Theses and Dissertations

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Date of Award

1-1-2026

Document Type

Dissertation - NSU Access Only

Degree Name

Doctor of Psychology (PsyD)

First Advisor

Christian DeLucia

Keywords

abstinence self-efficacy; alliance; empathy; positive coping; residential treatment; substance use disorder

Abstract

Primary Purpose: Common factors (e.g., the alliance, therapist empathy) play an influential role in predicting favorable outcomes in psychotherapy. Despite this, much of the substance use disorder (SUD) treatment outcome research is focused on specific interventions (e.g., cognitive restructuring in CBT). Review of empirical literature supports an association between common factors and favorable SUD treatment outcomes. However, the preponderance of data that examine common factors focus on narrow outcomes (e.g., substance use frequency) for individuals experiencing alcohol-related impairment. Consequently, this study explored common factors (i.e., the therapeutic alliance, the working alliance, therapist empathy) in the context of residential SUD treatment for individuals who use substances other than or in addition to alcohol. In addition, associations between common factors and treatment outcomes (adaptive coping, abstinence self-efficacy, and substance use) were examined during a six-month follow-up period. Hypotheses: The following hypotheses were tested: (a) participants will experience strong relationships with their therapists during treatment as measured by the therapeutic alliance, the working alliance, and client perceptions of therapist empathy; (b) higher levels of the therapeutic alliance, the working alliance, and therapist empathy will be associated with more optimal changes in positive coping; (c) higher levels of the therapeutic alliance, the working alliance, and therapist empathy will be associated with more optimal changes in abstinence self-efficacy; (d) higher levels of the therapeutic alliance, the working alliance, and therapist empathy will be associated with more optimal changes in substance use. Methods: Study participants (N = 205) were adults—age 18 or older—recruited from a short-term residential substance use treatment program in the southeastern United States. Participants were assessed on several occasions during treatment, and again at one-, three-, and six-months post-discharge. Analyses: Data were primarily analyzed using growth curve modeling to examine trajectories of change while controlling for baseline mental health symptoms and age of substance use onset. Results: Participants reported favorable therapeutic relationships. All three measures of common factors exceeded the suggested cut point. Common factors were not associated with longitudinal substance use or abstinence self-efficacy. Instead, substance use increased over time following discharge, and abstinence self-efficacy demonstrated early gains that gradually attenuated. In contrast, therapeutic alliance and therapist empathy were associated with positive coping trajectories. Specifically, stronger therapeutic relationships were associated with greater early improvements in adaptive coping, although these gains leveled off over time. Baseline mental symptoms and earlier age of substance use onset were associated with lower initial abstinence self-efficacy. Conclusions: These results suggest that common factors may be more closely associated with adaptive recovery processes than to abstinence alone. Although therapeutic relationships did not predict substance use outcomes following discharge from residential treatment, therapeutic alliance and therapist empathy were associated with early changes in positive coping. Collectively, these findings highlight the importance of examining recovery outcomes beyond abstinence alone and suggest common factors may be particularly relevant to adaptive coping during early recovery. Keywords: substance use disorder, therapeutic alliance, working alliance, therapist empathy, positive coping, abstinence self-efficacy, residential treatment, longitudinal research

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