Confirming,Validating, and Norming the Factor Structure of Systemic Therapy Inventory of Change Initial and Intersession

Progress or feedback research tracks and feeds back client progress data throughout the course of psychotherapy. In the effort to empirically ground psychotherapeutic practice, feedback research is both a complement and alternative to empirically supported manualized treatments. Evidence suggests that tracking and feeding back progress data with individual or nonsystemic feedback systems improves outcomes in individual and couple therapy. The research reported in this article pertains to the STIC^® (Systemic Therapy Inventory of Change)—the first client‐report feedback system designed to empirically assess and track change within client systems from multisystemic and multidimensional perspectives in individual, couple, and family therapy. Clients complete the STIC Initial before the first session and the shorter STIC Intersession before every subsequent session. This study tested and its results supported the hypothesized factor structure of the six scales that comprise both STIC forms in a clinical outpatient sample and in a normal, random representative sample of the U.S. population. This study also tested the STIC's concurrent validity and found that its 6 scales and 40 of its 41 subscales differentiated the clinical and normal samples. Lastly, the study derived clinical cut‐offs for each scale and subscale to determine whether and how much a client's score falls in the normal or clinical range. Beyond supporting the factorial and concurrent validity of both STIC forms, this research supported the reliabilities of the six scales (Omega_hierarchical) as well as the reliabilities of most subscales (alpha and rate–rerate). This article delineates clinical implications and directions for future research.     

Effectiveness of Couple Therapy in Practice Settings and Identification of Potential Predictors for Different Outcomes

Even though couple therapy is efficacious, there is no improvement in up to 50% of the couples. Also effect sizes found in effectiveness studies in real-world settings are considerably lower than those found in efficacy studies. There is a need to understand more about couple therapy effectiveness in practice settings and the factors responsible for different outcomes. A German nationwide study on the effectiveness of couple counseling including 554 couples applied the same methodology as two earlier studies in the same field. A remarkable consistency was found over the three independent studies in the burden with individual and relationship distress as well as in the rates of improvement. This supports the insight that the improvements reached through couple therapy in practice settings are only about half of the effect sizes reached in efficacy trials. Additionally this study investigated 64 factors, which were found to be influential for relationship quality and stability in earlier studies, for their impact on outcome. Factors present at initiation and termination of therapy were found, which correlate significantly with outcome and with separation of the couple in the follow-up. These factors could be included in prediction models for improvement and separation of the couple. The implications for the practice of couple therapy and for future research are discussed.     

Introducing the Expectations and Preference Scales for Couple Therapy (EPSCT): Development,Psychometric Evaluation,and Suggested Use in Practice and Research

While it is known that client factors account for the largest proportion of outcome variance across treatment modalities, little is known about how clients’ characteristics affect the process and effectiveness of couple therapy. To further knowledge in this area, we created a brief, practice‐friendly measure, the Expectation and Preference Scales for Couple Therapy (EPSCT). Three self‐report scales assess clients’ Outcome expectations (e.g., I expect our relationship to improve as a result of couple therapy) and role expectations for Self (e.g., I expect to listen to my partner's concerns) and Partner (e.g., I expect my partner to blame me). Three Cognitive‐Behavioral, Emotionally Focused, and Family Systems preference scales use a forced‐choice format to measure the comparative strength of respondents’ preferences for interventions broadly reflective of each approach. A large item pool was developed from relevant literature and clinical experience and refined based on face and content analyses with two panels of experienced couple therapists and researchers. Across four studies with 1,175 participants, the scales’ internal consistency reliabilities were similar and their construct validity was supported with confirmatory factor analyses and significant correlations with several established measures, including expectation measures developed for individual psychotherapy and measures of attitudes toward professional help seeking and valuing personal growth. Across all studies, participants had stronger role expectations for themselves than their partners, although gender effects differed by sample. We discuss how to use the 15‐item EPSCT in clinical practice and in future research as a predictor of couple therapy processes and outcomes.     

Chronic Eating Disorders in Therapy: Clinical Stories Using Family Systems and Psychoanalytic Approaches

This paper presents three pieces of work, all focused around a person presenting with a long history of disordered eating patterns. One treatment was a couple therapy, one a family plus individual therapy and the third a purely individual therapy. The three different psychotherapies demonstrate an approach which uses psychoanalytic as well as family therapy thinking and techniques. The material is offered to show examples of the clinical practice within which individual and couple or family therapy constitute a range of psychotherapeutic responses to people and, in particular, to people with eating disorders. The context of the therapy is described in some detail as it accounts for many features of the treatments, for example, that they are justified within the institution by having been subject to empirical investigation. A metaphor, that of the medieval castle, is offered as an evocation of the experience of the person that is relevant in the practice of both individual and family therapy.     

Premarital Predictors of Remarital Quality: Implications for Clinicians

This paper presents a review of the research literature from 1980 to present on the premarital predictors of remarital satisfaction and stability (quality). The predictive factors are organized with an ecosystemic theoretical model using three general predictor categories: background and context factors (e.g., stepchildren), individual traits and behaviors (e.g., attachment to an ex-spouse), and couple interactional processes (e.g., couple consensus). Major factors related to lower remarriage quality include the roles of stepchildren, stepfamily complexity, emotional attachment to an ex-spouse, serial marriage, and economic strain. Predictors related to higher remarital quality include couple consensus on important topics, social support from family and friends, and financial stability. Implications for couple therapy before remarriage are discussed.     

The Findings of a Cochrane Meta-Analysis of Couple Therapy in Adult Depression: Implications for Research and Clinical Practice

The association between depressive symptoms and distressed intimate relationships supported the assumption that couple therapy, by focusing on the interpersonal context of depression, might be more effective as a treatment for depression than individual psychotherapy or drug therapy. This issue was addressed by a Cochrane meta-analysis assessing the evidence from clinical trials of couple therapy for depression in comparison with individual psychotherapy, drug therapy, and no/minimal intervention, including fourteen studies with 651 participants. No study was found free of bias and the quality of the evidence was low, with major problems of small sample sizes, missing outcome data, selective reporting, lack of information on random sequence generation and allocation concealment, recruitment of people not representative of clinical practice, and allegiance bias. The meta-analysis showed that both couple therapy and individual psychotherapy improved depressive symptoms at end of treatment and after 6 months or longer, with moderate effect sizes, without any difference between the two treatments. Couple therapy was more effective in reducing couple distress. This effect was larger in studies with distressed couples only and should be considered as relevant in its own right. Couple therapy is a viable option for the treatment of a depressed partner, especially in discordant couples. Future research should address several issues left open to provide a sound empirical foundation for clinical practice.     

From Couple Therapy 1.0 to a Comprehensive Model: A Roadmap for Sequencing and Integrating Systemic,Psychodynamic, and Behavioral Approaches in Couple Therapy

Couple therapy is a complex undertaking that proceeds best by integrating various schools of thought. Grounded in an in‐depth review of the clinical and research literature, and drawing on the author's 40‐plus years of experience, this paper presents a comprehensive, flexible, and user‐friendly roadmap for conducting couple therapy. It begins by describing “Couple Therapy 1.0,” the basic conjoint couple therapy format in which partners talk to each other with the help of the therapist. After noting the limitations of this model, the paper introduces upgrades derived from systemic, psychodynamic, and behavioral/educational approaches, and shows how to combine and sequence them. The most important upgrade is the early focus on the couple's negative interaction cycle, which causes them pain and impedes their ability to address it. Using a clinical case example, the paper shows how all three approaches can improve couple process as a prerequisite for better problem solving. Additional modules and sequencing choice points are also discussed, including discernment counseling and encouraging positive couple experiences.     

An Attachment Perspective on Reunions in Couple Psychoanalytic Psychotherapy

Psychoanalysis has been slow to acknowledge attachment theory as one of its own. Yet traditions of observational and representational research associated with it have much to offer in shedding light on intrapsychic as well as interpersonal phenomena. This paper explores these traditions and their potential clinical utility for couple psychoanalytic psychotherapy. In particular, attention is drawn to behaviour and representations associated with the experience of reunion in therapy sessions.     

Confirmatory Factor Analysis of the Family Therapy Alliance Scale: An Evaluation of Factor Structure Across Parents and Adolescents Referred for At Risk Services

This study examines the factor structure of the Family Therapy Alliance Scale for mothers, fathers, and adolescents. Participants are 425 individuals from 216 families referred for family therapy for child abuse or neglect. Findings provide some evidence of construct validity. The three-factor model comprised of the alliance content domains of bonds, goals, and tasks and the interpersonal domains of individual, other, and family provided excellent fit. The nine-factor model exhibited poor fit, while an adjusted six-factor model which eliminated the “other” sub-category showed promise for further research. Findings support the reliability of the content and interpersonal domain’s subscales.     

Toward making progress feedback an effective common factor in couple therapy

Systematic monitoring of individual therapy progress, coupled with feedback to the therapist, reliably enhances therapy outcome by alerting therapists to individual clients who are off track to benefit by the end of therapy. The current paper reviews the possibility of using similar systematic monitoring and feedback of therapy progress as a means to enhance couple therapy outcome, including what measures of therapy progress are most likely to be useful, how to structure feedback to be most useful to therapists, and the likely mediators of the effects of therapy progress feedback. One implicit assumption of therapy progress feedback is that clients unlikely to benefit from therapy can be detected early enough in the course of therapy for corrective action to be taken. As a test of this assumption, midtherapy progress was examined as a predictor of final couple therapy outcome in a sample of 134 distressed couples. Either a brief 7- or 32-item assessment of couple therapy progress at midtherapy detected a substantial proportion (46%) of couples who failed to benefit by the end of therapy. Given that failure to benefit from couple therapy is somewhat predictable across the course of therapy, future research should test whether systematic monitoring and feedback of progress could enhance therapy outcome.     

Defining a family heritage and a new relationship identity: two central tasks in the making of a marriage

The roles of origin family environmental characteristics and couple consensus-building process within the development of marital relationships were examined prospectively in 16 premarital couples. Three important findings emerged. First, significant correlations were found between dimensions of origin family environment and the reported level of satisfaction within the couple's current relationship. Second, measures of the couple's ability to reach consensus concerning important interpersonal relationships appeared to be important mediators of the association between origin family environment and current relationship satisfaction. Third, important gender differences emerged that replicate and extend prior findings that portray women in the role of "relationship specialist" within their marriages. As a group, these findings were best explained by a developmental model of early marriage that envisions the young couple as facing two entwined tasks: to define both their family heritage and their new relationship identity. Overall, the importance of examining family-of-origin characteristics and consensus-building process as critical determinants of the fate of intimate relationships received strong support. The gender differences found in the literature reviewed, as well as the results of this study, have largely been overlooked by the theory and practice of family therapy. Efforts on both the research and theory construction fronts are needed to increase our understanding of the mechanisms whereby prior family experience is brought forward into current intimate relationships.     

The therapeutic alliance–A conceptual analysis

The role and function of the therapeutic alliance in psychotherapy has increasingly been the focus of clinicians' and researchers' interests over the last decade. Alliance concepts have, however, been criticized for lack of conceptual clarity. The paper presents a generic model as a heuristic means for clarifying the conceptual meaning of the therapeutic alliance. The model distinguishes between the personal relationship aspect, and the collaborative, task-related aspect of the alliance, with therapist, patient, and common contributions to each of these aspects. The model is compared to other alliance conceptualizations, and its implications for alliance theory and research are discussed. A content analysis of four widely used alliance scales in relation to the model shows the scales to represent conceptually different, yet overlapping constructs. It is argued that the componential nature of the therapeutic alliance will render difficult any interpretation of findings regarding the relationship between alliance and outcome in traditional process-outcome research. More complex research strategies guided by theory are called for, if the therapeutic alliance should remain a vital field of research.     

Suicidal persons and their partners: individual and interpersonal dynamics

The individual and interpersonal dynamics of 21 suicidal persons (15 females and 6 males) and their partners were investigated. Each couple was interviewed at the time of the suicidal person's psychiatric hospitalization following a recent episode of suicidal behavior or serious suicidal ideation. Each partner was administered two tests of individual functioning and one test of interpersonal functioning. The results revealed that the dynamics of these couples were characterized by complementarity at the level of overt individual functioning, and similarity at the level of covert individual functioning. Both partners in a couple tended to describe the suicidal partner as psychologically disabled and the nonsuicidal partner as well-functioning. However, the suicidal patients and their partners were similar in terms of covert individual functioning both showing a tendency toward anclitic, dependent object relations. The communication between the partners was found to be disturbed in a large majority of the couples. The implications of these findings are discussed in terms of an integrative model of individual and interpersonal dynamics.     

Construction and validation of the Intragroup Marginalization Inventory

This study reports the development and validation of the Intragroup Marginalization Inventory (IMI). The IMI consists of three scales that assess the extent to which an individual perceives interpersonal distancing from family, friends, and ethnic group community members. Intragroup marginalization is defined as the interpersonal distancing that occurs when an acculturating individual is believed to exhibit behaviors, values, and beliefs that are outside the heritage culture's group norms. Intragroup marginalization is based on social identity theory that asserts that groups maintain their identity by the distinctive behaviors of its members. When an acculturating individual displays behaviors or attitudes that differ from the heritage culture group's norms, the group may respond to the threat with social alienation of the transgressor. The results support the IMI's validity via a) content validity in the development of the items, b) construct validity in the selection of the factors based upon an exploratory factor analysis, c) the replicability of the factors based upon a confirmatory factor analysis, and d) discriminant validity through examining the relationship of the factors with other established measures.     

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 Relative Influence of Client Characteristics on the Process and Outcomes of Premarital Counseling: A Survey of Providers

To explore the influence of client characteristics in premarital counseling, a five factor model is presented that includes the social context, family-of-origin influences, individual characteristics, couple interactional processes, and motivation for attending premarital counseling. The findings demonstrate that providers believe that many client characteristics influence the degree to which couples benefit from premarital counseling. Providers rated the influence of the client characteristic factors in the following order (from most to least influential): couple interactional processes, family-of-origin influences, individual characteristics, motivation for premarital counseling, and the social context. Recommendations for future theory development, practice, and research are discussed.The findings presented in this article were part of the authors doctoral dissertation at the University of Florida.     

Attachment,Contemporary Interpersonal Theory and IPT: An Integration of Theoretical,Clinical, and Empirical Perspectives

Interpersonal Psychotherapy (IPT) is an effective, pragmatic treatment for depression but interpersonal explanations of its effectiveness are not fully developed. This paper presents an integration of aspects of attachment theory and contemporary interpersonal theory which explains how interpersonal interactions contribute to a clinical understanding of depression and its treatment through IPT. We test hypotheses of interpersonal change in a case series of depressed patients treated with IPT. The results demonstrate that both attachment insecurity and interpersonal problems improve significantly over a 16 week course of treatment. Further research into the interpersonal processes that alleviate depression is needed.     

Interpersonal development, stability, and change in early adulthood

The goal of this research was to explore the development of the interpersonal system mapped by the interpersonal circumplex in early adulthood (ages 18–22). This study uses the Longitudinal Study of Personality Disorders sample (N = 250; 53% female). Participants completed the Revised Interpersonal Adjective Scales (Wiggins, Trapnell, & Phillips, 1988) in their freshman, sophomore, and senior years of college. Estimates of structural, rank‐order, mean, individual, and ipsative stability were calculated for the broad interpersonal dimensions of Dominance and Affiliation and also the lower order octant scales. Additionally, the interpersonal profile parameters of differentiation and prototypicality were calculated at each wave and explored longitudinally and also used as predictors of interpersonal stability. We found excellent structural and high rank‐order and ipsative stability in the interpersonal scales over this time period. Mean increases on the Affiliation axis, but not on the Dominace axis, were found to mask differential rates of change among the octant scales, along with significant individual variation in the rates of change. Interpersonal differentiation and prototypicality were related to higher stability in overall interpersonal style. Results point to evidence of both stability and nuanced change, illuminating some of the features of the structural variables that can be derived from interpersonal circumplex profiles.     

Spezifische psychoanalytische Interventionen

It is held that specific ingredients are responsible for the effectiveness of various psychotherapies and it is supposed that for this reason particular therapeutic approaches are more efficient than others. First, this article presents Bruce E. Wampold’s research on psychotherapeutic efficacy, which gives evidence that psychotherapies efficiency is due to general, not to specific factors. It is shown that in the end the common factors like alliance, compliance, empathy and the fact, that therapists generally make best use of their personality, are interpersonal factors. The impact of these empirical results on psychotherapy, on theory and practice is described in the light of two metatheories, the “medical modell”and the “contextual model”. The author delineates some consequences, for instance that in psychotherapeutic practice the diagnosis-based indication for therapy has to be replaced by fitting-indication. Regarding outcome research, the randomized goldstandard research design has to be replaced by a fitting indication concerning therapist /patient and patient/paticular treatment. Further it is shown that although specific ingredients in a strict sense are not active, therapists have to realize that they are nessessary even if active only as a component of the healing context. How specific ingredients might be realized within a healing context is shown with regard to the adaptive approach to psychoanalysis.