Forming Therapeutic Alliances across the Milieu: Clinical Implications and Challenges of Working with Adjudicated Adolescent Males in Residential Treatment

Abstract

Forming a positive and collaborative relationship with a therapist is perceived to be one of the key change agents in the psychotherapeutic process (Bordin, 1979). While a limited number of studies have examined the factors that predict alliance formation with children and adolescents, even fewer studies consider the effects of systems-based care (Hogue et al., 2006; Shirk & Karver, 2003). The current study aims to tell the story of how adjudicated adolescents form healing, collaborative, and therapeutic relationships with various adults within the structured, clinical context of residential treatment. We examine the formation and maintenance of therapeutic alliances across the milieu by identifying the strength of alliances formed over time in counseling and the residential setting. We also explore how the TA varies based on adolescents’ history of trauma exposure and level of psychiatric distress. Participants included 32 adolescent males convicted of illegal sexual behavior in the state of Alabama and mandated to receive treatment in a secure residential treatment center. Each month, adolescents and adults evaluated the quality of their relationship using the Working Alliance Inventory, Short Form (Tracey & Kokotovic, 1989). Data analysis focused on describing the phenomenon of TA within the existing treatment program. Results indicate that youth form positive relationships with their therapists, but alliances with residential staff members deteriorate over time. In order to improve the adolescents’ day-to-day experience in the program and maximize their long-term clinical gains, recommendations for how to improve alliances in the milieu are offered. We hope to provide empirical evidence that will support and encourage systems to invest fiscal and human resources in building positive, collaborative, and genuine relationships with at risk youth.