Therapeutic Alliances with Families
A Book Review
“Therapeutic Alliances with Families: Empowering Clients in Challenging Cases”
Author: Valentín Escudero, Ph.D. and Myrna, L Friedlander, Ph.D.
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With this book, the therapeutic alliance with couples and families research has finally coalesced into a skilful and wise clinical tool. In the last ten years there have been a plethora of books (Sprenkle at al 2009) and papers (Higham 2012) raising the importance of attending to the therapeutic alliance for couple and family therapists. Almost every study of therapeutic outcomes in the field of family therapy includes a nod to one of the alliance measuring scales. But most of this literature functions as a rallying cry for clinicians and a side interest for the researchers. Escudero and Friedlander’s book is very far from either of these positions. It provides a creative, research based practical way of enhancing the therapeutic alliance. Not, I need to say, just in the ‘easy’ cases but also in those family contexts where a family member doesn’t want to engage in treatment, or the family is so compromised by internal strife or external pressure, that building an alliance seems almost impossible. In other words, this book is a manual from which established clinicians and students alike can glean interventions that will expand their skills as well as their understanding about how to engage families in those challenging situations. In many ways the final line of the book justifies this summary. “Challenge can bring joy” (2017: 180) write Escudero and Friedlander, who capture in this paradoxical but compassionate phrase the crucial role family therapists can play in helping families overcome the most difficult interpersonal situations.
The book is built upon over two decades of research into how the therapeutic alliance operates within family and couples therapy. The authors who created SOFTA (System for Observing the Family Therapy Alliance) (Friedlander et al 2006) uniquely blend this research into their latest book. Thus, although this is a magisterial summation of all this research (theirs and others), their aim is to “be eminently practical” (Escudero and Friedlander 2017: 4) and clinical lessons are constantly drawn from the various studies that range from outcome, process, qualitative and quantitative studies.
The SOFTA model is thoroughly outlined and explained. The book has Appendices that give the reader the full SOFTA measures which include an observational tool (for both family members’ and therapists’ behaviour); the various self report measures (again including family members’ and therapists’ tools) and a short four item version, which functions like the Session Rating Scale (Duncan et al 2003). SOFTA divides the therapeutic alliance in couple and family therapy into four dimensions. These include: engagement in the therapeutic process; emotional connection to the therapist; safety within the therapeutic system and finally shared sense of purpose. Within the SOFTA system, the first three are rated individually (by family member) whilst the last is rated globally (as a ‘within family’ measure). This model is the foundation of the whole book with Escudero and Friedlander proposing which aspects of these dimensions are crucial at each of the clinical impasses they address. The authors argue that whatever the theoretical orientation of the practitioner, their analysis is valuable because alliance factors are common across all interventions.
The book is divided into chapters that address a number of common problems that emerge in couples and family therapy. Issues such as “cross complaints” (e.g. “it’s her/his fault”); “blamed adolescents”; lone parenting; relational trauma and abusive contexts; mandated clients and multi-stressed families. In each chapter, care is taken to apply the evidence to the issue, e.g. apply the SOFTA way of thinking and then reach concrete proposals about helping the family or couple move through the impasse. The emphasis is always upon what the therapist can do to influence the situation so that families and couples can reach their own goals. Not surprisingly, the authors draw on a range of other literature (Rivett and Buchmüller 2018) and integrate techniques from these sources into potent methods to turn the alliance around.
In the chapter considering working with families where an adolescent is designated as the “problem”, for instance, Escudero and Friedlander draw on reframing. If the young person expresses unwillingness to engage in therapy, the SOFTA model encourages the therapist to assume that this is not ‘resistance’ but an expression of insecurity. In SOFTA terms, the therapist attends to the dimension of SAFETY. Alternatively, the therapist defines the unwillingness as evidence that this person has a different definition of the problem than that of other family members. This curious stance increases the CONNECTION between the therapist and family member.
What is particularly valuable is that this book does not shy away from those family contexts where many couple/ family therapists would ‘fear to tread’. The chapter about how to work in abuse or trauma situations demonstrates this commitment to the most vulnerable and compromised families. Again, by staying close to the alliance model, with a wholly systemic emphasis on relational trauma, Escudero and Friedlander provide a staged approach to deepening the alliance so that families can be encouraged to build up their own resources. They argue that in such situations, the therapist must work firstly on the “four threats to safety” whilst teaching family members that ruptures to the alliance are indeed an integral part of the healing process itself. The therapist must also find ways of building a CONNECTION before creating a space where a SHARED SENSE OF PURPOSE emerges. This might often reflect the joint “hidden pain” that is affecting all family members, which emerges as a perfect reframe that provides the healing of relational trauma.
There were moments when I noted the advice to build alliances with individual family members rather than remain in the conjoint context. As a rather ‘die hard’ family therapist trained in the era of Minuchin and Haley, I did question this practice. But as I read on, I acknowledged that this is a sign of the maturity of the field and one that is echoed in other contemporary approaches, such as Attachment Based Family Therapy (Diamond et al 2014). As a British family therapist, who works primarily for a National Health Service, there were times when I found some of the examples seemed to imply that the authors worked within a context in which they were private practitioners or contracted by a State body to provide certain therapeutic services. This meant I needed to adapt their approach to fit my own. But none of this should distract from the ‘trans-theoretical’ value of this approach which can be so significant in multiple contexts and with multiple presentations.
This is an erudite and well written book, peppered with engaging case examples that provide excellent clinical material that helps the reader translate the ideas into practice. It is also peppered with enlightening quotes such as Bob Marley’s, “the mind replays what the heart can’t delete.” There are other nuggets of clinical enlightenment in the text which calls for careful reflection and application. Indeed, this is one of the few instantly applicable family therapy books which deserves to be read by every student and family therapy practitioner.
Cite This Article
Rivett, M. (2018, September). Therapeutic alliances with families: A book review [Web article] [Review of the book Therapeutic alliances with families: Empowering clients in challenging cases, by V. Escudero and M. L. Friedlander]. Retrieved from https://societyforpsychotherapy.org/therapeutic-alliances-with-families
Diamond, G.; Diamond, G. and Levy, S. (2014) Attachment based family therapy for depressed adolescents. Washington, DC: American Psychological Association.
Duncan, B.; Miller, S.; Sparks, J.; Claud, D.; Reynolds, L.; Brown, J. and Johnson, L. (2003). The Session Rating Scale: Preliminary Psychometric Properties of a “Working” Alliance Measure. Journal of Brief Therapy: 3, 3-12.
Friedlander, M.; Escudero, V. and Heatherington, L. (2006) Therapeutic alliances with couples and families: an empirically-informed guide to practice. Washington, DC; American Psychological Association.
Higham, J.; Friedlander, M.; Escudero, V. and Diamond, G. (2012) Engaging reluctant adolescents in family therapy: an exploratory study of in-session processes. Journal of Family Therapy: 34, 24-52.
Rivett, M. and Buchmüller, J. (2018) Family therapy: skills and techniques in action. London: Routledge.
Sprenkle, D,; Davis, S. and Lebow, J. (2009) Common factors in couple and family therapy. Guilford: New York.