The Revised Helping Alliance Questionnaire (HAq II)vuir.vu.edu.au/19368/16/260.pdf · 2012. 2. 29. · HAq-II patient version filledoutatsession 2 byusing aprincipal components analysis

VOLUME 5 #{149}NUMBER 3 #{149}SUMMER 1996

The Revised Helping Alliance

Questionnaire (HAq - II)

Psychometric Properties

LESTER LUBORSKY, PH.D.

JACQUES P. BARBER, Pi-i.D.

LYNNE SIQUELAND, PH.D.

SUZANNE JOHNSON, B.A.

LISA M. NAJAVITS, PH.D.

ARLENE FRANK, PH.D.

DENNIS DALEY, M.S.W.

The concept of the therapeutic alliance andits operationalization have received much at-tention in recent years. One of the early self:report measures of tize therapeutic alliancewas the Helping Alliance questionnaire(HAq-I). This scale was recently revised to ex-clude the items that explicitly reflect improve-ment. Using the revised 19-item HAq-II on asample of246 patients diagnosed with DSM-III-R cocaine dependence, the authors foundthat the new scale had excellent internal con-sistency and test-retest reliability. Further, theHAq-II demonstrated good convergent valid-ity with the Cal�fbrnia Psychotherapy Alli-ance Scale (CALPAS) total score. Alliancelevels as measured by the CALPAS or theHe�ping Alliance questionnaire during earlysessions were not associated with pretreat-ment psychiatric severity or level of depression.

(The Journal of Psychotherapy Practice

and Research 1996; 5:260-271)

D escription and measurement of the thera-peutic alliance based on the collabora-

tion and bond between therapist and patienthas been a major focus of theoretical andempirical studies in the last two decades.Many measures have been developed to assessthe construct of the therapeutic alliance.Helped by Bordin’s’ theoretical division of thealliance into “goals, tasks, and bonds,” Lubor-

skf introduced the quantitative concept of the

Helping Alliance with three different types of

measures composed of similar items: theHelping Alliance Global Rating method,3 theHelping Alliance Counting Sign method,4 andthe self-report Helping Alliance question-naire5 (L Luborsky et al., “The Penn HelpingAlliance Questionnaire (HAq-I): Its Composi-

Received July 20, 1994; revised September 12, 1995;

accepted September 20, 1995. From the Center for Psy-chotherapy Research, University of Pennsylvania School

of Medicine, Philadelphia, Pennsylvania Harvard Medi-cal School, Boston, Massachusetts; and Western Psychi-atric Institute and Clinic, Pittsburgh, Pennsylvania.Address correspondence to Dr biborsky, 514 Spruce

Street, Philadelphia, PA 19106.Copyright 01996 American Psychiatric Press, Inc.

LUBORSKY ETAL. 261

JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

tion and Research Supports,” submitted for

publication, 1995).The Helping Alliance methods, as well as

other measures of the therapeutic alliance,have been successful predictors of outcome.

Summarizing 24 studies, Horvath and Sy-monds6 showed that the average effect size ofthe correlation between alliance and outcomewas estimated as r= 0.26. This was a conser-vative estimate because the authors consid-ered all nonsignificant findings where thevalue of the correlation was not presented bythe original authors as r= 0.0.

In recent years, we have become awarethat the HAq-I was limited by the presenceof items that were explicitly assessing earlysymptomatic improvement7’8 and by the factthat all the items were worded positively. Toaddress these limitations, we deleted the 6items reflecting early improvement andadded 14 new items that appeared to tapmore fully the various aspects of the allianceas described by Bordin’ and Luborsky.2 Fiveof the new items related to the collaborativeeffort of patient and therapist; for example,“The therapist and I have meaningful ex-

changes.” Five additional items addressedthe patient’s perception of the therapist; for

example, “At times I distrust the therapist’sjudgment.” One of the other added itemsdealt directly with the patient’s motivation:“I want very much to work out my prob-lems”; and one other was related to thepatient’s perception of the therapist’s feel-ings about the patient: “I believe that the

therapist likes me as a person.” In contrastto the previous version, the revised HAq(hereafter referred to as the HAq-II) in-cluded five items that were worded nega-tively; for example, “The procedures used inmy therapy are not well suited to my needs.”

In the present article we describe thepsychometric properties of the HAq-II. Wealso examine its relations with anotherwidely used measure of the alliance, the

California Psychotherapy Alliance Scale7’9(CALPAS) and with selected sociode-mographic variables.

METHODS

Subjects

Participants in this study were 246 out-patients drawn from a total sample of 313outpatients with a DSM-III-R diagnosis of

cocaine dependence who were randomized

to one of four treatment conditions de-scribed below as part of their participationin the training/pilot phase of the NationalInstitute on Drug Abuse (NIDA) Cocaine

Collaborative Study (CCS). The study is co-ordinated from a center at the University ofPennsylvania and is being conducted thereand at Brookside Hospital, McLean/Massa-chusetts General Hospital, and Western Psy-chiatric Institute and Clinic.

Exclusion criteria included history of bi-polar disorder, psychotic symptoms or disor-der, organic brain syndrome, current opioiddependence, current active suicidal or homi-cidal potential, medical contraindication, orhomelessness.

At intake, the patients’ average age ( ± SD)was 33±6.6 years (range 19-59); 69% of thepatients were male and 31% were female.Fifty-six percent were Caucasian, 41% AfricanAmerican, and 3% Hispanic or American In-dian. Sixty-one percent of the patients wereemployed. Seventy-six percent of the patientslived alone, and 24% were married or lived

with a partner. Seventy-five percent of thesample were primarily crack users, 21% wereprimarily snorters, and 4% primarily injectedcocaine. On average at the time of intake,patients were using cocaine 8.9 days permonth and were spending more than $1,000 amonth on drugs. Fifty-two percent of patientshad other substance dependence diagnoses(mostly alcohol dependence), and 55% had apersonality disorder diagnosis, of which group20% had antisocial personality disorder. Inaddition, 15% of patients had a diagnosis ofcurrent depressive disorder (9% current majordepression), and 17% had some other Axis Idiagnosis.

262 HELPING ALLIANCE QUESTIONNAIRE

VOLUMES #{149}NUMBER 3. SUMMER 1996

Treatment

The pilot study was designed to train

therapists and counselors and to finalize the

protocol for a clinical trial to examine the

efficacy of four psychosocial treatments foroutpatients diagnosed with cocaine depen-dence. The treatments were supportive-expressive dynamic therapy’#{176} (SE), apsychodynamic treatment based on Lubor-sky’s model;” cognitive therapy’2 (CT) based

on Beck’s model; individual drug counseling

(IDC) based on the 12-step addiction model(D. Mercer and G. Woody, unpublished,1992); and group drug counseling (GDC), apsychoeducational and problem-solvinggroup treatment also grounded in the 12-stepaddiction model (D. Mercer et at., unpub-lished, 1994). In the pilot phase, patients wererandomized to one of the treatment conditionsafter a brief stabilization phase in which pa-tients had to establish that they could achievea period of initial abstinence measured by 3consecutive drug-free urine screens within 30days. All patients in the individual conditionsalso received the GDC treatment. Those pa-tients randomized to the GDC-alone condi-tion received only the group treatment. Groupsessions were held twice a week for 2 months

and once a week for the next 4 months. Theactive phase of the individual treatment wasalso 6 months long and consisted of twice-

weekly sessions for the first 3 months of treat-ment and once-weekly sessions for months4-6. Three to six booster sessions were offered

to patients who had stayed in active treatmentfor the full 6 months.

Therapists and drug counselors had beenselected by their training units on the basis ofa combination of background education and

training, letters of reference, and two audio-taped samples of their therapy/counselingwork. Educational requirements for SE andCT therapists were the same (a Ph.D., M.S.W,or M.D.), but the experience criteria differed.SE required 3 to 4 years of postgraduate clini-cal experience; CT required 6 months of post-graduate experience for M.S.Ws, 1 year for

Ph.D.s, or, for M.D.s, 1 year of supervisedindividual CT experience during residency.The SE and CT therapists recruited to thisstudy had performed an average of 9.9 and

10.6 years of postgraduate clinical work, re-

spectively.Drug counselors could not exceed certain

levels of qualifications. The highest terminal

degree allowable was a bachelor’s degree in amental health-related field, a counseling cer-tificate, or a master’s degree in addiction coun-seling (Certified Alcoholism Counselor). Allcounselors were required to have 2 to 3 years

of drug counseling experience, and, if in re-covery themselves, to have at least 5 years inrecovery.

Measures

Beck Depression Inventorf (BDI). This is a

21-item self-report measure of depression. It isa much-used, reliable measure of depressivesymptoms.’4

Helping Alliance questionnaire (HAq-II).The original HAq-I5 is a widely used 11-itemquestionnaire that measures the strength of thepatient-therapist therapeutic alliance. To makeup the 19 items of the HAq-II, 6 items wereremoved from the HAq-I and 14 new items

were added. Each item is rated on a 6-point

Likert scale (1 = I strongly feel it is not true, 6

= I strongly feel it is true). Both a patient and

a therapist version were developed. Nega-tively worded items are reverse scored. The

patient version is reproduced as Appendix A.Addiction Severity Index’s (ASI). The ASI is

a structured interview that assesses the pa-tient’s lifetime and current (last 30 days) func-tioning in seven target areas related tosubstance use: medical status, employmentstatus, alcohol use, drug use, legal status, psy-chiatric status, and family/social relationships.The measure offers composite scores for each

target area as well as severity ratings. It hasbeen shown to be reliable and valid.’6”7 Test-retest reliability of 0.83 or higher is reported

on all scales.’8 We report here only the drug

use and psychiatric composite scores because

LUBORSKY ETAL. 263


these are prognostic factors that might affect,

or have been shown to affect, the estab-lishment of alliance.’9

BriefSymptom j�.#�/o (BSI). � is a

brief, 53-item version of the self-report Symp-tom Checklist-90-Revised, a measure of psy-chiatric symptoms. Each item is rated on a5-point Likert scale that ranges from “not at all

distressed” to “extremely distressed.” Themeasure yields three global indicators andnine symptom dimensions. The global sever-ity index (GSI), the mean of the 53 items, is

used in the current study. Reliability and va-lidity data on the measure are reviewed inDerogatis.2’

Ca4f#{244}rniaPsychotherapy Alliance7’9 (CAL-PAS). This is a 24-item questionnaire with a7-point Likert scale (1= not at all, 7= verymuch so). The CALPAS is composed of fourscales: Patient Working Capacity, PatientCommitment, Therapist Understanding andInvolvement, and Working Strategy Consen-sus. Like the HAq, the CALPAS has both apatient and a therapist version. Reliability andvalidity are reviewed in Gaston.7

Cocaine Invento,y. This is a measure modi-

fied for this study from an unpublished mea-sure originally designed by Bristol-Myers

Squibb.22 There are no summary scores forthis measure, but it consists of the followingquestions: how many times she or he has usedcocaine in the last week, how much moneywas spent on cocaine in the last week, themethod of administration, and number oftimes other drugs were used in the last week.In this study, only the first item was used to

reflect that week’s cocaine use.Hamilton Rating Scale Jbr Depression.23 The

Structured Interview Guide for the HamiltonRating Scale for Depression24 (SIGH-D) wasused. Although the 27-item version of the in-terview was administered to patients, thescores reported are for the 17 items in the mostcommonly used version of the Hamilton. TheSIGH-D is a structured clinical interview thatassesses a variety of depressive symptoms,including depressed mood, guilt, neurovege-tative symptoms, hopelessness, helplessness,

and suicidality. The Ham-D and the SIGH-D

are standard measures in the field.Global Assessment of Fursctioning2� (GAF,

DSM-III-R, Axis V). This is a single globalrating scale that takes into account psychologi-

cal, social, and occupational functioning. TheGAF is much the same as the older 100-point

Health-Sickness Rating Scale,26 but it ranges

from 0 to 90. These scores reflect low to highlevels of functioning.

Procedures

Patients filled out the HAq-II and theCALPAS at the end of sessions 2, 5, and 24and the last session of the active phase of

treatment. The therapists filled out the HAq-II

and the CALPAS on the same occasions. Thepatients also completed the Cocaine Inven-

tory prior to each session and had twice-

weekly urine screens for drug use. The BDI,Hamilton, GAF, BSI, and other measureswere administered at intake into the study.

A total of 246 patients completed one ofthe alliance measures at least once. As a result,the ifs differ for the different analyses. Ex-

cluded from the sample are 6 patients who hadto change therapists during treatment becausetheir therapists left the study.

RESULTS

Basic descriptive statistics for the alliance mea-sures at the different points in time are pre-sented in Table 1. One hundred andninety-seven patients filled out both the CAL-PAS-P and the HAq-II at session 2.

Reliability

Internal consistency (Cronbach’s alpha)of the 19-item HAq-II and of the CALPAS(total scale) was measured separately for ses-sions 2, 5, and 24 and was found to reflecthomogeneous scales (Table 2). For example,correlations between corrected item and totalscale for the items of the HAq-II patient ver-sion at session 2 ranged from 0.30 to 0.79.

HAq-P

HAq-P

HAq-P

HAq-T

HAq-T

HAq-T

CALPAS-P

2

5

24

2

5

24

2

5.15 ±0.58

5.26 ± 0.55

5.30 ± 0.62

4.63 ± 0.61

4.72±0.53

4.92 ± 0.57

5.84 ± 0.65

2.11

3.26

1.53

2.42

300

3.00

3.78

6.00

6.00

6.00

5.95

5.95

6.00

6.96

201

182

87

200

178

90

246

CALPAS-P 5 5.90 ± 0.69 3.58 7.00 213

CALPAS-P 24 6.00 ± 0.69 3.65 7.00 92

CALPAS-T 2 457 ± 0.89 1.67 6.96 246

CALPAS-T 5 4.74 ± 0.83 2.75 6.17 206

CALPAS-T 24 4.94 ± 0.97 2.38 6.67 93

.sNote: HAq-P = Helping Alliance questionnaire-I!, Patient version; HAq-T = HAq-ll, Therapist version;CALPAS-P = California Psychotherapy Alliance Scales, Total Scale, Patient version; CALPAS-T = CALPAS,Total Scale, Therapist version.

VOLUME 5 #{149}NUMBER 3 #{149}SUMMER 1996


Only 3 out of 19 correlations were below 0.40,and the median correlation between correcteditem and total was 0.64. Because patientssometimes did not complete a particular itemon a scale or subscale, the number of patientson which the Cronbach’s alphas were com-puted is somewhat lower than the number ofpatients presented in Table 1 for all measures.

Test-retest reliability coefficients for allmeasures, but especially for the HAq-II pa-tient version, were quite high over a three-ses-sion span from session 2 to session 5 (Table 3).A mean (± SD) of 16.3 ± 10.3 days elapsedbetween these sessions. We also examined thecorrelations between the alliance measuresfilled out at session 5 and again at session 24.The correlations that are shown in Table 4provide an index of the stability of the measureover the relatively longperiod of time betweenthose two sessions (a mean of 112.3 ± 41.1days). The degree of similarity between alli-ance ratings at session 5 and at session 24 werequite high. Nevertheless, it needs to be empha-sized that only between 75 and 88 patients andbetween 78 and 88 therapists had scores on thedifferent instruments on these two occasionsbecause of patient attrition and lack of compli-

ance with research requests (where patientsand therapists either were not given the formsor did not fill them out).

Factor Structure

We examined the factorial structure of theHAq-II patient version filled out at session 2

by using a principal components analysis witha varimax rotation. Using the scree test and acriterion of eigenvalues greater than 1, threefactors were extracted. Because the third factorconsisted of only two items (#11 and #14) andexplained only 6% of the variance, this factorwas not retained. Factor 1 (“positive therapeu-tic alliance”) was made up of items 1, 2, 3, 5,

6, 7,9, 10, 12, 13, 15, 17, and 18 and explained43.3% of the variance. Factor 2 (“negativetherapeutic alliance”) was made up of items 4,8, 16, and 19 and explained 10.6% of thevariance. At session 2 the correlation betweenfactors 1 and 2 was found to be r= 0.48 (n=200, P< 0.001). At session 5, the correlationwas r= 0.60 (n= 182, P< 0.001); atsession24,r was 0.64 (n = 87, P< 0.001). Because of thehigh correlations between these two factors at

the different points in time, the high internal

TABLE!. Descriptive statistics of the alliance measures at sessIons 2,5, and 24

VariableSessIon Mean ± SD Minimum Maximum a

LUBORSKY ETAL. 265


consistency of the entire scale, and the smallnumber of items in factors 2 and 3, only theresults using the entire scale are presentedthroughout the rest of this article.

Validity Studies

Convergent Validi�y With Another Measure of theAlliance: Table 5 shows the correlations be-tween the HAq-II and the CALPAS total

scores for both the patient and therapist ver-sions at sessions 2,5, and 24. Large significant

correlations were found between the two mea-sures of alliance when filled out by the sameperson. The correlations between the patientversion of the CALPAS subscales and theHAq-II ranged from 0.38 to 0.71, indicating afair amount of common variance (ranging

from 35% to 49%, depending on the subscaleand the session measured). The relation be-tween the therapists’ version of the CALPASand HAq-II tended to be slightly higher thanthe patients’ correlations, ranging from 0.61 to

0.79.

Dsscriminant Validity: Alliance versus sociode-mographic variables: Correlations between thealliance measures early in treatment and age,race, gender, marital status, and employmentwere also computed. As expected, no relation

between those variables and either measure ofalliance at session 2 or sessionS was found.

Discnminant Validity: Alliance versus pretreat-ment measures ofseverfty ofpsychiatric dysfunctionand drug use: To examine the discriminant

validity of the alliance and psychiatric sever-ity, we computed correlations among thosevariables. As shown in Table 6, neither mea-sure of alliance was associated with intake

measures of psychological functioning (GAo,

psychiatric severity (ASI psychiatric severityand BSI), drug use (ASI drug use), or depres-sion level (Hamilton Depression and BDI).Because of the number of correlations done,we corrected the alpha level by dividing it by12. There was no indication that higher alli-

ance was related to intake measures of symp-tom severity. Furthermore, inspection of thedata in Table 6 does not reveal any differencesin the patterns of correlations of the HAq-II orof the CALPAS.

D�scnminant Validity: Alliance versus concurrentmeasures of severity of psychiatric dysfunction anddrug use: To complete this further analysis,

we looked at the symptom measures that wereavailable at the time the alliance question-naires were filled out. The only session mea-sure given to the patient at the same time as

the alliance measure was the Cocaine Inven-tory. We examined the correlations betweenone item on this instrument (“How many timeshave you used cocaine in the last week?”) andthe respective alliance measures at both ses-

TABLE 2. Internal consistency of HAq-I! and CALPAS for patient and therapist versions and theircorrelations

Scale SessIon 2 SessIon 5 SessIon 24

HAq-!!-Patient 0.90

(n=174)

0.90

(n=171)

0.93

(n=83)

HAq-H-Therapist 0.93

(n=193)

0.90

(n=169)

0.91

(n=88)

CALPAS-Patient 0.80

(n=217)

0.94

(n=217)

0.84

(n= 199)

0.94

(n=188)

0.82

(n=83)

0.95

(n=87)

CALPAS-Therapist

.1 Note: HAq-il-P= Helping Alliance questionnaire-il, Patient version; HAq-II-T= HAq-II, Therapist version;

CALPAS-P = California Psychotherapy Alliance Scales, Total Scale, Patient version; CALPAS-T= CALPAS,Total Scale, Therapist version.

HAq-II

CALPAS Total

0.78 0.56

(n=168) (n=166)

0.59 0.53

(n=197) (n=194)

0.46 0.44

0.55 0.53

0.50 0.49

0.34 0.59

TABLE 4. Correlations of the HAq-II and the CALPAS between sessions 5 and 24: stabilIty

Scale Patient Version Therapist Version

aNok: HAq-il = Helping Alliance questionnaire-il; CALPAS = California Psychotherapy Alliance Scales, TotalScale.P<0.0l; “P<0.005; “P<000l.


VOLUMES #{149}NUMBER 3 #{149}SUMMER 1996

sion 2 and 5. Because the number of times

cocaine was used was not distributed normally(many patients had not used in the last week),we calculated Spearman rank correlations. Asshown in the bottom row of Table 6, we foundthat the higher the alliance (as measured bythe HAq-II and the CALPAS), the lower theamount of drug use during the same week. Thecorrelations were significant for session 5, al-though not for session 2.

DiscuSSION

In this report we present psychometric data onthe HAq-II, an improved version of the HAq-Iin composition and length. Both patient andtherapist versions of the new scale showed

good internal consistency and test-retest reli-ability even though the latter coefficientsmight have been reduced by opportunities forchanges in the patient-therapist relationshipoccurring in the normal course of treatment.Long-term stability of the alliance in thosepatients who stayed in treatment until at least

session 24 also was found to be adequate

considering the amount of time between thetwo sessions.

In terms of convergent validity, the HAq-

II demonstrated high convergence with an-other, widely used self-report measure ofalliance, the CALPAS total score (correlationsof 0.59 to 0.69 for the patient version and 0.75to 0.79 for the therapist version; Table 5). Thiswas the first demonstration of this agreement;

TABLE 3. That-retest reliability of the HAq -II and the CALPAS ov cr3 sessions (from session 2 to 5) forpatient and therapist versions

Scale Patient Version Therapist Version

Patient Working Capacity

Patient Commitment

Working Strategy Consensus

Therapist Understanding

and Involvement

.�Note: HAq-II = Helping Alliance questionnaire-I!; CALPAS = California Psychotherapy Alliance Scales, TotalScale. All P<0.001.

HAq-II

CALPAS Total

Working Capacity

Patient Commitment

Working Strategies


0.34”

(n=74)

0.49

(n=85)

0.39”

0.52

0.36”

0.28’

0.55m

(n=78)

0.52

(n=88)

0.41

0.54

0.48’”

0.46m

TABLE 5. Correlations between HAq-II and CALPAS subscales and total filled out by patients andtherapists at sessions 2,5, and 24

Session

Patient

2

Therapist

HAq4I

SessIonS

Patient TherapistSession

Patient

24

TherapistScale (u-’197) (a-200) (is-182) (ii-174) (a-92) (s-87)

CALPAS scale

Working Capacity

Patient Commitment

0.43

0.38

0.63

0.74

0.45

0.54

0.64

0.77

0.39

0.59

0.62

0.72

Working Strategies


0.57

0.53

0.75

0.64

0.69

0.58

0.68

0.61

0.71

0.63

0.70

0.69

CALPAS Total 0.59 0.79 0.68 0.79 0.69 0.75

.o�Nok: HAq-il = HelpingScale. All P<0.001.

Alliance questionnaire-il; CALPAS = California Psychotherapy Alliance Scales, Total

LUBORSKY ETI4L. 267


an earlier study had reported low convergence

between the Helping Alliance Rating Scale

and the CALPAS? That study, however, usedrater-based methods, rather than self-report, to

assess alliance. It thus seems that, at least in

cocaine-dependent patients. the two self-re-port measures converge, although further

studies are needed to generalize across clinicalsamples. The level of convergence is also evi-dent when comparing the two measures quali-tatively. Five of the items from each scale are

virtually the same, and several others are veryclose in meaning.

One of the most important changes intro-duced in this new version of the HAq is theattempt to eliminate items that directly reflectsymptomatic improvement.28 Neither of the

alliance measures in the early sessions of ther-apy was associated with intake measures, indi-cating that the alliance is not a function ofpretreatment symptomatology. This finding

supports the discriminant validity of bothmeasures of alliance and is consistent with thereport of Gaston et al.,29 who similarly founda lack of relation between the Hamilton De-pression Scale and the CALPAS in a group of

elderly depressed patients.Nevertheless, lower drug use in the pre-

vious week was found to be associated withrelatively better alliance at sessionS, althoughnot at session 2. Because this finding was con-sistent across both the CALPAS and the HAq,

and because the CALPAS has not been criti-cized as reflecting early improvement, it is ourimpression that the present results reflect therelation between alliance and outcome. Thisfinding is consistent with Fenichel’s3#{176} observa-

tion that greater cocaine use is associated with

poor alliance because drug abusers’ involve-ment with the addictive substance minimizes

meaningful involvement with people.It may be presumptuous on our part to

expect that alliance measures will be com-pletely independent from early symptomaticimprovement, since patients are likely to feel

better about the therapist (increased alliance)when they experience the therapist as helpfuland symptoms are relieved. Moreover, beinghelped is likely to generate the expectationthat additional help may be forthcoming.Therefore, the best one can hope for in termsof developing measures of alliance is to mini-mize items that manifestly reflect early im-provement. In the present study we haveshown that the pattern of associations betweenthe HAq-II and early symptomatic improve-ment is no different from the pattern of rela-tions between the CALPAS-P and earlysymptomatic improvement. Further, becausealliance is sometimes related to early symp-

tomatic improvement, this covariation has to

be partialed out as Gaston and colleagues didwhen predicting outcome2�

The initial results on the validity of the

TABLE 6. Correlations between alliance at sessIon 2 and sessIon 5, as viewedmeasures of psychiatric severity and concurrent drug use

by the patient, and intake

Measure

CALPAS

SessIon 2 Session 5 Session 2

HAq-II

SessIon 5

Intake measures

ASI PSYCH

n

0.04

235

0.04

203

0.05

192

0.12

173

AS! drug use

Is

-0.01

240

0.07

207

-0.08

199

0.02

180

BD!

n

-0.09

220

0.04

189

-0.07

181

0.01

162

SIGH-D

n

-0.01

231

0.03

202

-0.10

191

0.03

175

GAF

n

-0.01

235

0.02

205

0.03

195

-0.02

177

BSI (GSI)

n

-0.05

225

-0.03

194

-0.03

183

0.03

165

Cocaine use

n

-0.05

244

-0.01

212

-0.09

200

0.02

181

-0.01

214

-0.21”

189

-0.09

179

-0.18’

163Is

Concurrent measure of drug use

Times cocaine useda

.�Note: HAq-II = Helping Alliance questionnaire-I!. CALPAS = California Psychotherapy Alliance Scales, TotalScale. AS! = Addiction Severity Index; PSYCH = Psychiatric severity composite; Drug use = drug use

composite; BD! = Beck Depression Inventory; SIGH-D = Structured Interview Guide for the Hamilton RatingScale for Depression; GAP = Global Assessment of Functioning; BSI = Brief Symptom Inventory; GS! = globalseverity index; Cocaine use = cocaine use at intake for the last 30 days; Times cocaine used = during last week.a5��an rank correlation.P< 0.05; “P< 0.001.


VOLUME 5. NUMBER 3 #{149}SUMMER 1996

HAq-II are promising, and we recommend

this version of the alliance measure as an

improvement over the HAq-I. Nevertheless,

there are several limitations. Although the

overall patterns of results obtained in the pres-

ent sample of cocaine-dependent patients do

not seem to deviate from results in more “neu-

rotic” samples,28 further experience with the

HAq-II in nonaddicted patients would in-

crease confidence in the generalizability of the

present findings. Moreover, the HAq-I andHAq-II have not yet been administered con-currently. Therefore, it cannot be concluded

with confidence that the present version is, in

general, more valid than the older one or,

more specifically, that it reduces the inclina-

tion toward measuring early improvement.

Nevertheless, data from this study suggest that

the HAq-II provides some improvement in

the measurement of the alliance over the HAq-

I, since the pattern of covariation between the

HAq-II and other variables does not differ

from the pattern of covariation between the

CALPAS-P and other variables.

This research was supported in part by NationalInstitute on Drug Abuse Research Scientist Award2K05 DA00168-24 and by NIDA Grant 5U18DA07085 (to Lester Lubors/cy); 5R01 DA08237(to Jacques P. Barber); and NIMH Clinical Re-search Center Grant P50 MH451 78 and Coordi-nating Center Grant U18-DA07090 (to PaulGrits-Christ oph).

The NIDA Cocaine Collaborative Study is aNIDA -funded cooperative agreement involvingfourclinical sites, a coordinating center, and NIDA staff

LUBORSKY ETAL. 269


The coordinating center at the University of Penn-�sylvania, Philadelphia, PA, includes Paul Grits-Christoph, Ph.D., Principal Investigator (P1);Lynne Siqueland, Ph.D., Project Coordinator;Karla Mor&s, Ph.D., Assessment Unit Director;

Jesse Chittams, Ph.D., Director of Data Manage-ment/Analysis; Lariy Muen� Ph.D., Statistician;Aaron T. Beck, M.D., and Bruce Liese, Ph.D.,Heads of Cognitive Therapy Training Unit; LesterLuborsky, Ph.D., and David Mark, Ph.D., Headsof Supportive-Expressive Training Unit; GeorgeWoody, MD., and Delinda Mercer, MA., Heads ofthe Drug Counseling/Addiction Recovery Program;and Delinda Mercer, Denis Daley, and GloriaCarpenter, Heads of Group Drug Counseling Unit.

The collaborating staff at NIDA include JackBlame, MD., and Lisa Onken, P/iD. The fourparticz�ating dinical sites are University of Penn-sylvania, Lester Luborsky, Ph.D. (PI),Jacques P.Barber, Ph.D. (Co-PI); Brookside Hospital,Nashua, NH, Arlene Frank, Ph.D. (P1), SteveButler (Co-PI); McLean/Massachusetts GeneralHospital, Boston, MA, Roger Weiss, MD. (P1),David Ga4rien#{128}l,M.D. (Co-PI); University ofPittsburgh/Western Psychiatric Institute andClinic, Pittsburgh, PA, Michael Those, MD. (P1),Dennis Daley, MS. W. (Co-PI). The contributionsofJohn Boren, Ph.D., the project officer for thiscooperative agreement, are aLco gratefully acknowl-edged.

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LUBORSKY ETAL.

Appendix A. Helping Alliance Questionnaire, Patient Version

271

Instructions: These are ways that a person may feel or behave in relation to another

person-their therapist. Consider carefully your relationship with your therapist, and thenmark each statement according to how strongly you agree or disagree. Please mark every one.

StronglyDis� Thseg� Slightly

Diseg��SlightlyAg�e agreeStrongly

Ifeellcandependuponthetherapist. 1 2 3 4 5 6

understands me. 1 2 3 4 5 6

wants me to 1 2 3 4 5 6

2 3 4 5 6

iajoint effort. 2 3 4 5 6

similar Ideas 1my problems. 2 3 4 5 6

i 2 3 4 5 6

In my therapy1 2 3 4 5 6

as a person. 1 2 3 4 5 6

therapist and1 2 3 4 5 6

progress of the therapy. � 2 3 4 5 6

has formed i 2 3 4 5 6

to be 1people. 2 3 4 5 6

2 3 4 5 6

have 1 2 3 4 5 6

sometimes1 2 3 4 5 6

F�omtImetotime,webothtalkabout ievents In my past. 2 3 4 5 6

likes me as a i 2 3 4 5 6

seems distant 1 2 3 4 5 6

Documents

The Revised Helping Alliance Questionnaire (HAq II)vuir.vu.edu.au/19368/16/260.pdf · 2012. 2. 29. · HAq-II patient version filledoutatsession 2 byusing aprincipal components analysis