Working Alliance and Its Relationship With Treatment Outcome in a Sample of Aboriginal and Non-Aboriginal Sexual Offenders

Abstract

The relationship that develops between a client and therapist is arguably one of the most important factors toward achieving positive outcomes from therapy. The present study examined the therapeutic alliance, as measured by Horvath and Greenberg’s Working Alliance Inventory (WAI), as a function of Aboriginal ancestry and the relationship of alliance to important program outcomes, in a Canadian correctional sample of 423 treated sexual offenders. The men rated their primary therapists on the WAI 3 months into treatment. Higher self-report ratings on the WAI and its Task, Bond, and Goal subscales were associated with lower rates of treatment non-completion and longer stay in treatment. Aboriginal men scored significantly lower on the WAI’s Bond subscale (i.e., the emotional connection between client and therapist) than non-Aboriginal men, although by and large, the offender sample as a whole otherwise registered fairly high mean scores on the tool. Aboriginal men scoring below the median on WAI total score had the highest rates of treatment non-completion. WAI total score and scores on the three subscales were unrelated to post-program recidivism in the community. Cultural implications for correctional client engagement and service delivery within the context of the risk-needs-responsivity model are discussed.

Keywords

working alliance sexual offender treatment treatment non-completion recidivism Aboriginal

The importance of developing a strong positive relationship between therapist and client has long been acknowledged in the helping professions. In recent years, research has suggested that despite the specific therapy mode or approach taken, the client–therapist relationship is a particularly important factor toward achieving positive outcomes (Bordin, 1979, 1994; Horvath & Greenberg, 1994; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). A strong working alliance is based on feelings of reciprocal trust, confidence, and acceptance, in addition to a mutual agreement on the objectives of therapy and the subsequent tasks involved.

Bordin (1979) proposed that the successful working alliance is composed of three elements: goals (i.e., mutually agreed-upon objectives for treatment endorsed and valued by both therapist and client), tasks (i.e., mutually agreed-upon activities or “in-counseling behaviors” that are aimed at achieving the goals; Horvath & Greenberg, 1989, p. 224), and bond (i.e., the positive personal attachment that develops between the client and the therapist characterized by “mutual trust, acceptance, and confidence” between therapist and client; Horvath & Greenberg, 1989, p. 224). Working alliance research spanning decades has consistently demonstrated the client–therapist relationship to be associated with important therapy outcomes, with mean effect sizes from meta-analytic reviews ranging from .22 to .26 (Horvath & Symonds, 1991; Martin et al., 2000) supporting the notion that the alliance is therapeutic in and of itself.

Working Alliance as a Responsivity Consideration With Offender Clientele

Research supports the contention that correctional programming can and does “work” if it adheres to the principles of risk (program intensity should match the offender’s level of risk), need (criminogenic needs, i.e., dynamic risk factors directly linked to criminal behavior, should be targeted in treatment), and responsivity (treatment delivery should match the offender’s level of insight, cognitive capacity, language, and culture; see Andrews & Bonta, 2010; Andrews & Dowden, 2006; Beyko & Wong, 2005; Dowden & Andrews, 2000; Hanson, Bourgon, Helmus, & Hodgson, 2009). According to Andrews and Bonta (2010), there are two types of responsivity, general and specific. The principle of general responsivity asserts that effective programs use cognitive behavioral social learning methods to influence behavior while specific responsivity involves adapting service delivery to individual client features that can affect engagement (e.g., cognitive ability, learning style, motivation, etc.). Hanson et al.’s (2009) meta-analytic review of sexual offender treatment outcome found that greater adherence to a larger number of risk-need-responsivity (RNR) principles was associated with successively larger reductions in sexual violence, as well as other recidivism outcomes.

A recent meta-analysis of 114 offender treatment attrition studies and more than 41,000 offenders further found that treatment responsivity issues (i.e., negative impression management, negative treatment attitudes, and denial) were among the strongest and most consistent predictors of attrition (Olver, Stockdale, & Wormith, 2011). As would be expected, offenders with higher levels of motivation and who were engaged in treatment were less likely to drop out of treatment. Although the wisdom of RNR suggests that high risk offenders would most benefit from high intensity treatment programs, it is ironically this population that was found to be most likely to discontinue treatment. Treatment non-completion, in turn, was associated with a 10% to 23% increase in recidivism, depending on the type of outcome.

As such, it may come as little surprise that research has shown that clients’ overall perceptions of their therapists are related to improvements in treatment (Andrews, Bonta, & Hoge, 1990; Marshall et al., 2003), and for specifically this reason, working alliance may rightly be considered an important responsivity factor. For instance, Polaschek and Ross (2010) examined 50 high risk violent offenders and their therapists in seven consecutive treatment cohorts in an 8-month treatment program operated through New Zealand’s correctional services over a period of 3.5 years. Using the Working Alliance Inventory–Short Form (WAI-S) to assess the therapeutic alliance and the Violence Risk Scale (Wong & Gordon, 2006) to measure changes in violence risk, Polaschek and Ross (2010) concluded that offenders who viewed their therapists as interpersonally warm, empathic, and collaborative tended to demonstrate more positive behaviors and increased motivation. That is, those offenders whose alliance increased the most throughout the course of treatment also demonstrated the most change. By contrast, across 12 sexual offender treatment groups in the United Kingdom, Beech and Fordham (1997) found sexual offender group members rated their therapists as being significantly less helpful and friendly on the Group Environment Scale, than the therapists rated themselves. Of note, however, there were no differences in rating task orientation or decision making, which may be construed as another proxy (task) of the alliance, while the former dimension bears similarity to the bond component. Dahle (1997) in turn examined the issue of trust in a sample of 400 German prison inmates who provided self-ratings regarding their motivation for therapy; trust in the treatment provider’s intentions predicted treatment readiness and commitment. Marshall et al. (2003) similarly contend that generating trust in offenders is crucial to instilling substantive change in individuals with mental health difficulties. As such, overcoming lack of trust between client/offender and treatment provider is imperative and conducive to forming a strong alliance.

Working Alliance and Cultural Considerations With Aboriginal Clientele

Although Aboriginal people comprise only 3% of the general Canadian population, Aboriginal offenders are significantly overrepresented in Canadian corrections, representing approximately 19% of federal admissions and 27% of provincial/territorial admissions in 2010 (Statistics Canada, 2012).¹ Recidivism, parole revocations, and conditional release statistics further illustrate that Aboriginal offenders are also less successful on release than non-Aboriginal offenders (Bonta, Rugge, & Dauvernge, 2003). Correctional agencies understandably place much importance on offender programming (e.g., substance abuse, cognitive skills, sexual offender treatment, violence prevention, literacy) in an attempt to address criminogenic needs, reduce recidivism, and promote successful reintegration (Correctional Service of Canada, 2009). Many of these correctional programs take some form of cognitive behavioral therapy (CBT) with an intention of changing offense-related cognitions and replacing them with more anti-criminal, prosocial cognitions. Given the statistics cited above, many correctional clients in Canadian programs will be of Aboriginal ancestry. To cite an extreme example, however, an examination of a high intensity CBT-based violence reduction program in Canada found that roughly 80% of high risk Aboriginal offenders did not complete programming (Wormith & Olver, 2002). Although there are likely several reasons for such a high rate of attrition, a possibility may be that the Westernized (i.e., Euro-North American) mode of therapy did not meet the needs of this particular client group, vis-à-vis the responsivity principle.

Suffice it to say, sensitive and careful attention to Aboriginal cultural considerations in correctional program delivery is an important responsivity consideration. Although it is difficult to generalize cultural practices to Aboriginal people given their diversity, D. W. Sue and Sue (1999) identify three sets of values common to many Aboriginal groups. Within the context of these values, it may become apparent how some Aboriginal offenders can have difficulty with some aspects of CBT-based treatment. For instance, one value is mutual sharing and giving to gain honor and respect. In sexual offender programs, the men are typically expected to share extremely personal details of their lives with other group members, whereas treatment providers rarely, if ever, share details of their own lives. Although it is common practice in western treatment modalities for therapists to avoid making personal disclosures, this can be seen as selfish or as a violation of a core value to many Aboriginal people.

A second value is cooperation, that is, a reluctance to compete with others and to display individuality so as to maintain harmony and avoid discord (D. W. Sue & Sue, 1999). To successfully complete treatment in many sexual offender programs, the individuals must fulfill certain therapeutic tasks outside of group sessions with the help of their primary therapists. Although the men are instructed to include personalized narratives, Waldram (2012) notes that the men often would not do this initially and would be given corrective feedback to incorporate them. It is possible that some Aboriginal offenders disagree with these inclusions but owing to a cultural practice of cooperation, they quietly move on without necessarily “buying into” these changes; this allows them to avoid disagreement and instead give the impression of cooperating with their therapist. Furthermore, the focus of these activities is placed on the individual and his actions, which can also be seen as contradictory to viewing the self as part of a greater whole.

Third, D. W. Sue and Sue (1999) contend that Aboriginal peoples tend to focus on the “here and now” rather than the future. This stems from a belief that things are done according to a natural order, and to interfere or plan for events in the future, rather than living in the present, may be seen as self-centered. This time orientation naturally stands in contrast to the relapse prevention plans that the men are often expected to develop and ultimately implement, which are entirely focused on future goals and behaviors to assist with reintegration and prevention of recidivism. Ellerby and Ellerby (2000) further note that many Elders who work in correctional settings with sexual offenders also believe that there is too much focus on the past in Westernized treatment (i.e., the criminal offense); the Elders they interviewed believed that a focus on past events tends to hinder any movement forward and negatively impacts the healing process. Mason (2000) also noted that some of his participants held the perception that a focus on historical events “has a tendency to steal too much energy away from the present and future” (p. 150), maintains a focus on negativity, and fills the offender with hopelessness about the future.

With such considerations in mind, correctional programs that are explicitly designed to address the needs of Aboriginal offenders take a different therapeutic tack. Rather than applying a Westernized CBT approach, many Aboriginal programs are designed to address the spiritual and cultural needs of its participants (Wilson, 2007). Emphasis tends to be placed on teaching the offender client Aboriginal culture, traditions, and history as opposed to a strict emphasis on altering distorted cognitions and dysfunctional behaviors tied to the individual’s criminogenic needs. According to Aboriginal spirituality principles, gaining knowledge of culture and tradition induces healing to occur (Waldram, 1993). In a qualitative investigation of Aboriginal offender healing, Mason (2000) interviewed 11 federally incarcerated Canadian Aboriginal men who were participating in both CBT and traditional Aboriginal Sweat Lodge ceremonies at the Regional Psychiatric Centre (RPC) in Canada. Although participants identified some similarities between programs (e.g., promotion of insight, awareness, and understanding as it relates to various areas in life such as family, relationships, community, and society), ultimately they viewed the programs as more dissimilar than similar, particularly regarding the therapeutic alliance and engagement. In a subsequent ethnographic examination of sexual offenders attending a program (Clearwater Program) at the same facility referenced above, Waldram (2012) noted “Aboriginality to play a minor role in program participation generally, and treatment staff made few efforts to search for or accommodate any perceived cultural differences” (p. 52).

Although there is ample evidence to support the importance of developing and maintaining a strong therapeutic alliance, how this relationship is affected by ancestry is not clear. Cultural paradigms tend to help shape people and their identities, and, hence, how they interact with others (Shonfeld-Ringel, 2001); therefore, it stands to reason that cultural ancestry should impact the therapeutic alliance. Unfortunately, however, there is a dearth of information in this area. S. Sue, Allen, and Conaway (1978) assert that Aboriginal peoples find mental health services unhelpful for several reasons (e.g., concerns over White supremacy, feeling unwelcome and out of place, bureaucratic runaround, services that are unusual to their traditional ways of being). They suggest that language barriers, stereotypes, and discrimination may contribute to high attrition rates among ethnic minorities and that the inability of therapists to provide culturally responsive forms of treatment is a likely culprit. When coupled with the discomfort individuals tend to face when attending sexual offender treatment, this may serve to compound the stigma. Despite such challenges and the large number of Aboriginal people in correctional facilities program, expectations are often no different. Although there are additional treatment options for Aboriginal offenders (i.e., attending sweats and working closely with elders), including an increase in Aboriginal-specific treatment programs (e.g., Aboriginal Offender Substance Abuse), most mainstream correctional programming has been designed based on a Western style of thinking as alluded to above. Therefore, understanding how cultural issues might affect the offenders and their responsiveness to Westernized programs, vis-à-vis the working alliance, is paramount.

Present Study

Given that the majority of correctional treatment programs in Canada and in other countries worldwide (e.g., Australia, New Zealand, United States) follow a CBT approach (Howells, Heseltine, Sarre, Davey, & Day, 2004), are designed for a general population, and may not be Aboriginal-specific, it is important to examine how factors such as the working alliance may vary as a function of cultural differences and how this relates to program outcome. The present research examined the therapeutic relationships between offenders and their primary therapists in a CBT-based sexual offender program operated by the CSC. Based on Mason’s (2000) results and Waldram’s (2012) critique, we proposed the following five hypotheses:

Hypothesis 1: Aboriginal offenders would generate lower scores on the WAI and its constituent subscales than non-Aboriginal offenders, thus demonstrating weaker alliances as operationalized by the WAI.

Hypothesis 2: The WAI and its constituent scales would predict treatment completion and length of program stay, such that stronger alliances were associated with higher rates of completion and longer stays in treatment.

Hypothesis 3: Aboriginal offenders demonstrating weaker alliances would have the highest rates of attrition, while non-Aboriginal offenders with strong alliances would show the lowest attrition. It was anticipated that Aboriginal offenders with strong alliances would likely still evince higher rates of attrition than non-Aboriginal offenders with strong alliances, but less attrition than Aboriginal men with weaker alliances.

Hypothesis 4: The WAI and its constituent subscales would be inversely correlated with recidivism, that is, stronger alliances would be associated with lower rates of recidivism, particularly for non-Aboriginal offenders.

Hypothesis 5: It was anticipated that Aboriginal men would have higher recidivism rates consistent with the extant literature (e.g., Rugge, 2006), but the rates may vary as a function of working alliance (i.e., lower recidivism for Aboriginal men with strong alliances).

Method

Participants

Participants included 427 male federal offenders representing consecutive admissions to the Clearwater Program at the RPC Prairies in Saskatoon, Saskatchewan, Canada, between 1998 and 2005. All men were serving sentences of at least 2 years and are thus a responsibility of the CSC, Canada’s federal correctional department. Approximately 45.9% of participants were self-identified from one of three ancestral Aboriginal groups (see Note 1), and the majority of the remaining balance (51.8%) was White. The proportion of Aboriginal offenders observed in the present sample is somewhat higher than the CSC Prairie region average of approximately 37%, but otherwise consistent with the proportion of Aboriginal offenders in the province of Saskatchewan (Correctional Service of Canada, 2013) and with other RPC treatment samples (cf. Lewis, Olver, & Wong, 2013). The mean age of the sample at program admission was 36.8 years (SD = 10.2). Overall, 93.4% had an index conviction for a sexual offense, while the remaining 6.6% did not have an index sexual conviction, but had prior histories of sexual violence. Of the men with index sexual offenses, 50.8% were classified as rapists (adult victims only), 21.3% were extrafamilial child molesters (unrelated child victims), 18.9% were mixed offenders (at least one adult and one child victim), 5% were incest offenders (related child victims only), 2.1% were mixed intra/extrafamilial child molesters, 0.9% were non-contact sexual offenders, 0.2% were offenders whose victims were adult family members only, and 0.7% engaged in sexually motivated non-sexual offenses.

Four offenders were excluded from analysis because their Fingerprint Service (FPS) numbers could not be located through the Offender Management System (OMS; CSC’s computerized case file management system) or the Canadian Police Information Centre (CPIC; a computerized criminal record database system operated by the Royal Canadian Mounted Police). This reduced the total N to 423 for analysis. Of the 423 participants, the average sentence length for individuals with a determinate sentence (n = 375) was 6.2 years (SD = 4.1). The remainder of the participants (n = 48) were serving life sentences (n = 35, mean parole eligibility = 20.6 years) or indeterminate sentences (n = 13). The average length of stay in the Clearwater Program was 204.7 days (SD = 68.3) with 86.8% (367/423) individuals successfully completing this program. Of the 56 cases that did not successfully complete treatment, 32 were attributable to poor participation and progress, 6 were suspended, 5 were transferred out of the institution, 5 had the program assignment cancelled, 4 withdrew, and 4 were early releases.

Treatment Program

The Clearwater Sex Offender Program is a formalized sexual offender treatment program offered in a Canadian federal maximum-security correctional treatment facility, the RPC in Saskatoon, Saskatchewan (see Olver & Wong, 2013 for a detailed description of the program). The program’s mandate has historically been to develop and provide effective and efficient therapeutic programming for high risk sexual offenders. Programming and assessment is delivered through an interdisciplinary treatment team that consists of nurses, psychologists, psychiatrists, social workers, and parole officers. The program aims to adhere to the RNR principles through the selection of clientele and dosage of treatment, prioritization of criminogenic needs, and flexible mode of service delivery following a CBT model. Offenders are required to attend group and engage in individual treatment, receiving 15 to 20 hr per week of clinical contact. In addition, participants are offered opportunities to upgrade their education, learn work and life skills, and address interpersonal needs (i.e., attitudes and values) when appropriate. Furthermore, the Clearwater Program endeavors to attend to specific offender responsivity factors such as cultural factors, cognitive functioning, and treatment readiness whenever possible. At the time of data collection, there were approximately 48 beds and programming lasted between 6 to 9 months, depending on the needs of the individual. Treatment outcome research has demonstrated completion of the Clearwater Program to be associated with decreased rates of sexual recidivism relative to untreated comparison controls (Nicholaichuk, Gordon, Gu, & Wong, 2000; Olver, Wong, & Nicholaichuk, 2009).

Measures

WAI

The WAI (Horvath, 1981, 1994; Horvath & Greenberg, 1986, 1989) is a 36-item self-report instrument developed to measure the strength of the alliance that develops between a client and his or her therapist. The tool was developed and validated based on Bordin’s (1979) model; that is, the bond that develops between the client and therapist and the mutually agreed-upon tasks and goals of therapy (Martin et al., 2000). Although there are a variety of tools used to measure the working alliance, the WAI is currently the most widely used and the most vigorously researched (Skeem, Louden, Polaschek, & Camp, 2007). Moreover, the WAI was designed to capture the multiple perspectives of the working alliance by providing three rater versions of the measure: the client, the therapist, and/or from an observer’s perspective. For the purposes of the present study, “the client” refers to the offender participating in sexual offender treatment, and “the therapist” refers to the client’s primary therapist. The current study examines the clients’ ratings of this alliance on the self-report version of this tool.

The WAI is comprised of three subscales that are based on Bordin’s (1979) conceptualization of the working alliance: Task, Bond, and Goals. Ratings are assigned on a 7-point rating scale ranging from 1 (never) to 7 (always). Scores are summed to generate scale totals for the three subscales and a total score. Total scores can range from 36 to 252, with higher scores reflecting more positive ratings and hence, stronger alliance. Horvath and Greenberg (1989) demonstrated adequate reliability estimates based on item homogeneity indexes (ranging from r = .85 to r = .93) and a composite alpha value for the 32 items of .93. Studies of convergent and discriminant validity have been supportive (see Horvath, 1994, for a review). Overall, studies using the WAI have shown the working alliance to have a positive impact on outcome and that a strong alliance between client and therapist allows for engagement, trust, and agreement on therapeutic objectives (Horvath & Greenberg, 1994).

Outcome Variables

Treatment completion

Program start and end dates were recorded to obtain the length of time spent in treatment for each offender, which was coded as a continuous variable. Whether the offender completed the program or not was explicitly specified on the OMS computer database system, and reasons for non-completion were usually outlined in the offender’s final treatment report. Treatment non-completion was coded as a binary variable (0 = completer; 1 = non-completer). The type of attrition (i.e., reason for non-completion) was also recorded, specifically whether it was system generated (e.g., released prior to program completion), client generated (e.g., low motivation and decision to discontinue), or program generated (e.g., client discharged for disruptive behavior; see Wormith & Olver, 2002).

Recidivism

Recidivism was operationally defined as any new conviction following first release to the community after program participation. Recidivism data were coded in both binary (1 = recidivism, 0 = no recidivism) and continuous (number of offenses) manner. Three types of recidivism were coded: (a) sexual recidivism was defined as any crime that was deemed sexual in nature or was sexually motivated (e.g., sexual assault, sexual touching, exposure); (b) violent recidivism was defined as any crime that used or threatened to use force upon a victim (e.g., robbery, non-sexual assault), including sexual offenses; and (c) general recidivism included any and all crimes, violent and non-violent (i.e., without any person being physically hurt or injured during the crime, such as break and enter, theft).

Procedure

Ethical approval to conduct the present research was obtained from the CSC and the University of Saskatchewan’s Behavioral Research Ethics Board. As this was an archival investigation, permission to access participant records for research purposes was provided by these agencies in lieu of obtaining consent in person from each individual participant, most (if not all) of whom had left the RPC several years prior and many of whom would no longer be under CSC jurisdiction. The first author was provided with a list of WAI scores for approximately 427 federal offenders who had previously participated in the Clearwater Program between 1998 and 2005. During this time frame, the men completed the WAI voluntarily approximately 3 months following their admission as part of the evaluation of the Clearwater Program. In so doing, the men were instructed to rate their relationships with their primary therapists. Scores for all three components of the WAI were recorded and entered into a database by RPC research staff. Offender demographic and treatment completion information were gathered from OMS while recidivism data were gathered via CPIC by the first author. The CPIC database is arguably the most comprehensive source of criminal outcome data available on Canadian citizens.

Planned Analyses

We conducted three sets of planned analyses to examine the five aforementioned hypotheses. First, to examine the relationship of ancestry to strength of working alliance, we conducted comparisons between Aboriginal and non-Aboriginal groups on the WAI total score and its three subscales via t-tests. To evaluate the magnitude of effect, we computed Cohen’s d, which reports the effect size in standard deviation units in which values of .20, .50, and .80 correspond to small, medium, and large effects, respectively (Cohen, 1992). In addition, we ran moderator analyses to examine the extent to which age was associated with the strength of the working alliance, and if this partly contributed to observed differences between Aboriginal and non-Aboriginal participants using MANCOVA (i.e., covarying out age). Second, we examined the relationship of the working alliance to treatment outcome variables, namely, binary treatment completion as well as length of program stay. For these analyses, we correlated WAI total and subscale scores with each of these criteria for the overall sample, as well as within Aboriginal and non-Aboriginal groups. We followed with a set of Kaplan-Meier survival analyses in which dichotomized high and low WAI and Aboriginal–non-Aboriginal subgroups were compared on rate of program completion over the time duration of the program. Pairwise comparisons were then conducted on the trajectories of the survival curves among four subgroups: Aboriginal Low WAI, Non-Aboriginal Low WAI, Aboriginal High WAI, and Non-Aboriginal High WAI.

In the third and final set of analyses, we examine the relationship of the working alliance to post-program sexual, violent, and general reconviction through computing point biserial correlations between these three outcome variables and WAI total and subscale scores. We also examine actual base rates of recidivism among the four aforementioned subgroups. In addition, given that some extant findings have reported Aboriginal offenders to be at higher risk for recidivism and to have higher rates of recidivism, we controlled for offense history and age at admission; two prominent static predictors. We did this through logistic regression modeling, in which the base rate of the sample for a given recidivism outcome and the magnitude of the predictive relationship of these two variables to outcome are entered into the following formula: e^B0+B1xScore / (1+e^B0+B1xScore) (Tabachnick & Fidell, 2001). This, in turn, would generate recidivism estimates as a function of these predictors for the entire sample. Comparisons conducted among the four subgroups would demonstrate if group differences remained, and thus to what extent Aboriginal ancestry may uniquely contribute to observed differences in rates of recidivism.

Results

Working Alliance and Ancestry: Group Comparisons

WAI descriptive statistics and ancestral group comparisons are reported in Table 1. The mean score of 195.1 (SD = 34.5) out of a possible 252 was quite high; equivalent to an average item rating of 5.4 out of 7. Similarly high scores were observed in the sample as a whole on the Task, Bond, and Goal subscales (with a maximum possible total of 84 points for each). Significant between-group differences were observed only with respect to the Bond subscale, with Aboriginal clients scoring significantly lower, the magnitude of difference being small in effect (d = .24). No other group differences were significant on WAI Task, Goal, or Total scores.

Table 1.

WAI Descriptive Statistics and Group Comparisons as a Function of Ethnicity.

WAI measure	Non-Aboriginal (n = 229)	Aboriginal (n = 194)	Total sample (N = 423)
WAI measure	M (SD)	M (SD)	M (SD)	t	d
Task	68.23 (11.08)	67.16 (10.89)	67.74 (34.50)	0.99	.10
Bond	63.91 (14.39)	60.51 (14.17)	62.35 (14.37)	2.45*	.24*
Goal	65.21 (12.74)	64.70 (11.57)	64.97 (12.21)	0.43	.04
Total	197.35 (35.19)	192.37 (33.54)	195.07 (34.54)	1.49	.15

Note. WAI = Working Alliance Inventory.

p < .05.

Age at program admission was positively correlated with WAI Task (r = .13, p = .009), Bond (r = .08, p = .084), Goal (r = .06, p = .200), and Total (r = .10, p = .045) scores, such that increasing age was slightly associated with higher WAI scores, at least on the Task and Total scales. Aboriginal men were also significantly younger (M = 33.73, SD = 8.79) than non-Aboriginal (M = 39.3, SD = 10.6) men, t(421) = 5.83, p < .001. When Aboriginal–non-Aboriginal group comparisons were repeated via a MANCOVA (controlling for age at admission), only the group differences on Bond were significant as with previous univariate analyses with age uncontrolled, F(1, 420) = 4.22, p = .04. Thus, age did not moderate the relationship of ancestry to WAI score in these analyses.

Working Alliance, Ancestry, and Treatment Completion

The next set of analyses examined the relationship of working alliance to treatment completion and length of program stay in the sample as a whole and as a function of ancestry. As reported in Table 2, WAI Total, Task, Bond, and Goal subscales were all significantly inversely correlated with treatment non-completion; that is, non-completers scored significantly lower on all components of the tool and hence, had weaker alliances. Length of program stay, in turn, had significant (albeit modest) relationships with the Bond, Goal, and WAI total scores in the sample as a whole. When the analyses were disaggregated as a function of ancestry, some interesting differences emerged. Among non-Aboriginal participants, three out of four WAI scale components were significantly negatively correlated with treatment non-completion, but none of the WAI scale measures were significantly associated with length of stay. Among Aboriginal participants, however, the reverse trend was observed; all WAI scale components were significantly positively correlated with length of program stay, but none were significantly correlated with treatment completion.

Table 2.

WAI Correlations With Treatment Non-Completion and Length of Program Stay.

	Overall sample (N = 423)			Non-Aboriginal (n = 229)			Aboriginal (n = 194)
	Treatment non-completion		Length of stay	Treatment non-completion		Length of stay	Treatment non-completion		Length of stay
WAI	r	d	r	r	d	r	r	d	r
Task	−.15**	.43**	.09	−.23***	.76***	.04	−.06	.16	.17**
Bond	−.12**	.35*	.15**	−.10	.33	.11	−.12	.33	.20**
Goal	−.15**	.46***	.10*	−.21***	.70***	.04	−.09	.25	.21**
Total	−.15**	.45**	.13**	−.19**	.63**	.07	−.10	.28	.21**

Note. WAI = Working Alliance Inventory.

p < .05. **p < .01. ***p < .001.

To examine the relationship of ancestry and working alliance to treatment completion, a set of chi-square and survival analyses were conducted. Overall, Aboriginal offenders had higher rates of non-completion (16.5%) than non-Aboriginal offenders (10.5%), although this difference fell slightly short of significance, χ²(1, N = 423) = 3.31, p = .069. A mean split of the WAI Total score was then used to create high and low WAI groups (above or below 195.1) and in combination with the binary ancestry variable, four groups were created. The highest rates of non-completion were observed among individuals with low WAI scores (Aboriginal, 19.4%; Non-Aboriginal, 16.8%), followed by Aboriginal men with high WAI scores (13.2%), and non-Aboriginal men with high WAI scores (4.9%), χ²(3, N = 423) = 11.97, ϕ = .17, p = .007.

Kaplan-Meier survival analysis was subsequently conducted to examine program completion rates over time (Figure 1). Pairwise comparisons revealed that Aboriginal offenders with low WAI scores failed to complete treatment at a higher and faster rate than the Non-Aboriginal High WAI, log rank χ²(1, n = 225) = 12.52, p < .001 and (at trend level), Aboriginal High WAI, log rank χ²(1, n = 194) = 3.52, p = .061, groups. The only other substantive difference was observed between the Non-Aboriginal Low WAI group and the Non-Aboriginal High WAI group, log rank χ²(1, n = 229) = 8.72, p = .003. The program non-completion rate of Aboriginal men with high WAI scores was also higher than that of non-Aboriginal men with high WAIs (trend level), log rank χ²(1, n = 213) = 3.16, p = .075.

Figure 1.

Survival analysis: Rates of program non-completion as a function of working alliance (WAI score) and Aboriginal versus non-Aboriginal ancestry.

Working Alliance, Ancestry, and Recidivism

The final set of analyses examined the relationship of WAI score to recidivism in the sample overall and as a function of ancestry. The present sample was followed up for a mean 10.4 years (SD = 3.1) post-program (n = 395) during which 13.2% of the men were convicted for a sexual offense, 37.1% for a violent (including sexual) offense, and 57.4% for any new offense (general recidivism). Table 3 presents the results of predictive validity correlational analyses between each of the WAI scale components and binary sexual, violent, and general recidivism. All of the relationships were weak and non-significant. The WAI did not predict any recidivism criteria in the samples as a whole or among Aboriginal and non-Aboriginal ancestral groups. In the final set of analyses, recidivism base rates were examined among the four ancestry-WAI groups (reported in Table 4). Aboriginal participants had significantly higher actual base rates of violent and general recidivism than non-Aboriginal men, irrespective of WAI score (ϕ = –.18 to –.25). There were no significant differences in actual base rates of sexual recidivism among any of the groups (ϕ = –.04).

Table 3.

WAI Predictive Validity Correlations With Sexual, Violent, and General Recidivism.

	Overall (N = 395)			Non-Aboriginal (n = 211)			Aboriginal (n = 184)
WAI	Sexual	Violent	General	Sexual	Violent	General	Sexual	Violent	General
Task	.06	.04	.01	.09	.06	.03	.04	.05	.01
Bond	.06	.02	−.01	.01	.03	.00	.12	.07	.04
Goal	.03	.03	−.02	.04	.05	.02	.02	.03	−.06
Total	.05	.03	−.01	.05	.05	.02	.07	.05	.00

Note. No correlations are significant. WAI = Working Alliance Inventory.

Table 4.

Actual and Predicted Base Rates of Sexual, Violent, and General Recidivism as a Function of Ancestry and WAI Group.

WAI and ancestry	Sexual		Violent		General
WAI and ancestry	Actual	Predicted	Actual	Predicted	Actual	Predicted
Aboriginal Low WAI	14.3	14.7	44.9	41.9	69.4	65.7
Non-Aboriginal Low WAI	11.5	12.7	27.4	31.6	43.0	52.1
Aboriginal High WAI	15.1	14.7	51.2	42.2	62.0	65.1
Non-Aboriginal High WAI	12.2	12.4	27.8	30.1	47.4	50.9

Note. Predicted rates of recidivism estimated from logistic regression modeling using Age at Admission and Prior Convictions variables. Both Aboriginal groups have significantly higher actual and predicted rates of violent and general recidivism than both non-Aboriginal groups. No significant group differences for sexual recidivism. WAI = Working Alliance Inventory.

We then used logistic regression modeling to estimate base rates for each of the recidivism outcomes from age and offense history and then drew the same comparisons between groups. As previously noted, we proposed that risk-related variables may partly explain individual differences observed in rates of recidivism; that is, in this sample, Aboriginal participants were both younger and had more serious offense histories. We anticipated that the group differences may decrease as a result, when predicted base rates of recidivism based solely on age and offense history were generated. The predicted base rates of recidivism were lower than the actual rates for Aboriginal men while the opposite pattern was found for non-Aboriginal men; however, the group differences between Aboriginal and non-Aboriginal participants were still significant for violent and general recidivism, indicating that Aboriginal ancestry in part uniquely accounted for observed individual differences in these two outcomes. Again, no significant between-group differences were observed in predicted rates of sexual recidivism.

Discussion

The present study examined the working alliance as operationalized by the WAI in a large Canadian sample of Aboriginal and non-Aboriginal sexual offenders who attended a high intensity cognitive behavioral treatment program operated by the CSC. In turn, the relationship of the WAI and its Task, Bond, and Goal subscales to important program outcomes was examined in the sample overall and as a function of Aboriginal ancestry. Four out of five primary hypotheses were supported by the present findings to varying degrees. We discuss each of these in turn.

WAI Scores in Relation to Other Samples

First, the sample by and large demonstrated strong working alliances as evidenced by fairly high WAI Total and subscale scores in and of themselves (average item score of 5.4 on a 7-point scale), regardless of ancestry. The results suggest that the men were rating their therapeutic relationship with their primary therapist and the corresponding therapeutic tasks or activities, emotional connection or bond, and treatment objectives or goals quite positively. These high scores, however, may be tempered by the possibility of demand characteristics that could have served to inflate the scores. These men were all rating their primary therapists 3 months into their treatment program. The primary therapist is chiefly responsible for writing the admission assessment, interim progress reports, and the final treatment evaluation, which documents the progress the individual made in the program. Naturally, such circumstances could increase the motivation of the men to rate their alliances in especially positive terms. While this could serve to inflate ratings, we argue that it unlikely invalidated the ratings, given that several anticipated findings emerged based on the extant literature.

That said, it is also important to bear in mind similarly high ratings on the WAI and its variants among other client groups. In a university counseling setting sample, Erdur, Rude, Barón, Draper, and Shankar (2000) found mean WAI scores for clients with ethnically dissimilar therapists to be quite high (210.1 corresponding to an item mean of 5.8), and to be marginally higher for clients with ethnically similar therapists (213.2, item mean = 5.9). Polaschek and Ross (2010), using the 12-item short form of the WAI, found their violent offender clients had a mean overall rating of the alliance with their therapists in the low 70s (exact means were not reported), a conservative average item estimate would be around 5.8 out of 7. Thus, while demand characteristics may have been present, the scores for the present sample are comparable with at least one treated violent offender sample and a large community-based non-offender client sample. The findings are also consistent with survey results from sexual offender programs from several U.S. states (Wisconsin, Connecticut, and Florida, to cite a few), which demonstrate on average high levels of consumer satisfaction and generally positive perceptions of treatment (Levenson, MacGowan, Morin, & Cotter, 2009; Levenson & Prescott, 2009; Levenson, Prescott, & D’Amora, 2010).

Aboriginal and Non-Aboriginal Comparisons in WAI

In partial support of the first hypothesis, the only significant difference emerging between Aboriginal and non-Aboriginal men was in the strength of the bond; an effect that was small in magnitude, although it is possible that the actual effect may have been larger, given the potential limitation cited above. This makes sense conceptually, given that the Bond subscale assesses the emotional connection between the client and therapist, with high scores reflecting perceived warmth, reciprocity, and caring. It is precisely the bond component of the working alliance that arguably would stand to suffer from therapeutic services or service providers that are not culturally sensitive, in which case, clients could be at risk for not feeling validated, understood, respected, or appreciated.

In his ethnographic research examining the culture and practices of the Clearwater Program, as previously noted, Waldram (2012) charged that “Aboriginality” (p. 52) played a minor role in the program, and that treatment facilitators made little effort to incorporate cultural differences that might have existed between offenders into their service delivery. It may be tempting to criticize staff for lacking cultural awareness, although Waldram noted that the Aboriginal men also seldom emphasized these differences or made them an issue. Based on these observations, one may reasonably conclude that the men in this particular program were not particularly distressed by limited cultural accommodations of the core program, although this may have continued to impact the bond with their primary therapist.

It is also important to note that the ancestral group difference in bond scores were small in magnitude, and the scores were generally quite strong overall. It is also possible that Aboriginal offenders may have been able to identify and agree on the goals and the tasks of treatment, even with somewhat weaker bonds on average. These WAI scores and the low attrition rates observed in this cohort of treated sexual offenders in the Clearwater Program provide some support for the contention that the program is devoting attention to responsivity considerations. The observations and insights of Waldram (2012) and Mason (2000), however, suggest important opportunities for improvement. This may be why the overall difference between Aboriginal and non-Aboriginal offenders was small.

Working Alliance and Program Non-Completion

The Clearwater Program evinced low rates of attrition at 13.2%, demonstrating that the vast majority of offenders, regardless of ancestry, successfully completed the treatment program. Putting such a finding in context, while this is not only considerably lower than the weighted average rate of non-completion for sexual offender programs (27.6%) found by Olver, Stockdale, and Wormith (2011), this is also lower than the mean weighted non-completion rate in the general psychotherapy literature (19.7%) found by Swift and Greenberg (2012) in their adult psychotherapy meta-analysis of 669 studies.

Consistent with the second hypothesis, the WAI predicted both shorter stays in treatment and program non-completion; no single one of the WAI subscales seemed to predominate. While the correlations tended to be quite small in magnitude (r = –.12 to –.15), these were likely attenuated owing to low base rates of non-completion; the corresponding d values, which are not impacted by fluctuations in base rates, approached moderate in magnitude (d = .38 to .46). Among non-Aboriginal offenders, the relationships approached large in magnitude, with the exception of the Bond subscale, which, interestingly, demonstrated the weakest relationship to non-completion. Conversely, among Aboriginal men, the relationship of WAI score to treatment non-completion was weaker, whereas the strength of working alliance predicted longer length of stay. Our interpretation of this finding is that men with stronger alliances were willing to stay longer and to make an attempt to complete the program, while other factors seemed to have a greater bearing on whether they would eventually successfully complete the program.

Aboriginal men with weaker working alliances, in turn, had the highest rates of attrition whereas non-Aboriginal men with stronger alliances had the lowest rates of attrition, supporting our third study hypothesis. The results of survival analysis demonstrated that Aboriginal men with stronger working alliances still had higher rates of attrition than similar scoring non-Aboriginal men, although both groups had higher retention than men with weaker alliances. These findings are consistent with results from Sharf, Primavera, and Diener’s (2010) recent meta-analysis of 11 studies, which found that weaker therapeutic alliances predicted treatment dropout in adults engaged in individual psychotherapy. Overall, results of the present study are consistent with the notion that offenders who were able to develop stronger therapeutic alliances would also be more likely to remain in treatment and complete it (Castonguay, Constantino, & Holtforth, 2006).

Working Alliance and Recidivism

The results indicate that working alliance clearly matters and has important implications for treatment retention. However, equally clear from these data were that working alliance, good or bad, had little impact on post-program recidivism, irrespective of ancestry and contrary to our fourth hypothesis. What may account for this? One possible explanation is that the working alliance may have an impact that is more indirect and distal than perhaps other factors, such as reducing risk through targeting criminogenic needs, and thus any direct relationships when tested are small or non-existent. A further possibility is that strength of working alliance did not necessarily translate into risk-relevant changes that would otherwise have an impact on outcome. It is possible that some offenders with strong alliances still made little risk-relevant change in treatment despite having a good bond or connection with their therapist. Moreover, given that the working alliance scores were taken fairly early into treatment and measured at only one time point, it is possible that the alliances changed (for better or for worse) over the weeks and months of treatment that ensued, and perhaps post-treatment measures of alliance would be a better and certainly more proximal predictor of success or failure upon release.

Irrespective of working alliance strength, Aboriginal men had higher rates of violent and general recidivism than non-Aboriginal men in partial support of our fifth hypothesis, although there were no group differences in sexual recidivism. When logistic regression modeling was used to generate recidivism estimates as a function of age and offending history, the differences among the groups decreased to demonstrate that preexisting differences in risk level partly contributed to the observed differences in base rates of recidivism; however, the fact that significant differences remained showed that factors unique to Aboriginal ancestry contributed to outcome. Contrary to our fifth hypothesis, there were no alliance-based differences in outcome within ancestral groups given the overall null findings between the WAI and outcome.

Further Cultural Considerations Regarding the Working Alliance and Clinical Services With Aboriginal Offenders

The present study findings have implications for clinical services with Aboriginal offenders from a responsivity standpoint. As previously noted in the introduction, D. W. Sue and Sue (1999) identified a number of common values among Aboriginal peoples (i.e., mutual sharing and giving, cooperation, and focus on the “here and now”) that seem to stand in some contrast to standard CBT approaches to sexual offender treatment. But while this contrast exists, by no means are such differences insurmountable, nor do they nullify the impact of sexual offender treatment with Aboriginal offenders. Underpinning these core values identified by D. W. Sue and Sue is arguably a common theme of respect and acceptance. According to Marshall and Serran (2004), sexual offenders expect to be judged harshly given the egregious nature of their crimes, which in turn contributes to their lack of trust in professionals and exacerbates expectations of being rejected. In his examination of federally incarcerated Aboriginal men who participated in both cognitive behavioral treatment and traditional Aboriginal Sweat Lodge ceremonies, Mason (2000) noted that respondents viewed the programs as more dissimilar than similar. One such prominent difference was a sense of safety and refuge in the Sweat Lodge ceremonies and feeling respected by the Elders while often feeling judged by CBT treatment providers. Mason further noted that Elders were automatically granted respect and reverence based on their title; however, in the eyes of some of the offenders interviewed for his research, respect for the facilitators was something to be earned, and they had to show respect before receiving respect.

Ariel (1999) also notes that the formation of a strong cross-cultural working alliance requires an awareness of one’s own culture, an understanding of how it differs from the client’s, and an openness and receptivity to new ideas and cultural practices. The adoption of a therapeutic mind-set such as this emphasizes respect and humility, integrates traditional and contemporary therapeutic approaches, and maintains program integrity. These principles are central to RNR and have the net effect of promoting retention, minimizing attrition, and maximizing treatment gains. The alliance, however, is a two-way street; the client eventually needs to reciprocate in some form. This is not an easy feat given that offenders are prone to mistrusting health providers, although positive alliances are apt to occur more frequently if the individual feels that they are being respected and treated fairly.

Strengths, Limitations, and Future Directions

The present study has several strengths and limitations, some of which have been noted, with implications for future research. Some important strengths are that the study featured a large sample of treated sexual offenders with prospectively administered WAIs and robust measurements of the outcome variables. The sample, in turn, was fairly evenly divided between Aboriginal and non-Aboriginal men, and this permitted a number of important group comparisons.

One potential limitation, however, is the archival nature of the study. Limited to completing the WAI, the participants did not have other opportunities to report their experiences and provide narrative accounts of their relationships with treatment providers. Future qualitative research efforts incorporating interviews may provide rich data. A second limitation is that therapist ratings on the WAI were not completed to offer another perspective of the alliance and a means to examine the veracity of offender ratings. Polaschek and Ross (2010), however, found that offenders tended to rate the alliances even higher than their own therapists did and concluded that one perspective was not necessarily more accurate or valid than the other (although, see also Beech & Fordham, 1997, for more mixed results regarding client–therapist perceptions of the group treatment environment). A third limitation is that WAI scores administered at one time point, roughly 3 months into treatment, were only available for the present study. The working alliance is arguably a dynamic process that can ebb and flow and is also prone to rupture and repair as treatment progresses. Having WAI scores near the end of treatment would enable an examination of changes in the alliance over treatment, and if such changes were related to outcome.

A fourth limitation is that more detailed information was not available regarding Canadian Aboriginal peoples, with more than 600 First Nations bands, Métis chapters, and the circumpolar peoples of the Arctic. By necessity, the Aboriginal men in the present study were analyzed as a single group, and caution is warranted when interpreting and generalizing the results to Aboriginal offenders as a whole. A further line of research may be to examine working alliance and Aboriginal ancestry as a function of level of acculturation; that is, distinguishing between Aboriginal people whose behaviors and lifestyles are more consistent with their traditional Aboriginal culture versus Aboriginal people whose lifestyles and behaviors more consistently reflect the mainstream urban North American culture. It would be equally simplistic to also assume that all Aboriginal men in the present study were closely aligned, or even desired to be so, with traditional cultural beliefs and way of life. Thus, the lack of a measure of acculturation for this archival study may be construed as an additional study limitation. Finally, while the vast majority of treatment staff rated were psychiatric nurses, many, but not all, of whom were White, a fifth and further limitation is that we did not have information regarding the ancestry or gender of the therapists or other important characteristics (e.g., training backgrounds) to be examined as potential moderators.

In conclusion, the present research was intended to provide some insight into the relationship that develops between treatment providers and Aboriginal sexual offenders. There is a paucity of research in this area, despite the rise of Aboriginal offenders in Canada’s federal correctional system. Perhaps having a better understanding of how to develop and promote stronger therapeutic relationships between sexual offenders and treatment providers can help to increase treatment completion, reduce recidivism, and improve community reintegration.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

References

Andrews

D. A.

Bonta

(2010). The psychology of criminal conduct (5th ed.). New Providence, NJ: LexisNexis.

Andrews

D. A.

Bonta

Hoge

R. D.

(1990). Classification for effective rehabilitation: Rediscovering psychology. Criminal Justice and Behavior, 17, 19-52. doi:10.1177/0093854890017001004

Andrews

D. A.

Dowden

(2006). Risk principle of case classification in correctional treatment: A meta-analytic investigation. International Journal of Offender Therapy and Comparative Criminology, 50, 88-100. doi:10.1177/0306624X05282556

Ariel

(1999). Culturally competent therapy: A general model. Westport, CT: Greenwood.

Beech

Fordham

(1997). Therapeutic climate of sexual offender treatment programs. Sexual Abuse: A Journal of Research and Treatment, 9, 219-237. doi:10.1177/107906329700900306

Beyko

M. J.

Wong

S. C. P.

(2005). Predictors of treatment attrition as indicators for program improvement not offender shortcomings: A study of sex offender treatment attrition. Sexual Abuse: A Journal of Research and Treatment, 17, 375-389. doi:10.1007/s11194-005-8050-8

Bonta

Rugge

Dauvergne

(2003). The reconviction rate of federal offenders. Ottawa, Ontario: Solicitor General of Canada.

Bordin

E. S.

(1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, Practice, Training, 16, 252-260.

Bordin

E. S.

(1994). Theory and research in the therapeutic working alliance: New directions. In Horvath

A. O.

Greenberg

L. S.

(Eds.), The working alliance: Theory, research, and practice (pp. 13-37). New York, NY: John Wiley.

10.

Castonguay

L. G.

Constantino

M. J.

Holtforth

M. G.

(2006). The working alliance: Where are we and where should we go? Psychotherapy: Theory, Research, Practice, Training, 43, 271-279. doi:10.1037/0033-3204.43.3.271

11.

Cohen

(1992). A power primer. Psychological Bulletin, 112, 155-159. doi:10.1037/0033-2909.112.1.155

12.

Correctional Service of Canada. (2009). Facts and figures: Aboriginal community development in corrections. Retrieved from http://www.csc-scc.gc.ca/text/prgrm/abinit/know/4-eng.shtml

13.

Correctional Service of Canada. (2013). Aboriginal offender statistics. Retrieved from http://www.csc-scc.gc.ca/aboriginal/002003-1010-eng.shtml

14.

Dahle

K. P.

(1997). Therapy motivation in prisons: Towards a specific construct for the motivation to enter psychotherapy for prison inmates. In Redondo

Garriso

Perez

Barberet

(Eds.), Advances in psychology and law: International contributions (pp. 431-441). Berlin, Germany: Walter de Gruyter.

15.

Dowden

Andrews

D. A.

(2000). Effective correctional treatment and violent reoffending: A meta-analysis. Canadian Journal of Criminology, 42, 449-476.

16.

Ellerby

L. A.

Ellerby

J. H.

(2000). The role of traditional healers in the treatment of aboriginal sexual offenders. Forum on Corrections Research: Aboriginal People in Corrections, 12, 40-44.

17.

Erdur

Rude

Barón

Draper

Shankar

(2000). Working alliance and treatment outcome in ethnically similar and dissimilar client-therapist pairings. Research Reports of the Research Consortium of Counseling & Psychological Services in Higher Education, 1, 1-21. Retrieved from http://cmhc.utexas.edu/pdf/WorkAll.pdf

18.

Hanson

R. K.

Bourgon

Helmus

Hodgson

(2009). The principles of effective correctional treatment also apply to sexual offenders: A meta-analysis. Criminal Justice and Behavior, 36, 865-891. doi:10.1177/0093854809338545

19.

Horvath

A. O.

(1981). An exploratory study of the working alliance: Its measurement and relationship to outcome (Unpublished doctoral dissertation). University of British Columbia, Vancouver, Canada.

20.

Horvath

A. O.

(1994). Empirical validation of Bordin’s pantheoretical model of the alliance: The Working Alliance Inventory perspective. In Horvath

A. O.

Greenberg

L. S.

(Eds.), The working alliance: Theory, research, and practice (109-128). New York, NY: John Wiley.

21.

Horvath

A. O.

Greenberg

L. S.

(1986). The development of the Working Alliance Inventory. In Greenberg

L. S.

Pinsof

W. M.

(Eds.), The psychotherapeutic process: A research handbook (pp. 529-556). New York, NY: Guilford Press.

22.

Horvath

A. O.

Greenberg

L. S.

(1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223-233. doi:10.1037/0022-0167.36.2.223

23.

Horvath

A. O.

Greenberg

L. S.

(1994). The working alliance: Theory, research, and practice. New York, NY: John Wiley.

24.

Horvath

A. O.

Symonds

B. D.

(1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139-149. doi:10.1037/0022-0167.38.2.139

25.

Howells

Heseltine

Sarre

Davey

Day

(2004). Correctional offender rehabilitation programs: The national picture in Australia. Adelaide: University of South Australia, Forensic Psychology Research Group, Centre for Applied Psychological Research.

26.

Levenson

J. S.

MacGowan

M. J.

Morin

J. W.

Cotter

L. P.

(2009). Perceptions of sex offender about treatment: Satisfaction and engagement in group therapy. Sexual Abuse: A Journal of Research and Treatment, 21, 35-56. doi:10.1177/1079063208326072

27.

Levenson

J. S.

Prescott

D. S.

(2009). Treatment experiences of civilly committed sex offenders: A consumer satisfaction survey. Sexual Abuse: A Journal of Research and Treatment, 21, 6-20. doi:10.1177/1079063208325205

28.

Levenson

J. S.

Prescott

D. S.

D’Amora

D. A.

(2010). Sex offender treatment: Consumer satisfaction and engagement in therapy. International Journal of Offender Therapy and Comparative Criminology, 54, 307-326. doi:10.1177/0306624X08328752

29.

Lewis

Olver

M. E.

Wong

S. C. P.

(2013). The Violence Risk Scale: Predictive validity and linking changes in risk with violent recidivism in a sample of high risk offenders with psychopathic traits. Assessment, 20, 150-164. doi:10.1177/1073191112441242

30.

Marshall

W. L.

Fernandez

Y. M.

Serran

G. A.

Mulloy

Thornton

Mann

R. E.

Anderson

(2003). Process variables in the treatment of sexual offenders: A review of the relevant literature. Aggression and Violent Behavior, 8, 205-234. doi:10.1016/S1359-1789(01)00065-9

31.

Marshall

W. L.

Serran

G. A.

(2004). The role of the therapist in offender treatment. Psychology, Crime & Law, 10, 309-320. doi:10.1080/10683160410001662799

32.

Martin

D. J.

Garske

J. P.

Davis

M. K.

(2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438-450. doi:10.1037//0022-006X.68.3.438

33.

Mason

(2000). The healing of Aboriginal offenders: A comparison between cognitive-behavioral treatment and the traditional Aboriginal sweat lodge ceremony (Unpublished master’s thesis). University of Saskatchewan, Saskatoon, Canada.

34.

Nicholaichuk

T. P.

Gordon

Wong

(2000). Outcome of an institutional sexual offender treatment program: A comparison between treated and matched untreated offenders. Sexual Abuse: A Journal of Research and Treatment, 12, 139-153. doi:10.1177/107906320001200205

35.

Olver

M. E.

Stockdale

K. C.

Wormith

J. C.

(2011). A meta-analysis of predictors of offender treatment attrition and its relationship to recidivism. Journal of Consulting and Clinical Psychology, 79, 6-21. doi:10.1037/a0022200

36.

Olver

M. E.

Wong

S. C. P.

(2013). A description and research review of the Clearwater Sex Offender Treatment Program. Psychology, Crime & Law, 19, 477-492. doi:10.1080/1068316X.2013.758983

37.

Olver

M. E.

Wong

S. C. P.

Nicholaichuk

T. P.

(2009). Outcome evaluation of a high-intensity inpatient sex offender treatment program. Journal of Interpersonal Violence, 24, 522-536. doi:10.1177/0886260508317196

38.

Polaschek

D. L.

Ross

E. C.

(2010). Do early therapeutic alliance, motivation, and stages of change predict therapy change for high-risk, psychopathic violent prisoners? Criminal Behaviour and Mental Health, 20, 100-111. doi:10.1002/cbm.759

39.

Rugge

(2006). Risk assessment of male Aboriginal offenders: A 2006 perspective. Ottawa, Ontario: Public Safety and Emergency Preparedness Canada.

40.

Sharf

Primavera

L. H.

Diener

M. J.

(2010). Dropout and therapeutic alliance: A meta-analysis of adult individual psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 47, 637-645. doi:10.1037/a0021175

41.

Shonfeld-Ringel

(2001). A re-conceptualization of the working alliance in cross-cultural practice with non-western clients: Integrating relational perspectives and multicultural theories. Clinical Social Work Journal, 29, 53-63. doi:10.1023/A:1005258511296

42.

Skeem

J. L.

Louden

J. E.

Polaschek

Camp

(2007). Assessing relationship quality in mandated community treatment: Blending care with control. Psychological Assessment, 19, 397-410. doi:10.1037/1040-3590.19.4.397

43.

Statistics Canada. (2012). Adult correctional statistics in Canada, 2010/2011 (Juristat Statistics Canada—Catalogue No. 85-002-X). Retrieved from http://www.statcan.gc.ca/pub/85-002-x/2012001/article/11715-eng.pdf

44.

Sue

D. W.

Sue

(1999). Counseling the culturally different: Theory and practice. New York, NY: John Wiley.

45.

Sue

Allen

D. B.

Conaway

(1978). The responsiveness and equality of mental health care to Chicanos and Native Americans. American Journal of Community Psychology, 6, 137-146. doi:10.1007/BF00881035

46.

Swift

J. K.

Greenberg

R. P.

(2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80, 547-559. doi:10.1037/a0028226

47.

Tabachnick

B. G.

Fidell

L. S.

(2001). Using multivariate statistics (4th ed.). Needham Heights, MA: Allyn & Bacon.

48.

Waldram

J. B.

(1993). Aboriginal spirituality: Symbolic healing in Canadian prisons. Culture, Medicine and Psychiatry, 17, 345-362. doi:10.1007/BF01380009

49.

Waldram

J. B.

(2012). Hound pound narrative: Sexual offender habilitation and the anthropology of therapeutic intervention. Los Angeles: University of California Press.

50.

Wilson

(2007). Enhancing the role of Aboriginal communities in federal corrections. Retrieved from http://www.csc-scc.gc.ca/text/prgrm/abinit/ab6-eng.shtml

51.

Wong

S. C. P.

Gordon

A. E.

(2006). The validity and reliability of the Violence Risk Scale: A treatment-friendly violence risk assessment tool. Psychology, Public Policy, and Law, 12, 279-309. doi:10.1037/1076-8971.12.3.279

52.

Wormith

J. S.

Olver

M. E.

(2002). Offender treatment attrition and its relationship with risk, responsivity, and recidivism. Criminal Justice and Behavior, 29, 447-471. doi:10.1177/0093854802029004006