The Impact of Therapeutic Alliance on AMA Rates
Nathan Dean Fitch, Michael Krause, Kinan Moukamal, Michael Castanon.
Abstract
The therapeutic alliance, long regarded as a
cornerstone of effective behavioral health treatment, remains difficult to
measure and operationalize across diverse levels of care. This study examines how
provider attachment style and related interpersonal characteristics—assessed
through the Care Predictor Index (CPI), a 234-item psychometric
instrument—predict patient retention outcomes across five behavioral health
organizations. Drawing upon attachment theory, alliance research, and data from
over six months of clinical practice, the study evaluates how therapist CPI
scores correlate with treatment completion and discharges against medical
advice (AMA) within detoxification, residential, partial hospitalization,
intensive outpatient, and outpatient settings. The CPI integrates elements from
the Adult Attachment Questionnaire (AAQ), the Counselor Activity Self-Efficacy
Scales (CASES), and the Analog to Multi-Broadband Inventories (AMBI) to
generate multidimensional provider profiles that capture attachment,
confidence, and personality traits empirically linked to alliance formation.
Findings demonstrate that therapists with CPI scores above 70 achieved higher
treatment completion and lower AMA rates, underscoring the predictive validity
of attachment-informed provider assessment. Beyond identifying measurable
therapist level predictors, this analysis situates relational competence as a
central determinant of program retention and proposes the CPI as a scalable
mechanism for workforce development, quality improvement, and outcome
optimization across the continuum of behavioral health care.