Clients’ perceptions of marriage and family therapists’ way‐of‐being: a phenomenological analysis

Previous research highlights the influence of therapist factors on treatment outcomes. One therapist factor proposed as fundamental to the process of therapy is the therapist's way‐of‐being, a relational concept that refers to how the therapist regards a client—either as a person or object (Fife et al., [2014] Journal of Marital and Family Therapy, 40, 20–33). Although this case has been made conceptually, there is little empirical research on therapists’ way‐of‐being with clients. The primary purpose of this research is to investigate clients’ perceptions of their therapists’ way‐of‐being. Utilizing a common factors perspective, the study seeks to explore: (a) how clients experience their therapists’ way‐of‐being and (b) the influence therapists’ way‐of‐being has on clients’ engagement. Phenomenological methods were used to gain a nuanced understanding of the phenomenon. Qualitative data were collected through semi‐structured face‐to‐face interviews with clients (N = 10) who received individual therapy from a marriage and family therapist. Results were organized into two main themes: core tenets (attunement, congruency, and aligning with clients) and operational tenets (providing affirmation and validation, balancing flexibility and structure, and accomplishing goals). Findings are used to make a case for adding the concept of way‐of‐being as an overarching construct for several well‐established therapist factors. Clinical and training implications are discussed.     

Therapeutic Alliance and Retention in Brief Strategic Family Therapy: A Mixed‐Methods Study

We explored how the therapeutic alliance contributed to retention in Brief Strategic Family Therapy by analyzing videotapes of eight‐first sessions in which four therapists worked with one family that stayed in treatment and one family that dropped out. Although behavioral exchange patterns between clients and therapists did not differ by retention status, positive therapist alliance‐related behavior followed negative client alliance behavior somewhat more frequently in the retained cases. In the qualitative aspect of the study, four family therapy experts each viewed two randomly assigned sessions and commented on their quality without knowing the families’ retention status. A qualitative analysis of the audiotaped commentaries revealed 18 alliance‐related themes that were more characteristic of either the retained or the nonretained cases.     

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.     

How Do the Professional Lives of Family Therapists Affect their Private Relationships: A Qualitative Study

This article is based on a qualitative research project about how the professional lives of family therapists affect their private relationships. The overarching research question was: How does your professional work as a family therapist affect your private relationships? To answer this question, semi‐structured qualitative interviews were conducted with four therapists from two different Family Counseling Services. Through the use of interpretative phenomenological analysis, three main findings were identified: (1) family therapists’ knowledge and values are a basis for interpersonal encounters; (2) participants describe resonance in relation to clients’ stories; and (3) therapists can be challenged in managing confidential knowledge particularly where they belong to the same communities as clients. The study also explores societal expectations and discourses that accompany the role of therapist, which can affect therapists’ freedom of movement in their private lives. These issues are discussed in relation to family therapy theory and relevant research.     

Action-oriented evaluation of an in-home family therapy program for families at risk for foster care placement

The purpose of this study was to conduct an action-oriented evaluation of an in-home family therapy program serving families deemed at risk for the placement of children in foster care. In this study, feedback was solicited from both clients and therapists. Results indicate "duality" associated with several aspects of in-home family therapy, including the opportunity to observe families in their own homes versus the vulnerability some families feel when therapy is conducted in-home; therapists suggesting that sufficient training is required for in-home family therapy to be effective versus clients' opinions that therapists' lived experiences are more relevant; and the importance of the therapeutic alliance versus feelings of abandonment upon termination. Implications for researchers and practitioners are discussed.     

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.     

Therapist Differentiation and Couple Clients' Perceptions of Therapeutic Alliance

Therapeutic alliance has been acknowledged as one of the catalysts for change within a therapeutic relationship. The contributions of therapists' characteristics to alliance are not often studied. From a Bowen System's Theory perspective, the therapist's level of differentiation would be highly relevant to the development of a therapeutic alliance. The hypothesis for this study was that therapists who are able to take a more differentiated stance in therapy will build a stronger therapeutic alliance. To test this hypothesis, multilevel modeling procedures were performed, using data from nine therapists and 93 couple cases collected at a large, Midwestern university. Therapist differentiation of self was found to be weakly associated with the clients' perception of therapeutic alliance across the early sessions of therapy, but not in the expected direction. Although the results were unexpected, this study provides an example of the potential of examining therapist characteristics from within one model of therapy, that can be applied across various clients and various models of therapy.     

User Involvement in Therapy: Couples' and Family Therapists’ Lived Experiences with the Inclusion of a Feedback Procedure in Clinical Practice

User involvement in therapy includes some form of feedback from the clients. The feedback guides the therapist and the clients toward a best possible result through a best possible therapy process. In recent years many different procedures for collecting feedback have been developed. In a previous study presented in this journal we explored the expectations therapists had before including the comprehensive clinical feedback procedure, Systemic Therapy Inventory of Change (STIC), in their clinical practices. Our aim with this present study is to explore couples' and family therapists’ experiences with STIC from the perspective of user involvement. We found that the term ‘using STIC’ represented many different variations both between therapists and between the families each therapist worked with. Likewise user involvement, combined with a feedback procedure like STIC, was also a many faceted area. We discuss how therapists’ experiences may relate to the different aspects of user involvement in therapy.     

Therapist effects on dropout in couple therapy

Marriage and family therapy scholars have argued that therapists play a crucial role in successful couple therapy, yet little research has empirically documented that the therapist in couple therapy has a significant impact on outcomes. Known as the study of therapist effects, this study sought to assess the amount of variance attributed to the therapist in couple therapy outcomes. Using dropout as the outcome variable, this study analyzed data from 1,192 couples treated by 90 masters and doctoral student therapists at a university‐based training clinic. Results from multilevel analysis indicated that therapists in the sample accounted for 9.4% of the variance in couple dropout while controlling for initial couple impairment. Therapist gender and therapist experience did not significantly predict variability in therapist effects. These findings give promise to future research on therapist effects in couple therapy and encourage exploration into which therapist characteristics and behaviors contribute to successful clinical outcome.     

Ethics and family therapy: the case management of family violence*

All family therapists, and especially Milan-style systemic therapists, have been trained to take a neutral stance regarding family issues, based on a circular causality model of family interaction. Therefore, when therapists deal with family violence, their ability to perceive individual responsibility for unethical behavior is weakened or suppressed. In fact, this ability is the primary tool in developing effective treatment planning in cases of family violence: The actively physically abusive man needs to be in individual and/or group therapy, not conjoint or family therapy. The ethical judgment of the therapist is what determines the limits of family therapy.     

Partners in the Spiritual Dance: Learning Clients’ Steps While Minding All Our Toes

We present four case illustrations highlighting the complex interplay of therapists’ and clients’ spirituality in therapy. Complexity, in these cases, results from (a) degrees of similarity and difference, both real and perceived, between clients’ and therapists’ spiritual beliefs and practices; (b) degrees of spiritual disclosure; (c) characteristics of the therapeutic relationship; and (d) geographic and cultural influences. Practicing therapists and therapist training programs can benefit from addressing how therapist and client spirituality intersect and influence therapy, how both similarity and difference present obstacles and opportunities, and how ambiguity and assumptions can contribute to misunderstandings. We believe that both the therapist’s and the client’s spiritualities are key influences in therapy that can contribute to the frustration, and the growth, of clients and therapists alike.     

Sex and sexual orientation as variables in therapists' biases and therapy outcomes

The extent to which the variables of sex and sexual orientation are factors in therapy efficacy and therapist bias are examined through an extensive review of the literature. Data analysis based on a large sample of lesbian women indicate that female therapists, either heterosexual or lesbian, were assessed to be more beneficial than male therapists. However, the author suggests that therapists' sex role ideology may be a more salient factor than sex or sexual orientation in positive therapy outcomes with lesbian women.     

Exploring the influence of the attachment organizations of novice therapists on their delivery of emotionally focused therapy for couples

Clinicians' own internal resources for understanding relationships--that is, their attachment organizations--have been found to influence the process and outcome of treatment. The current study addressed whether the attachment organizations of novice couple and family therapists were associated with couples' experiences of their therapists, therapeutic alliance, session impact, and emotionally focused couple therapy (EFT) fidelity (i.e., especially as related to targeting and working with attachment needs and overt and underlying emotions). Novice couple and family therapists delivered EFT, an attachment-based approach, to couples in a simulated session and an embedded multicase study design guided a cross-case analysis. Findings indicated that secure therapists, when compared to their insecure peers, were more competent at working with attachment needs, as well as the overt and underlying emotions of their clients. Secure therapists perceived themselves as being more skilled in emotion regulation, which may have contributed to their abilities to remain attuned to their clients' attachment needs and emotional expression, even in the face of emotional arousal in session. Couples of insecure therapists also reported greater alliance splits. Future research is needed to further explore the dyadic influences of both therapists' and clients' attachment organizations, as well as the training and supervision practices these findings implicate.     

PREDICTORS OF SUCCESS IN EMOTIONALLY FOCUSED MARITAL THERAPY

This study examined client variables expected to predict success in emotionally focused marital therapy (EFT), now the second most validated from of marital therapy after the behavioral approaches. The relationship of attachment quality, level of emotional self-disclosure, level of interpersonal trust, and traditionality to the therapy outcome variables, marital adjustment, intimacy, and therapist ratings of improvement, was examined. These variables were chosen for their relevance to the theory and practice of EFT and to intimate relationships in general. Overall, therapeutic alliance predicted successful outcome; the task dimension of the alliance in particular predicted couples' satisfaction. More specifically, one dimension of female partners' trust, their faith in their partner, predicted couples' satisfaction at follow-up. Females' faith also significantly predicted males' level of intimacy at follow-up. Males who were most likely to be nondistressed at termination indicated higher levels of proximity seeking on an attachment measure at intake, and older males and males whose partners had higher levels of faith in them were more likely to be nondistressed at follow-up. Traditionality was not found to be significantly related to outcome. Couples who made the most gains at follow-up also indicated lower initial marital satisfaction and included males who indicated lower levels of use of attachment figure on the attachment measure at intake. Males who made the largest gains at termination were older and were rated as less expressive by their partner on self-disclosure measures at intake. Age was the only variable significantly related to males' gains in satisfaction at follow-up, Implications for the practice of marital therapy and future research are delineated.     

The Norway Couple Project: Lessons Learned

Couple therapists in routine practice may find it difficult to apply findings from an increasingly expanding and complex body of couple therapy research. Meanwhile, concerns have been raised that competency in evidence‐based treatments is insufficient to inform many practice decisions or ensure positive treatment outcomes (American Psychological Association Presidential Task Force on Evidence‐Based Practice, American Psychologist, 2006, 271). This article aims to narrow the research/practice gap in couple therapy. Results from a large, randomized naturalistic couple trial (Anker, Duncan, & Sparks, Journal of Consulting and Clinical Psychology, 2009, 693) and four companion studies are translated into specific guidelines for routine, eclectic practice. Client feedback, the therapeutic alliance, couple goals assessment, and therapist experience in couple therapy provide a research‐informed template for improving couple therapy outcomes.     

Collaborative Influence

Collaborative therapists acknowledge their role in influencing clients and the outcomes of therapy. But the word ‘influence’, for many new to the collaborative therapies, can be mistakenly connoted as an undue exercise of therapist power. From a dialogic and social constructionist perspective, this article reflects on how therapists can be influential in collaborative ways. Negotiating ‘shared intentionalities’ with clients, while privileging their preferences in meaning‐making and change—as part of respecting their primary authorship over their lives—assists therapists to employ their influence in ways that stay collaborative. Furthermore, by regarding client ‘resistance’ and misunderstanding as instructive, therapists can enhance their efforts to stay collaborative.     

Individual Therapy for Couple Problems: Perspectives and Pitfalls

Despite the demonstrated efficacy of conjoint couple therapy, many clients seeking help for couple problems ultimately find themselves in individual therapy for these concerns. Individual therapy for couple problems (ITCP) may evolve from a partner's refusal of conjoint therapy or from the treatment format preferences of either the client or therapist. Having acknowledged the role of partner refusals, we offer some perspectives about the idiosyncratic personal factors and professional background factors that may lead therapists to provide ITCP and discuss the significant pitfalls in its practice. We emphasize five central areas of concern in the ongoing practice of ITCP: structural constraints on change; therapist side‐taking and the therapeutic alliance; inaccurate assessments based on individual client reports; therapeutic focus; and ethical issues relevant to both attending and nonattending partners. We conclude by urging that this very important but largely neglected topic be paid greater attention in psychotherapy research, training and continuing education.     

Responsive Persistence Part I: Therapist Influence in Postmodern Practice

Feminist and social constructionist developments in family therapy highlighted the importance of attending to therapist–client power relations and incorporating clients' understandings and preferences as a part of therapy. Significantly, less attention has been given to how postmodern therapists do use their power and influence. This is an important topic because it is therapists who have the major responsibility for guiding the interaction with clients and persisting in this so that change is facilitated. Therapist persistence in various forms and across dimensions of therapy process is examined to expand understanding of therapist influence in postmodern and collaborative work. An analysis of responsive persistence in a session with Karl Tomm as the therapist is presented to illustrate this conceptual framing.     

“If I Can Grapple With This I Can Truly Be Of Use In The Therapy Room”: Using The Therapist's Own Emotional Struggles To Facilitate Effective Therapy

This study premises that self‐of‐the‐therapist work is pivotal in the development of effective therapists. However, therapy models vary in their goals for this work and the means of accomplishing them. This study presents the perspective of the person‐of‐the‐therapist Training (POTT) model that prioritizes the ability to consciously and purposefully use the self‐as‐is at the moment of contact with the client over the traditional goal of therapists working to resolve their issues. A key underlying assumption of the model proposes that therapists' core issues (referred to as “signature themes”) are potent resources that can be tapped into to connect, assess and intervene effectively with clients. The study presents the model and illustrates the use of signature themes in clinical work.