Abstract
Client discontinuation is prevalent in psychotherapy with up to half discontinuing therapy before meeting the goals of therapy (Thalmayer, 2018). When therapists work to improve the therapeutic alliance, clients are more likely to stay in treatment and chances of recovery improve (D’Aniello et al., 2018; Escudero & Friedlander, 2017). Most of the alliance research, however, comes from client self-report of the alliance with less research based on observations of alliance behaviors that occur during a session. There has been limited research on how in-session alliance behaviors may be related to client discontinuation in couple therapy. The current exploratory study examined this question in a sample of thirty matched pairs of heterosexual couples (15 couples who discontinued prematurely and 15 who successfully completed treatment). Alliance behaviors were coded using the System for Observing Family Therapy Alliances (Friedlander et al., 2005; SOFTA-o) and t-tests were used to identify whether couples differed significantly on four dimensions of the therapeutic alliance: Engagement in the therapeutic process, emotional connection to the therapist, safety within the therapeutic system, and shared sense of purpose within the family. Results indicate that emotional connection was significantly lower for both male and female partners in the discontinuation group, as was the male partner’s sense of safety and shared sense of purpose. Within these dimensions, several individual alliance behaviors were also significant suggesting their potential importance in helping therapists identify couples at risk of discontinuation.
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References
Anderson, S. R., & Johnson, L. N. (2010). A dyadic analysis of the between and within system alliance on distress. Family Process, 49, 220–235. https://doi.org/10.1111/j.1545-5300.2010.01319.x
Anderson, S. R., Johnson, L. N., Banford Witting, A. B., Miller, R. B., Bradford, A. B., Hunt, Q. A., & Bean, R. A. (2023). Validation of the intersession alliance measure: Individual, couple, and family versions. Manuscript Submitted for Publication.
Anderson, S. R., Tambling, R., Yorgason, J. B., & Rackham, E. (2019). The mediating role of the therapeutic alliance in understanding early discontinuance. Psychotherapy Research, 7, 882–893. https://doi.org/10.1080/10503307.2018.1506949
Bartle-Haring, S., Glebova, T., Gangamma, R., Grafsky, E., & Delaney, R. O. (2012). Alliance and termination status in couple therapy: A comparison of methods for assessing discrepancies. Psychotherapy Research, 22(5), 502–514. https://doi.org/10.1080/10503307.2012.676985
Bartle-Haring, S., Glebova, T., & Meyer, K. (2007). Premature termination in marriage and family therapy within a Bowenian perspective. American Journal of Family Therapy, 35(1), 53–68. https://doi.org/10.1080/01926180600550528
Bischoff, R. J., & Sprenkle, D. H. (1993). Dropping out of marriage and family therapy: A critical review of research. Family Process, 32(3), 353–375. https://doi.org/10.1111/j.1545-5300.1993.00353.x
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. https://doi.org/10.1037/h0085885
Bourgeois, L., Sabourin, S., & Wright, J. (1990). Predictive validity of therapeutic alliance in group marital therapy. Journal of Consulting and Clinical Psychology, 58(5), 608–613. https://doi.org/10.1037/0022-006X.58.5.608
Cahill, J., Barkham, M., Hardy, G., Rees, A., Shapiro, D. A., Stiles, W. B., & Macaskill, N. (2003). Outcomes of clients completing and not completing cognitive therapy for depression. British Journal of Clinical Psychology, 42, 133–143. https://doi.org/10.1348/014466503321903553
Christensen, L. L., Russell, C. S., Miller, R. B., & Peterson, C. M. (1998). The process of change in couples therapy: A qualitative investigation. Journal of Marital and Family Therapy, 24(2), 177–188. https://doi.org/10.1111/j.1752-0606/1998/tb01074.x
Corey, G. (2005). Theory and practice of counseling and psychotherapy (7th ed.). Brooks/Cole.
D’Aniello, C., Anderson, S. R., & Tambling, R. R. (2021). Psychotherapeutic processes associated with couple therapy discontinuance: An observational analysis using the Rapid Marital Interaction Coding System. Journal of Marital and Family Therapy, 47, 891–908. https://doi.org/10.1111/jmft.12482
D’Aniello, C., Piercy, F. P., Dolbin-MacNab, M. L., & Perkins, S. N. (2018). How clients of marriage and family therapists make decisions about therapy discontinuation and persistence. Contemporary Family Therapy: An International Journal, 41(1), 1–11. https://doi.org/10.1007/s10591-018-9469-7
D’Aniello, C., & Tambling, R. B. (2016). The effect of expectations on intention to persist in therapy. American Journal of Family Therapy, 45(1), 37–50. https://doi.org/10.1080/01926187.2016.1223568
Doss, B. D., Hsueh, A. C., & Carhart, K. (2011). Premature termination in couple therapy with veterans: Definitions and prediction of long-term outcomes. Journal of Family Psychology, 25(5), 770–774. https://doi.org/10.1037/a0025239
Escudero, V., & Friedlander, M. (2017). Therapeutic alliances with families: Empowering clients in challenging cases. Springer. https://doi.org/10.1007/978-3-319-59369-2
Fife, S. T., Whiting, J. B., Bradford, K., & Davis, S. (2014). The therapeutic pyramid: A common factors synthesis of techniques, alliance, and way of being. Journal of Marital and Family Therapy, 40(1), 20–33. https://doi.org/10.1111/jmft.12041
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55, 316–340. https://doi.org/10.1037/pst0000172
Friedlander, M. L., Bernardi, S., & Lee, H. (2010). Better versus worse family therapy sessions as reflected in clients’ alliance-related behavior. Journal of Counseling Psychology, 57(2), 198–204. https://doi.org/10.1037/a0019088
Friedlander, M. L., Escudero, V., & Heatherington, L. (2005). Therapeutic alliances in couple and family therapy: An empirically informed guide to practice. Washington: American Psychological Association.
Friedlander, M. L., Escudero, V., Horvath, A. O., Heatherington, L., Cabero, A., & Martens, M. P. (2006). System for observing family therapy alliances: A tool for research and practice. Journal of Counseling Psychology, 53(2), 214–225. https://doi.org/10.1037/0022-0167.53.2.214
Friedlander, M. L., Lambert, J. E., & de la Pena, C. M. (2008). A step toward disentangling the alliance/improvement cycle in family therapy. Journal of Counseling Psychology, 55(1), 118–124. https://doi.org/10.1037/0022-0167.55.1.118
Friedlander, M. L., Lee, H., Shaffer, K. S., & Cabrera, P. (2014). Negotiating therapeutic alliances with a family at impasse. Psychotherapy, 51(1), 41–52. https://doi.org/10.1037/a0032524
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. https://doi.org/10.1037/pst0000161
Glebova, T., Bartle-Haring, S., Gangamma, R., Knerr, M., Delaney, R. O., Meyer, K., McDowell, T., Adkins, K., & Grafsky, E. (2011). Therapeutic alliance and progress in couple therapy: Multiple perspectives. Journal of Family Therapy, 33(1), 42–65. https://doi.org/10.1111/j.1467-6427.2010.00503.x
Graff, F. S., Morgan, T. J., Epstein, E. E., McCrady, B. S., Cook, S. M., Jensen, N. K., & Kelly, S. (2009). Engagement and retention in outpatient alcoholism treatment for women. The American Journal on Addictions, 18(4), 277–288. https://doi.org/10.1080/10550490902925540
Hamilton, S., Moore, A. M., Crane, D. R., & Payne, S. H. (2011). Psychotherapy dropouts: Differences by modality, license, and DSM-IV diagnosis. Journal of Marital and Family Therapy, 37(3), 333–343. https://doi.org/10.1111/j.1752-0606.2010.00204.x
Harris, R., Savage, S., Jones, T., & Brooke, W. (1988). A comparison of treatments for abusive men and their partners within a family-service agency. Canadian Journal of Community Mental Health, 7(2), 147–155.
Heyman, R. E., Brown, P. D., Feldbau-Kohn, S., & O’Leary, K. D. (1999). Couples’ communication behaviors as predictors of dropout and treatment response in wife abuse treatment programs. Behavior Therapy, 30(2), 165–189. https://doi.org/10.1016/S0005-7894(99)80002-1
Horvath, A. O. (2001). The alliance. Psychotherapy: Theory, Research, Practice, Training, 38(4), 365–372. https://doi.org/10.1037/0033-3204.38.4.365
Janeiro, L., Ribeiro, E., Faísca, L., & Lopez Miguel, M. J. (2018). Therapeutic alliance dimensions and dropout in a therapeutic community: “Bond with me and I will stay.” Therapeutic Communities, 39(2), 73–82. https://doi.org/10.1108/TC-12-2017-0036
Jurek, J., Janusz, B., Chwal, M., & de Barbaro, B. (2014). Premature termination in couple therapy as a part of therapeutic process. Cross case analysis. Archives of Psychiatry and Psychotherapy, 16(2), 51–59. https://doi.org/10.12740/APP/26962
Lambert, M. J. (1992). Implications of outcome research for psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94–129). Basic Books.
Lampropoulos, G. K. (2010). Type of counseling termination and trainee therapist-client agreement about change. Counseling Psychology Quarterly, 23, 111–120. https://doi.org/10.1080/09515071003721552
Masi, M. V., Miller, R. B., & Olson, M. M. (2003). Differences in dropout rate among individual, couple and family therapy clients. Contemporary Family Therapy, 25, 63–75. https://doi.org/10.1023/A:1022558021512
McCrady, B. S., Epstein, E. E., & Hirsch, L. S. (1996). Issues in the implementation of a randomized clinical trial that includes alcoholics anonymous: Studying AA-related behaviors during treatment. Journal of Studies on Alcohol, 57(6), 604–612. https://doi.org/10.15288/jsa.1996.57.604
Muniz de la Peña, C., Friedlander, M., & Escudero, V. (2009). Frequency, severity, and evolution of split family alliances: How observable are they? Psychotherapy Research, 19(2), 133–142. https://doi.org/10.1080/10503300802460050
Ogrodniczuk, J. S., Joyce, A. S., & Piper, W. E. (2005). Strategies for reducing patient-initiated premature termination of psychotherapy. Harvard Review of Psychiatry, 13, 57–70. https://doi.org/10.1080/10673220590956429
Pekarik, G. (1992). Posttreatment adjustment of clients who drop out early vs. late in treatment. Journal of Clinical Psychology, 48, 379–387. https://doi.org/10.1002/1097-4679(199205)48:3%3c379::AID-JCLP2270480317%3e3.0.CO;2-P
Pinsof, W. M., Zinbarg, R., & Knobloch-Fedders, L. (2008). Factorial and construct validity of the revised short form integrative psychotherapy alliance scales for family, couple, and individual therapy. Family Process, 47(3), 281–301. https://doi.org/10.1111/j.1545-5300.2008.00254.x
Roddy, M. K., Walsh, L. M., Rothman, K., Hatch, S. G., & Doss, B. D. (2020). Meta-analysis of couple therapy: Effects across outcomes, designs, timeframes, and other moderators. Journal of Consulting and Clinical Psychology, 88(7), 583–596. https://doi.org/10.1037/ccp0000514
Sheehan, A. H., & Friedlander, M. L. (2015). Therapeutic alliance and retention in brief strategic family therapy: A mixed methods study. Journal of Marital and Family Therapy, 41(4), 415–427. https://doi.org/10.1111/jmft.12113
Shnaider, P., Pukay-Martin, N., Sharma, S., Jenzer, T., Fredman, S. J., Macdonald, A., & Monson, C. M. (2015). A preliminary examination of the effects of pretreatment relationship satisfaction on treatment outcomes in cognitive-behavioral conjoint therapy for PTSD. Couple and Family Psychology: Research and Practice, 4(4), 229–238. https://doi.org/10.1037/cfp0000050
Swift, J. K., & Greenberg, R. P. (2015). Premature termination in psychotherapy: Strategies for engaging clients and improving outcomes. American Psychological Association. https://doi.org/10.1037/14469-000
Talbot, C., Ostiguy-Pion, R., Painchaud, E., Lafrance, C., & Descôteaux, J. (2019). Detecting alliance ruptures: The effects of the therapist’s experience, attachment, empathy and countertransference management skills. Research in Psychotherapy, 22, 325. https://doi.org/10.4081/ripppo.2019.325
Thalmayer, A. G. (2018). Personality and mental health treatment: Traits as predictors of presentation, usage, and outcome. Psychological Assessment, 30(7), 967–977. https://doi.org/10.1037/pas0000551
Tschuschke, V., Koemeda-Lutz, M., von Wyl, A., Crameri, A., & Schulthess, P. (2022). The impact of clients’ and therapists’ characteristics on therapeutic alliance and outcome. Journal of Contemporary Psychotherapy: On the Cutting Edge of Modern Developments in Psychotherapy, 52(2), 145–154. https://doi.org/10.1007/s10879-021-09527-2
Yoo, H., Bartle-Haring, S., & Gangamma, R. (2016). Predicting premature termination with alliance at sessions 1 and 3: An exploratory study. Journal of Family Therapy, 38(1), 5–17. https://doi.org/10.1111/1467-6427.12031
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Esplin, S.C., Anderson, S.R., Bean, R.A. et al. Behavioral Indicators of the Therapeutic Alliance in Relation to Discontinuation in Couple Therapy. Contemp Fam Ther 46, 139–150 (2024). https://doi.org/10.1007/s10591-023-09685-6
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DOI: https://doi.org/10.1007/s10591-023-09685-6