The therapeutic alliance in sex offender treatment: The juxtaposition of violence and care

Group psychotherapy is the most widely utilized treatment modality for convicted sex offenders, and the therapeutic alliance is considered a fundamental concept in virtually all applications of psychotherapy. However, empirical examination of how the therapeutic alliance impacts upon treatment effectiveness for sex offenders has been neglected. In a prospective design, a sample of 95 consecutive admissions to an inpatient treatment program for convicted adult male sex offenders was studied with regard to their experience of the therapeutic alliance with treatment staff, with their copatients, and with the overall treatment program. Patients of the Phoenix Program (Alberta Hospital Edmonton) rated their sense of alliance at monthly intervals. The therapists who worked with them (n = 21) also completed monthly evaluations of their own emotional responses toward these same patients. Pre- to post-treatment comparisons on personality tests, interpersonal distress, and interpersonal functioning showed a number of statistically significant changes consistent with treatment goals. Patients’ self-report over time in treatment showed a gradual, consistent increase of large effect size on all three alliance targets. Sex offenders in this sample were able to experience positive alliance with therapists and peers and the sense of alliance was shown to grow stronger over time. Staff ratings revealed that positive and negative affect increased as patients’ time in treatment increased. Significant associations between patient-rated alliance and outcome were found to be positive and in desired directions. The growth rate in alliance toward therapists was positively and significantly associated with the growth rate of “conflict within oneself” among female therapists. Male therapists also reported significant growth in “conflict within oneself” but this was independent of patient-rated alliance growth rates. Thus, female therapists experienced heightened affect in the face of greater patient alliance, while male therapists also experienced heightened affect but for reasons unrelated to patient alliance. There was virtually no reduction in negative affect toward patients despite moderate increases in positive affect toward patients. This study represents an important endorsement of a treatment model that seeks to improve general adjustment and ameliorate risk factors associated with recidivism, via positive changes in interpersonal relationships.