Therapeutic alliance in post-acute brain injury rehabilitation: Predictors of strength of alliance and impact of alliance on outcome

Primary objective: To determine factors that influence the strength of therapeutic alliance for patients with traumatic brain injury ( TBI) attending post- acute brain injury rehabilitation ( PABIR) and to examine the association of therapeutic alliance with outcome after PABIR. Research design: Prospective cohort study. Methods and procedures: The study sample consisted of 69 of 95 patients with TBI admitted to the PABIR programme during the study period. Demographic and injury severity data were abstracted from medical records or obtained through interview. Study questionnaires ( the modified California Psychotherapy Alliance Scales - patient, family and clinician forms; the Prigatano Alliance Scale; the Awareness Questionnaire; the Center for Epidemiologic Studies - Depression scale; and the Family Assessment Device - General Functioning Scale) were obtained within 2 weeks of patient admission to the PABIR programme. Main outcomes and results: Study outcomes were functional status ( Disability Rating Scale), programme completion and employment status at discharge from PABIR. Higher levels of family discord were associated with poorer therapeutic alliance. Greater discrepancies between family and clinician ratings of patient functioning were associated with poorer therapeutic alliance and poorer effort in therapies. Poor participation was predictive of programme dropout. Productivity status at discharge was predicted by functional status at admission and degree of therapeutic alliance. Conclusions: Findings indicate that family perceptions and family functioning are important determinants of therapeutic alliance for patients in PABIR. These results indicate that therapists in PABIR programmes should address family perceptions and functioning to facilitate patient bonding with the programme.