Family Therapy Alliances Research Articles

Ethnic background, therapeutic alliance, and treatment retention in functional family therapy with adolescents who abuse substances.

In this study, the authors examined the role of balance between adolescent-therapist and parent-therapist alliances in the retention of functional family therapy clients. Therapeutic alliances of mothers, fathers, and adolescents were assessed from videotapes of the 1st treatment session for 43 Hispanic and 43 Anglo families. Hispanic families who dropped out before completing the requisite number of sessions were found to have greater imbalance in alliance (parent-adolescent) than those who did complete therapy. However, this finding was not replicated with Anglo families. Results are interpreted in terms of previous research on family-level balanced alliance effects.

The therapeutic alliance and family psychoeducation in the treatment of schizophrenia: An exploratory prospective change process study.

Although family psychoeducation has been shown to be highly efficacious in the treatment of schizophrenia, the mechanisms underlying the treatment's success are poorly understood. The therapeutic alliance in behavioral family management (BFM) was examined to determine whether the alliance plays a role in the efficacy of this treatment. One early BFM session (mean session = 6.5) involving 28 schizophrenia patients and their relatives who participated in the National Institute of Mental Health's Treatment Strategies in Schizophrenia study was coded using the System for Observing Family Therapy Alliances. Results indicated that when relatives developed a positive therapeutic alliance, patients were less likely to show prodromal signs of relapse and be rehospitalized over a 2-year follow-up period. When patients developed a positive alliance, relatives became less rejecting and were less likely to feel burdened over a 2-year period. The data suggest that the development of a positive therapeutic alliance within family psychoeducation may play an important role in preventing the escalation of psychotic symptoms and improving family relationships. (PsycINFO Database Record (c) 2008 APA, all rights reserved).

How do therapists enhance family alliances? Sequential analyses of therapist-client behavior in two contrasting cases.

To identify alliance-related behavior patterns in more and less successful family therapy, the authors intensively analyzed two cases with highly discrepant outcomes. Both families were seen by the same experienced clinician. Results showed that participants' perceptions of the alliance, session impact, and improvement at three points in time were congruent with the families' differential outcomes and with observer-related alliance behavior using the System for Observing Family Therapy Alliances. In this measure, therapist behaviors contribute to the alliance and client behaviors reveal the strength of the alliance on four dimensions: Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family. In the poor outcome case, observer ratings and self-reported alliance scores revealed a persistently "split" alliance between family members; this family dropped out midtreatment. Only in the good outcome case did the clients follow the therapist's alliance-building interventions with positive alliance behaviors; sequential analyses showed that therapist contributions to Engagement significantly activated client Engagement behavior, and therapist Emotional Connection interventions significantly activated client Emotional Connection. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

The Discursive Performance of the Alliance in Family Therapy: A Conversation Analytic Perspective

Following the ‘discursive’ turn in family therapy, the attention of practitioners shifted towards understanding how culture and language shape meaning‐making in therapy. In this article, we demonstrate how conversation analysis (CA) can be used to examine the processes and outcomes of systemic/constructionist practice. We used CA to study collaborative interactions of a renowned constructionist therapist Karl Tomm and one client‐family. Viewing collaboration as a pivotal aspect of the therapeutic alliance, we demonstrate how the ‘split’ within‐system alliances were developed and sustained in the course of therapy and how they were discursively transformed into ‘intact’ alliances. The therapist's efforts to align with perspectives of family members (and subsystems) seemed pivotal in this process.

Journey of acculturation: developing a therapeutic alliance with Chinese adolescents suffering from eating disorders in Shenzhen, China

Adolescents suffering from eating disorders (ED) including anorexia nervosa (AN) and bulimia nervosa (BN) are typically ambivalent towards change, and often have low motivation in seeking help and participating in treatment (Bruch, 1973; Selvini Palazzoli, 1981; Ward et al., 1996). Developing a therapeutic alliance and engaging them in treatment are often insurmountable tasks for clinicians and psychotherapists. The challenge will be even greater for family therapists who have to relate to both the emaciated adolescents and their parents at the same time. The family therapist faces a dilemma to support the emaciated adolescents on the one hand, and to collaborate with the parents to combat the disorder on the other. Winning the trust of both parties is an ideal goal, but in reality there is the risk of losing the trust of either the afflicted adolescent or the parents, and if the situation is not handled appropriately, the resistance of both parties may be heightened, resulting in premature termination of treatment. Therapeutic alliance can be defined as the joint product of the therapist and client(s) together focusing on the work of therapy (Sprenkle and Blow, 2004). Maintaining a strong therapeutic alliance in family therapy has been identified as one of the common factors accounting for treatment success. There are three groups of factors affecting the therapeutic alliance in family therapy: the therapist characteristics (such as accurate empathy, non-possessive warmth), the client characteristics (such as treatment expectation, motivation and personal strengths) and the therapist–client interaction. As cultural background shapes a person’s experience and influences his or her worldview and behaviours, family therapists and r The Association for Family Therapy 2007. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. Journal of Family Therapy (2007) 29: 389–402 0163-4445 (print); 1467-6427 (online)

Book Reviews: Therapeutic Alliances in Couple and Family Therapy: An Empirically Informed Guide to Practice (2006). Myrna L. Friedlander, Valentin Escudero, and Laurie Heatherington, Washington, DC: American Psychological Association, 338 pages. Reviewed by Kristen M. English

Book Reviews: Therapeutic Alliances in Couple and Family Therapy: An Empirically Informed Guide to Practice (2006). Myrna L. Friedlander, Valentin Escudero, and Laurie Heatherington, Washington, DC: American Psychological Association, 338 pages. Reviewed by Kristen M. English

Attachment and the Therapeutic Alliance in Family Therapy

The therapeutic alliance has consistently predicted client outcomes in psychotherapy. This study uses attachment theory as a resource in understanding the therapeutic alliance. Participants in this study were 27 mothers, 15 fathers, and 23 adolescents that participated in family therapy. Results indicate that mothers' reports of trust in their oldest child predicted the alliance, and adolescent ratings of trust in mothers and fathers moderated the relationship between therapy alliance and symptom distress. Implications for family therapy research and practice are discussed.

THREE PERSPECTIVES ON CLIENTs' EXPERIENCES OF THE THERAPEUTIC ALLIANCE: A DISCOVERY‐ORIENTED INVESTIGATION

To deepen our understanding of the therapeutic alliance in conjoint treatment, we interviewed clients in four families about their individual, private experience of the alliance after an early session. These qualitative data were triangulated with family members' scores on Pinsof's Family Therapy Alliance Scale-Revised and observational ratings of their behavior on the System for Observing Family Therapy Alliances. This discovery-oriented investigation focused on three interrelated aspects of the alliance: the family's shared sense of purpose about the needs, goals, and value of therapy (i.e., within-system alliance), split alliances with the therapist, and felt sense of safety within the therapeutic context. Results were highly consistent across the three perspectives and congruent with idiographic, therapist-rated outcomes.

System for observing family therapy alliances: A tool for research and practice.

To advance research and inform practice, the authors developed an observational rating of client behavior reflecting strong and weak therapeutic alliances in couple and family therapy. The System for Observing Family Therapy Alliances (SOFTA), in both English and Spanish, has 2 dimensions that are common across therapy modalities (emotional connection to the therapist and engagement in the therapeutic process) and 2 dimensions that reflect the uniqueness of conjoint treatment (safety within the therapeutic system and shared sense of purpose within the family). Psychometric support is provided by 5 reliability studies, an exploratory factor analysis with data from 120 diverse English- and Spanish-speaking couples and families, and meaningful associations with various process and outcome indices. Recommendations are made for using the SOFTA in research, training, and (self-)supervision.

Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems.

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations.

Role of therapeutic alliance in family therapy for adolescent anorexia nervosa

The purpose of this study is to examine the role of therapeutic alliance in predicting treatment dropout, response and outcome in a cohort of adolescents with anorexia nervosa (AN) and their families who were treated using a manualized form of family-based therapy (FBT). Independent assessors scored early and late therapeutic alliances for patients and parents using the Working Alliance Inventory-Observer (WAIo). Outcomes were weights and scores on the subscales of the Eating Disorder Examination at the end of 12 months of FBT. Therapeutic alliance throughout treatment was strong both for adolescents and for their parents. A strong early alliance with adolescents was associated with early treatment response in terms of weight gain. A strong early alliance with parents prevented dropout, whereas a strong late parental alliance predicted their child's total weight gain at the end of treatment. Therapeutic alliance in both patients and parents treated with FBT is generally strong and likely contributes to treatment retention and treatment outcome.

Adolescent and Parent Alliance and Treatment Outcome in Multidimensional Family Therapy.

In this study, the authors examined the relation between adolescent and parent therapeutic alliances and treatment outcome among 65 substance-abusing adolescents receiving multidimensional family therapy. Observer ratings of parent alliance predicted premature termination from treatment. Observer ratings, but not self-report, of adolescent alliance predicted adolescents' substance abuse and dependency symptoms at posttreatment, as well as days of cannabis use at 3-month follow-up. The association between adolescent alliance and substance abuse and dependency symptoms at posttreatment was moderated by the strength of the parent alliance. Results reveal the unique and interactive effects of the 2 alliances on treatment outcome and emphasize the need for a systemic and well-articulated approach to developing and maintaining the multiple alliances inherent to family therapy.

Alliance and dropout in family therapy for adolescents with behavior problems: individual and systemic effects.

This study examined the relationship between alliance and retention in family therapy. Alliance was examined at the individual (parent and adolescent) and family levels (within-family differences). Participants were 34 families who received functional family therapy for the treatment of adolescent (aged 12-18 years) behavior problems. Families were classified as treatment dropouts (n=14) or completers (n=20). Videotapes of the first sessions were rated to identify parent and adolescent alliances with the therapist. Results demonstrated that individual parent and adolescent alliances did not predict retention. However, as hypothesized, dropout cases had significantly higher unbalanced alliances (parent minus adolescent) than did completer cases. These findings highlight the importance of alliances in functional family therapy and suggest that how the alliance operates in conjoint family therapy may be a function of systemic rather than of individual processes.

Therapeutic Alliance in Family Therapy for Adolescents with Epilepsy: An Exploratory Study

Nineteen adolescents with epilepsy and their parents completed all phases of the study. Families were assigned randomly to either issue-specific single-family counseling (IFCM) or to a multi-family psychoeducational group (PG). Three issue-specific scales were used to evaluate problem improvement. A modified version of the Working Alliance Inventory assessed therapeutic alliance. No overall differences in alliance were found between IFCM and PG. However, IFCM adolescents reported significantly stronger alliance than those in PG. Alliance remained stable from sessions three to six. Finally, there was a trend for alliance to correlate positively with therapy outcome for teens, but not for mothers.

The therapeutic alliance in home-based family therapy: is it predictive of outcome?

This study examined the association between the therapeutic alliance in family therapy and changes in symptom distress, interpersonal relationships, and family coping. The participants (N = 81) were members of low socioeconomic status families referred to a university clinic for in-home family therapy. Participants completed the Outcome Questionnaire, Family Crisis Oriented Personal Evaluation, and the Family Therapy Alliance questionnaires. Regression analyses revealed that the therapeutic alliance explained 19% of the variance in symptom distress changes for mother, 55% for fathers, and 39% for adolescents. The implications of these findings for practicing and researching family therapy are presented.

Culturally competent family therapy: a general model

Foreword by Florence Kaslow Acknowledgdments Introduction Culture and Family Therapy: An Overview The Necessity to Incorporate Culture into the Theory and Practice of Family Therapy The General Model of Culturally Competent Family Therapy:A Brief Outline Family-Cultural Concepts Relevant to Diagnosis and Treatment The Family's Conceptualization of Its Environment The Family's Cultural Identity The Family's Functioning and Lifestyle The Family's Coping with Problems and Difficulties The Information-Processing Framework The Family as an Information-Processing System Culturally Determined Family Dysfunction Culturally Competent Family Diagnosis Data-Collection Instruments and Procedures Analysis of Diagnostic Data Therapy The Therapeutic Alliance in Culturally Competent Family Therapy Planning the Therapy: Strategies, Tactics and Techniques The Therapeutic Process Epilogue Appendix References Index

Alliance-building interventions with adolescents in family therapy: A process study.

This exploratory, process-research study identified, articulated, and measured therapist behaviors associated with improving initially poor therapistadolescent alliances in multidimensional family therapy (MDFT). A list of preliminary alliance-building interventions was generated from MDFT theory and adolescent development research. This list was then refined through the observation of videotaped MDFT sessions. A sample of five improved and five unimproved alliance cases was then drawn from a larger treatment study. Participants were primarily African American, male, adolescent substance abusers and their families. Coders rated the first three sessions of each case (30 sessions) to

Dimensions of Therapeutic Alliance and Their Associations with Outcome in Family Therapy

The relationship between the client and the therapist continues to be regarded as an important aspect of the therapeutic process. This study examined the various aspects of therapeutic alliance and their associations with treatment outcome in family therapy. The inclusion of two or more family members in the therapeutic process introduces complexity into the relation between alliance and outcome. Results of this study corroborate prior research demonstrating an association between alliance and therapeutic outcome. In addition, associations between alliance and outcome were stronger for wives compared to husbands. A more revealing finding was that when wives' alliance scores were higher than husbands' scores, the outcome of therapy was reported to be more positive than when husbands' alliance scores were higher than wives' scores. Future directions for research investigating alliance in marriage and family therapy are discussed.Die Beziehung zwischen dem Klienten und dem Therapeuten wird nach wie vor als ganz wesentlicher Aspekt des therapeutischen Prozesses erachtet. Diese Untersuchung prüfte verschiedene Aspekte der therapeutischen Allianz und ihrer Beziehung zum Therapieergebnis im Kontext der Familientherapie. Die Hinzunahme zweier oder mehrerer Familienmitglieder in eine Behandlung macht die Beziehung zwischen der Allianz und dem Therapieergebnis naturgemäss komplexer. Die Ergebnisse dieser Studie unterstreichen jene Forschungbefunde, die eine deutliche Beziehung zwischen der Allianz und dem Therapieergebnis darlegen. Dazu kommt, dass die Zusammenhänge zwischen der Allianz und dem Therapieergebnis ausgeprägter für die Frauen verglichen mit den Männern waren. Es zeigte sich ferner, dass die Therapie insgesamt positiver beurteilt wurde, wenn die Einschätzungen der therapeutischen Allianz der Frauen über jener der Männer lag. Abschliessend werden in diesem Beitrag künftige Forschungsstrategien zur Untersuchung der therapeutischen Allianz in der Paar- und Familientherapie diskutiert.La relation entre le patient et le thérapeute continue à être considérée comme un aspect important du processus thérapeutique. Cette étude a examiné les aspects variés de l'alliance thérapeutique et ses associations avec le résultat en thérapie familiale. Inclure deux membres de la famille ou plus dans le processus thérapeutique rend complexe la relation entre alliance et résultat. Les résultats de cette étude corroborent une recherche antérieure qui a démontré une association entre alliance et résultat thérapeutique. De plus, les associations entre alliance et résultat étaient plus fortes chez les épouses comparées aux maris Un résultat encore plus révélateur a été que, lorsque les scores d'alliance des épouses étaient supérieurs aux scores des maris, le résultat de la thérapie était rapporté comme plus positif que lorsque les scores d'alliance des maris étaient supérieurs aux scores des épouses. Des directions futures de la recherche sur l'alliance dans la thérapie de couple et de famille sont discutées.

Complementarity and symmetry in family therapy communication.

We examined relational control communication patterns in systemic family therapy sessions. Therapist interactions with each family member (N = 29 families) were examined with the Family Relational Communication Control Coding System. Results showed significantly more complementarity, which reflects mutuality in the definition of a relationship, than symmetry, which characterizes relational control competition. Transitional probabilities showed that family members were likely to respond to therapists in a complementary manner (following therapist one-up, 1, messages with one-down, J,, messages and vice versa); therapists were likely to respond to client 1' and ~ messages in either a competitive symmetrical or complementary manner. Neither complementarity nor symmetry was predictive of family members' perceptions of the therapeutic alliance as measured by Couple and Family Therapy Alliance Scales.

COUPLE AND FAMILY THERAPY ALLIANCE SCALES: EMPIRICAL CONSIDERATIONS1

The introduction of the concept of the therapeutic alliance to the family literature has considerable heuristic value. We undertook a study of the psychometric properties of the Couple and Family Therapy Alliance Scales (IPAS) (Pinsof & Catherall, 1986), two theoretically derived and systemically based measures of the alliance. Outpatient couple and family clients completed the respective scale and the Session Evaluation Questionnaire (SEQ) (Stiles, 1980; Stiles & Snow, 1984) immediately following an early‐to‐mid treatment interview. Descriptive analyses provided support for the continued use of the instruments. Specifically, ratings were fairly normally distributed, reliability estimates reflected good internal consistency, and no statistical differences in mean ratings were found between couples and families or between men and women. Patterns of association between the content subscales and the SEQ depth and smoothness scales were consistent with some predictions. Finally, Pinsof and Catherall's theoretical concept of the split alliance was found to be empirically identifiable among family members' ratings.