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.     

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 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.     

Occupational variations in drinking and psychological distress: a multilevel analysis

The relationship between alcohol intake and psychological distress has been overlooked in studies on the working population. Using a multilevel multivariate model, this study reports results obtained from a sample of 8812 workers nested in 387 occupations. Results show that alcohol intake and psychological distress vary significantly at the worker and occupation levels, but they do not show a large variation at the occupation level. Occupational socioeconomic status appears to be a common factor explaining the correlation between alcohol intake and psychological distress at the occupation level. Semi-professionals, middle management, foreman and semiskilled clerical-sales-services occupations are particularly at risk. Gender is related to both outcomes, while work schedule and number of weekly working hours are associated only with psychological distress. Implications and limitations of these results are discussed.     

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.     

Client Psychological Distress: An Important Factor in Career Counseling

The authors explored client psychological distress as a variable in career counseling. Forty‐two clients in a naturalistic setting were seen for a total of 290 sessions by 21 counselors‐in‐training. The results indicated that (a) 60% of the clients were psychologically distressed, (b) clients' scores decreased significantly from pretest to posttest on psychological distress variables, (c) significant linear growth occurred in the clients' perception of the working alliance across sessions, and (d) the psychological distress outcome variables were significantly related to both the first session level of the working alliance and its linear growth.     

Contributions of the Working Alliance in the Practice of Career Counseling

We see the working alliance, a construct well articulated in the psychoanalytic counseling literature, as a key element in enhancing the counseling of those with career concerns. This article describes the working alliance as that sector of the overall experience of counseling participants characterized by their collaboration, mutuality and cooperation with regard to the work of counseling. The dimensions of the working alliance, the counselor and client contributions to it, and the perspectives of others about it are discussed. This study reviews obstacles to building and sustaining the alliance, such as resistance in the form of fear of counseling, and confusion related to counseling goals, tasks, and bonds. Finally, mention is made of the possible research and policy implications of emphasizing the working alliance in career counseling practice.     

Motivational interviewing as a pregroup intervention for partner-violent men

This study investigated the effects of a pregroup motivational intervention for domestic abuse perpetrators. Men presenting for treatment at a community domestic violence agency (N = 108) were assigned to receive either a two-session intake using the techniques of motivational interviewing (MI) or a structured intake (SI) control. All participants were then referred to a cognitive behavioral treatment (CBT) program in groups homogeneous with respect to intake condition. The motivational intake led to more constructive in-session behavior during the early phase of group CBT, greater compliance with group CBT homework assignments, higher late session therapist ratings of the working alliance, and more help seeking outside of the domestic violence program. No significant effects of intake condition were found on session attendance, self-reports of readiness to change abusive behavior, or client reports of the working alliance. Partner reports of abusive behavior outcomes during the 6 months after group CBT revealed a marginal effect favoring the MI condition on physical assault. The findings suggest that motivational interviewing can increase receptivity to partner violence interventions.     

The Course of Dyadic Adjustment and Depressive Symptoms During and After Couples Therapy: A Prospective Follow-up Study of Inpatient Treatment

A clinical sample of adult patients suffering from relational distress and concurrent psychiatric symptoms was followed from admission, through residential couple therapy, to 1-year follow-up. At follow-up, 9.8% were separated. The remaining couples showed significant improvement in dyadic adjustment at posttreatment. However, at 1-year follow-up, a subgroup of 25% of the positive treatment responders had deteriorated to below their admission levels of dyadic adjustment. Contrary to expectation, the deteriorated group had showed significantly less distress both in depressive symptoms and in one early maladaptive schema domain—Impaired Autonomy—at admission, when compared with the rest of the sample, which suggests the need for further research and possible replication in this area.     

Experiences of Violence, Post-Traumatic Stress, Academic Achievement and Behavior Problems of Urban African-American Children

This study examined the frequency of family violence, community violence, and witnessing of violence for 110 African-American children. Levels of post-traumatic stress, academic achievement and behavior problems of the children were also examined. The students were sixth graders between the ages of 11 and 13 from four inner-city Chicago public schools. The level of exposure to family violence was significantly related to levels of behavior problems and negatively related to school achievement. The level of exposure to community violence was associated with levels of behavior problems and approached significance in a negative direction with school achievement. Academic achievement was not significantly related to behavior, but was significantly associated with post-traumatic stress disorder, family violence, witnessing violence and approached significance with community violence exposure.     

Adolescent and Parent Alliances With Therapists in Brief Strategic Family TherapyTM With Drug-Using Hispanic Adolescents

This study examined the relationship between alliance and retention in family therapy. Alliance was examined at the individual (parent, adolescent) and family level (within-family differences) for families that either dropped out or completed family therapy. Participants were 31 Hispanic adolescents and their family members who received brief strategic family therapy for the treatment of adolescent drug use. Videotapes of first sessions were rated to identify parent and adolescent alliances with the therapist. Results demonstrated that Completer cases had significantly higher levels of alliance across all family members than Dropout cases, and Dropout cases had significantly higher unbalanced alliances than Completer cases. Clinical implications are discussed.     

Adolescent and parent alliances with therapists in Brief Strategic Family Therapy with drug-using Hispanic adolescents

This study examined the relationship between alliance and retention in family therapy. Alliance was examined at the individual (parent, adolescent) and family level (within-family differences) for families that either dropped out or completed family therapy. Participants were 31 Hispanic adolescents and their family members who received brief strategic family therapy for the treatment of adolescent drug use. Videotapes of first sessions were rated to identify parent and adolescent alliances with the therapist. Results demonstrated that Completer cases had significantly higher levels of alliance across all family members than Dropout cases, and Dropout cases had significantly higher unbalanced alliances than Completer cases. Clinical implications are discussed.     

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.     

Impact of marital and psychological distress on therapeutic alliance in couples undergoing couple therapy

In this study, we describe the psychometric properties of the Couple Therapy Alliance Scale--revised (CTAS-r) and investigates the impact of marital and psychiatric distress on alliance. Seventy-nine couples in therapy completed a French version of the Dyadic Adjustment Scale and of the Psychiatric Symptoms Index at session one, and a French version of the CTAS-r at session three. Results indicate that the French version of the CTAS-r has adequate psychometric properties, although the subscales of the instrument are highly intercorrelated. Furthermore, marital adjustment predicts alliance scores, whereas psychiatric symptoms do not. Finally, male marital adjustment and female psychiatric symptoms are lower in couples where spouses have divergent perceptions of the alliance. Future research directions are discussed.     

Domestic violence in veterans with posttraumatic stress disorder who seek couples therapy

Domestic violence rates among veterans with posttraumatic stress disorder (PTSD) are higher than those of the general population. Individuals who have been diagnosed with PTSD who seek couples therapy with their partners constitute an understudied population. Self-report measures of domestic violence, relationship satisfaction, and intimacy were administered at intake to 179 couples seeking relationship therapy at a Veterans Affairs clinic. Couples in which the veteran was diagnosed with combat-related PTSD were compared with two other groups based on the veteran's primary diagnosis (depression, adjustment disorder/V-code). Both the PTSD- and depression-diagnosed veterans perpetrated more violence than did those with adjustment/V-code diagnoses. Domestic violence rates among depressed and PTSD-diagnosed veterans were much higher than those found in previous research. Implications for assessment and treatment are discussed.     

Engaging Fathers in Family Therapy with Violent Adolescents

Violent behavior in adolescents can often signal profound distress or pain arising from family conflicts, hostile marital separations, sudden losses and other family turmoil. By circumventing blame the therapist engages the family in a constructive process that allows adolescents to change and grow and parents to share pain and sorrow about their own issues and responsibilities for their children. This re‐establishes healthy generational boundaries, produces a clearer co‐parenting alliance (e.g. after divorce) and creates sibling support. This paper describes an experiential approach, for working with violent adolescents in family therapy influenced by the pioneer work of Satir and Whitaker. It integrates systemic and developmental theories linking the presenting problem to relevant family events. The therapist: (1) explores adolescent development in the family and social context; (2) establishes a therapeutic alliance through understanding the interpersonal context for violent behavior, and (3) re‐directs negative actions into positive connections with family members. Segments of family therapy sessions with two adolescent boys and their families from different cultural backgrounds illustrate the impact of paternal absence for adolescent well‐being and the need to actively engage fathers in family therapy. Mario, the father's ‘tumor’, and Juan with his despairing violence are two problematic adolescents brought to therapy because of their aggressive behavior at home and/or in the school. The paper describes how to give them a different voice and build a therapeutic alliance with the family.     

Inner‐City Children's Exposure to Community Violence: How Much Do Parents Know?

This study examines the psychological impact of children's exposure to violence and the influence of mothers' knowledge about their children's encounters with violence. Our sample consists of a poor, multiethnic sample of 104 fourth‐ or fifth‐grade children and their mothers. Children in this sample were exposed to rather high levels of community violence, and on the whole, mothers greatly underestimated their children's exposure to violence and feelings of psychological distress. Hierarchical regression analyses indicated that children's exposure to violence was associated with greater psychological distress. Our findings suggest that the detrimental effects of community violence are present for all children, irrespective of their racial background. Further, greater mother‐child agreement about children's exposure to violence was related to better psychological functioning. The implications of these results for effective parenting strategies and community‐based interventions are discussed.     

Therapeutic alliance and treatment progress in couple psychotherapy

This study examined the ability of the therapeutic alliance to predict treatment progress on individual- and relationship-level variables from the early to middle phase of couple treatment. Although alliance did not predict progress in individual functioning, it accounted for 5-22% of the variance in improvement in marital distress. Women's mid-treatment alliance uniquely predicted improvement in marital distress, over and above early treatment alliance. When men's alliances with the therapist were stronger than their partners' at session 8, couples showed more improvement in marital distress. Treatment response was also positively associated with women's ratings of their partners' alliance. Results confirm that the therapeutic alliance in conjoint treatment is composed of distinct client subsystems that are useful predictors of treatment progress.     

Talking about violence: a microanalysis of narrative processes in a family therapy session

In this article, we look at the development in family therapy of narratives about domestic violence. We report on microanalyses of a family therapy session, using narrative research methods, including some conversation analytic tools. The main questions posed in this investigation were: How does storytelling of a highly charged and delicate topic like domestic violence develop in the session?; how do the different actors in the therapy room contribute to telling such stories?; how do actors try to put forward domestic violence as a conversational topic? and how do different actors react to these attempts? Our research illustrates how the recounting of stories of violence seems to go hand in hand with modes of interaction that discourage the telling of these stories. In the back‐and‐forth process between voices of hesitation and voices of reassurance, the participants weigh the level of safety in the session. In as far as the voices of hesitation can be reassured of the safety, it becomes gradually possible to talk about delicate, problematic experiences, such as violence in the family.