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Friedlander M.L., Escudero V., Heatherington L. et al.
Psychotherapy: 2011, 48(1), p. 25–33.
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This meta-analytic review commissioned by the American Psychological Association revealed that relationships between therapists and couples or families are as important as in individual therapy. Practice recommendations will aid therapists working with couples and families, among the most effective ways to treat substance use problems.
Summary Editor's note: Though not specific to patients with drug and alcohol problems, many of the studies in the analyses described below will have included such patients, and the principles are likely to be applicable to these disorders among others, not least because substance use problems generally form part of a complex of broader psychosocial problems.
This review is one of several in a special issue of the journal Psychotherapy devoted to evidence-based, effective therapist-client relationships. It reports on a research synthesis of the links between outcomes of therapy for problems between couples or within families, and the alliance between the therapist and the people involved in the therapy.
The concept of alliance was originally developed in individual psychotherapy, where it has been variously defined as a bond between the therapist and client which holds the client in therapy, or as a collaborative working relationship, and is sometimes seen as mainly working at the unconscious level, sometimes at the conscious. In couples and family therapy, alliances develop simultaneously on an individual level (self-with-therapist) and a group level (group-with-therapist). Unlike individual therapy, there are multiple alliances that interact as a complex system. For example, whether mother likes the psychotherapist and is committed to treatment can affect her children's willingness to trust the therapist. How comfortable and safe each family member feels with other members affects each person's willingness to negotiate goals and be open in therapy; revelations and in-session exploration of conflicts are not easily left behind at the end of the session. As well as individual-to-therapist alliances, there is the within-family alliance – the family's willingness to collaborate in treatment and the emotional bond between family members. The most widely used self-report measures of alliance in these forms of therapy assess not only (as in individual therapy) emotional bonds with therapists, agreement over goals, and collaborative working, but also the within-family alliance.
The review incorporated meta-analyses A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. synthesising results from relevant studies to provide estimates of the overall strength of the link between outcomes and alliance, and to be able to probe for influences on the strength of that link. Strength is expressed as effect sizes A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. By convention, in the behavioural sciences an effect size of the type used in the featured analyses is considered a small effect at 0.10, a medium effect at 0.30, and a large effect at 0.50. using the 'r' metric, which can be squared to calculate how much of the difference in outcomes can be attributed to differences in the therapy dimension being investigated. The assumption was made that there is no single, true strength of the link between outcomes and alliance which appears to vary only because of methodological differences, but that instead strength really might vary across the studies included in the analysis.
A search found 24 relevant English-language studies which related alliances (self-reported or observed) to subsequent client progress. Progress was expressed as treatment retention, within-treatment improvement, and/or final outcomes, generally in terms of the quality of relationships or psychological well-being. Target problems ranged from parent-adolescent communication difficulties to substance abuse, child abuse or neglect, and schizophrenia, or general family or couple dysfunction or distress.
Across all these studies the strength of the link between alliance and subsequent progress equated to an effect size of 0.26, a statistically significant link representing a small-to-medium relationship which accounts for about 7% of the variance in progress, almost identical to that reported for individual adult psychotherapy. In other words, the more solid the working relationship or bond between therapist and clients and within the family, the greater the progress the couple of family makes and the better they are retained in therapy.
However, effect size varied substantially across the studies and also within the subsets of family therapy studies and couples therapy studies, raising questions about the circumstances under which the alliance figures more or less strongly in outcomes. Given that few studies documented possible reasons for this variation, it was not possible to explore this issue using the data gathered for the meta-analysis. Instead the authors summarised what is known and has been suggested about such influences, comments selectively reflected in the following paragraphs.
There seems a complex relation between alliance and retention which is not just about the strength of the alliances but also how balanced they are (some may be strong, others weak). Sometimes the parent-therapist bond is the sole influence on retention, sometimes the bond with both parent and child. In one study of couples therapy for alcoholism, more experienced therapists developed stronger alliances, seemingly because they were relatively more active, more responsive to topics initiated by clients, more flexible in following manualised treatment guidelines, and better at managing the couples' negativity. Generally, in a couple the man's alliance tends to be more strongly associated with outcomes, perhaps because they tend to be the unwilling and/or more powerful partner. Alliances involving people with different roles in the family (parent, child, etc) are differentially influential, and the mesh of influences also varies in different types of family and couples therapy.
Family members who achieve success in therapy form a close, trusting bond with their therapists. Between themselves they are able to negotiate (and renegotiate) treatment goals and tasks. They have a shared sense of purpose, listen respectfully to one another, validate each other's perspectives, offer to compromise, and avoid excessive cross-blaming, hostility, and sarcasm. Family members who feel safe and comfortable in therapy are emotionally expressive, ask each other for feedback, encourage one another to open up and speak frankly, and share thoughts and feelings, even painful ones, that have never been expressed at home. In couples therapy greater trust within the relationship and openness in therapy is related to more favourable alliances, and challenging or negative comments about each other to less favourable.
There is no evidence that therapist gender, race/ethnicity, or therapist-family ethnic match are significant factors in the strength of alliance or affect the degree to which this is related to outcomes.
The therapeutic alliance is a critical factor in the process and outcome of couples and family therapies. Therapists need to be aware of what is going on within the family system, while monitoring the personal bond and agreement on goals and tasks with each individual family member. Periodically asking clients to complete a brief measure of the alliance would provide an opportunity for directly addressing and repairing problematic alliances.
Fostering a shared sense of purpose within the family, a particularly important dimension of the alliance, involves establishing common goals (eg, "It sounds like what the two of you want is a relationship in which you feel both connected and that you can sometimes do your own thing") rather than competing individual goals (eg, "I want him to stop watching sports on TV every Saturday"). Creating a safe space is critical, particularly early in therapy, but doing so requires caution. For example, a therapist who allies too strongly with a resistant adolescent may unwittingly damage the alliance with the parents, particularly when the latter are expecting the teen to change but are not expecting to be personally challenged by the therapist.
Evaluating the alliance based on observation is a skill that can be taught. Therapists may train themselves to validly assess their alliances with different family members by reviewing videotaped sessions.
In short, each person's alliance matters, and alliances are not interchangeable. Each and every alliance exerts both direct and interactive effects on the course of treatment. Clinicians should build and maintain strong alliances with each party and be aware of the ways in which, depending on the family's dynamics, the whole alliance is more than the sum of its parts.
commentary This article was in a special issue of the journal Psychotherapy devoted to effective therapist-client relationships. For other Findings entries from this issue see:
Evidence-based psychotherapy relationships: Psychotherapy relationships that work II
Evidence-based psychotherapy relationships: Alliance in individual psychotherapy
Evidence-based psychotherapy relationships: The alliance in child and adolescent psychotherapy
Evidence-based psychotherapy relationships: Cohesion in group therapy
Evidence-based psychotherapy relationships: Empathy
Evidence-based psychotherapy relationships: Goal consensus and collaboration
Evidence-based psychotherapy relationships: Positive regard
Evidence-based psychotherapy relationships: Congruence/genuineness
Evidence-based psychotherapy relationships: Collecting client feedback
Evidence-based psychotherapy relationships: Repairing alliance ruptures
Evidence-based psychotherapy relationships: Managing countertransference
Evidence-based psychotherapy relationships: Research conclusions and clinical practices
The special issue which contained the article featured above was the second from the task force. The first was a special issue of the Journal of Clinical Psychology. While the second aimed to identify elements of effective therapist-client relationships ('What works in general'), the first aimed to identify effective ways of adapting or tailoring psychotherapy to the individual patient ('What works in particular'). For Findings entries from this first special issue see this bulletin. Both bodies of work have also been summarised in this freely available document from the US government's registry of evidence-based mental health and substance abuse interventions.
Last revised 27 May 2011
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