alliance With Depressed Adolescents: Predictor or Outcome? Disentangling Temporal Confounds to Understand Early Improvement. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2015; 46:600-610. [PMID: 26042461 DOI: 10.1080/15374416.2015.1041594] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Psychotherapy research reveals consistent associations between therapeutic alliance and treatment outcomes in the youth literature; however, past research frequently suffered measurement issues that obscured temporal relationships between alliance and symptomatology by measuring variables later in therapy, thereby precluding examination of important early changes. The current study aimed to explore the directions of effect between alliance and outcome early in therapy with adolescents by examining associations between first- and fourth-session therapeutic alliance and symptomatology. Thirty-four adolescents (∼63% female, 38% ethnic/racial minority) participated in a school-based cognitive-behavioral therapy for adolescents with depression. Participants completed the Beck Depression Inventory at baseline and Session 4, and therapeutic alliance was coded from audiotapes of Sessions 1 and 4 by objective coders using the Alliance Observation Coding System. Autoregressive path analyses determined that first-session therapeutic alliance was a strong significant predictor of Session 4 depression symptoms, but pretreatment depression scores were not significantly predictive of subsequent therapeutic alliance. Adding reciprocal effects between alliance and depression scores did not adversely affect model fit, suggesting that reciprocal effects may exist. Early therapeutic alliance with adolescents is critical to fostering early gains in depressive symptomatology. Knowing alliance's subsequent effect on youth outcomes, clinicians should increase effort to foster a strong relationship in early sessions and additional research should be conducted on the reciprocal effects of therapeutic alliance and treatment outcome in adolescence.
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Affiliation(s)
- Christa D Labouliere
- a Division of Child & Adolescent Psychiatry , New York State Psychiatric Institute at Columbia University Medical Center
| | - J P Reyes
- b Outpatient Department , New York-Presbyterian Hospital - Westchester Division
| | | | - Marc Karver
- d Department of Psychology , University of South Florida
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