Subjective outcome of brain injury rehabilitation in relation to the therapeutic working alliance, client compliance and awareness

Objective: To investigate the relationship between working alliance, compliance, awareness and subjective outcome of brain injury rehabilitation. Subjects were 86 patients who were clients in an holistic neuropsychological outpatient rehabilitation programme. They had suffered a traumatic brain injury (n = 27), a cerebrovascular accident (n = 49) or some other neurological insult (n = 10). Measures: The therapeutic alliance, clients' awareness and their compliance were rated four times during the 14-week rehabilitation programme. The therapeutic alliance was rated by both clients and therapist using the Working Alliance Inventory (WAI), awareness and compliance were rated by the therapists. Clients completed the European Brain Injury Questionnaire (EBIQ) at programme start and end. Clients and therapists rated the overall success of their collaboration at programme end. Results: Clients' experience of a good emotional bond between themselves and therapists in mid-therapy was predictive for the reduction of clients' report of depressive symptoms on the EBIQ depression sub-scale (R = 0.68, n = 43, p < 0.001). Good compliance early in the programme was predictive of changes on the EBIQ. Improvement of awareness was related to the amplification of depressive symptoms (r = 0.27, n = 56, p < 0.05). Conclusions: Brain injury rehabilitation should be seen as a dynamic process that develops between clients and therapists. Future research should further investigate the relationship between process and outcome and how the therapeutic process can be optimized.