Systemic alliance in individual therapy: factor analysis of the ITAS-SF and the relationship with therapy outcomes and termination status

Clients providing systematic feedback to therapists via self-report measures of psychological distress and working alliance have been shown to increase therapy outcomes. However, there are few systemic-based measures that are feasible for therapists to use. Recently, Pinsof et al. (Family Process, 2008, 47, 281) developed a brief systemic alliance measure (ITAS-SF) for individual therapy. The current study tested the factor structure of this measure and examined whether the subscales related to clients' therapy outcomes and termination status (N = 570). The results demonstrated supported a 3-factor model for the ITAS-SF (as compared to the seven factors proposed by Pinsof et al.). In the first factor, content combined the goals for therapy, the tasks or methods to reach those goals and bond between the client and therapist. The second factor reflected how clients perceive the relationship with the therapist (i.e., interpersonal dimension-self/therapist), and the third factor reflected how clients perceive the alliance between their social network and the therapist (i.e., interpersonal dimension others/therapist). The two interpersonal factors were related to therapy outcome and termination status.     

The Alliance in Relationship Education Programs

Couple relationship education (CRE) programs are associated with positive romantic relationship outcomes; however, the mechanisms by which these gains occur are less understood. The current study (122 couples) utilized actor–partner modeling to examine the association between the therapeutic alliance and dedication and negative and positive communication for racial/ethnic minority couples. Additionally, we examined whether gender and delivery format moderated these relationships. Results demonstrated that both men's and women's alliance scores were significantly related to their own outcomes. Higher ratings of alliance were related to partner outcomes for men only. The association between partners' alliance and dedication outcomes was stronger within the group format as compared to the couple format. Implications for leaders of CRE programs are offered.     

How are we doing? Results of receiving family-driven feedback on alliances between families and residential treatment staff over time

Developing working alliances and actively engaging families is essential for youth success in residential treatment. Ideally, these alliances can be fostered by sharing feedback with residential staff about their alliances with families over time to encourage more family engagement and better outcomes for families of youth in treatment. This study measured alliances between families and residential treatment family workers and assessed the effectiveness of an unobtrusive method of sharing working alliance feedback with residential treatment staff. Results revealed that family members rated the working alliance higher than family workers, and that these discrepancies in scores converged over time. In addition, higher family member ratings of the alliance predicted higher family functioning, and longer time in treatment resulted in higher family functioning scores. Lastly, receiving feedback about the working alliance resulted in higher family member ratings of the alliance with their family worker.     

Conceptions of Family and Adoption Among Older Adoptees

ABSTRACT

Research on older child adoptions that incorporates the adoptee's perspective is noticeably absent from the literature. Drawing on the theoretical, clinical and empirical literature on children's understanding of family and adoption, this paper reports a study that examined older adoptees' conceptions of family and adoption relative to nonadopted peers. Interviews with 15 children adopted between ages 8 and 11 and a sample of 15 demographically matched nonadopted children (47% male; 84% Caucasian, 13% African American, 3% Biracial Asian/American) provided data that were analyzed for differences in children's understanding and elaboration of family and adoption concepts. Although no group differences were found in children's basic understanding of family or adoption, differences emerged in children's ratings of the acceptability and typicality of family constellations, as well as in the nature of concept elaboration. Older adoptees were more likely to accept and view as typical nontraditional family constellations. Whereas nonadopted children relied more on biological themes, older adoptees' concept elaboration was qualitatively richer, reflecting their varied birth family and foster care experiences. Within-group comparisons among older adoptees revealed differences: Children with more experience in foster care and children who lived in the adoptive home longer displayed higher levels of family understanding and a more realistic perspective of the permanence of the placement. Implications for future research and adoption service delivery are discussed.     

Therapeutic alliance between youth and staff in residential group care: Psychometrics of the therapeutic alliance quality scale

Therapeutic alliance has been frequently studied in individual counseling sessions; however, research on therapeutic alliance in residential settings for youth with mental health diagnoses has been limited. This may be due, in part, to the presence of multiple service providers often in caregiving roles. The purpose of this study was to examine the psychometric quality of a widely utilized measure of therapeutic alliance used in psychotherapy with youth in residential care where the treatment is provided by a trained married couple. We also compared the relationship between youth ratings of their male and female service providers, as well as examined correlations in ratings between youth and staff on therapeutic alliance. Finally, we investigated the direction, magnitude, and trajectory of change in therapeutic alliance over a 12-month period following admission into residential care. The method was a longitudinal assessment of 135 youth and 124 staff regarding therapeutic alliance over the course of 12 months or discharge from services. Results indicated strong psychometric properties and high correlations for youth ratings of both their male and female service providers. However, the correlation was low between youth and service provider ratings of alliance. Longitudinal analyses indicated that rates of therapeutic alliance changed over time.     

Evaluation of Family Therapy: A Comparison of Therapists' and Clients' Views**

In this evaluation of therapy experience for 82 families by brief therapy at Bouverie Clinic to 1976–1977, therapists' and clients' rating of outcome were obtained. After termination of therapy both therapists and clients reported high improvement rates in the presenting problem(s) as well as in the quality of family relationships and in the family's ability to deal with further problems. High agreement was found between therapist’ and clients' ratings of outcomes. Therapists were more favorable than clients in their ratings of change in the presenting problem and in their ratings of change in the quality of family relationships, but not in assessing the change in family's further problem solving ability. At follow-up clients were predominantly satisfied with their therapy experience. In addition, therapists' ability to predict outcome accurately, after the second of therapy, was strongly supported by our finding.     

Clients' Attributions of the Presenting Problem and the Therapeutic Alliance in Couple Therapy: Systemic Versus Intrapersonal Perspectives

The therapeutic alliance is central to couples' therapy success. The current study examined associations between couples' initial agreement and causal attributions of the presenting problem and changes in the therapeutic alliance. To test study hypotheses, 85 couples were recruited from a university training clinic focused on couple and family therapy. Couples completed an intake questionnaire concerning their attribution of the presenting problem, either as systemic or individual, and therapeutic alliance was assessed at the end of sessions 2–8. A dyadic multilevel model revealed that a disagreement in the couple's attributions of the problem (with one viewing it as systemic, the other as individual) was associated with a larger initial discrepancy in the couple's therapeutic alliance, as well as a decline in the discrepancy over time. Findings were discussed in the context of systemic family theory, with implications for improving assessment, treatment, and psychoeducation aimed toward couples in distress.     

THE INTEGRATIVE PSYCHOTHERAPY ALLIANCE: FAMILY,COUPLE AND INDIVIDUAL THERAPY SCALES*

The therapeutic alliance concept has been confined primarily to the literature on individual psychotherapy. This paper formally introduces the concept into the family and marital therapy domain and presents various clinical hypotheses about the nature of the alliance and its role in familyand marital therapy. A systemic perspective is brought to bear on the concept within individual psychotherapy. A new, integrative definition of the alliance is presented that conceptualizes individual, couple and family therapy as occurring within the same systemic framework. The implications of this integrative-alliance concept for family, couple and individual therapy research are examined. Three new system-ically oriented scales to measure the alliance in individual, couple and family therapy are presented along with some preliminary data on their methodological characteristics.     

Individual and Crossover Effects of Work Schedule Fit: A Within‐Couple Analysis

A couple‐level analysis with a sample of 105 female reduced‐hours physicians and their full‐time–employed husbands found individual and spouse crossover effects: Each spouse's ratings of own schedule fit predict own job‐role quality; wives' ratings of partner/family schedule fit predict their marital‐role quality, with a similar trend for husbands; husbands' ratings of own schedule fit predict wives' marital‐role quality; and husbands' ratings of partner/family schedule fit and wives' ratings of own schedule fit predict husbands' psychological distress. These findings highlight the interdependence of couple members' experiences and illustrate potential costs of wives' trading off time at work for time at home.     

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.     

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.     

Siblings' Reactions to Parental Divorce

Because previous studies of children and divorce have typically included only one child per family, little is known about how siblings in the same family experience their parents' divorce. Three samples, totalling 49 pairs of white middle-class adolescent and preadolescent first-born and second-born siblings whose parents were separated no more than 24 months, were studied to assess the relation between siblings' divorce adjustment and the relation between siblings' general behavioral adjustment. Siblings' self-reports and custodial mothers' ratings of each sibling were obtained. For both sets of data, siblings' scores were positively related; when differences were found, older siblings were better adjusted than younger siblings. Based on siblings' self-report scores, relative to younger siblings, older siblings had a better understanding of the divorce, fewer problematic beliefs regarding the divorce, a better understanding of conflict resolution, and a more internal locus of control. Relative to boy/boy dyads, girl/girl dyads had a better understanding of both the divorce and conflict resolution. Based on mothers' ratings, older siblings had more positive reactions to the divorce and were less dependent on adults than younger siblings. There was no support for the position that second-born children with older brothers would show enhanced adjustment.     

Student Ratings and Teacher Effectiveness: A Reappraisal

A new conceptualization of the student rating method, incorporating the degree of discrepancy between the students' ratings of the characteristics of their ideal (desired) as well as of their real (actual) course instructor, was developed for the purpose of exploring the validity of using student ratings in assessing teacher effectiveness. Movement scores derived from a pre and post testing of course-related content were used to operationalize teaching effectiveness. The study found that the ideal or desired teacher characteristics reflected in the students' ratings were largely consistent with previous research findings. No significant correlations, however, were found between discrepancy scores and movement scores. Additionally, all correlations were positive. Both findings suggest caution in how student ratings are used.     

Resident and Family Perspectives on Assisted Living

Abstract

This research describes and compares the relative importance residents and family members place on attributes of the environment, the programs, and the policies of assisted living; describes their satisfaction with these features; and identifies factors associated with congruence between residents' and family members' ratings of importance and satisfaction. Both residents and their family members had high importance and satisfaction ratings. Family members gave the assisted living setting lower satisfaction ratings on all features than did residents. Congruence ranged from 34% to 71% for importance items and from 29% to 63% for satisfaction. Female residents, affectionate family relationships, and residing in an AL owned by a chain were positively associated with congruence on importance items, while resident and family education, resident income, and family involvement were negatively associated with congruence on importance items. For congruence on satisfaction items, having an affectionate relationship was positively associated and higher ADL dependency, more family involvement at the facility, and family members who viewed the facility as a safe place were negatively associated with congruence. This study makes a major stride forward because cognitively intact residents' perspectives are compared and contrasted with their own family members' perspectives, thus showing that residents and family members are two distinct groups, each with a unique set of preferences.     

Telehealth for Patients with Chronic Pain: Exploring a Successful and an Unsuccessful Outcome

Abstract

Cognitive-behavioral therapy (CBT) is effective for treating chronic pain, but little is known about the mechanisms that might facilitate or hinder its utility when delivered by videoconference. In a single-case experimental design, we explored the outcomes of two adults with chronic pain who were provided with videoconference-based CBT. The goal was to examine the relationship between therapeutic alliance as well as presence felt and clinical outcomes. Therapeutic alliance was high overall for both participants; however, only the successful case’s alliance ratings significantly increased over treatment. Levels of presence felt in videoconferencing were also high, but were not related to therapy outcome.     

Pressure to Attend Therapy,Dyadic Adjustment,and Adverse Childhood Experiences: Direct and Indirect Effects on the Therapeutic Alliance in Couples Therapy

In this study we examine the role that pressure to attend therapy, dyadic adjustment, and adverse childhood experiences (ACEs) play in developing the therapeutic alliance. A total of 351 couples received treatment as usual at three family therapy training clinics. Participants rated predictor variables at intake and alliance at the fourth session. Results of a path analysis indicate that each partner's dyadic adjustment is directly associated with the quality of her or his own alliance. In addition, when male partners report more ACEs and pressure to attend treatment, their own alliance scores decrease. Additionally, when one partner reports feeling pressure to attend therapy, the other partner's alliance decreases. Finally, for males, there is an indirect effect of dyadic adjustment on alliance through pressure to attend therapy. These results suggest that clinicians should routinely assess relationship adjustment, how pressured each partner is feeling to attend treatment, and ACEs; as these may impact alliance quality.     

AGE-OF-RECALL EFFECTS ON FAMILY-OF-ORIGIN RATINGS

Family rating scales, particularly those tapping one's view of family of origin, rely heavily on one's summary impressions, perceptions, and recall of the family. Previous research has demonstrated that fairly consistent age, gender, and parent/offspring differences exist in ratings of current family functioning, but little information exists on such differences in rating one's family of origin. The present study had college-age subjects rate current family, family when they were elementary-school age, and family when they were 16 years old. Subjects were 141 college students (93 women, 48 men) who completed the self-Report Family Inventory (SFI) of the Beavers Systems Model of Family Functioning separately for the three specified recall periods (age 10, age 16, and current family). Significant differences were found between age-of-recall groups, with recall ratings from age 10 significantly more competent, cohesive, and less conflicted than those from age 16; current family ratings were intermediate. Relatively few gender by age interactions were significant. Implications for the use and interpretation of family ratings and family-of-origin scales are discussed.     

Therapeutic Alliance; A View Constructed by a Family Therapy Team

Therapeutic Alliance is a construct which may have value for a family therapy team and influence its day to day practice. This paper discusses whether family therapeutic alliance can be observed, described and measured, and gives an account of the development of the Family Therapeutic Alliance Scale (FTAS) by a brief strategic family therapy team. Our focus is on the use of statistical technique as a means of clarifying the team's construct of therapeutic alliance, informing the team process without being the final arbiter in development of the scale. The second stage outlines the investigation of the usefulness of the construct with a wider group of family therapists. In individual psychotherapies measures of therapeutic alliance have been shown to predict outcome. Our early work suggests this is also true for family therapies and the FTAS may be a predictor for outcome in family work.     

Interpersonal Behaviour in Families: Research on the Theoretical Relationship of Two Models*

An integration of theories of family process under a recently formulated unified theory is proposed. Research was conducted testing hypothesized interrelationships between two models subsumed under the unified theory: Satir's model of defended communication and Kantor and Lehr's psychopolitical model of family process. Behavioural ratings from an Australian sample and self-report ratings from an American sample both show the two models to be significantly correlated and structurally consistent with the unified theory.