Authors’ Note: This article is abstracted from Friedlander, M. L., Escudero, V., Welmers-van de Poll, M. J., & Heatherington, L. (2018). Meta-analysis of the alliance-outcome relation in couple and family therapy. Psychotherapy, 55(4), 356-371. http://dx.doi.org/10.1037/pst0000161
Clinical Impact Statement: This information in this article is directly relevant to therapy practice with couples and families (CFT). It contains specific suggestions for therapist strategies that can enhance the therapeutic alliance. The therapeutic alliance in CFT is a critical factor in therapeutic outcomes.
Many therapists in training, and even experienced therapists, anticipate working with couples and families with trepidation. As family therapists and researchers, we understand that trepidation, and indeed, sometimes find ourselves experiencing these same feelings! However, we know that understanding systemic interactions really helps in learning to work with couples and families; thus, we offer some evidence-based information to demystify this work. We hope it inspires readers who have not received training in couple and family therapy (CFT) to consider doing so, given the abundant evidence of its effectiveness across a range of relational problems and diagnoses (Friedlander, Heatherington, & Diamond, in press).
Our recent meta-analysis of the CFT alliance-outcome association (Friedlander, Escudero, Welmers-van de Poll, & Heatherington, 2018) soundly demonstrated its importance: In 40 samples, stronger alliances were significantly associated with better outcomes, r =.297, p < .001, d =.622. Not surprising, perhaps, and, as the saying goes, “Good work if you can get it!” But how do you get it?
Alliances in CFT are both similar to and different from individual therapy alliances. In both modalities, therapeutic goals and tasks need to be discussed and agreed upon early and throughout treatment. Emotional bonds between therapist and clients are critical. However, CFT alliances must be built and nurtured with multiple individuals simultaneously. Moreover, family members observe the unfolding alliances between the therapist and other members. A mother’s alliance with the therapist may be enhanced by seeing her daughter bond with therapist; an angry adolescent’s alliance may be challenged by observing her parents’ bonding with the therapist.
Multiple alliances interact, covertly and overtly, particularly when family members are in conflict, at different developmental levels, or have differing motivations for help-seeking. Further, given the family members’ long history together, what underlies conflictual interactions is often invisible to the therapist. Mother’s slightly puckered lip when Father offers his perspective can shut him down, since he knows that a puckered lip means “you’re in trouble!”
Balancing multiple alliances is the sine qua non of relationship building in conjoint therapy. To do so, therapists must (1) deliberately foster the within-family alliance, or the degree to which family members share a sense of purpose about the problems, treatment goals, and (especially) the value of working collaboratively in therapy, and (2) avoid creating severely split alliances (Pinsof & Catherall, 1986), which occur when one (or more) family members has a much stronger connection with the therapist than do the others (Friedlander, Escudero, Horvath, Heatherington, Cabero, & Martens, 2006). Our meta-analysis found within-system alliances to be more predictive of outcome than individual alliances with the therapist, and more split or unbalanced alliances contributed significantly to worse treatment outcomes (Friedlander et al., 2018). Split alliances are quite common, but severe splits can be pernicious, since family members who view their experience with the therapist very differently can wind up becoming polarized about the value of the therapy itself (Escudero & Friedlander, 2017; Friedlander et al., 2006).
In our multidimensional alliance model, the SOFTA (System for Observing Family Alliances), individual clients’ alliances are strong when they are engaged in the therapeutic process, emotionally connected to the therapist, feel safe in the therapeutic context, and share a sense of purpose with other family members (see Friedlander et al., 2006, and http://softa-soatif.com/ for a full description of this conceptual model and associated self-report and observer measures.) Based on qualitative and quantitative research as well clinical experience, we have identified some therapeutic practices that foster strong CFT alliances. Here, we briefly offer some practice recommendations, focused on the two features noted earlier.
Promoting Strong Within-Family Alliances
In more successful treatments, the within-family alliance tends to start out strong or strengthens over time (Escudero, Friedlander, Varela, & Abascal, 2008). However, some research shows (e.g., Friedlander, Escudero, Lambert, & Cragun, 2008) that even highly experienced therapists tend to neglect this element, employing more engagement and emotional connection behaviors to address individual family members and fewer behaviors that specifically foster a shared sense of purpose among family members. Identifying clients’ shared feelings (“You are both feeling overworked and underappreciated”) and experiences (“In previous relationships, your trust has been betrayed, so understandably, you are both wary of really investing”) and validating common struggles (“You are all working hard to get past this crisis”) strengthens the within-family alliance, as does proposing goals to which everyone can sign on (“How about if together we seek ways to share clear strategies with the children and thus reduce this tension that you all feel at home?”).
High emotional reactivity and sustained conflict can erode the within-family alliance. Asking one (or more) clients to step out of the room briefly or conducting alternating sessions with different subsystems can enhance individuals’ sense of safety, thus decreasing the chances of dropout. In fact, our mantra is: “Safety first.” Conjoint therapy takes place in a “public” forum. What one family member divulges about another not in the other’s control, and secrets revealed in a family session (e.g., infidelity, incest, intention to leave one’s partner, or even a failing grade in school) cannot be put back in the box. Interventions such as acknowledging that family therapy takes risks, or asking a parent to assure a child that it’s okay to tell the truth can promote safety within the session (Friedlander et al., 2006).
Avoiding and Repairing Severely Split Alliances
Split alliances occur frequently (Heatherington & Friedlander, 1990; Muñiz de la Peña , Friedlander, & Escudero, 2009), but need not be a cause for alarm. Rather, noticing and taking steps to repair them can prevent dropout and, ideally, results in stronger alliances.
Approach, rather than avoid, signs of a shaky emotional bond with the disaffected family member. When clients challenge the usefulness of the therapy, or behave in highly guarded, defensive, or hostile ways, the therapist can respond with deliberate alliance-enhancing interventions, such as asking for the client’s willingness to engage in a specific in-session task or “homework assignment” (rather than simply imposing it), or pointing out small changes and reasons for optimism, and so on. Respectfully (i.e., nondefensively) exploring and recognizing the reasons behind a client’s “reluctance” is one way to reframe resistance. When interacting with adolescents, therapists should avoid domineering or authoritarian responses and should rather convey a sincere interest in hearing their perspectives, help them identify personal goals, and encourage the parent(s) to the support their involvement in the therapy (Higham, Friedlander, Escudero, & Diamond, 2012).
A client’s experience of safety and engagement can be threatened by the perception that the therapist is “siding” with another family member. For example, some studies have found that in heterosexual couples, since it is most often the female partner who initiates the treatment, fostering a strong individual alliance with the male partner is important for retention and outcomes (e.g., Anker, Owen, Duncan, & Sparks, 2010). As the therapy progresses, it is also important to ensure that the female partner continues to be invested in therapy. These patterns are, of course, not universal.
In short, alliances in CFT are “more than the sum of their parts.” Successful therapy requires not only attending to the alliance with each family member, but also to their shared sense of purpose and felt safety working together in a conjoint session.
Cite This Article
Heatherington, L., Friedlander, M. L., & Escudero, V. (2019). Balancing alliances with couples and families: A primer. Psychotherapy Bulletin, 54(3), 21-24.
Anker, M. G., Owen, J., Duncan, B. L., & Sparks, J. A. (2010). The alliance in couple therapy: Partner influence, early change, and alliance patterns in a naturalistic sample. Journal of Consulting and Clinical Psychology, 78(5), 635-645. doi:10.1037/a0020051
Escudero, V., & Friedlander, M. L. (2017). Therapeutic alliances with families: Empowering clients in challenging cases. New York, NY: Springer. doi: 10.1007/978-3-319-59369-2
Escudero, V., Friedlander, M. L., Varela, N., & Abascal, A. (2008). Observing the therapeutic alliance in family therapy: Associations with participants’ perceptions and therapeutic outcomes. Journal of Family Therapy, 30(2), 194-214. doi: 10.1111/j.1467-6427.2008.00425.x
Friedlander, M. L., Escudero, V., Horvath, A. O., Heatherington, L., Cabero, A., & Martens, P. (2006). System for observing family therapy alliances: A tool for research and practice. Journal of Counseling Psychology, 53(2), 214-225. doi: 10.1037/0022-0220.127.116.11
Friedlander, M. L., Escudero, V., Welmers-van de Poll, M. J., & Heatherington, L. (2018). Meta-analysis of the alliance-outcome relation in couple and family therapy. Psychotherapy, 55(4), 356-371. http://dx.doi.org/10.1037/pst0000161
Friedlander, M. L., Heatherington, L., & Diamond, G. M. (in press). Systemic and conjoint couple and family therapies: Recent advances and future promise. In M. Barkham, W. Lutz, & L. Castonguay (Eds.), Bergin and Garfield’s handbook of psychotherapy and behavior change (7th ed.).
Friedlander, M. L., Lambert, J. E., Escudero, V., & Cragun, C. (2008). How do therapists enhance family alliances? Sequential analyses of therapist → client behavior in two contrasting cases. Psychotherapy: Theory, Research, Practice, Training, 45(1), 75-87. doi: 10.1037/0033-318.104.22.168
Heatherington, L. & Friedlander, M. L. (1990). Couple and family therapy alliance scales: Empirical considerations. Journal of Marital and Family Therapy, 16(3), 299-306. doi: 10.1111/j.1752-0606.1990.tb00851.x
Higham, J., Friedlander, M. L., Escudero, V., & Diamond, G. M. (2012). Engaging reluctant adolescents in family therapy: An exploratory study of in-session processes. Journal of Family Therapy, 34(1), 24-52. doi: 10.1111/j.1467-6427.2011.00571.x
Muñiz de la Peña, C., Friedlander, M. L., & Escudero, V. (2009). Frequency, severity, and evolution of split family alliances: How observable are they? Psychotherapy Research, 19(2), 133-142.doi: 10.1080/10503300802460050
Pinsof, W. M., & Catherall, D. R. (1986). The integrative psychotherapy alliance: Family, couple, and individual therapy scales. Journal of Marital and Family Therapy, 12(2), 137-151. doi: 10.1111/j.1752-0606.1986.tb01631.x