The development and maintenance of a strong, trusting relationship between the individual young person and an individual practitioner is the most fundamental component of therapeutic practice. Effective youth AOD services value and encourage a strong emphasis on this relationship in order to promote engagement and retention in services, and because there is evidence that a high quality working relationship is therapeutic in itself.
The therapeutic relationship or alliance is widely recognised as an essential ingredient of any form of counseling or psychotherapy (Meier, Barrowclough, & Donmall, 2005). A number of studies have demonstrated that the strength of the alliance between client and practitioner enhances the chances of retaining clients in treatment for longer periods of time, including treatment for problems with substance misuse (Meier et al., 2005). Longer time spent in treatment for substance misuse is a highly reliable predictor of more positive outcomes (Greenfield et al., 2004; Simpson, Joe, & Brown, 1997). Thus efforts to enhance the therapeutic alliance can be expected to improve outcomes via longer retention in treatment. The question of whether therapeutic alliance predicts outcomes over and above the effect on retention is less clear (Meier et al., 2005), but evidence from a range of different studies provides reasonable support for this possibility.
Even more so than for adults, the practice-based literature on child and adolescent behavioural health emphasises the importance of the relationship between the young person and the provider as vital to any chance of positive outcomes of therapeutic interventions. Surveys of child and adolescent behavioural health care practitioners suggest that for many, the quality of the therapeutic alliance is of paramount importance as opposed to the specific therapy techniques that are the focus of evidence-based practice research (Garland, Hurlburt, & Hawley, 2006). A focus on relationship building over therapeutic strategies has traditionally been viewed as essential to getting and keeping young people engaged in the therapeutic process (Brannigan et al., 2004; McLeod & Weisz, 2005). Qualitative research involving adolescents with multiple and complex needs has found that young people place very strong value on having quality relationships with workers (Green, Mitchell, & Bruun, under review; Russell & Evans, 2009).
Well designed prospective research has also demonstrated that therapeutic alliance, measured objectively, predicts outcomes of therapy for children and adolescents (McLeod & Weisz, 2005). It has been argued that the quality of the client-therapist relationship can account for up to 30 per cent of the variance in therapeutic outcome, while the particular therapeutic techniques used may account for less than 15 per cent (Miller & Duncan, 2000). This is not to suggest that the relationship can suffice as an alternative to other therapeutic interventions. Rather, we concur with Miller & Rollnick (2002) who argue that “optimal care is likely to happen within the context of an ongoing relationship … attuned to the person’s particular social context, network of relationships, and the full spectrum of strengths and problems” (p. 22).
In work with particularly vulnerable young people such as homeless, offending, and drug using populations, the engagement function of relationship building has long been recognised as particularly critical because this vulnerable group is notoriously difficult to engage in AOD and other behavioural health services (Barry et al., 2002; Brannigan et al., 2004; Henderson et al., 2007). Relationships based on respect, trust, and oriented towards empowerment are particularly advocated as catalysts for building a sense of free choice, autonomy, competence and hope for youth whose previous experiences have undermined this (Aronowitz, 2005; Crago et al., 2004; Ungar, 2005a). Facilitating active participation by the young person in a collaborative process with the practitioner to develop a shared understanding and joint decision process has been identified as instrumental in this regard (Bruun, 2008; Munford & Sanders, 2008).
With respect to client-centred care for example, the working relationship serves as the foundation of a collaborative process whereby the client and the worker develop a shared understanding of the issues requiring attention and make decisions about how they will be addressed. The relationship does not privilege any particular disorder, illness, problem or therapeutic intervention. Instead it creates a neutral or unbiased space that can act as a vehicle or platform for identifying, accessing, containing and integrating a diversity of supports and intervention types. Practitioners adopt an egalitarian stance. Clients are respected as experts in their own lives, an approach which opens up the opportunity for such expertise to develop further, thereby building on clients’ strengths. A commitment to a long term working relationship also supports enactment of a developmental perspective and an orientation to continuous care which recognises that the frequency and severity of problems are constantly changing.