Heterosexual couples' initial role and outcome expectations as predictors of the therapeutic alliance and relationship satisfaction prior to the fourth session.

We sampled routinely collected measures of role and outcome expectations, the expanded therapeutic alliance, and relationship satisfaction completed by 253 heterosexual couples seen by 35 therapists in the Marriage and Family Research Practice Network (Johnson et al., 2017) and investigated these variables as interdependent dyadic processes using the latent congruence model (Cheung, 2009) and the mediated actor-partner interdependence model (Ledermann et al., 2011). Taken together, we found a direct association between a couple's mean role and outcome expectation scores at Session 1 and individual partners' alliance perceptions at Session 3. Further, men rated the alliance more favorably when their outcome expectations were higher and the partners' outcome expectations were less discrepant. In terms of role expectations, both men and women began therapy expecting to be more actively engaged in the process than their partner. Whereas women rated the alliance more favorably when they had high role expectations for their partner as well as themselves, men rated the alliance more favorably when they had high expectations for their female partner's engagement in the therapy. Notably, alliance at Session 3 did not mediate the association between initial expectations and Session 4 relationship satisfaction due to a strong association (r = 0.85) between relationship satisfaction rated prior to Sessions 1 and 4. In other words, although the best predictor of relationship status before the fourth session was how the relationship was perceived before couple therapy began, men's and women's initial role and outcome expectations were important contributors to the early alliance. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Family therapy for maltreated youth: Can a strengthening therapeutic alliance empower change?

We tested the process of change in Alliance Empowerment Family Therapy (AEFT; Escudero, 2013), a systemic, team-based approach for treating child welfare involved families. Since building and balancing strong personal and within-family therapeutic alliances are crucial for motivating and sustaining change in these multistressed, overburdened families, we assessed alliance perceptions over time in relation to two indices of therapy outcome, youth functioning, and family-specific goal attainment. Specifically, we administered the self-report version of the System for Observing Family Therapy Alliances (Friedlander et al., 2006) following Sessions 3, 6, and 9 to 156 Spanish families seen by 20 therapists in six agencies whose mission is to serve child welfare referred maltreated youth. Results showed that AEFT delivered in M = 11.04 sessions (SD = 3.29) was effective in attaining family-specific goals and improving child functioning, d = 1.16, as rated by the therapist team in coordination with the referring caseworker. A unique aspect of the study was the modeling, at each time point, of the shared therapeutic system alliance, a latent variable consisting of the therapist's rating of the alliance as well as the alliance ratings of the youth and primary caregiver. As we hypothesized, shared alliance perceptions strengthened with time and positively predicted posttreatment outcomes. Moreover, a comparison of linear growth models with and without the therapist's perspective showed that inclusion of the therapist ratings in the shared alliance variables improved the predictability of child and family outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Illustrating systemic change in family therapy: How therapists' and clients' alliance perceptions codevelop over time.

Research showing that caregivers', adolescents' and therapists' perceptions of the therapeutic alliance become more similar over time has not examined conceptual models, like emotional contagion and interdependence, that are theorized to account for this convergence. Objective: We modeled codevelopment in systemic family therapy to examine mutual influence and shared environment processes among the alliance perceptions of youth, caregivers, and therapists. Method: The self-report version of the System for Observing Family Therapy Alliances (SOFTA-s) was administered after sessions 3, 6 and 9-156 Spanish maltreating families and 20 therapists. Results: Using a triadic version of the repeated measures actor-partner interdependence analysis, a random intercepts cross-lagged panel model, we found significant effects of the shared environment and mutual influence in caregivers' and therapists' alliance scores over time, reflecting emotional contagion. Additionally, (i) therapists' alliance scores at session 6 significantly predicted youth alliance scores at session 9, and (ii) therapist alliance at session 6 significantly mediated the relationship between caregiver alliance at session 3 and youth alliance at session 9, suggesting that therapists bridge the caregiver's and youth's perceptions of the alliance. In successful (compared to unsuccessful) cases, therapists' alliance perceptions at session 6 positively influenced caregivers' alliance perceptions at session 9. Conclusion: Therapist's perceptions of the alliance can bridge differences in alliance perceptions of caregivers and adolescents resulting in greater similarity in alliance perceptions over time.

Mapping the progress of the process: Codevelopment of the therapeutic alliance with maltreated adolescents.

We used a longitudinal actor-partner interdependence model to examine the codeveloping alliance in alliance empowerment therapy (AET; Escudero, 2013), a manualized team-based approach developed in Spain specifically for child welfare-involved youth. In this first evaluation of AET, we sampled 102 adolescents, 83% of whom had been removed from their homes due to abuse or neglect, and 40% of whom were in crisis at the time of referral. Before each session, clients rated their improvement-so-far; after each session, both clients and therapists completed a brief alliance measure, an adaptation of the System for Observing Family Therapy Alliances (SOFTA-s; Friedlander et al., 2006) for individual therapy. In terms of outcome, clients' improvement ratings were significantly associated with posttreatment changes in overall functioning and personal goal attainment. With respect to the change process, growth was observed in both clients' and therapists' ratings of the alliance over 12 sessions, and an increased similarity in alliance ratings was due to more rapid growth in the therapists' ratings than the clients' ratings. Dynamic structural equation modeling indicated that at higher levels of adolescent goal attainment, a stronger association was observed between increased therapist-rated alliance and goal attainment. In other words, in the most effective cases, therapists were more responsive to how the adolescents seemed to have experienced the alliance in the previous session. The cocreated alliance perceptions were due to therapist (rather than client) responsiveness, as well as to unspecified aspects of sharing a therapy environment over time, such as familiarity with the process, regular meetings, and so on. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Couple and family therapists' experiences with Telehealth during the COVID-19 pandemic: a phenomenological analysis.

In designing this study, we aimed to obtain a rich, phenomenological understanding of the experiences of couple and family therapists who transitioned their practice to telehealth due to the COVID-19 pandemic. Twelve experienced therapists from the U.S., Spain and Australia were interviewed in depth about their experiences of this transition, particularly how they developed and maintained therapeutic alliances in a virtual context with couples and families suffering pandemic-related hardships. The qualitative analysis identified 40 themes reflecting participants' initial impressions of telehealth and their positive and negative reactions and adjustments to practicing remotely. Upon overcoming some initial wariness about providing services virtually, many participants described advantages to this way of working with families. Indeed, participants were creative in adjusting to this novel therapy modality, finding new ways to connect emotionally with their clients, to work meaningfully with children, to assess in-session dynamics, and to ensure their clients' privacy and safety. Notably, several participants commented on the relatively slower development of alliances with new cases and the challenge of repairing split alliances between family members. Many of these difficulties were described as due to having minimal access to their clients' raw emotions and the inability to use typical systemic interventions, such as moving family members around physically. Participants also reflected on being a "participant observer" to the upheaval caused by the pandemic, a distressing experience they shared with the families in their care.

How Effective is Online Couple Relationship Education? A Systematic Meta-Content Review.

Due to logistical and financial barriers that keep many distressed couples from seeking psychotherapy, online relationship education is a more accessible alternative. In the decade since a web-based program showed equivalent effectiveness to traditional marriage education (Duncan et al., 2009), several fully online programs have been developed and evaluated. We reviewed nine studies of four different programs that sampled 2,000 + couples. Specifically, we rated each study's experimental rigor and compared research designs, theoretical and empirical grounding, average post-intervention and follow-up effect sizes, and differential effectiveness. Across studies, measured outcomes included relational (improved satisfaction, quality, confidence, commitment, communication; reduced conflict and aggression) and individual functioning on various indices of mental and physical health, emotional expression, and quality of life. Finally, we discuss the strengths and limitations of the research evidence, describe the two most evidence-based programs (ePREP and OurRelationship) in some detail and make recommendations for future study of these promising kinds of interventions.

Toward a broader understanding of split alliances in family therapy: Adding the therapist to the mix.

To broaden our understanding of a split alliance in family therapy, we investigated the frequencies and correlates of sessions in which therapists, youth, and caregivers reported markedly different perceptions of the alliance. The sample consisted of 156 Spanish families who received Alliance Empowerment Family Therapy (Escudero, Adolescentes y familias en conflicto, 2013) for child maltreatment. Family members and therapists rated the alliance on the SOFTA-s (Friedlander et al., Journal of Counseling Psychology, 2006, 53, 214) after sessions 3, 6, and 9; family members rated their perceptions of treatment progress before sessions 4, 7, and 10. A cluster analysis differentiated sessions with a split adult-youth alliance (27.7%) from a split family-therapist alliance (44.1%), and a balanced alliance (similar ratings across the three perspectives; 28.2%). Client-rated treatment progress was differentially associated with the type of alliance split and the average alliance rating, whereas better posttreatment outcomes (child functioning and family goal attainment) were associated with fewer sessions having either type of split alliance.

Con el fin de ampliar nuestros conocimientos de una alianza dividida en la terapia familiar, investigamos las frecuencias y las correlaciones de las sesiones en las cuales los terapeutas, los jóvenes y los cuidadores informaron percepciones marcadamente diferentes de la alianza. La muestra estuvo formada por 156 familias españolas que recibieron terapia familiar de empoderamiento y alianza (Escudero, 2013) para el maltrato infantil. Los miembros de la familia y los terapeutas calificaron la alianza en el SOATIF-s (Friedlander et al., 2006) después de las sesiones 3, 6 y 9; los familiares calificaron sus percepciones del avance del tratamiento antes de las sesiones 4, 7 y 10. Un análisis de agrupamiento diferenció las sesiones con una alianza dividida entre los adultos y los jóvenes (27.7 %) de una alianza dividida entre la familia y el terapeuta (44.1 %) y una alianza equilibrada (calificaciones similares entre las tres perspectivas; 28.2 %). El avance del tratamiento calificado por el paciente estuvo asociado diferencialmente con el tipo de alianza dividida y la calificación promedio de la alianza, mientras que los mejores resultados posteriores al tratamiento (el funcionamiento del niño y el logro de objetivos familiares) estuvieron asociados con menos sesiones que tenían cualquiera de los tipos de alianza dividida.

A close look at therapist contributions to narrative-emotion shifting in a case illustration of brief dynamic therapy.

Objective: In a secondary analysis of Friedlander et al.'s [(2018). "If those tears could talk, what would they say?" multi-method analysis of a corrective experience in brief dynamic therapy. Psychotherapy Research, 28, 217-234. doi:10.1080/10503307.2016.1184350] case study of Hanna Levenson's Brief Dynamic Therapy over Time (from APA's Psychotherapy in Six Sessions DVD series), we re-visited the Narrative-Emotion Process Coding (Angus, L. E., Boritz, T., Bryntwick, E., Carpenter, N., Macaulay, C., & Khattra, J. (2017). The Narrative-Emotion Process Coding System 2.0: A multi-methodological approach to identifying and assessing narrative-emotion process markers in psychotherapy. Psychotherapy Research, 27, 253-269. doi:10.1080/10503307.2016.1238525) to identify specific therapist behaviors that may have facilitated the client's movement from expressing mostly Problem markers in early sessions to expressing considerably more Transition and Change markers in later sessions. Method: Using open coding and constant comparison qualitative methods, we identified Levenson's behaviors immediately preceding the client's "change shifts" (Problem → Transition/Change and Transition → Change) and "problem shifts" (Transition/Change → Problem). Results: Compared to problem shifts, change shifts were preceded by more therapist behavior reflecting Attaching New Meaning (e.g., linking the client's self-deprecation to her avoidant behavior) and Exploring/Expanding emotions (e.g., inviting the client to give voice to her tears), cognitions (e.g., pointing out the client's self-talk) and motivation (e.g., reflecting on the client's dissatisfaction with her defenses). Conclusions: In this successful case, facilitative therapist behavior reflected common therapeutic responses (e.g., validating the client's perspective) as well as responses characteristic of brief dynamic therapy (e.g., interpreting the client's defenses) and the therapist's personal style (e.g., repeating the client's words for emphasis).

Introducing the Expectations and Preference Scales for Couple Therapy (EPSCT): Development, Psychometric Evaluation, and Suggested Use in Practice and Research.

While it is known that client factors account for the largest proportion of outcome variance across treatment modalities, little is known about how clients' characteristics affect the process and effectiveness of couple therapy. To further knowledge in this area, we created a brief, practice-friendly measure, the Expectation and Preference Scales for Couple Therapy (EPSCT). Three self-report scales assess clients' Outcome expectations (e.g., I expect our relationship to improve as a result of couple therapy) and role expectations for Self (e.g., I expect to listen to my partner's concerns) and Partner (e.g., I expect my partner to blame me). Three Cognitive-Behavioral, Emotionally Focused, and Family Systems preference scales use a forced-choice format to measure the comparative strength of respondents' preferences for interventions broadly reflective of each approach. A large item pool was developed from relevant literature and clinical experience and refined based on face and content analyses with two panels of experienced couple therapists and researchers. Across four studies with 1,175 participants, the scales' internal consistency reliabilities were similar and their construct validity was supported with confirmatory factor analyses and significant correlations with several established measures, including expectation measures developed for individual psychotherapy and measures of attitudes toward professional help seeking and valuing personal growth. Across all studies, participants had stronger role expectations for themselves than their partners, although gender effects differed by sample. We discuss how to use the 15-item EPSCT in clinical practice and in future research as a predictor of couple therapy processes and outcomes.

Aunque se sabe que los factores de los clientes representan la mayor parte de la variación en los resultados a través de las modalidades de tratamiento diversas, no se sabe mucho acerca de cómo las características de los clientes afectan el proceso y efectividad de la terapia de pareja. Para avanzar el conocimiento en este campo, hemos creado una breve medida favorable a la práctica, las Escalas de expectativas y preferencias para terapia de pareja (EPSCT en inglés). Tres escalas de autoinforme evalúan las expectativas de resultados de los clientes (p.ej. Espero que nuestra relación mejore como resultado de la terapia de pareja) y las expectativas de roles para sí mismo (p.ej. Espero escuchar las preocupaciones de mi pareja) y para la pareja (p.ej. Espero que mi pareja me culpe). Tres escalas de preferencias cognitivo-conductiva, enfocada en emociones y de sistemas familiares emplean un formato de elección forzada para medir la fortaleza comparativa de las preferencias de los interrogados por intervenciones que reflejan cada enfoque a grandes rasgos. Se elaboró un conjunto amplio de ítems a partir de la literatura y experiencia clínica pertinentes y se refinó a base de análisis de apariencia y contenido con dos paneles de terapistas de pareja e investigadores experimentados. En la totalidad de cuatro estudios con 1175 participantes, las fiabilidades de coherencias internas fueron similares y su validez de constructo fue respaldada por análisis factoriales confirmatorios y correlaciones significativas con varias medidas ya establecidas, incluyendo medidas de expectativas desarrolladas para psicoterapias individuales y medidas de actitudes hacia la búsqueda de ayuda profesional y la valoración del crecimiento personal. En todos los estudios, los participantes mostraron expectativas de roles más fuertes para sí mismos que para sus parejas, aunque hubo diferencias en los efectos de género por muestra. Discutimos cómo usar el EPSCT con sus 15 ítems en la práctica clínica e investigaciones futuras como predictor de procesos y resultados de la terapia de pareja.

Toward a nuanced understanding of nondisclosure in psychotherapy supervision.

Previous research indicates that trainees often withhold important information related to their clients' progress and their reactions to supervision. Moreover, factors associated with the occurrence of supervisee nondisclosure (SND) are not well established. As one of the few studies to compare clinically related with supervision-related nondisclosure, we tested the relation of these two dimensions of the construct, as measured by Siembor and Ellis's (2012) Supervisee Nondisclosure Scales, to three important process variables: perceptions of (a) the supervisory alliance, as measured by Bahrick's (1989) Working Alliance Inventory-Trainee; (b) collaborative supervision, as measured by Rousmaniere and Ellis's (2013) Collaborative Supervision Behavior Scale; and (c) explicitly relational supervisor behaviors, as measured by Shaffer and Friedlander's (2017) Relational Behavior Scale. Participants were 257 North American trainees, predominately White female doctoral students receiving supervision in a practicum or internship setting. As hypothesized, the three process variables inversely contributed to the multivariate composite of SND, jointly accounting for roughly one quarter of the variability; alliance and relational behavior were uniquely significant contributors (24.5% and 7%, respectively). Follow-up analyses indicated that only alliance perceptions contributed unique variance (23%) to supervision-related nondisclosures, which were endorsed much more frequently than clinically related nondisclosures in this sample. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Medically Unexplained Physical Symptoms: What They Are and Why Counseling Psychologists Should Care about Them.

Medically unexplained symptoms and syndromes (MUS) affect the health of 20%-30% of patients seen in primary care. Optimally, treatment for these patients requires an interdisciplinary team consisting of both primary care and mental health providers. By developing an expertise in MUS, counseling psychologists can improve the care of patients with MUS who are already in their practice, expand the number of patients they help, and enhance the integration of counseling psychology into the broader medical community. Additionally, counseling psychologists' expertise in culture, attunement to therapeutic processes, and our focus on prioritizing patients' perspectives and quality of life can fill the gap in research on MUS and bringing increased attention to counseling psychologists' unique contributions to health service delivery.

Meta-analysis of the alliance-outcome relation in couple and family therapy.

This article reviews meta-analytic evidence for the alliance-outcome relation in couple and family therapy (CFT), with implications for clinical practice. We begin by describing the unique features of CFT alliances and their measurement, followed by two case descriptions. We explain that due to the systemic context of CFT, each patient's personal alliance with the therapist affects and is affected by other family members' levels of collaboration. Because family members often seek help when they are in conflict with one another, "split" alliances are common, as are problematic within-system alliances, defined as the degree to which family members agree on the nature of their problems and value participating in therapy together to achieve shared goals. In our meta-analysis of 48 studies with 40 independent samples, we used a three-level random effects model (Ns = 2,568 families, 1,545 couples, and 491 effect sizes) and found r = .297. In another analysis with seven independent samples and 31 effect sizes, the split alliance-outcome association was also significant, r = .316, indicating that the more split or unbalanced the alliance, the poorer the outcome. Moderator analyses showed that alliance-outcome associations did not differ for couple versus family therapy, but correlations were significantly stronger in samples with younger problem children, older adults, proportionally more male youth and adults, and when the families voluntarily sought help (as compared with involuntary or mandated families). The article concludes with research-informed strategies for building and sustaining strong systemic alliances in CFT. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Illustrating novel techniques for analyzing single-case experiments: Effects of pre-session mindfulness practice.

In this article we describe and illustrate various visual and nonparametric techniques that can be used to evaluate the effectiveness of interventions in single-case experiments. Using an alternating treatments design across 2 cases, we tested whether practicing mindfulness would help a novice therapist stay focused and respond to a client more empathically and genuinely. Specifically, after taking a brief workshop on mindfulness, one male and one female doctoral trainee were asked, immediately before beginning each of 10 sessions, either to engage in a guided mindfulness practice for three minutes or a control activity of their choice. Five experimental and 5 control sessions were randomly scheduled for each therapist. The clients were unaware of the purpose of the study and the nature of the experimental manipulation. After each session, we administered measures of client-rated empathy, client- and therapist-rated real relationship, and therapist-rated level of hindering self-awareness. The graphed data were examined separately for each measure. Results showed that the client in Dyad 1 perceived the therapist as more empathic following mindfulness sessions, and the therapist reported less hindering self-awareness and rated the real relationship more favorably, with moderate to strong experimental effects. By contrast, Dyad 2 showed moderate to strong experimental effects for mindfulness practice on ratings of the real relationship, but not on empathy or hindering self-awareness. A cross-case comparison illustrates how replicated single-case experimental research with self-report data can advance our understanding of individual differences in response to psychotherapeutic interventions. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

"If those tears could talk, what would they say?" Multi-method analysis of a corrective experience in brief dynamic therapy.

We analyzed master theorist/therapist Hanna Levenson's six-session work with "Ann" in American Psychological Association's Theories of Psychotherapy video series to determine if and how this client had a corrective experience in Brief Dynamic Therapy. First, we identified indicators of a corrective experience in the therapist's and client's own words. Complementing this analysis, we used observational coding to identify, moment by moment, narrative-emotion markers of shifts in Ann's "same old story"; the frequency, type, and depth of immediacy; and the client's and therapist's behavioral contributions to the working alliance. Additionally, we qualitatively analyzed Levenson's session-by-session accounts of the therapy from two sources. Convergent evidence from these multi-method analyses suggested how the intertwined relational and technical change processes seemed to bring about this client's corrective experience. Through consistent attention to the alliance and increasingly deep immediacy, Levenson created a safe space for Ann to "bring down the wall"-by allowing herself to cry and be deeply understood and cared for in a way that she had never before experienced. Concurrently, Ann began seeing herself quite differently, signified by self-identity narrative change. Then, following Session 4, she took Levenson's suggestion to risk behaving more authentically with a friend and with her romantic partner.

What do "interpersonally sensitive" supervisors do and how do supervisees experience a relational approach to supervision?

OBJECTIVE: In two investigations, we identified explicitly relational supervision strategies and examined whether use of these strategies was associated with perceptions of the supervisory alliance and evaluations of the supervisor. METHOD: First, ratings by nine supervision researchers identified five clearly relational in-session strategies (focus on countertransference, exploration of feelings, attend to parallel process, focus on the therapeutic process, focus on the supervisory alliance) in the Critical Events model of supervision. Based on these expert ratings, we created and assessed the Relational Behavior Scale (RBS). RESULTS: Analyses with two samples of supervisees at all levels of training supported the measure's reliability and factorial validity. The RBS's validity was further indicated by its unique association with the "interpersonally sensitive" style of supervision. In both studies, supervisees perceived more frequent use of relational behavior on the part of psychoanalytic/psychodynamic/humanistic supervisors than cognitive-behavioral supervisors. Moreover, as hypothesized, supervisors' use of relational behavior in a specific session mediated the association between trainees' alliance perceptions and evaluations of their supervisors in that session. CONCLUSION: The identification of specific in-session supervision behaviors that explain one way in which a strong alliance contributes to trainees' positive experiences of their supervisors has implications for supervision theory, research, and practice.

Therapeutic Alliance and Retention in Brief Strategic Family Therapy: A Mixed-Methods Study.

We explored how the therapeutic alliance contributed to retention in Brief Strategic Family Therapy by analyzing videotapes of eight-first sessions in which four therapists worked with one family that stayed in treatment and one family that dropped out. Although behavioral exchange patterns between clients and therapists did not differ by retention status, positive therapist alliance-related behavior followed negative client alliance behavior somewhat more frequently in the retained cases. In the qualitative aspect of the study, four family therapy experts each viewed two randomly assigned sessions and commented on their quality without knowing the families' retention status. A qualitative analysis of the audiotaped commentaries revealed 18 alliance-related themes that were more characteristic of either the retained or the nonretained cases.

Use of relational strategies to repair alliance ruptures: How responsive supervisors train responsive psychotherapists.

Inasmuch as therapist responsiveness is the crucial ingredient in psychotherapy success, teaching supervisees to be optimally responsive to their clients is the primary function of supervision. Responsive supervision is particularly critical when a trainee experiences a faltering or problematic working alliance with a client. In this article, I describe and illustrate how supervisors can work responsively, both explicitly (through instruction) and implicitly (through modeling) when their supervisees report a serious alliance rupture. Next, I illustrate, with the same case example, how quickly ruptures in the therapeutic alliance can lead to ruptures in the supervisory alliance when the supervisor is not sufficiently responsive to the trainee's needs and, instead, relies exclusively on case management. Throughout the article, I discuss how the construct of responsiveness fits within the substantial body of theory and research on relational processes in supervision.

25 years of systemic therapies research: progress and promise.

OBJECTIVE: In this article we describe and assess the state of the science on systemic psychotherapies. In the quarter century since the first issue of Psychotherapy Research was published, considerable progress has been made. There is an increasingly solid evidence base for systemic treatments, which includes a wide range of approaches to working conjointly with couples and families. Moreover, there are exciting new developments that hold promise for explicating the dynamic processes of therapeutic change in couple and family systems. METHOD: We begin by explaining how we view "systemic therapies" as different from individual approaches and then summarize what we have learned in the past 25 years about this set of treatments, how we have learned it, and what we have yet to learn. RESULTS AND CONCLUSIONS: We consider current trends in research on outcomes and change process mechanisms, and end with speculations about what lies ahead in the interrelated domains of systemic research and practice.