Optimizing the alliance in couple therapy

The complexity of the relation between alliance and outcome in couple therapy was investigated in a study of 47 couples in brief therapy. Self-rated alliance was measured after the first and third sessions using the couple version of the Working Alliance Inventory. The results indicated that the correlation between alliance and outcome was significantly stronger when the partners agreed about the strength of the alliance, when the male partner's alliance was stronger than the female's, and when the strength of both partners' alliance increased as therapy progressed. The authors suggest that a unique feature of couple therapy is that the partners have both a preexisting relationship with each other (allegiance) and an alliance with the therapist to balance.     

Differentiation,perceived stress and therapeutic alliance as key factors in the early stage of couple therapy

A sample of 168 couples were assessed at intake and over the first six sessions of treatment providing the opportunity to investigate not only the impact of client and common factors on initial levels of satisfaction, but also trajectories of change in satisfaction over time. The study used multi‐level modelling to examine changes in relationship satisfaction for both partners, thus enabling the couple to be maintained as the unit of analysis. We first examined changes in satisfaction and, having discovered differences there, we then investigated the impact of client factors of differentiation and stress in explaining these differences in relationship satisfaction. Finally we explored the additional influence of the common factor, therapeutic alliance, while controlling for the client factors, on relationship satisfaction.     

The therapeutic alliance in couples therapy: clinical considerations

This article presents clinical considerations about the therapeutic alliance in couples therapy, stimulated by pertinent new research findings reported in this issue. A loyalty dimension of the couple's relationship is described, as well as its influence on the therapeutic alliance in couples therapy. The therapist's establishment of a "meta-alliance" with the couple around their loyalty conflicts, avoidance of splits and disruptions, and prioritization of marital distress (versus individual symptoms) as the primary focus of treatment all serve to solidify the therapeutic alliance. In addition, identifying the partners' early family-of-origin distress can help predict and respond to strains in the therapeutic alliance that may occur later in therapy. Finally, the therapist helping the couple to balance their relational power differences in therapy and to address their concerns about the impact of the therapist's gender also strengthens their therapeutic alliance. A clinical case and vignettes are included to illustrate these issues.     

Therapeutic alliance and progress in couple therapy: multiple perspectives

Therapeutic alliance research in couple therapy using multiple perspectives and longitudinal data has been sparse. This study used structural equation modelling to explore relationships between changes in alliance and in progress from clients' and therapists' perspective in a fairly large sample of couples (N=195) during the initial stage of therapy at an on‐campus training clinic. Self‐rated alliance was measured after sessions 2 through 4 with the Working Alliance Inventory. There was very little change in alliance over the early sessions of therapy, and changes in alliance did not always account for changes in relationship satisfaction. Husbands' perceptions of satisfaction and alliance seem to play an important role in the dynamics of the therapeutic process. Findings suggest a reciprocal relationship between perceptions of alliance and progress in therapy when combining perceptions of therapists and couple clients. Clinical implications and future research are discussed.     

The concept of the therapeutic alliance.

Certain conceptual aspects of the therapeutic alliance are considered. Although therapeutic alliance, transference, and the real relation are intermingled and intertwined in the actuality of the analytic relationship, they remain distinguishable and open to differentiating analysis. The distinctions between the therapeutic alliance and transference, and between alliance and the real relation, are explored and their differences clarified, including the difference between therapeutic misalliances and transferences. Some of the component dimensions of the therapeutic alliance are explored, including empathy, the therapeutic framework, responsibility, authority, freedom, trust, autonomy, initiative, and ethical considerations including values and confidentiality. Further exploration of these and other dimensions of the therapeutic alliance is called for, especially the extension of these dimensions to their practical clinical application.     

Love in the therapeutic alliance

Volumes have been written about the patient's love for the therapist, but there has been relatively little discussion of the therapist's love for the patient. In an attempt to create a theoretical and technical space for discussing the appropriateness and role of love in the therapeutic relationship, a revised concept of the therapeutic alliance is applied to provide technical guidelines and understanding of two kinds of love between patient and therapist, corresponding to two systems of self-esteem regulation: an open, reality-oriented system and a closed, sadomasochistic system organized according to omnipotent beliefs. Examples of the role of love through the phases of treatment illustrate the interrelationship of love and the accomplishment of therapeutic alliance tasks.     

Observing the therapeutic alliance in family therapy: associations with participants' perceptions and therapeutic outcomes

Positive and negative alliance‐related behaviours of thirty‐seven families seen in brief family therapy were rated from videotapes using the System for Observing Family Therapy Alliances ( Friedlander et al., 2006b ). Positive associations were found between in‐session behaviour and participants' perceptions of the alliance and improvement so far both early (session 3) and later in therapy (session 6). Binary logistic regression showed that successful outcomes (defined as consensus by therapist and all family members on general improvement and reduced problem severity) were significantly predicted by positive individual behaviour (Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System) in session 3 and productive within‐family collaboration (Shared Sense of Purpose within the Family) in session 6. Shared Sense of Purpose was the alliance indicator most consistently associated with clients' and therapists' perceptions of therapeutic progress; moreover, it was the only alliance indicator to improve significantly over time in treatment.     

The therapeutic alliance: Adolescent perspectives

This paper presents a conceptualisation of the therapeutic alliance from the adolescent perspective and discusses implications for practitioners. The main aim of the study was to focus on the factors that participants identified as important in relationship formation and maintenance. Eighteen individuals were interviewed using a semi‐structured format. Three major themes were identified: therapeutic environment, uniqueness of the therapeutic relationship, and therapist characteristics. Participants identified both positive and negative aspects of the therapeutic relationship. A strong alliance was found to be necessary in that the perception of the therapist as accepting, supportive and trustworthy influenced the adolescent's evaluation of the appropriateness of therapeutic tasks and goals. Participants stressed the importance of the supportive nature of the relationship in their willingness to collaborate in therapeutic interventions.     

The couple who fell in hate: Eclectic psychodynamic therapy with an angry couple

Couples in which the husband is passive and the wife aggressive are a common sight in today's therapy clinics. Such couples are difficult to work with because they have become addicted to their ritual of hate, which offers each a secondary gratification. To work with them, therapists often need to be creative and utilize eclectic approaches. In this instance, I have used a paradoxical behavioral approach combined with psychoanalysis.     

Developing the therapeutic alliance in acute mental health care

The establishment of a good working relationship, or therapeutic alliance, is seen as a key indicator of good outcome in all forms of psychological therapy. Such a relationship, however, is difficult to establish in acute mental health, when the patient may both need and fear therapeutic contact. The patient care plan can give the appearance of a positive working alliance when this is not truly established. The Care Plan Approach can prioritize case management and risk assessment over treatment. A good therapeutic alliance can often be achieved in times of acute crisis, but only when the difficulties in so doing are recognized and acknowledged. The distinction between benign and malign dependency can be a useful way of conceptualizing therapeutic and non‐therapeutic factors in acute care. Apparently progressive paradigms in mental health care serve to deny the inherent difficulties and conflicts involved in establishing a therapeutic alliance in cases of severe mental illness. Developing a genuine therapeutic culture in acute mental health requires that organizational structures and protocols are clinically informed and are congruent with the therapeutic ethos desired. Examples from a recently established Acute Day Hospital will illustrate how a psychodynamically‐informed group‐based treatment can be effective in developing the therapeutic alliance. I will focus on Psychiatric Nursing, although I hope that the content of the paper is more widely applicable.     

The therapeutic alliance and the interface of career counseling and personal counseling

This article proposes a very specific pathway for bringing career counseling back into mainstream counseling psychology: more explicit research and clinical attention to the therapeutic alliance. The author hopes that this abbreviated review on the alliance serves as an impetus for increased attention to the alliance in career counseling theory, research, and practice as well as for including training in alliance formation and strengthening in career counselor education and supervision.     

The clinical representativeness of couple therapy outcome research

The clinical representativeness of outcome studies is defined as the generalizability of recruitment processes, assessment/diagnostic procedures, treatment protocols, and therapeutic results from research settings to naturalistic treatment settings. The main goal of the present study was to examine the clinical representativeness of couple therapy in outcome studies. The data set was formed by 50 published clinical trials, including 34 couple therapy outcome studies for marital distress (CTMD) and 16 couple therapy outcome studies for comorbid relational and mental disorders (CTMD + C). The present findings showed that, overall, the clinical representativeness of couple therapy outcome studies is only fair (i.e., the mean global score is slightly lower than the midpoint of the rating scale used to assess representativeness). CTMD + C studies fared better than CTMD studies on many dimensions of clinical relevance. Studies in which pretherapy training was less intensive (for CTMD studies only), treatment was less structured, and therapists were more experienced showed larger effect sizes than those in which such was not the case.     

The effect of therapist interventions on the therapeutic alliance with borderline patients

The authors draw attention to the problems of establishing and maintaining a therapeutic alliance in the psychotherapy of the borderline patient. They elaborate an extensive methodology designed to study the manner in which shifts in collaboration occur in response to therapist interventions. This report demonstrates how one particular borderline patient increased his ability to collaborate with the therapist in response to a transference focus in the psychotherapy. Methodological problems are noted as are directions for future research. Only a series of patients studied with this or with similar methodology will allow for a sophisticated and empirical rationale for choosing a particular form of psychotherapy for a particular kind of borderline patient.     

The interpersonal alliance as the principle of psychoanalytic therapy]

The classical opinion encountered in psychoanalytic psychotherapy is that the main curative agent is language, i.e. the information proffered by the analysand and the interpretations of the analyst. Over and against this view the author draws attention to the non-verbal structures in the twosome relationship between analysand and therapist. Essential elements of this working alliance, he suggests, operate via non-verbal behaviour. Hence this behaviour needs to be systematically observed and evaluated. His conclusion is that it requires the consideration of non-verbalized fantasies and affects for the therapeutic relationship to develop into a "good relationship".     

Factorial and construct validity of the revised short form integrative psychotherapy alliance scales for family, couple, and individual therapy

The Integrative Psychotherapy Alliance model brought an interpersonal and systemic perspective to bear on theory, research, and practice on the psychotherapeutic alliance. Questions have been raised about the independence of the theoretical factors in the model and their operationalization in the Individual, Couple, and Family Therapy Alliance Scales. This paper presents results of a confirmatory factor analysis of the scales that delineated at least three distinct interpersonal factors as well as shorter versions of the three scales to facilitate their use in research and practice. The paper also presents the results of a study testing each factor's association with client retention and progress over the first eight sessions in individual and couple therapy. At least two of the interpersonal factors were uniquely associated with progress in individual and couple functioning. Implications of the results for theory, research, practice, and training in individual, couple, and family therapy are elaborated.     

Training family therapy students in conceptual and observation skills relating to the therapeutic alliance: an evaluation

This paper describes a training intervention to develop students' conceptual and observation skills relating to the therapeutic alliance (TA) in family therapy. An evaluation methodology was developed and piloted. The knowledge and observation skills of family therapy students pre‐ and post‐training were assessed in comparison to a non‐intervention group of experienced clinicians. Students' mean scores on the knowledge measure improved significantly from 43 per cent to 74 per cent (p<0.001) and on the observation test from 43 per cent to 65 per cent, although this failed to reach statistical significance (p=0.08). There were no significant changes in the clinicians' scores over the same period. The clinicians' knowledge was higher initially, but the students had caught up after six months. In conclusion, training students in conceptual and observational skills relating to the therapeutic alliance may have a measurable effect. A ‘stepwise’ methodology for demonstrating the relationship between training in TA and outcomes for families is proposed.