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.     

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.     

A Dyadic Analysis of the Between‐ and Within‐System Alliances on Distress

To read this article's abstract in both Spanish and Mandarin Chinese, please visit the article's full‐text page on Wiley InterScience ( http://interscience.wiley.com/journal/famp ). This study examines the relationship between the therapeutic alliance and distress using the couple rather than the individual as the unit of analysis. One hundred and seventy‐three couples receiving treatment for relational distress at two university clinics participated in this study. The actor–partner interdependence model was used to analyze the relationship of each partner's between‐ and within‐system alliance scores and distress at session four. Results provide support for actor effects on relational distress for both male and female partners and for actor effects on psychological distress for female partners. Limited support was found for partner effects on distress. Furthermore, results indicate that the alliance between partners is a stronger predictor of improvement in early sessions in comparison with the alliance between the individual and the therapist.     

Emotion in an alliance rupture and resolution sequence: A theory‐building case study

Aims: Alliance rupture and resolution processes are occasions for the client to have his or her core interpersonal patterns activated in the here and now of the therapy and to negotiate them with the therapist. So far, no studies have been conducted on emotional processing, from a sequential perspective using distinct emotion categories, in alliance rupture and resolution therapy sessions. This is the objective of this theory‐building case study. Method: This client underwent a 34‐session long, psychodynamic psychotherapy within the context of an open trial. An alliance rupture‐resolution sequence of two subsequent sessions, along with a third control session, was selected from this case and these sessions were rated using the Classification of Affective‐Meaning States (CAMS), an observer‐rated method to classify distinct emotions, according to current emotion‐focused models. Results: The results indicate that the rupture session was associated, above all, with core maladaptive fear, evoked in the actual here and now of the therapeutic relationship, whereas the resolution session was associated with the expression and experience of adaptive hurt as regards biographical issues of the client. Discussion: These results are discussed with regard to the alliance rupture and resolution model and the exploration of integrating client's emotional processing in the model.     

Sudden gains in treatment-as-usual couple therapy for military veterans

Previous studies of couple therapy have conceptualized change as a gradual process. However, there is growing evidence that, for many clients, the majority of gains in other treatment modalities are often achieved between just 2 sessions. Isolating the frequency, nature, and predictors of these sudden gains (SGs) in couple therapy can add to a growing understanding of how and why couple therapy works. In a sample of 67 couples receiving treatment-as-usual couple therapy in two Veterans Affairs hospitals, 25% of individuals experienced a SG in relationship satisfaction. The magnitude of these SGs were large (d = 1.62) and fully explained the total pre-post change for individuals who experienced them. Individuals with SGs showed significantly greater satisfaction gains during therapy; however SGs were not related to relationship satisfaction or relationship status at 18-month follow-up. SGs were predicted by the content of the previous session, putative change mechanisms of communication, intimacy, and behavior, as well as the partner's SGs during the same period. Results suggest that SGs are an important component of change during couple therapy for some individuals, challenging the assumption of continuous change in previous studies. In addition, predictors of SGs were generally consistent with theoretical and empirical examinations of mechanisms of change in couple therapy.     

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.     

Dropping Out of Couple Therapy

Abstract

Current literature on dropouts in marriage and family therapy includes few studies that focus exclusively on couple therapy and only a limited number of qualitative studies. Clients' perceptions of premature termination are seldom considered. This qualitative case study describes, from both the clients' and the therapist's perspectives, one couple's experience of dropping out of couple therapy after three, sessions. Findings from this case study are compared with existing literature and a fourfold typology of dropouts is proposed. We offer recommendations for future research of dropouts in couple therapy.     

The Supervisory Working Alliance,Trainee Self-Efficacy,and Satisfaction

Theoretically, when the supervisory working alliance is strong, the trainee and supervisor share a strong emotional bond and agree on the goals and tasks of supervision. Tested was Bordin's (1983) proposition that changes in counselor trainees' perceptions of the supervisory alliance over the course of supervision would predict supervisory outcomes. A national sample of beginning practicum- to intern-level trainees were assessed at the beginning and end of an academic semester. Contrary to predictions, changes in the alliance were not predictive of changes in trainees' self-efficacy. However, improvements in the emotional bond between the trainees and supervisors were associated with greater satisfaction.     

Long‐term partners' relationship satisfaction and their perceptions of each other's attachment insecurities

In this research, we examined actors' and partners' perceptions of each other's attachment insecurities and the associations of these perceptions with relationship satisfaction. A sample of 148 heterosexual couples completed measures of self and partner attachment insecurities and relationship satisfaction. Results indicate that partners agree in their perceptions of their own and each other's attachment insecurities (anxiety and avoidance). Based on the actor–partner interdependence model (APIM), we also found that both actors' scores on avoidance and their perceptions of their partner's degree of avoidanc are associated with lower relationship satisfaction. Finally, we found that the way an actor perceives his or her partner's avoidance plays a mediational role in the association between partner's self‐reported avoidance and actor's relationship satisfaction.     

Minority Stress and Same‐Sex Relationship Satisfaction: The Role of Concealment Motivation

Most lesbian, gay, and bisexual (LGB) people want a stable, satisfying romantic relationship. Although many of the predictors of relationship outcomes are similar to those of heterosexual couples, same‐sex couples face some additional challenges associated with minority stress that also impact upon relationship quality. Here, we investigate the association between minority stressors and relationship quality in a sample of 363 adults (M age = 30.37, SD = 10.78) currently in a same‐sex romantic relationship. Internalized homophobia and difficulties accepting one's LGB identity were each negatively associated with relationship satisfaction via heightened concealment motivation. We also examined the protective role of identity affirmation on relationship quality, finding a direct positive relationship between the two variables. Minority stressors were negatively associated with couple relationship satisfaction via heightened concealment motivation. The finding that identity affirmation directly predicted increased couple satisfaction also highlights the important role of protective factors in same‐sex couple relationships.     

Is Committed Desire Intentional? A Qualitative Exploration of Sexual Desire and Differentiation of Self in Couples

The question of what heightens or diminishes sexual desire has long been a passionate theme across cultures in literature, arts, media, and medicine. Yet, little research has been conducted to determine what affects level of desire within couples. The degree of differentiation of self has been suggested as an important variable in shaping partners' level of desire. Through a qualitative analysis of dyadic couple interviews, this study provides an account of characteristics, processes, and trajectories of sexual desire and differentiation in 33 heterosexual couples of varying ages and relationship duration. Factors associated with high desire were change and autonomy, whereas conflict and children were reported to be desire‐diminishing factors. Innovation, sharing, autonomy, and effort emerged as desire‐promoting strategies, while fostering personal interests, investing in a positive connection, and enhancing personal integrity were identified as couples' strategies to promote and preserve differentiation of self. The results also shed light on couples' perceptions of whether and how sexual desire changes over the course of the relationship and challenge common cultural assumptions about desire in committed relationships—namely the myth that the only authentic expression of desire is that which occurs spontaneously and without intention and planning. Implications for couple therapy are discussed.     

Anorexia nervosa: treatment satisfaction

Patient satisfaction plays a central role in treatment alliance and outcome. Investigating patient expectations and experiences of treatment sheds light on its importance. This study examines adolescent anorexia nervosa patients and their parents' satisfaction with family‐based treatment. Patients and parents answered a questionnaire at the eighteen‐month follow‐up focusing on expectations and experiences of treatment, therapists, aims of treatment and accomplishment. The results show that 73 per cent of the patients and 83 per cent of the parents felt that their pre‐treatment expectations had been fulfilled. The majority agreed that individual patient sessions and parental sessions were of great help, while the patients valued family therapy sessions as being less helpful than did parents. In overall terms, parents were more pleased with the therapists than were the patients. These data suggest that family‐based treatment with individual sessions for patients, in parallel with parental sessions combined with family sessions, corresponds well to patients' and parents' treatment expectations.     

Embodying the Couple Relationship: Kinesthetic Empathy and Somatic Mirroring in Couples Therapy

Kinesthetic sensitivity plays a central role in the development of empathy and in understanding others’ intentions, skills that greatly affect spousal satisfaction. The present study examines how, in the couple relationship, somatic mirroring of the other’s physical expressions creates an emotional experience in the relationship, and in couples therapy, sets processes in motion. Such understanding is critical in couples therapy to harness the embodied knowledge needed to address issues in areas where verbal discussion is insufficient. Nine couples (n?=?18) participated in 12 couples therapy sessions that incorporated somatic mirroring. The sessions were documented on video and through the personal diaries kept by the therapists and patients. The participants related to four main themes: Somatic mirroring (a) creates comfort and emotional availability, (b) contributes to identifying and labeling feeling, (c) contributes to arousing intimacy and desire, and (d) avoiding somatic mirroring is characteristic of moments of conflict in the relationship. To create a bridge between the research and the clinic, in the Discussion section methods for connecting with embodied knowledge in couples therapy are examined, with the implications of having familiarity with such knowledge on the intimate relationship and the couple’s communication.     

Treatment‐as‐Usual for Couples: Trajectories Before and After Beginning Couple Therapy

Couple therapy has been shown to be a meaningful way to improve couples’ relationships. However, less information is known about couples’ functioning prior to entering treatment in community settings, as well as how their relationship functioning changes from initiating therapy onward. This study examined 87 couples who began community‐based couple therapy during a longitudinal study of couples in the military. The couples were assessed six times over the course of 3 years, including time points before and after starting couple therapy. Using an interrupted‐time series design, we examined trajectories across the start of couple therapy in relationship satisfaction, divorce proneness, and negative communication. The results demonstrated that couples’ relationship satisfaction was declining and both divorce proneness and negative communication were increasing prior to entering couple therapy. After starting couple therapy, couples’ functioning on all three variables leveled off but did not show further change, but previous experience in relationship education moderated these effects. Specifically, those who were assigned to the relationship education program (vs. control) demonstrated greater reductions in divorce proneness and greater increases marital satisfaction after starting therapy; however, they also started more distressed.     

Cultural ruptures in short‐term therapy: Working alliance as a mediator between clients' perceptions of microaggressions and therapy outcomes

Aim: To determine whether or not clients' perceptions of microaggressions varied based on their own and the therapist's race/ethnicity and whether or not they would be negatively related to the effectiveness of therapy and if the working alliance would mediate this effect. Method: The study utilised a cross‐sectional, retrospective, methodology. Clients were recruited from a large university counselling centre in the United States (N=232 clients and 29 therapists). Results: Neither clients' race/ethnicity, therapists’ race/ethnicity, nor client‐therapist ethnic matching predicted perceptions of microaggressions. Clients' ratings of microaggressions were negatively associated with their psychological wellbeing; however, this effect was mediated by clients' ratings of the working alliance. Implications: Therapists should take into account the cultural messages they may be conveying to both white and racial/ethnic minority clients. Therapists should develop strategies that are consistent with a general therapeutic approach that promotes discussions about culture with their clients and, most importantly, should attend to the therapeutic relationship.     

Can you make my goals easier to achieve? Effects of partner instrumentality on goal pursuit and relationship satisfaction

Goal pursuits are strongly influenced by romantic partners, and a partner's instrumentality to goals may be particularly important for goal pursuit. This study examined the effects of partner instrumentality on goal‐related effort, goal progress, goal commitment, and relationship satisfaction over time. It also examined whether relationship satisfaction moderated the effects of partner instrumentality on goal pursuit processes. Newly dating romantic partners (N = 59 couples) reported on their goals and relationship satisfaction at two assessments 3 months apart. Multilevel models indicated that partner instrumentality predicted increases in progress over time but only for those high in relationship satisfaction. Partner instrumentality also predicted increases in one's own relationship satisfaction but was unrelated to changes in the partner's satisfaction. These findings suggest that partner instrumentality benefits increased goal progress, particularly for those with satisfying relationships, and further increases relationship satisfaction.     

The Development and Role of the Therapeutic Alliance in Supportive Psychotherapy with Adolescents

The formation of a therapeutic alliance is considered a central issue in therapy, and particularly crucial and challenging in work with adolescents. The relational and technical components of the therapeutic alliance were examined from the perspective of the adolescent client. 40 emotionally disturbed adolescent girls, aged 13 to 16 years, received brief supportive psychotherapy in the school setting. The alliance was assessed at sessions 3, 6 and 9, and outcome was evaluated on measures of internalizing problems, self-esteem, adjustment and client satisfaction. The results indicated the stability of the alliance between sessions 3 and 6, followed by significant linear increases between sessions 6 and 9. The strength of the alliance was most consistently related to reductions in internalising problems and client estimates of change. The implications for training and clinical practice with adolescent clients are discussed and future research avenues outlined.     

Treatment Engagement: Building Therapeutic Alliance in Home-Based Treatment with Adolescents and their Families

Client engagement is an essential yet challenging ingredient in effective therapy. Engaged clients are more likely to bond with therapists and counselors, endorse treatment goals, participate to a greater degree, remain in treatment longer, and report higher levels of satisfaction. This study explored the process of engaging high-risk youth and their parents in a unique home-based family therapy intervention. Qualitative interviews were conducted with 19 families who completed family therapy sessions that included a core component aimed at increasing treatment engagement. Parents’ and youths’ perceptions of engagement suggest the importance of developing therapeutic alliance with therapists, who facilitated building a shared alliance among family members. Implications for improving client engagement are discussed within the context of alliance building with the therapist and among family members.     

Hostile,volatile, avoiding,and validating couple‐conflict types: An investigation of Gottman's couple‐conflict types

Using two very different sets of survey data, we investigated Gottman's (1994a , 1999 ) observational findings regarding couple‐conflict types. We hypothesized that defensible couple‐conflict types could be established using survey data based on an individual's perception of the style he or she uses in couple‐conflict situations. Furthermore, we hypothesized that membership type would be related to relationship quality indicators such as satisfaction, stability, communication processes, and affect regulation. Our results showed that survey data can reliably produce couple‐conflict types similar to Gottman’s. We further found that, on satisfaction, stability, positive communication, and soothing, hostile couple‐conflict types had the lowest mean scores and validating couple‐conflict types the highest mean scores. The types related in the opposite manner to negative communication, the Four Horsemen of the Apocalypse, and flooding. The other couple‐conflict‐type means ‐ volatile and avoiding ‐ are almost always between the extreme means of the hostile and validating couple‐conflict types. Implications for research and practice conclude the article.