Alliance and Dropout in Family Therapy for Adolescents With Behavior Problems: Individual and Systemic Effects.

This study examined the relationship between alliance and retention in family therapy. Alliance was examined at the individual (parent and adolescent) and family levels (within-family differences). Participants were 34 families who received functional family therapy for the treatment of adolescent (aged 12-18 years) behavior problems. Families were classified as treatment dropouts (n=14) or completers (n=20). Videotapes of the first sessions were rated to identify parent and adolescent alliances with the therapist. Results demonstrated that individual parent and adolescent alliances did not predict retention. However, as hypothesized, dropout cases had significantly higher unbalanced alliances (parent minus adolescent) than did completer cases. These findings highlight the importance of alliances in functional family therapy and suggest that how the alliance operates in conjoint family therapy may be a function of systemic rather than of individual processes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Adolescent and Parent Alliance and Treatment Outcome in Multidimensional Family Therapy.

In this study, the authors examined the relation between adolescent and parent therapeutic alliances and treatment outcome among 65 substance-abusing adolescents receiving multidimensional family therapy. Observer ratings of parent alliance predicted premature termination from treatment. Observer ratings, but not self-report, of adolescent alliance predicted adolescents' substance abuse and dependency symptoms at posttreatment, as well as days of cannabis use at 3-month follow-up. The association between adolescent alliance and substance abuse and dependency symptoms at posttreatment was moderated by the strength of the parent alliance. Results reveal the unique and interactive effects of the 2 alliances on treatment outcome and emphasize the need for a systemic and well-articulated approach to developing and maintaining the multiple alliances inherent to family therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethnic background, therapeutic alliance, and treatment retention in functional family therapy with adolescents who abuse substances.

In this study, the authors examined the role of balance between adolescent-therapist and parent-therapist alliances in the retention of functional family therapy clients. Therapeutic alliances of mothers, fathers, and adolescents were assessed from videotapes of the 1st treatment session for 43 Hispanic and 43 Anglo families. Hispanic families who dropped out before completing the requisite number of sessions were found to have greater imbalance in alliance (parent-adolescent) than those who did complete therapy. However, this finding was not replicated with Anglo families. Results are interpreted in terms of previous research on family-level balanced alliance effects. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems.

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alliance-building interventions with adolescents in family therapy: A process study.

Identified, articulated, and measured therapist behaviors associated with improving initially poor therapist–adolescent alliances in multidimensional family therapy (MDFT). A list of preliminary alliance-building interventions was generated from MDFT theory and adolescent development research. This list was then refined through the observation of videotaped MDFT sessions. A sample of 5 improved and 5 unimproved alliance cases was then drawn from a larger treatment study. Ss (mean age 15 yrs) were primarily African American, male, adolescent substance abusers and their families. Coders rated the 1st 3 sessions of each case (30 sessions) to determine the extent to which each alliance-building intervention was employed. Measures of alliance features included the Vanderbilt Alliance Scale (D. E. Hartley and H. H. Strupp, 1983), the Alliance Building Behavior Scale (G. M. Diamond, et al, 1996), and the Self-Perception Profile for Adolescents (S. Harter, 1988). By session 3, therapists were attending to the adolescent's experience, formulating personally meaningful goals, and presenting as the adolescent's ally more extensively in the improved alliance cases than in the unimproved alliance cases. Using these data, proposed stages of alliance building with adolescents are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The alliance in couple therapy: Partner influence, early change, and alliance patterns in a naturalistic sample.

Objective: The purpose of this study was to explore the relationship between the alliance and outcome in couple therapy and examine whether the alliance predicted outcomes over and above early change. The authors also investigated partner influence and gender and sought to identify couple alliance patterns that predicted couple outcomes. Method: The authors examined the alliances and outcomes at posttreatment and follow-up of 250 couples seeking treatment for marital distress in a naturalistic setting. The Session Rating Scale was used to measure the alliance; the Outcome Rating Scale and Locke Wallace Marital Adjustment Scale were used to measure outcomes. Couples were White, Euro-Scandinavian, and heterosexual, with a mean age of 38.5 years and average number of years together of 11.8. On a subsample (n = 118) that included couples with 4 or more sessions, the authors investigated the relationship between the alliance and outcome controlling for early change, and patterns of alliance development were delineated. Results: In the full sample, first-session alliances were not predictive of outcomes, but last-session alliances were predictive for both individuals and their partners. In the subsample, third-session alliances predicted outcome significantly above early change (d = 0.25) that exceeded the reliable change index. Couple alliances that started over the mean and increased were associated with significantly more couples achieving reliable or clinically significant change. Gender influences were mixed. Conclusions: Given the current findings suggesting a potential alliance impact over and above symptom relief as well as the importance of ascending alliance scores, continuous assessment of the alliance appears warranted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family functioning and adolescent alcohol use disorders.

Adolescents with alcohol dependence or abuse (n?=?126) were compared with 124 adolescents with other (nondrug) mental disorders and with a control group of 94 adolescents with no mental disorders on dimensions of family functioning. General family functioning, mother–adolescent relationships, and parental monitoring and discipline practices were assessed by using both adolescent and mother reports. Although overall the groups differed significantly on all family variables, the relationships among groups differed for adolescent and mother reports. By mother reports, families of adolescents with alcohol use disorders functioned less well than did families of adolescents with other mental disorders, whereas by adolescent reports these groups were not significantly different. Examination of both adolescent and mother perspectives may be important in understanding the relationship between family functioning and adolescent alcohol use disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Do Gender and Racial Differences Between Patient and Therapist Affect Therapeutic Alliance and Treatment Retention in Adolescents?

Parents, referral sources, and even therapists wonder whether the gender and racial match between therapists and patients contributes to poorer alliances and treatment dropout. Six hundred adolescent substance abusers and their therapists from a large randomized clinical trial were grouped according to matches and mismatches on both gender and race, and alliance ratings were collected from both patients and therapists. Results revealed that gender-matched dyads reported higher alliances and were more likely to complete treatment. Racial matching predicted greater retention but not patient-rated alliance. However, therapists in mismatched dyads rated significantly lower alliances. Results suggest that, although multicultural training remains critical, training emphasis should also be placed on understanding how gender and racial differences affect therapeutic processes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A step toward disentangling the alliance/improvement cycle in family therapy.

The authors focused on 2 unique aspects of the alliance in conjoint therapy: feeling safe in the therapeutic context with other family members and the family's shared sense of purpose about treatment (i.e., productive within-family collaboration). Low-income, multiproblem families were seen in a community clinic by therapists with varying theoretical orientations and a wide range of experience. Alliance-related behavior was assessed using the System for Observing Family Therapy Alliances (M. L. Friedlander, V. Escudero, & L. Heatherington, 2006). The significant mediated model showed that parent safety contributed to productive family collaboration in the 1st session, which, in turn, predicted global improvement rated after Session 3. Given the heterogeneous sample of clients, therapists, and therapy approaches, findings support the ecological validity of the alliance in family therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alliance predicts patients' outcome beyond in-treatment change in symptoms.

The authors examined the relations among therapeutic alliance, outcome, and early-in-treatment symptomatic improvement in a group of 86 patients with generalized anxiety disorders, chronic depression, or avoidant or obsessive–compulsive personality disorder who received supportive–expressive dynamic psychotherapy. Although alliance at Sessions 5 and 10, but not at Session 2, was associated with prior change in depression, alliance at all sessions significantly predicted subsequent change in depression when prior change in depression was partialed out. The results are discussed in terms of the causal role of the alliance in therapeutic outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The immediate effect of reframing on client attitude in family therapy.

This study focused on the process of therapy with families of delinquent adolescents. Results demonstrated differential effects of functional family therapists' behaviors on family members' positivity-negativity as a function of family member role (i.e., mother, father, adolescent). More important, the data indicated that only following a therapist reframe was the adolescent's average response in the nonnegative range; following all other classes of therapist statement (i.e., frame, acknowledgment, pacer, prompt, other) the adolescent's average response valence was negative. Given the clinical importance of resistance and negativity in first therapy sessions, these results support the utility of (positive) cognitive restructuring techniques with conflicted, negative families. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

The authors examined the relation between therapeutic alliance, retention, and outcome for 308 cocaine-dependent outpatients participating in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. High levels of alliance were observed in supportive–expressive therapy (SE), cognitive therapy (CT), and individual drug counseling (IDC), and alliance levels increased slightly but significantly from Session 2 to Session 5 in all groups. In contrast to other studies, alliance was not a significant predictor of drug outcome. However, alliance did predict patient retention differentially across the 3 treatments. In SE and IDC, either higher levels of alliance were associated with increased retention or no relationship between alliance and retention was found, depending on the time alliance was measured. In CT, higher levels of alliance were associated with decreased retention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient interpersonal impacts and the early therapeutic alliance in interpersonal therapy for depression.

The therapeutic alliance consistently predicts positive psychotherapy outcomes. Thus, it is important to uncover factors that relate to alliance development. The goal of this study was to examine the association between patient interpersonal characteristics and alliance quality in interpersonal therapy for depression. Data derive from a subsample (n = 74) of a larger naturalistic database of outpatients treated at a mood disorders clinic of a university-affiliated psychiatric hospital. Following Session 3 of treatment, therapists completed the Impact Message Inventory (Kiesler & Schmidt, 1993) to assess patients' interpersonal impacts on them. Also following Session 3, patients completed the Working Alliance Inventory (Horvath & Greenberg, 1989) to assess alliance quality. As predicted, patients' affiliative interpersonal impacts, as perceived by their therapists, were positively associated with alliance quality, controlling for baseline depression severity. Although unrelated to the initial hypotheses, patients concurrently taking psychotropic medications reported better alliances than patients receiving psychotherapy only. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic alliance and outcome: Impact of treatment length and pretreatment symptomatology.

Studied data collected in 1978–1982 in a research project at a university psychological clinic that provides low-cost services to families in the community. Data consisted of pre- and posttherapy written measures and audiotapes from selected sessions with 40 patients (aged 20–57 yrs). Findings indicate that (1) strength of therapeutic alliance was established within the 1st 3 sessions of therapy with little change over the course of therapy, (2) short length therapy cases had lower levels of therapist positive alliance, (3) therapeutic alliance was predictive of outcome, and (4) therapeutic alliance was adversely affected by pretreatment symptomatology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Locus of control and problem-solving interaction in families with adolescents

The focus of this study is on further development and refinement of a classification system of family problem-solving interaction in families with adolescents. A rigorous qualitative analysis was conducted on the video-taped problem-solving sessions of 38 families which consisted of a father, mother and their adolescent son or daughter. The analysis concentrated on how families engaged the problem situations, how solutions were generated and evaluated, communication patterns, and how affect was managed. It was discovered through the analysis that family problem-solving interaction could be classified based on a concept the researchers call family locus of control (F-LOC). Four types of F-LOC were described: individualistic, collaborative, authoritarian and external. Internal classification reliability was assessed by three independent raters who were able to accurately classify 95% of the problem-solving sessions by F-LOC. Discussion focuses on comparing the classification system with previously developed classification systems.     

Quality of object relations and security of attachment as predictors of early therapeutic alliance.

Security of attachment and quality of object relations were measured as predictors of initial impressions of the therapeutic alliance as well as dropout. Fifty-five individual psychotherapy clients were administered the Revised Adult Attachment Scale and the Bell Object Relations and Reality Testing Inventory prior to their initial therapy session. Thirty of these participants completed the Working Alliance Inventory following their 1st, 2nd, and 3rd sessions. Security of attachment and quality of object relations were strongly related. Security of attachment and quality of object relations showed relations to early alliance that decreased over time. Attachment and object relations were not related to dropout. Limitations include small sample size and low research compliance rate. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family education to enhance the moral atmosphere of the family and the moral development of adolescents.

Examined the effects of a course for families in democratic conflict resolution on (a) the family's collective decision-making abilities, and (b) the moral reasoning of adolescent participants. 16 couples and their adolescent children were divided into 3 groups: parents and their adolescents, parents only, and a control group. Both experimental groups met for 10 weekly 2.5-hr sessions and received training in conflict resolution and the use of family meetings. Assessment was based on the Parental Attitude Research Instrument, 2 self-report inventories, a behavioral role-play test, the Kohlberg Moral Judgment Interview, and an analysis of tape recordings of the family meetings. A 1-yr follow-up assessment of the Kohlberg measure was also used. Parents in both experimental groups significantly increased their equalitarian attitudes toward family decision making. Furthermore, families in both groups significantly improved their effectiveness in collective decision making; the parent–adolescent group showed greater improvement than the parent group on most of the variables measured. Finally, the results suggest that adolescents who participated in the training significantly improved their scores in moral reasoning. This gain was maintained at follow-up. (24 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multisystemic treatment of juvenile offenders: Effects on adolescent behavior and family interaction.

57 delinquent adolescents received family ecological treatment, 23 delinquent adolescents received an alternative treatment, and 44 normal adolescents served as developmental controls. The mean age of the adolescents at pretreatment was 14.8 yrs. Pre- and posttreatment assessments were conducted with the adolescent and his/her parents. Measures included the Behavior Problem Checklist, the Eysenck Personality Inventory, and self-report and observational measures of family relations. Ss who received family ecological treatment evidenced significant decreases in conduct problems, anxious-withdrawn behaviors, immaturity, and association with delinquent peers. The mother–adolescent and marital relations in these families were significantly warmer, and Ss were significantly more involved in family interaction. In contrast, the families who received the alternative treatment evidenced no positive change and showed deterioration in affective relations. The normal families manifested relationship changes that were consistent with those identified by investigators of normal adolescent development. Findings support a multisystemic model of behavior disorders and treatment. (59 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of therapist adherence and competence on patient outcome in brief dynamic therapy.

The authors examined the relation between therapist process variables (adherence and competence) and subsequent symptomatic change in patients. 29 depressed patients were seen in 16 sessions of weekly supportive expressive (SE) dynamic psychotherapy. Change in depression from intake to Session 3 predicted higher ratings of adherence to expressive (interpretative) techniques during Session 3 but not their competent delivery. Partialling pretreatment psychiatric severity, therapists' adherence to use of expressive techniques, and previous symptomatic improvement, relatively competent delivery of SE-specific expressive techniques predicted subsequent improvement in depression, Secondary analyses addressing alternative explanations (such as the role of either therapeutic alliance or general therapeutic skills) did not change the results. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Parent–child acculturation, parenting, and adolescent depressive symptoms in Chinese immigrant families.

Using a sample of 388 father–adolescent and 399 mother–adolescent dyads in Chinese immigrant families, the current investigation tested Portes and Rumbaut’s (1996) assertion that generational dissonance may indicate a family context that places children at increased risk for adverse outcomes. Study findings suggest that a high discrepancy in father–adolescent acculturation levels relates significantly to more adolescent depressive symptoms. The study further demonstrates that the quality of the parenting relationship between fathers and adolescents operates as a mediator between father–adolescent acculturation discrepancy and adolescent depressive symptoms. Specifically, a high level of discrepancy in American orientation between fathers and adolescents is associated with unsupportive parenting practices, which, in turn, are linked to more adolescent depressive symptoms. These relationships are significant even after controlling for the influence of family socioeconomic status and parents’ and adolescents’ sense of discrimination within the larger society. (PsycINFO Database Record (c) 2010 APA, all rights reserved)