Abstract
This retrospective observational study aimed to examine the expanded therapeutic alliance in relation to drop out versus retention in systemic family therapy. Forty cases randomly selected from archived records at a university center for family therapy were identified as either dropouts (n = 13) or completers (n = 27). Videotapes of all first sessions were rated using the system for observing family therapy alliances by two trained judges. Identification of the alliance-related behaviors exhibited by clients and therapists in these sessions showed that compared to completed cases, dropout cases had significantly weaker clients’ alliances as well as more severely split alliances. Moreover, the three most critical dimensions of the alliance in relation to termination status were client engagement in the therapeutic process, a felt sense of safety within the therapeutic context, and the family’s shared sense of purpose about the needs, goals and value of therapy (i.e. the within system-alliance). These findings are consistent with other research that established an association between the therapeutic alliance and treatment retention in family therapy. Clinical implications for addressing the alliance threats in the first session are discussed along with specific recommendations for alliance training.
Similar content being viewed by others
References
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
Beck, M., Friedlander, M. L., & Escudero, V. (2006). Three perspectives on clients’ experiences of the therapeutic alliance: A discovery-oriented investigation. Journal of Marital and Family Therapy, 32(3), 355–368. https://doi.org/10.1111/j.1752-0606.2006.tb01612.x
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.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy Theory, Research, and Practice, 16(3), 252–260.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Lawrence Erlbaum Associates.
Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508–519.
Escudero, V., Boogmans, E., Loots, G., & Friedlander, M. (2012). Alliance rupture and repair in conjoint family therapy: An exploratory study. Psychotherapy, 49(1), 26–37. https://doi.org/10.1037/a0026747
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. https://doi.org/10.1111/j.1467-6427.2008.00425.x
Flicker, S. M., Turner, C. W., Waldron, H. B., Brody, J. L., & Ozechowski, T. J. (2008). Ethnic background, therapeutic alliance, and treatment retention in functional family therapy with adolescents who abuse substances. Journal of Family Psychology, 22(1), 167–170. https://doi.org/10.1037/0893-3200.22.1.167
Friedlander, M. L., Bernardi, S., & Lee, H. H. (2010). Better versus worse family therapy sessions as reflected in clients’ alliance-related behavior. Journal of Counseling Psychology, 57, 198–204. https://doi.org/10.1037/a0019088
Friedlander, M. L., Escudero, V., & Heatherington, L. (2006). Therapeutic alliances in couple and family: An empirically informed guide to practice. American Psychological Association.
Friedlander, M. L., Escudero, V., Heatherington, L., & Diamond, G. M. (2011). Alliance in couple and family therapy. Psychotherapy, 48(1), 25–33. https://doi.org/10.1037/a0022060
Friedlander, M. L., Escudero, V., Wellmers-van de Pol, M., & Heatherington, L. (2018). Meta-analysis of the alliance-outcome relation in couple and family therapy. Psychotherapy, 55, 356–371.
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. https://doi.org/10.1037/0033-3204.45.1.75
Garfield, S. L. (1986). Research on client variables in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 213–256). Berlin: Wiley.
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
Hendrix, C. C., Fournier, D. G., & Briggs, K. (2001). Impact of co-therapy teams on client outcomes and therapist training in marriage and family therapy. Contemporary Family Therapy: An International Journal, 23(1), 63–82.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 37–69). Oxford University Press.
Kivlighan, D. M., Jr., & Shaughnessy, P. (2000). Patterns of working alliance development: A typology of client’s working alliance ratings. Journal of Counseling Psychology, 47(3), 362–371.
Knobloch-Fedders, L. M., Pinsof, W. M., & Mann, B. J. (2004). The formation of the therapeutic alliance in couple therapy. Family Process, 43(4), 425–442. https://doi.org/10.1111/j.1545-5300.2004.00032.x
Marchionda, D. M., & Slesnick, N. (2013). Family therapy retention: An observation of first session communication. Journal of Marital and Family Therapy, 39(1), 87–97. https://doi.org/10.1111/j.1752-0606.2011.00279.x
Morris, S. B., & DeShon, R. P. (2002). Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs. Psychological Methods, 7, 105–125.
Muñiz 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
National Institute of Mental Health. (1981). Provisional data on federally funded community mental health centers, 1978–79. Report prepared by the Survey and Reports Branch, Division of Biometry and Epidemiology. U. S. Government Printing Office.
Ogrodniczuk, J. S., Joyce, A. S., & Piper, W. E. (2005). Strategies for reducing patient-initiated premature termination of psychotherapy. Harvard Review of Psychiatry, 13(2), 57–70.
Pestana, M. J., & Gageiro, J. N. (2005). Análise de dados para Ciências Sociais—A complementaridade do SPSS (4aed.). Edições Sílabo.
Pinsof, W. M. (1994). An integrative systems perspective on the therapeutic alliance: Theoretical, clinical and research implications. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance theory, research, and practice (pp. 173–195). Wiley.
Pinsof, W. B., & Catherall, D. R. (1986). The integrative psychotherapy alliance: Family, couple and individual therapy scales. Journal of Marital and Family Therapy, 12, 137–151. https://doi.org/10.1111/j.1752-0606.1986.tb01631.x
Postner, R. S., Guttman, H. A., Sigal, J. J., Epstein, N. B., & Rakoff, V. M. (1971). Process and outcome in conjoint family therapy. Family Process, 10, 451–473.
Quinn, W., Dotson, D., & Jordan, K. (1997). Dimensions of therapeutic alliance and their associations with outcome in family therapy. Psychotherapy Research, 7(4), 429–438. https://doi.org/10.1080/10503309712331332123
Rait, D. S. (2000). The therapeutic alliance in couples and family therapy. Psychotherapy in Practice, 56, 211–224.
Robbins, M. S., Liddle, H. A., Turner, C. W., Dakof, G. A., Alexander, J. F., & Kogan, S. M. (2006). Adolescent and parent therapeutic alliances as predictors of dropout in multidimensional family therapy. Journal of Family Psychology, 20(1), 108–116. https://doi.org/10.1037/0893-3200.20.1.108
Robbins, M. S., Mayorga, C. C., Mitrani, V. B., Szapocznik, J., Turner, C. W., & Alexander, J. F. (2008). Adolescent and parent alliances with therapists in brief strategic therapy with drug-using hispanic adolescents. Journal of Marital and Family Therapy, 34(3), 316–328. https://doi.org/10.1111/j.1752-0606.2008.00075
Robbins, M. S., Turner, C. W., Alexander, J. F., & Perez, G. A. (2003). Alliance and dropout in family therapy for adolescents with behavior problems: Individual and systemic effects. Journal of Family Psychology, 17(4), 534–544. https://doi.org/10.1037/0893-3200.17.4.534
Shields, C. G., Sprenkle, D. H., & Constantine, J. A. (1991). Anatomy of an initial interview: The importance of joining and structuring skills. American Journal of Family Therapy, 19(1), 3–18.
Smerud, P. E., & Rosenfarb, I. S. (2008). The therapeutic alliance and family psychoeducation in the treatment of schizophrenia: An exploratory prospective change process study. Journal of Consulting and Clinical Psychology, 76(3), 505–510. https://doi.org/10.1037/0022-006X.76.3.505
Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy. The overlooked foundation for effective practice. Guilford.
Sotero, L., & Relvas, A. P. (2014). Sistema de Observação da Aliança em Terapia Familiar—versão observacional (SOFTA-o). In A. P. Relvas & S. Major (Eds.), Instrumentos de Avaliação Familiar—Funcionamento e Intervenção (Vol. I, pp. 121–149). Imprensa da Universidade de Coimbra.
Sotero, L., Moura-Ramos, M., Escudero, V., & Relvas, A. P. (2018). When the family is opposed to coming to therapy: A study on outcomes and therapeutic alliance with involuntary and voluntary clients. Couple and Family Psychology: Research and Practice, 7(1), 47–61.
Sotero, L., Relvas, A. P., & Escudero, V. (2011). The therapeutic alliance with involuntary adolescent clients in the context of systemic family therapy. In Gary Diamond (Chair), Adolescents in Family Therapy: The Challenge of Building Therapeutic Alliances. Symposium conducted at the International Meeting of the 42nd Society for Psychotherapy Research (SPR), Bern, Switzerland.
Stiles, W. B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A., Agnew-Davies, R., Rees, A., & Barkham, M. (2004). Patterns of alliance development and the rupture-repair hypothesis: Are productive relationships U-shaped or V-shaped? Journal of Counseling Psychology, 51(1), 81–92.
Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber, J. P., Laurenceau, J., & Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. Journal of Consulting and Clinical Psychology, 74(2), 337–345. https://doi.org/10.1037/0022-006x.74.2.337
Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24(2), 190–195. https://doi.org/10.1037/0735-7028.24.2.190
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, 5–17.
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Sotero, L., Relvas, A.P. Dropout Versus Retention in Family Therapy: How are they Associated with Behavioral Manifestations of the Therapeutic Alliance?. Contemp Fam Ther 43, 320–328 (2021). https://doi.org/10.1007/s10591-021-09613-6
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10591-021-09613-6