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A study of the therapeutic alliance in couple therapy Gruman, Mary 1986

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A STUDY OF THE THERAPEUTIC ALLIANCE IN COUPLE THERAPY By MARY GRUMAN B.A. M c G i l l U n i v e r s i t y , 1968 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department of C o u n s e l l i n g Psychology) We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA J u l y 1986 (c) Mary Gruman, 1986 In presenting t h i s thes i s i n p a r t i a l fu l f i lment of the requirements for an advanced degree at the Unive r s i ty of B r i t i s h Columbia, I agree that the L ib ra ry s h a l l make i t f ree ly ava i l ab l e for reference and study. I further agree that permission for extensive copying of t h i s thes i s for s cho la r ly purposes may be granted by the head of my department or by h i s or her representa t ives . I t i s understood that copying or p u b l i c a t i o n of t h i s thes is for f i n a n c i a l gain s h a l l not be allowed without my wr i t t en permission. Department of K/QurtStiL'KJi Qjk^c/tc/of (/ ^ 7 ^ 7 y The Un ive r s i t y of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 -6 (2 /79 ) i i i ABSTRACT The p r e s e n t study was an e x p l o r a t o r y process-outcome examination of the t h e r a p e u t i c a l l i a n c e i n c o u p l e therapy as measured by a g e n e r i c measurement instrument of the a l l i a n c e . Measures were taken on a sample of e i g h t y - f o u r s u b j e c t s ; f i f t y -s i x s u b j e c t s r e c e i v e d e m o t i o n a l l y - f o c u s e d c o u p l e t h e r a p y and twenty-eight s u b j e c t s r e c e i v e d i n t e r a c t i o n a l / s y s t e m i c couple therapy. Three a s p e c t s of the a l l i a n c e were i n v e s t i g a t e d : (i> the power of the a l l i a n c e i n p r e d i c t i n g outcome i n the two models of c o u p l e t h e r a p y ; (2) the c h a r a c t e r i s t i c s of the a l l i a n c e i n terms of i t s c o n t e n t and i n t e r p e r s o n a l system dimensions; (3) the i n t e r a c t i o n of couple c h a r a c t e r i s t i c s w i t h a l l i a n c e and s t y l e of therapy i n e f f e c t i n g outcome. The c o n t e n t dimension r e f e r s to the (a) t a s k , <b) g o a l , and ( c ) bond components of the a l l i a n c e ; the i n t e r p e r s o n a l system components c o n s i s t of the c l i e n t ' s p e r c e p t i o n s of the a l l i a n c e between the t h e r a p i s t and: (a) the c l i e n t ( s e l f - t h e r a p i s t ) , (b> the c l i e n t ' s p a r t n e r ( o t h e r -t h e r a p i s t ) , and ( c ) the couple ( r e l a t i o n s h i p - t h e r a p i s t ) . R e s u l t s i n d i c a t e d t h a t the o t h e r - t h e r a p i s t component of the a l l i a n c e c o n s i s t e n t l y c o r r e l a t e d w i t h outcome measures i n the two t h e r a p i e s ; t h a t the a l l i a n c e c o r r e l a t e d d i f f e r e n t l y w i t h the three outcome measures, and t h a t i t c o r r e l a t e d d i f f e r e n t l y with the outcome measures f o r the two models of therapy; t h a t the c h a r a c t e r i s t i c s of the a l l i a n c e remained s t a b l e a c r o s s the t h e r a p i e s and over time; t h a t the s t r e n g t h of the a l l i a n c e i n -c r e a s e d over time i n e m o t i o n a l l y - f o c u s e d t h e r a p y . No i n t e r a c t i v e e f f e c t s of a l l i a n c e and couple c h a r a c t e r i s t i c s were d i s c o v e r e d . iv TABLE OF CONTENTS Page ABSTRACT i l l TABLE OF CONTENTS. iv LIST OF TABLES . . v i ACKNOWLEDGEMENTS v i i CHAPTER ONE INTRODUCTION. 1 D e f i n i t i o n of Terms 2 M a r i t a l Therapy 2 A l l i a n c e 2 Process Research 3 Background 3 The Problem. 7 TWO LITERATURE REVIEW..... . 10 The A l l i a n c e 14 Research on the R e l a t i o n s h i p i n I n d i v i d u a l Therapy 21 T h e r a p i s t F a c t o r s . . . . . . 21 C l i e n t F a c t o r s ..... 22 Research on the A l l i a n c e i n I n d i v i d u a l Therapy... 24 The A l l i a n c e i n Family Therapy 30 Summary 41 THREE METHODOLOGY 44 Design of the Study 44 Instruments 45 Process Measure 45 CTAS 45 Couple R e l a t i o n s h i p Measure 48 FACES II . 48 Outcome Measures 50 DAS 50 TC 50 CRS 51 Sample and P o p u l a t i o n 52 Treatment ..... 54 Emot i o n a l 1 y-Focused Therapy 54 I n t e r a c t i o n a l / S y s t e m i c Therapy 55 Hypotheses 58 V FOUR RESULTS 61 D e s c r i p t i o n of the A l l i a n c e 63 C o r r e l a t i o n s of I n i t i a l A l l i a n c e and Faces II with Outcome 66 C o r r e l a t i o n s i n the Combined Therapies Sample 70 C o r r e l a t ions i n the Emotionally-Focused Group 72 C o r r e l a t i o n s i n the I n t e r a c t i o n a l / S y s t e m i c Group 72 Summary of C o r r e l a t i o n s of I n i t i a l A l l i a n c e with Outcome. 72 C o r r e l a t i o n s of Termination A l l i a n c e with Outcome 73 C o r r e l a t i o n s to Examine the Form of the A l l i a n c e 76 F u r t h e r Tests to Examine A l l i a n c e Change 78 High, Medium and Low A l l i a n c e Groups 80 D i f f e r e n c e s on A l l i a n c e Between Couple P a r t n e r s . 86 Analyses on FACES II C a t e g o r i e s 88 FIVE SUMMARY AND DISCUSSION. 91 Summary 91 D i s c u s s i o n 95 L i m i t a t i o n s 99 Recommendations.. 101 REFERENCES 103 APPENDIX 108 v l LIST OF TABLES TABLE Page 1. Means, (Standard D e v i a t i o n s ) and t - t e s t values f o r the Treatment Groups: CTAS. 64 2. Means, (Standard D e v i a t i o n s ) and t - t e s t values f o r the Combined Therapies Sample: I n i t i a l and Termination CTAS 67 3. Means, (Standard D e v i a t i o n s ) and t - t e s t values f o r the Treatment Groups: I n i t i a l and Termination CTAS — . 68 4. Pearson C o r r e l a t i o n C o e f f i c i e n t s f o r the Treatment Groups: I n i t i a l CTAS and FACES II with DAS, CRS, TC 71 5. Pearson C o r r e l a t i o n C o e f f i c i e n t s f o r the Treatment Groups: Termination CTAS and FACES II with DAS, CRS, TC 74 6. Pearson C o r r e l a t i o n C o e f f i c i e n t s and t - t e s t values f o r the Treatment Groups: I n i t i a l CTAS T o t a l with Component P a r t s and Termination CTAS T o t a l with Component P a r t s . . . . 77 7. Pearson C o r r e l a t i o n C o e f f i c i e n t s and t - t e s t values f o r Treatment Groups: I n i t i a l CTAS with Termination CTAS 79 8. Means and Standard D e v i a t i o n s f o r High, Medium, and Low I n i t i a l A l l i a n c e Groups w i t h i n the Combined Therapies and Emotionally-Focused Treatment Groups: I n i t i a l and Termination CTAS ... 81 9. A n a l y s i s of Variance T e s t s : Termination CTAS on High, Medium, and Low I n i t i a l A l l i a n c e Groups 83 10. Means and (Standard D e v i a t i o n s ) : DAS, CRS and TC f o r High, Medium and Low A l l i a n c e Groups i n the Combined Therapies Sample .. . ..... 84 11. A n a l y s i s of Variance T e s t s : DAS, CRS and TC f o r High, Medium and Low I n i t i a l A l l i a n c e Groups i n the Sample.. 85 12. Means, (Standard D e v i a t i o n s ) and t - t e s t values f o r High and Low Combined A l l i a n c e Couples and S i m i l a r and S p l i t A l l i a n c e Couples: I n i t i a l CTAS, DAS, CRS, TC 87 v i i ACKNOWLEDGEMENTS I would l i k e to thank the members of my t h e s i s committee f o r the support and a s s i s t a n c e they have g i v e n me by way of t h e i r e x p e r t i s e * encouragement, and i n t e r e s t i n t h i s r e s e a r c h . My a p p r e c i a t i o n goes e s p e c i a l l y to Dr. Les Greenberg, f o r the pr o v o c a t i v e and p r o d u c t i v e mixture of encouragement and ch a l l e n g e he p r o v i d e d , both as teacher and c h a i r p e r s o n of the committee; to Dr. John A l l a n , f o r h i s e x c e p t i o n a l support throughout, and h i s re a d i n e s s to extend h i s r o l e i n the f i n a l stages of t h i s t h e s i s ; and t o Dr. Harold R a t z l a f f , f o r h i s pragmatic a s s i s t a n c e with data a n a l y s i s . In a d d i t i o n , I would l i k e to thank my f a m i l y f o r t h e i r support and understanding; and p a r t i c u l a r l y my son Jeremy f o r h i s maturity and independence, which has enabled me to pursue t h i s endeavor. CHAPTER ONE INTRODUCTION The f a m i l y has been seen as the f a b r i c of our s o c i e t y , and the m a r i t a l r e l a t i o n s h i p as the warp t h a t holds the weave of the f a m i l y t o g e t h e r . In r e c e n t years, the f a b r i c has rended; i f the r a t e of d i v o r c e c o n t i n u e s at the mld-1970's l e v e l , the p r o b a b i l i t y i s t h a t one marriage i n three w i l l end i n d i v o r c e (McKie, P r e n t i c e & Reed, S t a t i s t i c s Canada, 1983). C o n c u r r e n t l y , the t h e r a p e u t i c community has turned i t s a t t e n t i o n to mending the f a b r i c by d e v e l o p i n g m u l t i p l e m a r i t a l and f a m i l y t h e r a p i e s . The need f o r e f f e c t i v e m a r i t a l therapy i s e v i d e n t . In a d d i t i o n , there has been a resurgence of i n t e r e s t i n r e s e a r c h i n f a m i l y therapy. Wynne (1983), i n a s y n o p s i s of the h i s t o r y of f a m i l y r e s e a r c h and f a m i l y therapy, suggests that the present r e u n i o n of c l i n i c a l and r e s e a r c h i n t e r e s t s s i g n i f i e s a new phase in the growth of the f a m i l y therapy f i e l d . T h i s new phase i n v o l v e s a s y n t h e s i s of concepts and knowledge from both p r a c t i c e and r e s e a r c h . T h i s t h e s i s attempts to c o n t r i b u t e to the development of knowledge i n m a r i t a l therapy In a manner that Is u s e f u l both to p r a c t i c e and advancement of knowledge. The s p e c i f i c problem of i n t e r e s t i n t h i s study i s the r e l a t i o n s h i p between the t h e r a p e u t i c a l l i a n c e , developed between the t h e r a p i s t and the m a r i t a l dyad, and t h e r a p e u t i c outcome i n m a r i t a l therapy. 2 D e f i n i t i o n of Terms M a r i t a l Therapy. T h i s term i s used i n t e r c h a n g e a b l y with m a r i t a l c o u n s e l l i n g , couple c o u n s e l l i n g and couple therapy. Therapy and c o u n s e l l i n g are terms t h a t are used i n t e r c h a n g e a b l y in the l i t e r a t u r e , depending on the o r i e n t a t i o n of the c l i n i c i a n . The c u r r e n t study was conducted i n the Department of C o u n s e l l i n g Psychology a t the U n i v e r s i t y of B r i t i s h Columbia and c a l l e d the Couples C o u n s e l l i n g P r o j e c t . The o p e r a t i o n a l d e f i n i t i o n of t h e r a p y / c o u n s e l 1 i n g i s "treatment... intended to remedy or a l l e v i a t e a d i s o r d e r or u n d e s i r a b l e c o n d i t i o n " (Funk & Wagnalls, 1980, p. 701). T r a d i t i o n a l l y , the term m a r i t a l therapy has covered the domain of intimate r e l a t i o n s h i p c o u n s e l l i n g . However, in r e c e n t years, there has been a p r o l i f e r a t i o n of common law and homosexual r e l a t i o n s h i p s . The c r i t e r i a f o r couples i n t h i s study Included the c o n d i t i o n t h a t the couple had l i v e d together a minimum of e i g h t e e n months, whether married or not. The measurement s c a l e s used r e f e r to the couple, not m a r i t a l , a l l i a n c e , and speak of the " p a r t n e r " , not "spouse". Although couple therapy i s the most accurate term i n the present i n s t a n c e , the terms c o u p l e / m a r i t a l and therapy/ c o u n s e l l i n g are used interchangeably i n t h i s t h e s i s . Al1 lance. The a l l i a n c e r e f e r s to that aspect of the t h e r a p e u t i c r e l a t i o n s h i p between the t h e r a p i s t and the c l i e n t t h a t i s an i m p l i c i t agreement about the process of therapy. Various t h e o r e t i c i a n s and r e s e a r c h e r s have used d i f f e r e n t names f o r the a l l i a n c e : the h e l p i n g a l l i a n c e , the t h e r a p e u t i c a l l i a n c e 3 and the working alliance. Specific references indicate the name used by the researcher or theoretician cited. The generic term "the alliance" is being used in current application of the concept to family therapy process research, and is the umbrella term used in this thesis. This current research utilizes Bordin's (1979, 1980) construct of the working alliance as used in Pinsof and Catherall's (1984) family system-oriented measurement scale. The alliance is fully described in the Literature Review (Chapter II). Process Research. This mode of research is defined as the "study of the interaction between the patient and the therapist systems" (Greenberg & Pinsof, 1986, p. 36), with the goal of identifying the patterns and mechanisms of change, in order to facilitate effective therapy. It examines factors that are interactive rather than discrete. Background Relevant developments in family therapy and research follow below to help identify salient issues in the synthesis of both with the concept of the alliance from individual therapy. Gurman (1981), in developing an integrative approach to marital therapy, points out that brief therapy has been a modality of therapy since Freud, and marital therapy in particular has been of brief duration. Marital therapy originally evolved from psychoanalytically oriented practices of interpersonally oriented psychiatry in the 1930's and 1940's 4 (Gurman, Knlskern & Pinsof, 1986). In the last decade, theoretical orientations other than the psychodynamic one have won many professional adherents, and marital therapy is now viewed as a subtype of family therapy. Interventions at the level of the marital relationship are believed to create change at the individual and family level. Like family therapy, marital therapy is practiced as systemically oriented treatment, emphasizing intimate relationships, with research focusing predominantly on relational, not individual, difficulties. The marital therapies can be generally classified as psychodynamic, behavioral, strategic/systemic and integrative models; these numerous therapies address intrapsychic forces, interactive ones, or a combination of the two. While the theoretical foci in these different models have often been distinct, in practice, therapy has been pragmatic and eclectic. Research examining the outcome of family therapy has grown at an astounding rate (Gurman & Knlskern, 1981), and the evidence is that treatment is "effective beyond chance" (p. 745). However, such research validates rather than instructs. Gurman and Knlskern recommend research "toward discovery rather than verification" (p. 753) and Pinsof (1981) speaks to the need to evaluate and describe the process of family therapy and attempt to relate process to outcome. Gurman (1981) points out that few outcome studies have explicitly defined the actual process and Interventions of different models of family therapy. This lack of clearly defined treatment models is one of the difficulties that confronts 5 researchers interested in studying the process of change in marital therapy. Gurman cites other difficulties as well, first among them being the difficulty of analyzing and isolating the factors that affect interaction and Interpersonal communication. Secondly, there is a lack of adequate "microtherapy" theory, or, as Duncan and Fiske (Gurman, 1981) commented, a lack of "a set of low level constructs that can be tied directly and explicitly to the data" (p. 10). Thirdly, process research has been primarily individually-oriented and has ignored family therapy as a treatment modality and as a theoretical orientation. This is not surprising, in that process research is in its youth, and has been struggling to develop Itself on the firm ground of established research tradition. With the maturation of family therapy on a separate theoretical base, and with the recognition of its usefulness as a vehicle for studying the process of change, the interest of family therapy researchers is increasing in examining factors and processes that contribute to efficacy of treatment. Process and outcome research traditions have begun to converge, searching for links between process, which illuminates the basic mechanisms of therapy, and outcome, that demonstrates efficacy (Greenberg & Pinsof, in press). The major process variable contributing to effective therapeutic outcome in individual therapy appears to be the therapeutic relationship. The relationship has long been recognized as the foundation on which therapy is built. Jerome Frank (1973) hypothesized that the relationship Is a crucial common factor across therapies 6 which allows for the work of therapy. Of course, a relationship is not a static nor a discrete factor, but a process including the client, therapist and technique variables. The concept of the helping alliance has been explicated from the overall concept of the relationship; it has developed over the years into a well-defined construct that is hypothesized to be an essential factor in effective therapy. Hartley and Strupp (1982) cite Bordln, suggesting that the capacity and willingness of the client and therapist to undertake particular therapeutic tasks with each other would be the most Important predictor of therapy outcome. Bordln (1979) calls this aspect of the therapeutic relationship the working alliance. He suggests that it includes three components: the development of bonds and attachments between therapist and client; mutuality of goals; and agreement regarding the tasks of the therapy. Bordin's integrative conceptualization synthesizes what is commonly thought of as discrete relationship and technique factors in therapy, and captures the alliance in low-level constructs, facilitating research into the processes involved in therapeutic change (Greenberg & Pinsof, in press). The alliance is being examined as a generic variable that is nonsectarian and can be used to research common factors across treatment models. Within the last decade, study of the alliance in Individual therapy has led to the development of instruments to measure the strength of the alliance, and the finding that the strength of the alliance has related consistently to outcome (Gurman, Knlskern & Pinsof, In press). The same authors note "(the) 7 tremendous excitement within the psychotherapy research community about the potential of the alliance as: (a) a potent predictor of outcome; and (b> an organising and focal construct for subsequent process research." (Gurman, Kniskern & Pinsof, in press). Currently, there is interest in expanding alliance theory and research into the family therapy field. Application of the dyadic concept of the therapeutic alliance to marital therapy has been suggested by Smith and Grunebaum (1976) and Nadelson (1978). Couple nonalllance with the therapist often parallels the couples' nonalllance between themselves (Martin, 1976). Rutan and Smith (1985) state that a therapeutic alliance must be present In marital therapy if change is to result. They suggest the alliance is more than a bond based on therapeutic empathy; it Is built on therapist empathy, interpretation and confrontation ski l l s , and Involves the couple in the work of therapy. They further encourage "all couples therapists to assess the nature and quality of the alliance between themselves and both members of the couple they are treating" (p. 30). The Problem Research has not been conducted relating the alliance in couple therapy to counselling outcome. As the therapeutic alliance has significant power in predicting outcome in individual therapy, it seemed important to examine the strength of the alliance as a predictor of outcome in couple therapy. Knowledge about the impact of the alliance on the outcome of 8 marital counselling would be helpful and would direct therapist attention to the alliance as a vehicle of change, thereby providing an opportunity to improve therapeutic efficacy in the treatment of marital distress. Outcome studies indicate that no currently used model of marital therapy is more effective than any other (Gurman & Kniskern, 1981). Synthesis of cl inical practice and research on the variables that result in therapeutic change has not yet cohered well. Such synthesis offers potential for increasing knowledge about the process of change that could be cl inical ly useful in determining which interventions would be optimally efficacious in repairing and strengthening marital relationships. The alliance as a generic tool appears to hold promise for predicting therapeutic outcome, as well as identifying factors that illuminate the change process within different models of therapy. This research examined the therapeutic alliance as related to outcome in couple counselling across two models of couple therapy. The two models utilized were an experiential/systemic model developed by Greenberg and Johnson (1983) and an interactional/systemic model specified by Greenberg and Goldman (1985). Both models have been clearly delineated in terms of the actual procedures used in therapy. The question that was Investigated was whether the alliance predicted outcome in couple counselling. Further, the variability of the component parts of the working alliance (bonds, goals, tasks) was examined in relation to the different models of therapy. Finally, the 9 different types of couple configuration as related to outcome were examined, with the intent of exploring interaction between couple characteristics, alliance, and style of therapy. Ultimately, the value of asking and answering questions such as these lies not only in the theoretical accumulation of knowledge, but also in the dist i l lat ion of such knowledge into the cl inical arena in order to facilitate effective therapy for people seeking help. 10 CHAPTER TWO LITERATURE REVIEW As outlined in the introduction, this thesis examines the working alliance in marital counselling. This review briefly delineates the development of family therapy as a field separate from individual therapy, describes the evolution and development of concepts and measurement instruments in the alliance, and relates the examination of the alliance to the present study of couple therapy. Developments in Family Therapy and Research In his review, Wynne (1983) notes that family research in the sociological and social psychological traditions proceeded the development of family therapy theories and techniques. Clinical practice developed in the 1950's fused with research as family therapist/researchers studied schizophrenic processes in families. Wynne describes his own work with the National Institute of Mental Health, combining psychoanalytic and sociological concepts for the primary purpose of research into the social organization of the schizophrenic-involved family. Psychotherapy was the vehicle for keeping families under observation for research purposes; the development of family therapy was an ancillary but important occurrence. Through this and other research/therapy 11 projects headed by Bateson, Jackson, Haley and Weakland, "the families...taught (the therapists) to be more active, structuring and directive'' (Wynne, 1983, p. 114), giving birth to family therapy as a separate genre of therapy based on communication and systems theory that describes events in Interactive rather than intrapsychic terms. In the 1960's a split occurred between research and clinical practice (Wynne, 1983). Research in psychiatry and psychology was becoming more methodological and systematic, while family therapy, ln its surge of creative development, was not prepared to subject itself to traditional methods of measurement that did not recognize the value of what it had to offer. It was as if family therapy, in heady adolescence, rebelled against the authority of both research and individual therapy to find its own identity. With the maturation of family therapy, it is returning home and being accepted, offering new epistomologies and treatment strategies, and showing greater respect for established principles in research. As Jacobson, representing traditional research and treatment orientations, describes i t , "Now that family therapy has become respectable, its practitioners are free to become sober, self-reflective, and skeptical." (Jacobson, 1985, p. 163). At the same time that family therapy has moved from proving its effectiveness to investigating mechanisms of change in systemically oriented treatment, it has also challenged the methods of what Kuhn called "normal science" with its "new 12 epistomologles" based on the Ideas of Gregory Bateson (Gurman, Knlskern & Pinsof, in press). Among the premises which differentiate the "new" circular epistomology from the "old" linear one is the idea that the ecological interdependence of the parts of systemic wholes implies that the "whole" cannot be understood adequately or accurately by analyses which breaks wholes into their component parts, or by analyses of the parts In isolation (Gurman, Knlskern and Pinsof, in press). The systemic approach requires that we examine how these parts are connected, and this Is a commitment to process as well as structure. In fact, although not defined as systemic research, there are numerous ways in which traditional research designs and procedures implicitly acknowledge context, connectedness and inter-dependence. Examples are: (a) the study of the interactive effects of patient, therapist, treatment and setting variables; and (b) the use of multidimensional change measures. (Gurman, Knlskern & Pinsof, in press). The current "reunion" of the new field of family therapy and research that Wynne (1983) speaks of represents a step in the integration of theories of therapy, and the research methodologies used to study therapies. Jacobson (1985), from a behavioral perspective, acknowledges the contributions this new field offers, and joins i t , proposing that cl inical research adapt to the needs of family therapists while maintaining scientific directions, in order to advance knowledge and hone practice. As an example of such adaptation, he suggests the use of statistics which report Information about the variability of 13 outcome Instead of group means, which report only general efficacy, and are not useful to clinicians. In this common goal of finding what works in treatment, and how it works, diverse models of family therapy are laying down the sword of competition and attempting to find empirical research tools that apply across theories and research methodologies, offering new knowledge in therapy and research. Wynne (1983) identifies the value of the current reconnect ion of family research and therapy. For one thing, some of the techniques and goals of family therapy lend themselves to studying the process of change. Studies of family process are essential in order to understand outcome, and thus further refine the efficacy of therapy. Wynne also notes the value of rating scales and related research methods as useful in the assessment of families both init ial ly and at termination of treatment; such research materials, used cl inical ly , could potentially offer Improved therapeutic outcome. To summarize to this point, the current direction in family therapy and research is synthesis of old and new eplstomologies and methodologies in therapy and in research, with a focus on discovery rather than verification. The goal is to reunite therapy and research in order to identify factors that lead to greater efficacy In therapy. Out of this synthesis is arising an interest in process-outcome studies as the research strategy that will hopefully find the links between what occurs in therapy and the results. While l i t t l e work has been done to date on process research 14 In family and marital therapy, there has been an examination of process factors, both In theory and research, in individual therapy. The Alliance The value of the therapeutic relationship has been recognized since Freud first postulated his theories of transference and resistance. Freud conceptualized these elements as the work of therapy, and developed techniques towards a methodology of working through the "neurotic" unconscious elements of transference and resistance towards healthy intrapsychic functioning. Although his primary conceptual emphasis was on transference. Hartley and Strupp (1982) point out that, in his practice, Freud also advocated what we now call empathy and the therapeutic bond: It remains the first aim of treatment to attach (the patient) to (therapy) and to the person of the doctor... It is certainly possible to forfeit this first success if from the start one takes any standpoint other than that of sympathetic understanding, (p. 1) Freud, in 1940, further described the analyst and patient as collaborators against the patient's neurosis in an agreement based on free exploration by the patient, and discretion & competent understanding by the therapist (Hartley & Strupp, 1982). Freud called this the conscious, collaborative, level of the therapeutic relationship. Sterba (1934), working within a 15 psychoanalytic paradigm, wrote of an ego-level Identification with and positive attitudes toward the analyst that led the patient to work toward the accomplishment of the common therapeutic tasks. Horvath & Greenberg (in press) describe this as the construct of the working alliance, later explicated from the concept of transference by Bordln (1976). In essence, the seeds of what Bordln proposed as the generic elements common to the interaction process in a l l therapies are Inherent in Freud's formulation, specific to the theory and methodology of psychoanalysis. Gelso and Carter (1985) say, although the concept of the working alliance stems from psychoanalysis, a l l therapies agree that the working alliance is a prerequisite for effective therapy to take place. Before making the leap from Freud to Bordln, whose ideas of the place of the therapeutic relationship are of current interest, a review of the development of the concept of the therapeutic alliance is in order. Rogers (1957) conceptualized the relationship between client and therapist as providing the "necessary and sufficient" conditions for therapeutic change. Client-centered therapy conceptualized the relationship in terms of therapist-offered factors of empathy, congruence and positive regard. In addition to theoretical propositions about the importance of the relationship as the primary vehicle for change in the therapeutic relationship, Rogers' ideas were significant in that they led to empirical research into the therapeutic relationship. Client-centered research examined therapist factors, or therapist-16 offered conditions, and the patient's role in therapy. These research designs and findings have Important implications for this present inquiry, and will be examined ln detail in the section on research. Object relations theory developed concurrently with later conceptualizations of the alliance. Object relations theory hypothesized that client ego strength and prior relationships, and ability to trust others ln relationships, are prerequistes to the ability to enter Into a therapeutic alliance. Zetzel (1956) conceptualized the therapeutic alliance as a stable, cooperative aspect of the analytic relationship, that was an essential prerequisite for the effectiveness of any therapeutic intervention. Greenson (1967), influenced by Zetzel's work, became the leading proponent of the working alliance and the real relationship, separating theoretically and cl inical ly the cooperative, working aspects of the relationship from the more irrational transferential ones. Greenson stressed the primary importance of the therapeutic alliance as essential to enable the client to work cooperatively with the therapist in the therapeutic process. Mennlnger & Holzman (1973) also spoke of the alliance as a necessary condition for the amelioration of problems, though not curative In itself. While psychodynamic and client-centered therapy proposed the relationship as essential to therapeutic efficacy, other schools of therapy ascribed different value to the therapeutic relationship. Behaviorism proposed that the technique utilized constituted the entire cure, and that the relationship was 17 irrelevant. In the last decade, however, some behavioral theorists have began to examine the effects of interpersonal dynamics between therapists and patients, and are now giving credence to the relationship as a power base for the effective use of behavioral procedures and techniques (Gelso & Carter, 1985). While different schools of therapy looked at the relationship in different ways, and the relationship versus technique debate continued, Jerome Frank (1973) searched for common factors In effective therapy. Since outcome studies of therapeutic efficacy consistently showed that whereas therapy was effective, there was no model of therapy that was more effective than another (Pinsof, 1981), such a search followed logically. Frank (1973) hypothesized that the relationship was a common factor in therapy that fosters expectations of help and facilitates the arousal of emotions, on the basis of which a common understanding of the therapeutic goals and willingness to undertake tasks develops. He said that, on the basis of the relationship, the following factors are formed: a rationale for suffering and its relief; new information about the individual and the world; and experiences that lead to a renewed sense of success, mastery, independence and competence. These common factors apply to Greenson's formulation of the therapeutic relationship. Greenson (1967) proposed the therapeutic relationship has three components: the real relationship, In which there is appropriate and reasonable social interaction; the working alliance, based on rational 18 rapport, dependent on and reflective of the ability of the cllent/therapist dyad to work purposefully together in the treatment situation; and transference. Bordin similarly proposed that in addition to the transferential aspects of the therapeutic relationship, there are three factors that comprise the working alliance. Hartley and Strupp (1982) relate these to factors Greenson outlined. Bordin proposed the development of (a) bonds and attachments between the therapist and the patient, which can be seen as part of Greenson's real relationship; <b> mutuality of goals of therapy; and <c> agreement regarding the responsibilities, or tasks of therapy, and explication of the relationship of these responsibilities to the patient's goals. Goals and tasks f it with Greenson's concept of the working alliance. The working alliance, then, is seen as the reasonable, rational aspects of the relationship as opposed to the transferential elements. Ideally, in the init ial sessions, the bonds, goals and tasks develop together; the therapist conveys how therapy works and establishes the ground rules and boundaries of the treatment contract. Gelso and Carter (1985) point out that the agreement on tasks and goals can be Implicit or explicit. Originally, Bordin (1976) spoke of the alliance as a necessary but not sufficient condition for therapy. Later, he suggested that the differential effectiveness of therapies resides not in the styles of interventions, but in the strength of the working alliance. Therapies differ in terms of the demands they make of the working alliance: the more intensive 19 the therapy in exploring inner experience, the stronger the bond must be; the effectiveness of the therapy tasks depends on the vividness with which the therapist links techniques to the client's sense of the problem and how he wants to change. Bordln said the establishment of a sound alliance was dependent on the patient's capacity to meet the demands of the kind of therapy offered, and spoke of the desirability of optimally matching the client, therapist, and demands of the working alliance within a therapeutic approach (Bordln, 1979). Gelso and Carter (1985), in a review of the present status of the relationship In the three main orientations in individual therapy, that is, analytic, humanistic, and learning theory, say the working alliance "may be the most fundamental (part of the therapeutic relationship) to successful treatment" (p. 193). Hartley and Strupp (1982) suggest we view the relationship and technique not as discrete variables but as interacting processes, or complementary change agents, with the concept of therapeutic alliance capturing this interaction. Gelso and Carter (1985) define the relationship, and the working alliance, in discrete terms, separating the affective and attitudlnal "relationship" from the "techniques" of therapy. They qualify that with the recognition that the way in which therapeutic interventions are used, "the timing of such interventions, and the specific content that f i l l s in the technique are both reflections of and contributors to the ever-developing relationship" (p. 159). Bordln (1980) expanded on his original conceptualization of 20 the working alliance as a vehicle that allows the therapist and client to work collaboratively; he asserted that the treatment Itself rests in the alliance, and that change Is achieved by the building and repair of strong alliances. Differences in models of therapy are embedded in the change goals sought, the tasks assigned, the bonds required, or in combinations of the three. Greenberg and Pinsof <In press) describe Bordin's concept of the working alliance as an "integrative conceptualization in which both the relational bond and the tasks and goals of therapy are conceived as highly related components which combine synergist leally to produce the Therapeutic Alliance". This conceptualization does not dichotomize relationship and technical factors. The relationship is seen as a "general" factor, and the technique as a "specific" factor, different in the various models of therapy; the specific technical factors require a particular relational bond, and must be correctly combined to form a good alliance. This conceptualization combines "general" and "specific" factors "in a single overarching construct that does justice to the complexity of the processes involved in therapeutic change". Such a perspective reflects a systemic, cybernetic view of the alliance, that will be utilized ln this thesis. Like Rogers' conceptualization, Bordin's Integrative conceptualization has been valuable not only ln the concept it offers, but also in that it facilitates research by providing a new framework for examining the relationship between the therapist and the patient. In the last decade, various 21 Instruments have been developed to measure the alliance and study the relationship between the alliance as a process variable and outcome measures of efficacy. Research on the Relationship in Individual Therapy Therapist Factors Rogers' formulation of the "necessary and sufficient" conditions in the therapeutic relationship led to important research into these factors. While init ial observer-rated Investigation of therapist-offered conditions indicated that such factors, particularly empathy, related significantly to outcome, subsequent findings indicated the relationship between therapist factors and therapeutic efficacy was not entirely predictable (Parloff, Waskow & Wolfe, 1978). In addition, there was a problem inherent in therapist-offered conditions studies: they focused on only one variable in the relationship, the therapist. As such, they may identify good therapist relating behavior (Gelso & Carter, 1985), but they do not define the relationship as a two-party interactive process. From a process analysis point of view, defining the therapist as the major variable influencing both the process and outcome of therapy is incomplete (Horvath & Greenberg, in press). Initial attempts to study the core conditions of change in cllent-centered therapy used observer ratings as measures of therapist-offered conditions. Barrett-Lennard*s Relationship Inventory, an instrument developed to estimate the client's 22 perception of the therapist along Rogers' dimensions of empathy, congruence, and positive regard via a questionnaire, represented a different approach methodologically and conceptually. The most powerful of the client perception variables measured by the Relationship Inventory was found to be perceived empathy. Although there are methodological issues concerning the use of self-report (Marmor et. a l , in press) Horvath & Greenberg, In press), empirical studies using participant's perceptions of client-centered dimensions have proven to be more successful in predicting outcome than those that used third party evaluations. Cllent Factors Strupp (1973) postulated three conditions as basic ingredients of therapeutic change, that are common to a l l models of therapy. These conditions are: the creation and maintenance of a helping relationship; the transactions and techniques of therapy to incur therapeutic change, based on the strength of the therapeutic relationship; and the client's capacity to change in the context of the therapeutic relationship. While these conditions can be formulated as discrete, the definitions of these conditions indicates the intertwined nature of these factors in the process of therapy. Research has focused on studying therapist factors; there has been considerably less investigation of client factors. The Mennlnger Foundation's Psychotherapy Research Project (Moras & Strupp, 1982) found that pretherapy Interpersonal relationships assessment had predictive value for outcome in 23 dynamically oriented therapy. Hartley and Strupp (1982) reviewed research growing out of the client-centered tradition that has included some measures of the client's role in therapy; they concluded the results of these preliminary investigations are fragmentary, although indicating that client factors have some power in predicting outcome. Truax and Carkhuff's Depth of Self-exploration Scale indicates that degree of self-exploration has a significant impact on therapy across orientations. The same authors state that concepts Included in Klein's Experiencing Scale are "similar to analytic ideas of insight, lack of resistance, and working through" (p. 9); level of experiencing correlates positively with outcome measures. They refer to a review that concluded that client self-disclosure is positively associated with outcome. They also note Rice and her colleagues' scale measuring voice quality, connotations of language, and internal focus, that has predictive value. Hartley and Strupp (1982) cite Kirtner and Cartwright's finding that the client's perception of the locus of his or her problem was an important determinant of exploration and outcome. Greenberg & Pinsof (in press) suggest client involvement as a generic variable that has potential as a predictor of outcome. Although not fully developed, such a variable includes client participation, optimism, perceived task relevance and responsibility as related to change. 24 Research on the Alliance ln Individual Therapy Outcome studies examining client, therapist and technique variables have found that less than 10% of the variance in therapeutic outcome could be accounted for by the effects of these variables as discrete factors (Hartley & Strupp, 1982). To date, research on the alliance indicates that the alliance appears to be a potent predictor of therapeutic outcome in individual therapy. However, each research group and instrument has conceptualized the alliance differently. One of the many difficulties in evaluating research on the alliance data is the question as to whether the same construct is being measured in different studies (Greenberg & Pinsof, in press). This review of research on the alliance in individual therapy recognizes this difficulty, and notes the implication that a wide range of factors, that perhaps could profitably be extrapolated from the concept of the alliance, may be under examination under the umbrella heading of the alliance. In this thesis, the concept will be studied as Bordin's generic formulation of the working alliance, as developed in a theoretically integrative measurement instrument. The concept of the alliance developed out of the psychoanalytic tradition, and the first attempts to research the alliance came out of that tradition. Horwitz (Hartley & Strupp, 1982) interpreted the results of the Mennlnger Foundation's longitudinal study of psychotherapy to indicate that the strength of the alliance Is the major determinant of successful treatment. The major, focus of research on the alliance has been to 25 study its power as a predictor of outcome, and to examine pre-disposing client factors that contribute to the development of the alliance. Alexander and Luborsky (in press), in operationa-lizing two kinds of helping relationships, found that the existence of an alliance predicted improvement in therapy. An alliance was rated as existing if patients stated explicitly they felt better, therapy was helping them, or they felt understood by the therapist. Improvers developed positive attitudes toward therapy early, and nonlmprovers developed negative attitudes. The Vanderbilt Psychotherapy Process Scale (Suh et. a l , in press), an observer rating scale based on the ideas of Bordln, Greenson, Langs and Luborsky, was developed by Strupp and various associates as a general purpose, theoretically neutral instrument to assess salient aspects of the patient-therapist interaction. Gomez-Schwartz (Suh et. a l , in press), using a revised version of the scale, investigated the relationship between the process of therapy and outcome. She investigated the role of three factors that are postulated as determinants of outcome by different schools of therapy: exploratory processes, the therapist-offered relationship, and patient involvement. These variables relate to Strupp's (1973) formulation of the basic ingredients of therapy. Multiple regression analysis showed that the patient's positive involvement was the only variable that consistently predicted outcome. Strupp and his colleagues believe patient involvement is an indicator of the alliance. Moras and Strupp (1982) studied the relationship between 26 pretherapy assessments of interpersonal relations, patients alliance as measured by rating of patient involvement, and outcome in brief therapy. They hypothesized that clients who had prior "meaningful" relationships would have the ability to form a therapeutic alliance, and concluded that up to 25% of the variance of a client's collaborative participation in therapy, an appreciable portion, could be linked to assessments of interpersonal relations. These findings, they suggest, "are a direct extension of Gomez-Schwartz' finding that a patient's active, positively toned involvement in therapy was more predictive of outcome than therapist technique and relationship factors" <p. 408). However, in the same study, a major portion of the variance-in a client's alliance was not accounted for by inter-personal assessment, lending support to the possibility that other factors, such as therapeutic interventions or the particular client-therapist match play a major role in the development of an alliance, especially for clients who have difficulty in interpersonal relations. Hartley and Strupp (1982) found some evidence that the alliance increased and peaked in the early sessions of high-efficacy brief individual therapy. Their data suggests that the most important phase of therapy for developing a therapeutic alliance and for predicting outcome is the init ial phase. In addition, their data again suggests "the overriding importance of patient characteristics, behaviors and attitudes that appeared to predict outcome" (p 30). 27 Based on their findings and Bordin's emphasis on the importance of "the therapist's and the patient's capacity to undertake the tasks demanded of the treatment approach they have chosen" (p. 33), they speak of the importance of "fit", or matching patient, therapist and therapeutic approach, and advocate further research into the alliance to determine "the nodal points of productive therapeutic change" (p. 33). The Penn Helping All lance Scales (Alexander & Luborsky, in press) were developed to quantify the concept of the helping alliance. Observer ratings of (a) the perceived helpfulness of the therapist and (b) the patient's collaboration or bonding with the therapist, as two measures of the helping alliance, correlated with each other. The authors suggest that further research be directed at examining the therapist and client factors that potentiate the alliance in order to determine the mode of therapy that provides the optimal type of alliance for specific clients, as well as at further evidence of the predictive power of the alliance. Morgan, Luborsky et a l . (1982), utilizing the Penn Helping Alliance Rating Method, found that by the third session of individual therapy, the alliance measure had significant predictive power, accounting for 25% of the variance of outcome measures. They hypothesized that the formation of the helping alliance "may be a result of a patient trait , such as prior requirements and expectations in relationships, combined with the degree to which the therapist fits these requirements and expectations" (p. 400). The same authors note the need to 28 develop helping alliance measurement systems that are simpler and better-understood than the time-consuming Helping Alliance Rating Method, based on third-party ratings, and suggest the self-report questionnaire method. They cite the Barrett-Lennard Relationship Inventory and Orllnsky and Howard's Therapy Session Questionnaire as evidence of the value of such instruments in predicting the outcome of therapy. They suggest future research designs using both an observer-rating method and a self-report method on the same data base in order to compare the validity of both measures. The Therapeutic Alliance Rating System (Marmor et. a l , in press), dealing with the issue of the predictive validity of self-report, utilized a combination of observer rating and self-report measures of the therapeutic alliance. Self-report has not been considered to be as reliable a method as third-party ratings, even though client self-report has shown greater predictive validity. While client self-report is considered to be subjective, it is not biased by theoretical preconceptions. In addition, self-report reveals non-observable affective and cognitive components of the client's experience of the relationship, and offers more information about the interactive process than third party measures of behavior. Marmor and his colleagues note that reliance on self-ratings of both process and outcome carries with it the danger of circularity: a client pleased with therapy may reflect his global satisfaction in his assessment of the results of therapy. To avoid this "redundancy of perspective" <p. 1), the Therapeutic Alliance Rating System used observer ratings and self-reports of 29 therapist and client positive and negative contributions to the alliance, and found significant agreement in a l l three ratings of the clients' positive and negative contributions to the alliance. In addition, clients self-ratings of their positive contributions correlated significantly with their positive ratings of the therapists, indicating that interactive factors influence the rating of self and other in the interpersonal therapeutic relationship. Regardless of which alliance rating system is used, ratings of client positive contributions to the alliance were the best predictors of outcome. Based on Bordln's conceptualizations of the alliance that specify a generic variable based on task, goal and bond components, Horvath & Greenberg (in press) developed the Working Alliance Inventory as a cl inical ly useful tool to assess the strength and dimensions of the alliance in the early stages of the relationship. The Working Alliance Inventory is a self-report instrument that is free of any theoretical orientation. Horvath and Greenberg attempted to examine Interactive components of effective working alliances with therapists of different theoretical orientations, in order to discern the qualitative differences betweeen alliances developed with different theoretical approaches. They found significant correlations between the client's self-reported perception of the alliance and self-reported measures of client change. The task components were most predictive of outcome. Bordin (1980) noted that different measures studied different aspects of the alliance, addressing the strength rather 30 than the type of working alliance, and suggested the need for Investigating the technical aspects of the alliance in various styles of therapy. Pinsof and Catherall's Integrative Psychotherapy Scales (1984) provide a vehicle for such study. They include Individual, Family and Couple Scales, and are based on Bordin's formulation of the alliance synthesized with a systems model. Preliminary studies have shown adequate re l iabi l i ty , supporting the theory of relative stability of the alliance across therapies. These scales will be further described In discussion of the alliance ln family therapy following below. In summary, research on the alliance in individual therapy has indicated the power of the alliance in the early stages of therapy as a predictor of therapeutic efficacy. In terms of research design, self-report measures appear to be the optimal instrument in assessing the strength of the alliance. Research on the alliance in individual therapy also identifies the importance of client factors, and points to the need to "fit" client, relationship and technological factors to the specific client to facilitate effective therapy. The Alliance in Family Therapy Research has supported the theoretical and clinical observation that the alliance.is a vehicle for change ln individual therapy. Given the relative youth of process research, family therapy, and alliance research, it is not 31 surprising that alliance theory and research is just beginning to emerge within the field of family therapy. Family therapy process research "has just been born" (Pinsof, 1981, p.700), and no clear conclusions have been reached. To date, there has been some investigation of therapist behavior and family-as-cllent behavior, using either self-report measures to target the experiential reality of the therapy process, or direct observation measures to target the observational reality (Pinsof, 1981). The beginnings of process research in family therapy are reminiscent of the early research in individual therapy, examining only one factor in the therapeutic relationship. However, some tentative findings support the pursuit of research Into the alliance in family therapy. One relevant finding in a study by Shapiro and Budman (1973), evaluating the client's retrospective reports about the therapist's activity level, was that two thirds of the continuers in family therapy made positive comments about their therapists and specified approval of the therapists for being active. The client's perception of the therapist's activity clearly related to termination and continuation in family therapy. Another finding has implications for examining the working alliance, although it is not framed in alliance terms. Alexander, Barton, Schiavo and Parsons (1976) rated therapists on scales of behavior that tapped two dimensions: Affect-behavior integration, and Warmth and Humor scales, tapping 32 what they called a "relationship'' dimension; and DirectIveness and Self-confidence scales, tapping a "structuring" dimension, together accounting for almost 60% of the outcome variance. One can conjecture that these two scale blocks capture in part the concept of the alliance, encompassing both bond and task aspects of Bordin's conceptualization of the working alliance as performed by the therapist. The ratings were done by observer rating, and Pinsof notes that process research on the behavior of the family therapist by observer rating has not produced clear substantive findings. However, of the two scales, the relation-ship scales seemed to have the greatest predictive power. Pinsof (1981) refers to Chagoya, Presser and Sigal's Family Therapist Intervention Scale, and Pinsof's Family Therapist Coding System. Both measure only one factor in the relationship, the therapist, and attempt to differentiate therapist behaviors in different models of therapy. Both scales are attempts to develop instruments that apply across orientations. De Chenne (1973) applied the Experiencing Scale, developed in individual therapy, to family therapy, and Interpreted his finding that each spouse was involved in one experiential "system" with the therapist and another with the spouse. This represents an attempt to integrate instrumentation that can be used both in Individual and family therapy research. Potentially, the theoretical concept that has the greatest power for the development of instrumentation that can apply across theoretical orientations and fields of therapy is the 33 alliance. The emergence of alliance theory in the field of family therapy represents an integration of concepts from different theories towards developing "a generic variable that can function as an integrating construct for relating general (relationship) and specific (technical) factors across different types of therapy and research settings... (and) become a common thread or dimension providing greater coherence and intel l ig ibi l i ty to the entire field of psychotherapy research" (Greenberg & Pinsof, in press). Pinsof and Catherall (1984) developed the Integrative Psychotherapy Scales in order to integrate the construct of the alliance with couple and family therapy, and bring an inter-personal and systemic perspective to the alliance concept in individual therapy. Pinsof and Catherall note that the concept of alliance developed within psychoanalytic theory prior to the advent of family therapy. They further note that family therapists have framed their theories about the relationship between therapist and family not in terms of an alliance or relationship but in terms such as Minuchin's "joining", Davatz's "connecting" and Ackerman's "establishing a useful rapport" (p. 2). A search through The Handbook of Family Therapy, (Gurman and Knlskern, 1981) a compilation of up-to-date theory and practice in family therapy, confirms that the relationship is conceived of as an important prerequisite for successful therapy. The volume contains descriptions of family therapy in psychoanalytic, intergeneratlonal, systems theory and behavioural approaches. 34 Given that every model has its own language, it is unrealistic to expect to find generic, commonly defined terms being used in descriptions of the various therapies. However, several theories describe the process of therapy in terms that relate to factors that form part of the working alliance as formulated by Bordin. Within each approach, at least one contributor mentions the relationship as an Important factor, or speaks to the importance of the clients' involvement in working towards common goals and tasks. The early development of the therapeutic relationship is consistently mentioned. In a psychoanalytic model, Sager (1981) speaks of the Important part goals play In family therapy, and of the importance of client involvement: "Goal specificity is essential in treatment and also offers an approach to the rapid initiation of therapy... (goal specificity) involves the patients as full participants in deciding upon the goal they want" (p. 125). Recognition of the importance of the relationship is particularly interesting in a behavioral approach, given the historical lack of attribution of relationship factors in behavioral thinking. Jacobson (1981) talks of "inducing positive expectancies and the creation of a collaborative set" (p. 567). The early phases of therapy are crucial to the creation of positive outcome expectancies in both partners, which fosters a willingness to work collaboratively to Improve their relationship. The therapist contributes to this process by outlining the assessment process and explaining the rationale for each procedure. Initial information gathering allows the couple 35 time to become comfortable with the therapist and make a firm commitment to therapy. Although not expressed in the terms used to describe the alliance, the concepts are the same, and reflect Frank's common factors in therapy. The expectations/hope or "rationale" can be seen as part of the task, the comfort with the therapist as the bond, and collaboration fostered by early contacts with the therapist as the mutual goal the couple is working toward, so that collaboration with the therapist becomes couple collaboration with each other. Further, Jacobson <1981) notes, "Jacobson and Margolin (1979) have recently asserted that the most frequent impediment to successful BMT (Behavioral Marital Therapy) is not the unskillful application of behavioral technology, but rather relationship sk i l l deficits on the part of therapists attempting to implement the technology" (p. 584). The interrelatedness of relationship and technology is apparent. Of the intergeneratlonal theorists, two contributors address the issue of relationship. Framo, (1981) says: "Among the factors that have therapeutic...effects In the init ial interviews are...degree of 'connectedness' between client and therapist(s)." (p. 142). More specifically, he says "In the early phases the first goal is the establishment of a working relationship between the couple and co-therapists; without trust, therapy will never get off the ground." (p 143). The other theorists classified as intergeneratlonal are Whitaker and Keith, who say: "The family therapist must develop a basic empathy with the family— We work hard to capture the 36 family in the first interview." (p. 210) The clearest expression of the importance of the therapeutic alliance as a vehicle for change in therapy is found in the writings of two systems theory contributors who have developed integrative models of family therapy. Barton and Alexander (1981), classified as systems theorists, describe their model as an "integration and extension of two major conceptual models of human behaviour: systems theory and behaviorism." (p. 403). They speak very clearly about the importance of the relationship: "the relationship that the functional family therapist forms with the family is as important for change as consideration of family members' relationships and forms of influence...Family change seems related to the functional family therapist's ability to form an adaptive relationship with the family" (p. 430). Duhl and Duhl (1981), whose model, called Integrative Family Therapy, is classified as a systems theory, integrate systemic, individual, cognitive, behavioral, experiential and existentialist "maps" in a truly eclectic approach. They speak specifically of the alliance: "There must be a match, a f i t , on some level, between the therapist's reality and world view and the patients', or else the therapist will totally manipulate the patients, or the patients will leave. The old concept of a therapeutic alliance is s t i l l useful, for systems only change with an inside and an outside ally working together." (p. 489). Gurman (1981), in discussing integrative marital therapy, states that a working alliance must be developed early in marital 37 therapy "in order for the anxiety-evoking process of change to begin" (p. 435). At the same time, the collaboration or alliance between the marital partners must also be fostered. Gurman discusses three interrelated and concurrent alliances: the therapist-marital partner alliance, the therapist-couple alliance, and the husband-wife alliance. The therapist-marital partner alliance must be established in the first session; each spouse must feel he or she has gained something of personal value. Individual client differences dictate what is necessary for such an alliance to be formed in the first contact, ranging from empathy, identification of interactional patterns, to direction for behavior change. The marital partners may require different experiences to feel a sense of alliance. To develop the therapist-couple alliance, the therapist must speak to both partners at once; this is established by speaking to the spouses' collusion in their conflict areas as a reflection of their growth-oriented attraction and commitment to each other. This creates a sense of getting to work in therapy. The husband-wife alliance is strengthened by an acknowledgement of differences in personal style and equalization of fundamental relationship strivings; each partner is seeking the same relationship goals. The therapeutic relationship is clearly recognized as a major component of family therapy. Pinsof and Catherall (1984) state: "Family therapy theory and practice can be greatly enriched by incorporating the concept of the alliance." (p. 3). Such integration of the concept of the alliance into family 38 therapy theory would shed light on an unexamined but cri t ical aspect of therapy, differing across types of family therapy, therapists, and points in treatment. Examination of the alliance in the process of family therapy may result in more efficient utilization of an important change agent. Beyond that, Pinsof and Catherall (1984) suggest that incorporating the alliance concept in family therapy research can integrate the fields of family and individual therapy research, by facilitating "the development of a common variable base or language. The alliance is becoming a major variable for psychotherapy researchers aound which other variables can be organized." (p. 3). However, the concept of the alliance becomes complicated in family therapy because the family therapist has to deal with multiple family members, and with alliances with each member as well as with the family system as a whole. "The alliance the therapist has with one family member impacts the alliance with other family members in a circular, reciprocal fashion. No single dyadic (patient-therapist) alliance can be considered in isolation." (p. 4). In addition, the family therapist can have a "whole" or "split" alliance with a family: in a whole alliance al l family members feel similarly toward the therapist or therapy; in a split alliance, family members differ significantly in their attitudes toward the therapist or therapy. The same authors (1984) define the alliance in an integrative way so that "it integrates the individual and the social field and places family and individual therapy within the 39 same systemic universe." (p. 5). The alliance is "that aspect of the relationship between the therapist system and patient system that pertains to their capacity to invest in and collaborate on the therapy." (p. 5). The client system consists of a l l the people involved in the maintenance or resolution of the presenting problem. The therapist system is seen as consisting of a l l the people involved in administering treatment to the client system. The alliance is conceptualized as "that part of the relationship that mediates or pertains directly to the therapy." (p. 5). Based on this conceptualization of the alliance, Pinsof and Catherall (1984) developed the Integrative Psychotherapy Scales to measure the alliance in individual, couple and family therapy. The scales derive from two theoretical dimensions: content, referring to tasks, bonds and goals, as postulated by Bordin; and interpersonal system, referring to the self-therapist, other-therapist, and group-therapist systems. These scales will be described fully in the chapter on methodology. While the alliance concept has been adapted from individual therapy and is being examined in family therapy, "client family" factors in the therapeutic alliance have been overlooked. Although client factors have consistently predicted outcome in research on the alliance In Individual therapy (Hartley & Strupp, 1982), the impact of client factors on therapeutic outcome has not yet been investigated in family therapy research. Since client factors and the alliance have been found to correlate in predicting therapeutic outcome in individual therapy (Alexander & 40 Luborsky, in press), the hypothesis has been drawn that client factors predispose the client toward the formation of the alliance. This hypothesis is consistent with theory in individual therapy. Strupp's formulation of three intertwined conditions (the helping relationship, the techniques of therapy, and the client's capacity to change) as the basic ingredients of therapeutic change can be applied to the examination of change.in family therapy. Investigation into predisposing client family factors that may predict outcome and possibly facilitate the formation of an alliance has not yet begun, but is greatly needed. Very l i t t l e is known about what family characteristics are associated with positive treatment outcomes (Kniskern & Gurman, 1983). In the context of family therapy theory, client factors are not assessed in terms of personality factors, but in terms of relationship factors, since the client in family and marital therapy is the relationship. While prior relationship ability has been shown to be predictive of ability to form a therapeutic alliance in individual therapy, prior relationships are presupposed in family counse11ing. In family systems terms, assessment has to be on inter-actional lines. The most powerful concepts used in family therapy theory to assess family relationships are the dimensions of adaptability and cohesion, which are central to family functioning (Olson, Russell & Sprenkle, 1983). Adaptability refers to the extent to which the family is flexible and able to change in response to stress and developmental needs. Cohesion 41 refers to the emotional bonding families have among their members, while allowing for individual differences. The most prominent instrument for assessing family and marital function on these two dimensions is Faces II (Green, Kolevzon & Vosler, 1985), as described in the methodology section. The questions of interest in this study, based on Strupp's formulation, were whether couple characteristics related to outcome and whether couple characteristics, the alliance and style of therapy interacted in predicting outcome. Summary The alliance is hypothesized to be the vehicle for change in a l l therapies. Research in individual therapy has shown that the alliance, although differently conceptualized by different research groups, is predictive of outcome at an early stage of therapy. Bordln's conceptualization of the alliance allows for a generic variable that can examine the alliance across therapies, including marital and family therapies, and thereby study the process of change. Research has just begun to address the study of different types of alliance in different models of therapy. Instruments are being developed to study types of alliance. These instruments need further testing to establish both rel iabi l i ty and validity as predictors of efficacy. Adding assessment tools to the retinue of therapy techniques could ultimately assist the clinician assess the efficacy of the therapeutic process in progress by directing attention to points 42 where repair work needs to be done on the alliance, hypothesized by Bordin to be cri t ical change points. Such instruments could also assist the theoretically eclectic clinician choose interventions tuned to the unique capacities of the indivdual client-couple. The synthesis of process research, the alliance concept, and family therapy leads to new, interactive or circular epistomologies, and new research methodologies to study the process of change and its links to outcome. The units of interest in research are defined in "smaller", focused terms, and multidimensional assessments of change are utilized. This conceptual synthesis leads to many questions. Can a generic variable be found to be powerful across theoretical and epistomelogical lines? Can the same instrument assess the strength and type of individual and multiple alliances? Is the alliance as potent in couple and family therapy, where relationships among the client "members" are already strong and are the primary relationships to be developed in therapy, as it is in individual therapy? Do the bond, goal and task components in fact differ between styles of therapy? In addition, since client factors are important predictive variables in individual therapies, assessment of couple relationships may be valuable in predicting outcome of couple therapy. One of the important predictive factors in individual therapy is past relationship abil ity. Couples in therapy are se1f-screened, in that marital partners have, at some point had a meaningful relationship. The client factors that contribute to the ability to form a working 43 alliance may be of a different nature in couple therapy; an interesting question is whether assessment of the kind of relationships people form, along dimensions of cohesiveness and adaptability could be predictive of ability to enter into a working alliance and of outcome in the therapeutic context. Further, there is a question whether particular clients may require certain types of alliances. This thesis does not presume to find definitive answers to these questions, but, is an exploratory inquiry hoping to contribute towards further examination of these issues in the process of couple therapy. 44 CHAPTER THREE METHODOLOGY This chapter presents the design of the study, the instruments utilized, the sample and the population from which it was drawn, and the research procedures. The treatment models are described and the interventions delineated. Finally, the hypotheses that were tested are presented. Design of the Study The present study was a process-outcome study which investigated three aspects of the therapeutic alliance as related to two approaches to couple counselling. These three aspects of the alliance were: (a) the ability of the alliance to predict outcome in couple counselling! <b) the characteristics of the component parts of the alliance (tasks, bonds, goals) in the two styles of couple therapy; (c) the interaction of couple configuration with alliance and style of therapy, and its effect on outcome. The study compared and examined two independent variables, alliance and the type of couple relationship, with three dependent variables that measured the outcome of therapy, marital adjustment, conflict resolution abil ity, and target complaint reduction. 45 Instruments Process Measure Couple Therapy Alliance Scale (CTAS); (Pinsof & Catherall,  1984)• The Couple Therapy Alliance Scale was administered to al l the subjects after the third therapy session and to 52 subjects after the tenth therapy session to assess the strength of the alliance as perceived by the clients. This self-report measure contains 28 items on two dimensions: (a) the content dimension, consisting of tasks, goals and bonds; and (b) the interpersonal system dimension, consisting of the self-therapist, other-therapist, and couple-therapist systems. In the content dimension, the tasks, goals and bonds are operational terms that capture the spheres in which the alliance is most clearly expressed. The task component concerns the extent to which the methods and techniques of therapy are linked to "the patient's sense of his difficulties and his wish to change" (Bordin, 1979, p. 254). Pinsof and Catherall (1984) broadened the meaning of the task category to include the patient's belief in the therapist's power and method, an important element of the healing relationship as proposed by Frank. They consider the client's perception of the therapist's ability to understand him/her to be an element of tasks. The task component is at its strongest when the client experiences the tasks of therapy as relevant to his problems; feels understood by the therapist; and experiences the therapist as helpful. 46 The task sub-dimension, which measures engagement in the tasks of therapy, if equivalent in the two approaches, would show that clients were equivalently engaged in both types of therapy and perceived them as equally relevant. The goals component involves the extent to which the therapist and client agree on the goals of therapy. Agreement on goals is the basis for collaboration, an essential element of the alliance. The goals component is strongest when the client experiences him/herself and the therapist as agreeing about and working toward the same goals. The bond component refers to the quality of the relationship between therapist and client. It includes the client's feeling of being cared about and accepted by the therapist, and the extent to which the patient cares about and trusts the therapist. Basically, the bond component concerns the extent to which the patient can allow the therapist to become a significant person in the client's psychological l i fe . The interpersonal system dimension concerns the reporting client's perception of the content dimension categories within the relationships between him/herself and the therapist, the partner and the therapist, and the couple and the therapist. Of the 28 items, 11 relate to self, 11 to the partner, and 6 to the couple relationship. The clients are asked to respond individually to the Items on a Likert-type 7-point scale, on which about half the items are phrased positively and half negatively. The six subdimens ions of the content and Inter-personal systems dimensions form a three by three matrix, with at 47 least two Items drawn from each cell of the matrix, except for the couple-therapist bond ce l l , which contains only one. The subdimensions of the content dimension differ in number of items. The task subdimension contains the most items because it contains more elements: therapist understanding, agreement about methods/tasks, confidence in the therapist's abil ity, therapist helpfulness. The bonds subdimension includes more items than goals because it is bidirectional; it includes both the client's bonds to the therapist and the therapist's bond to the clients. The goals subdimension has the fewest items because it is confined to the single, non-directional issue of agreement about goals. The scale generates seven scores or variables: a score on the three categories of the content dimensions, a score on the three interpersonal system dimensions, and an overall score. The overall score is based on the mean rating on a l l the items on the instrument. The six category scores are based on the mean of a l l the items within each category, with scores ranging from a low of 1 to a high of 7. The couple, or conjoint score, is derived from combining the partners' scores; for instance, the overall mean score for the couple would be based on the mean of both partners' overall scale score. Pearson r rate-rerate rel iabi l i t ies after two therapy sessions were .79 (Pinsof & Catherall, 1984). Predictive validity of one-time alliance measurement, with N=48, correlated positively (p<.05) with therapist-reported measures of therapeutic progress. Further research is underway testing the 48 factor structure and construct validity of the six subdimensions (Gurman, Kniskern & Pinsof, 1986). Couple Relationship Measure Family Adaptability & Cohesion Evaluation Scales (FACES II)  /.Olson, Bell & Portner, 1979). The Couple Form of FACES II was administered pre-therapy to assess marital functioning on two primary dimensions integrated in the Circumplex Model (Olson, Russell & Sprenkle, 1980, 1983). This measure assesses couples on two dimensions found to be central to marital functioning: cohesion and adaptability. Cohesion is defined as the emotional bonding that couples have toward one another. Specific concepts used to diagnose and measure the cohesion dimension are: emotional bonding, boundaries, coalitions, time space, friends, decision-making, interests and recreation. The rating of the cohesion dimension ranges from extremely low, where the members are disengaged, to extremely high, where they are enmeshed, with balanced levels labelled separated and connected. Couple adaptability is defined as the extent to which the couple system is flexible and able to change its power structure, role relationships, and relationship rules in response to situational and developmental stress. Specific concepts used to diagnose and measure the adaptability dimension are: power (assertiveness, control), negotiation style, role relationships and relationship rules. The rating of the adaptability dimension ranges from low adaptability, characterized as rigid, through 49 high adaptability, characterized as chaotic, with balanced levels labelled flexible and structured. The two dimension give an assessment of the functioning of the couple relationship. Balanced levels of cohesion and adaptability are hypothesized to be most viable for healthy family functioning. FACES II is a self-report measure designed so marital partners could describe how they perceive their relationships. Clients rate 30 statements about their interaction within their marital relationship on a 5-polnt scale; 16 Items assess the cohesion factor, and 14 measure the adaptability factor. The items are positively phrased, with about half the items describing healhy interpersonal Interaction, and the other half describing problematic interaction. The client rates frequency of interaction on each Item, ranging from almost never to almost always. Reliability and validity studies on FACES II were reported by Olson & Portner (1983). Reliability was assessed by the Cronbach Alpha for internal consistency on a sample of 2,498 subjects. The cohesion dimension was rated .87; adaptability was .78; the total scale was .90. Factor analysis was done on data from the same sample to assess for construct validity. The factor analysis solution was restricted to two factors. Cohesion items loaded most heavily on Factor I, with loadings between .34 and .61. Adaptability items loaded mainly on Factor II, with loadings between .10 and .55. 50 Outcome Measures Three measures were administered pre and post-therapy to provide multiple assessments of outcome. Dyadic Adjustment Scale (DAS) (Spanler,;1976). This instrument is comprised of 32 items arranged into four subscales measuring dyadic satisfaction (10 items), consensus (13 items), cohesion (5 items) and affectional expression (4 items). It has been tested for rel iabi l i ty (.96, Cronbach's Coefficient Alpha). Spanler presents a validity correlation between DAS and the Locke Wallace Marital Adjustment Scale (Locke & Wallace, 1959) of .86. Spanler says the scale can be considered to be a measure of the dyad as a functioning group rather than a measure of Individual adjustment to the relationship. The scale has a theoretical range of 0 - 151. The mean total score In the norming sample for married and divorced couples was 114.8 (S.D. 17.8) and 70.7 S.D. 23.8) respectively. The rel iabil i ty of the subscales is Consensus .90, Satisfaction .94, Cohesion .86, and Affectional Expression .73. The majority of items involve a 5 or 6-point Llkert-type scale defining the amount of agreement on the frequency of an event. A rating measure for global happiness and for commitment is included in the Satisfaction subscale. Target Complaints Measure (TO (Battle, Imber, Hoehn-Saric,  Stone, Nash & Frank, 1966). This instrument is recommended in Waskow and Parloff (1975) as a core battery Instrument for use in psychotherapy outcome research. It is comprised of three 5-point 51 scales on which the client is asked to rate the amount of change on three different complaints, in this case complaints related to the main conflict in the relationship. Numerical values can be assigned to each rating point. The client's score on the instrument becomes a mean value consisting of the sum of the ratings for a l l target complaints divided by the number of complaints rated. Battle (1966) provides evidence as to the validity of this measure; it showed significant correlations with four other outcome measures. The main complaints derived from a target complaint interview were congruent with complaints obtained in intensive psychiatric interviews. Target Complaints was informative, made good clinical sense, and responded differentially to experimental manipulation. With regard to rel iabil i ty or consistency of clients' Initial definitions of problems, clients' rankings of problems between pre-post psychiatric interviews showed a correlation of .68. This measure taps couples' presenting problems directly. Conflict Resolution Scale (CRS); Subscale of Enriching and  Nurturing Relationship Issues, Communication & Happiness (ENRICH)  (Fournier, Olson & Druckman, 1983). This ten-item instrument was specifically developed to identify interpersonal processes that became problematic for many couples. To determine construct validity, the relationship between new measures and existing measures that are consistent with theoretically derived hypotheses relevant to the construct were assessed; the CRS significantly correlated with the Locke-Wallace Marital 52 Adjustment Scale. The Alpha coefficient for the CRS (Enrich) is .75 and test-retest rel iabi l i ty is .90. All items are answered on a 5-polnt Likert-type scale ranging from (1) Strongly agree to (5) Strongly disagree. Sample and Population The data to be examined was gathered from 42 couples who had taken part in two studies of couple counselling: 14 couples participated in The Couples Problem Solving Project, 1983 (Johnson, 1984), and 28 couples participated in the Couples * Therapy Research Project, 1984/85 (Goldman, in progress). In both projects, the couples were a sample selected from a population of distressed couples who responded to newspaper and/or radio advertising offering marital therapy for the resolution of couple conflicts. The criteria for client selection included a "distressed" rating on the Dyadic Adjustment Scale (Spanler, 1976). In the Johnson study, this meant a score below 100. In the Goldman study, a score between 60 and 95 was required. Other criteria for the sample were that the couple had lived together a minimum of 18 months (24 months in the Johnson study); had no plans for separation or divorce; and neither partner had required treatment for psychiatric problems > within the preceding two years. Clients were screened to exclude from the sample couples who had problems involving drugs or alcohol, physical violence, or problems that were primarily organic sexual problems. 53 Research Procedures The 42 couples of interest in this study received treatment consisting of eight to ten one-hour weekly therapy sessions. The 14 couples in the Johnson study received emotionally-focused therapy. Of the 28 couples in the Goldman study, 14 were assigned to the emotionally-focused therapy treatment and 14 were assigned to the interactlonal/systemic therapy treatment. Couples were randomly assigned with some attempt to match treatment groups in terms of severity of couple distress as indicated by DAS scores. At a pre-treatment assessment interview, couples completed pre-treatment measures of the DAS, TC and CRS as a baseline; post-treatment measurements on the same instruments provided data on outcome of therapy. The CRS measure was not administered to the 14 couples participating in the Johnson study; the 28 couples in the Goldman study were assessed on this measure pre and post-treatment. The Couple Form of Faces II was also administered at the assessment interview to assess the couple configuration. The CTAS was utilized to measure the strength of the couple alliance with the therapist after the third therapy session. The CTAS was administered again after the tenth therapy session to the 28 couples in the Goldman study. 54 Treatment Emotionally-Focused Therapy Developed by Greenberg and Johnson (1983), and deriving from experiential and systemic therapies, emotionally-focused therapy is directed toward present affective experience in an interactional context. The assumption is that change occurs within the individual as well as within the couple relationship; that is, both intrapsychic and interpersonal change occurs. The partners are regarded as active perceivers who construct meanings and organize perceptions and responses on the basis of current emotional states; the therapist attempts to induce change at the intrapsychic level by reframing and expanding cognitive constructs and linking these new awarenesses to the relationship. The mechanism for change is emotional experiencing. Steps in treatment are: (1) Defining conflict issues as presented, helping each partner establish his/her position. (2) Identifying negative interactional cycle. (3) Facilitating clients in accessing and accepting previously unacknowledged emotions by validating unmet needs for intimacy; legitimizing feelings of vulnerability or deprivation underlying the cycle. <4> Redefining the problem cycle in terms of these new emotions and the clients interacting sensitivities that lead to problematic responses. (5) Encouraging identification with previously unacknowledged aspects of experience by enactment of the redefined cycle. <6> Facilitating acceptance of the partners' redefined positions, both in expression of themselves and in behavior. (7) Encouraging clients to state needs and wants arising from their new emotional synthesis. 55 <8) Facilitating new solutions and responses in the couple interaction. <9> Helping clients to integrate new perspectives of the self and other, solidifying new relationship positions and ways of building intimacy. There is a high demand for self-disclosure in this therapy. Therapeutic techniques include methods of Gestalt therapy, particularly attending to the experience of the moment; empathic reflection; evocative responding to heighten the experience of the moment; and reframing the problem and responses in terms of underlying feelings, thereby elicit ing a different emotional understanding of the self and the partner. The establishment of a theoretical alliance is essential to this mode of therapy. The bond aspect of the alliance is of cri t ical Importance, as Bordin (1979) hypothesized it is in psychdynamic therapies: "...when attention is directed toward the more protected recesses of inner experience, deeper bonds of trust and attachment are required..." (p. 254). Pinsof and Catherall (1984) define the bond component as the quality of the human relationship between the therapist and the client, including the client's feeling of being cared about and accepted by the therapist,-and the extent to which the client cares about and trusts the therapist. Interactlonal/Systemic Therapy Developed by Greenberg and Goldman (1985), interactional/ systemic couples therapy is derived from family sytems theory and is based on an integration of process, structure, and world views orientations, with a focus on behavior. While it is assumed that 56 change at the behavioral, Interactional level leads to change at the inner, experiential level, therapy is directed primarily toward change at the overt interactional level. Change in repetitive, self-perpetuating negative inter-actional cycles is believed to lead to second-order change in the rules governing interactions in the relationship, as well as in the behaviors. Awareness of internal processes is seen as irrelevant to the-therapeutic process; the goal of therapy is to change present symptomatic behaviors which are believed to be anchored in circular interactional patterns, based on the partners' individual and shared world views and the structural traits of the relationship. The problematic behaviors and negative interactional cycles are seen as serving a purpose in the marital system, and a vicious circle occurs in which attempted solutions contribute to the problem maintenance. Change needs to occur around points at which the system seems to be stuck. The mechanisms for change stem from structural and paradoxical paradigms. The therapist's goal is to initiate a reversal in the repetitive negative communicational or interactional cycles and change the frame of reference or meaning attributed to the interaction. The basis of the therapeutic tasks is the therapist entering the couples' perspective and assigning homework, or tasks, that, although paradoxical in nature, strongly make sense to the couple. Steps in treatment are: <1) Defining the issue presented and each partner's position. 57 (2) Identifying the problem-behaviors that maintain the negative interactional cycle> identifying the partners' goals for change. <3) Restructuring the interaction. (4) If restructuring does not succeed, reframe the problem by a) positively connoting the negative interactional cycle by changing its conceptual or emotional meaning and focusing on its positive rather than negative functions in the marital system. b) prescribing the symptom, suggesting it is important to the relationship. (5) Paradoxical injunctions to restrain from change by: a) advising "go slow" b) warning of dangers of improvement. <6) Consolidating the frame to strengthen the changed frame of reference or meaning attributed to the cycle. (7) Prescribing a relapse - since one will probably occur - to put the cycle in the control of the therapist and, by extension, the couple. The therapist's role in this therapy is to not oppose the couples' positions or perceptions of reality and thereby "join" them, or form an alliance; the focus Is on the current interactions, or behaviors, between the partners, and the reframing of the negative interactional cycle. Therapy is present-centered, and the issues are defined in behavioral terras. The therapist's issuance of tasks is the cornerstone of the systemic approach (Gurman, 1981); the task component of the alliance Is cr i t ical in this approach, and rests on "the vividness with which the therapist can link the assigned task to the patient's sense of his difficulties and his wish to change" (Bordin, 1979, p. 254). , In strategic couple therapy, the therapist relies on a team behind a one-way mirror, adding the 58 the power of numbers and unknown authority to the therapist's power, an Ingredient of the task component. Hypotheses Given that this was a preliminary study of the alliance in couple therapy, there was no evidence to suggest what the findings would be. For this reason, the hypotheses were stated as null hypotheses, as follows: Ho 1 - It is hypothesized that the strength of the alliance will not predict outcome in couple therapy. Specifically, for the 84 subjects exposed to treatment, there will be no significant correlation between: a) the alliance, as measured by the Couple Therapy Alliance Scale after the third therapy session, and therapeutic outcome as measured at termination of treatment by the Dyadic Adjustment Scale, the Target Complaints Measure and the Conflict Resolution Scale. b) the alliance, as measured by the Couple Therapy Alliance Scale after the tenth therapy session, and therapeutic outcome as measured at termination of treatment by the Dyadic Adjustment Scale, the Target Complaints Measure and the Conflict Resolution Scale. 59 Ho 2 - It is hypothesized that the strength of the alliance will not differentially predict outcome in the two treatments. Specifically: a) for the 56 subjects exposed to emotionally-focused treatment, there will be no significant correlation between the alliance, as measured by the Couple Therapy Alliance Scale after the third therapy session, and therapeutic outcome as measured at termination of treatment by the Dyadic Adjustment Scale, the Target Complaints Measure and the Conflict Resolution Scale. For the 28 subjects exposed to interactional/systemic treatment, there will be no significant correlation between the alliance and treatment outcome as measured by the above instruments. b) for the 56 subjects exposed to emotionally-focused treatment, there will be no significant correlation between the alliance, as measured by the Couple Therapy Alliance Scale after the tenth therapy session, and therapeutic outcome as measured at termination of treatment by the Dyadic Adjustment Scale, the Target Complaints Measure and the Conflict Resolution Scale. For the 28 subjects exposed to interactional/systemic treatment, there will be no significant correlation between the alliance and treatment outcome as measured by the above instruments. 60 Ho 3 - It is hypothesized that the component parts of the alliance (tasks, bonds, goals) will not differ in the two treatments. There will be no statistically significant difference in the inter-relationship of the tasks, bonds, and goals components of the alliance, as measured by the Couple Therapy Alliance Scale, between the 56 subjects exposed to emotionally-focused treatment and the 28 subjects exposed to interactional/systemic treatment, either following the third or tenth therapy session. Ho 4 - It Is hypothesized that the different types of couple configuration, as measured by the Family Adaptability & Cohesion Evaluation Scales (FACES II): a) do not relate to outcome, as measured by the above-mentioned outcome measures; b) do not relate with either alliance, as measured by the Couple Therapy Alliance Scale, or type of therapy, that is, emotionally-focused or interactlonal/systemic treatment, in relation to outcome. Ho 5 - It is hypothesized that the alliance after the third therapy session, as measured by the Couple Therapy Alliance Scale, will not differ from the alliance, as measured by the same instrument, at termination of treatment, in the sample or the two treatment groups. 61 CHAPTER FOUR RESULTS This chapter presents the results of data analyses conducted to test the research hypotheses and related research questions. The tests that are cited were conducted using an alpha of .05; ln this chapter, the level of statistical significance will be assumed to be <?< = .05 unless otherwise stated. The Couple Therapy Alliance Scale was used to measure the alliance following the third and tenth therapy sessions. These measures will be referred to as the init ial alliance and termination alliance measures. The component parts of the alliance were measured along two dimensions: the content dimension, consisting of the task, goal and bond components; and the interpersonal system dimension consisting of the therapist-individual relationship (self-therapist), the therapist-partner relationship (other-therapist), and the therapist-couple relationship (relationship-therapist) components. Means were computed for the sample of 84 subjects representing the two treatment groups. The interactional/systemic (IS) treatment group consisted of 28 subjects. The emotionally-focused (EF) treatment group consisted of two subgroups of 28 subjects each, treated with the same style of therapy at two different times; the first subgroup received treatment as part of the Johnson study (1984), and the second in the Goldman study (in process). To ascertain whether the two subgroups which received 62 emotionally-focused therapy were equivalent In marital distress level, alliance level, and impact of treatment received, t-tests were conducted to compare the two subgroups on init ial CTAS, pre-therapy DAS, and post-therapy DAS. The results of the t-tests showed no statistically significant difference between the subgroups. On the init ial CTAS measure, the means of the two subgroups were: 162.32, with a standard deviation of 18.24 for the first subgroup; and 157.18, with a standard deviation of 18.06 for the second subgroup (t-1.06; p>.05). On the pre-therapy DAS, the means for the first and second groups were 89.86 (standard deviation 12.35) and 86.32 (standard deviation 11.08); the t-value was 1.13. On the post-therapy DAS, the means were 98.61, with a standard deviation of 12.17 for the first group; and 100.14, with a standard deviation of 15.29 for the second group. The t-value was .42. The two emotionally-focused therapy subgroups were therefore combined and treated as one group of 56 subjects. Further, an analysis of variance was conducted to test for statistically significant differences among the two emotionally-focused therapy subgroups and the interactional/systemic group of 28 subjects on the init ial CTAS. The group receiving interactional/systemic therapy had a mean of 151.36, with a standard deviation of 16.05. The computed F-ratio was 2.76. This result is not statistically significant, and the 3 subgroups were deemed to be equivalent in terms of the alliance measure. The CTAS was administered at termination of treatment to only one of the emotionally-focused treatment subgroups; because 63 of administration error, termination alliance scores were available for only 26 subjects in each of the treatment groups, totalling 52 scores in the combined therapies sample. The CRS measure was also administered to only one of the emotionally-focused subgroups; scores were available for a l l 28 subjects in each treatment group, totalling 56 scores in the combined therapies sample. The results of statistical tests on the alliance and correlations of the alliance with outcome follow below. As numerous statistical tests were conducted, the results are clustered under headings. Description of the Alliance The means and standard deviations of the alliance measure and its component parts in the combined therapies sample and ln the two treatment groups, following the third and tenth therapy sessions, were computed. T-tests were conducted on the init ial and termination alliance scores to test for statistically significant differences between the two treatment groups. The means, standard deviations, and t-test results appear in Table 1. The t-value for the init ial alliance means was 2.07 (the emotionally-focused group alliance mean was higher than the Interactional/systemic group alliance mean). This difference in the alliance means becomes apparent with a larger sample group; the ANOVA conducted to examine the alliance, as referred to earlier, showed no differences among the three groupings of two 64 Table 1 Means, (Standard Deviations) and t-test values for the Treatment Groups: CTAS Combined EF IS t-value Init ial: Content: a) Task b) Goal c) Bond Interpersonal: a) Self b) Other c) Relationship Total <N=84) 72.36 (9.18) 33.23 (4.19) 51.83 (6.09) 62.68 (7.48) 60.18 (7.55) 34.09 (4.22) 156.95 (17.84) (n=56) 73.75 (9.55) 33.89 (4.02) 52.80 (5.88) 63.63 (7.86) 61.32 (7.44) 34.80 (4.46) 159.75 (18.17) (n=28) 69.57 (7.84) 31.89 (4.29) 49.89 (6.14) 60.79 (6.38) 57.89 (7.36) 32.68 (3.33) 151.36 (16.05) 2.00 * 2.10 * 2.11* 1.66 * 2.00 * 2.23 * 2.07 * Termination: Content: a) Task b) Goal c) Bond Interpersonal: a) Self b) Other c) Relationship Total (N=52) 75.83 (10.70) 34.69 (5.29) 54. 17 (7.27) 64.92 (8.79) 63.79 (9.27) 35.88 (4.52) 164.60 (22.06) (n=26> 80.81 (10.51) 37.58 (4.18) 57.65 (5.73) 69.50 (7.46) 68. 19 (8.20) 38.35 (3.81) 176.04 (18.91) (n=26> 70.85 (8.46) 31.81 (4.72) 50.69 (7.06) 60.35 (7.65) 59.38 (8.23) 33.42 (3.83) 153;15 (19.04) 3.76 ** 4.66 ** 3.90 ** 4.37 ** 3.87 ** 4.65 ** 4.35 ** * p<.05 ** p<.01 65 emotionally-focused therapy groups and one interactional/ systemic group. Following the 10th session, t-test values suggested substantial differences on the alliance at termination between the two treatment groups in the Goldman study (ln process). The emotionally-focused group had a termination alliance mean of 176.04 (standard deviation 18.91); the interactional/systemic group had a mean of 153.15 (standard deviation 19.04). The t-value of the termination alliance means between the two groups was 4.35. Obviously, the emotionally-focused therapy group had higher means on a l l the component parts of the termination alliance than the interactional/systemic group. The mean alliance score was different when measured after the tenth session of therapy from when it was measured after the third session. Overall, the mean difference between the Initial and termination alliances was 10.78 (standard deviation 18.24). Within the group receiving emotionally-focused therapy, the mean difference was 19.00 (standard deviation 16.92); within the group receiving interactional/systemic therapy, the mean difference was 2.58 (standard deviation 15.88). Generally, the standard deviations of the termination alliance scores were greater than the standard deviations of the init ial alliance scores, indicating increased variability of alliance scores at termination of treatment. T-tests were conducted to compare the means of the init ial alliance and component parts with the means of the termination alliance and components for the combined therapies sample and the 66 two treatment groups. The results of the t-tests for the sample appear in Table 2, the results of the t-test for the two treatment groups appear in Table 3. The change pattern appears different in the interactional/systemic group from that in the emotionally-focused group. In the interactional/systemic group, differences between the init ial and termination alliance were nonsignificant. The findings in the emotionally-focused group are particularly interesting. Within this sample, in which there was a dramatic increase in alliance over time, the greatest t-values were registered between the init ial and termination alliance on the bond <t=5.94) and other-therapist <t=6.2i) components. Correlations of Initial Alliance and FACES II with Outcome In order to assess the relationship of the therapeutic alliance and couple characteristics to outcome of therapy, correlation coefficients between the two predictor variables, CTAS and FACES II, and outcome measures were computed for the 84 subjects participating in the study. Outcome measures utilized were the TC mean score representing average improvement on three target complaints, and gain scores on DAS and CRS. Consideration was given to the arguments contraindicating the use of gain scores. One argument is that the ceiling effect limits change on high pre-treatment scores; in the case of both DAS and CRS, which have a wide range of possible scores, the maximum possible scores were not approached. Pre-treatment 67 Table 2 Means, (Standard Deviations) and t-test values for the Combined Therapies Sample: Initial and Termination CTAS Content: Initial Termination t-value (N=84) (N=52) a) Task 72.36 75.83 3.89 ** (9.18) (10.70) i b> Goal 33.23 34.69 2.86 ** (4.19) (5.29) c) Bond 51.83 54.17 4.26 ** (6.09) (7.27) Interpersonal: a) Self 62.68 64.92 3.00 ** (7.48) (8.79) b) Other 60.18 63.79 4.83 ** (7.55) (9.27) c) Relationship 34.09 35.88 4.31 ** (4.22) (4.52) Total 156.95 164.60 4.25 ** (17.84) (22.06) * p<.05 ** p<.01 68 Table 3 Means, (Standard Deviations) and t-test values for the Treatment Groups: Initial and Termination CTAS Initial Termination t-value Emotionally-Focused Group: Content: a) Task b) Goal c) Bond Interpersonal: a) Self b) Other c) Relationship Total (n=56) 73.75 (9.55) 33.89 (4.02) 52.80 (5.88) 63.63 (7.86) 61.32 (7.44) 34.80 (4.46) 159.75 (18.17) (n=26) 80.81 (10.51) 37.58 (4.18) 57.65 (5.73) 69.50 (7.46) 68.19 (8.20) 38.35 (3.81) 176.04 ( 18.91) 4.31 ** 4.57 ** 5.94 ** 4.48 ** 6.21 ** 4.74 ** 5.66 ** Interact tonal/Systemic Group: <n=28) Content: Task Coal Bond Interpersonal: Self Other Relat ionship Total 69.57 (7.84) 31.89 (4.29) 49.89 (6.14) 60.79 (6.38) 57.89 (7.36) 32.68 (3.33) 151.36 (16.05) (n=26) 70.85 (8.46) 31.81 (4.72) 50.69 (7.06) 60.35 (7.65) 59.38 (8.23) 33.42 (3.83) 153.15 (19.04) 1.12 0.04 0.96 •0. 17 1.35 1.47 0.83 * p<.05 ** p<.0l 69 scores were well below the possible maximum (In DAS, on which 151 is the highest possible score, 118 was the highest pre-score and 136 was the highest post-score; on CRS, on which 50 is the highest possible score, 38 was the highest pre-score and 39 was the highest post-score). Another argument speaks to the two errors of measurement that are involved in the use of difference scores. Rogosa, Brandt and Zlmowski (1982) regard the difference score as an unbiased estimate regardless of the magnitude of the measurement error, and consider it reliable. They point out the true limitation of difference scores lies in the inadequacy of having only two measurement points of data. Certainly, that is a limitation in this instance, both for statistical reasons and in the pursuit of exploration of the alliance. However, given that this was a preliminary investigation of the alliance in couple therapy using such data as was available, and no more reliable measure of change was available, the decision was made to proceed with gain scores. The FACES II measure of couple configuration gave scores on adaptability and cohesion dimensions. Although these dimensions are linear, ranging from low to high adaptability and cohesion, the extremes of each dimension are conceptualized as dysfunctional. Of interest was whether couple characteristics along these dimensions correlated with therapeutic change, regardless of theoretical attributions made about the meaning of these dimensions. Further consideration was given to the meaning of the FACES II dimensions, and will be adressed later in this chapter. 70 Pearson correlations were computed among these predictor variables and outcome on TC, and on gain scores on DAS and CRS. Three separate correlation matrices were computed for the scores on three different groups: the combined therapies sample of 84 subjects exposed to therapy; the group of 56 subjects exposed to emotionally-focused therapy, composed of 28 subjects from each of the two equivalent emotionally-focused therapy subgroups described previously; and the group of 28 subjects exposed to interactional/systemic therapy. Table 4 shows the correlations among the predictor variables and the outcome measures in the combined therapies sample and the two groups. Correlations in the combined therapies sample. In the combined therapies sample, the CTAS total did not correlate significantly with the DAS gain score measure of outcome. The correlation of alliance with CRS gain was .40 and the correlation of alliance with TC was .38. Of the component parts of the alliance, the other-therapist component correlated with the DAS gain measure (r=.22); the other components did not correlate with DAS gain scores. The component parts of the alliance correlated with CRS gain scores and TC. In the content dimension, the bond component had a .47 correlation with CRS gain. In the interpersonal dimension, the other-therapist component had a .50 correlation with CRS gain, and a .44 correlation with TC. Overall, the other-therapist component consistently correlated with the outcome measures. The two measures of FACES II, the cohesion and adaptability dimensions, did not significantly correlate with outcome. 71 Table 4 Pearson Correlation Coefficients for the Treatment Groups: Initial CTAS and FACES II with DAS, CRS, TC DAS CRS TC " Combined Combined Combined <N=84) <N=56) <N=84> CTAS Content: a) Task .14 .29 .33 ** b) Goal .05 .33 ** .32 ** c) Bond .11 .47 ** .26 ** Interpersonal: a) Self .07 .24 * .27 ** b) Other .22 * .50 ** .44 ** c) Relation- .09 .36 ** .36 ** ship Total . 15 . 40 ** .38 ** FACES II Cohesion -.18 .06 .04 Adaptabi1lty -.17 -.09 .00 EF IS EF IS EF IS <n= 56) <n=28) <n=28) <n= 28) <n= 56) <n= 28) CTAS Content: a) Task . 15 .14 . 11 .47 ** .28 * .51 ** b) Goal .06 .05 . 10 .48 ** .33 ** .33 ** c) Bond . 10 . 16 .29 .59 ** . 19 .45 ** Interpersonal: a) Self .06 .13 .01 .47 ** .21 .46 ** b) Other .26 * . 17 .35 * .60 ** .43 ** .50 ** c) Relation- .11 .06 . 13 .58 ** .34 ** .45 ** ship Total . 16 .14 . 18 .58 ** .35 ** .51 ** FACES II Cohesion -.24 * -.03 -.02 .13 -.06 .32 Adaptabi1lty -.14 -.24 .13 .24 .03 .06 * p<.05 ** p<.01 72 Correlations In the emotionally-focused group. In the emotionally-focused group, there was no correlation of CTAS or Its component parts with either DAS or CRS gain, except for the other-therapist component, which had a .35 correlation with CRS gain and a .26 correlation with DAS gain. The correlation of CTAS total with TC was .35. The other-therapist component had a .43 correlation with TC. Of the FACES II measures, the cohesion dimension had a -.24 correlation with DAS gain. Although significant at the .05 level, this was a low correlation, and the only instance of correlation between FACES II and outcome In the three samples. Correlations in the interactlonal/systemic group. In the interactional/systemic group, there was non-significant correlation of CTAS total with DAS gain. The correlation of CTAS total with CRS gain was .58, and the correlation of CTAS total with TC was .51. The bond, other-therapist, and relationship-therapist components had correlations with CRS ranging between r=.58 and r=.60; the task, goal, and self-therapist components had correlations with CRS ranging between r=.47 and r=.48. All the component parts of the alliance had correlations with TC ranging between r=.45 and r=.51 except for the goal component, which had a .33 correlation with TC. The two measures of FACES II, the cohesion and adaptability dimensions, did not significantly correlate with outcome. Summary of correlations of init ial alliance with outcome. The correlation results show that there was not a significant 73 correlation between the DAS gain scores and the alliance scores in either treatment group. There was significant correlation between CRS and CTAS in the interactlonal/systemic treatment group; in the emotionally-focused group, only the other-therapist component had a significant correlation with CRS. There was significant correlation between TC and CTAS and its components in the IS group; in the EF group, the bond and self-therapist components did not correlate with TC; Overall, the most consistent correlation of a component part of the alliance with outcome in a l l three outcome measures was the other-therapist component, which correlated with a l l the outcome measures except with DAS gain in the interactional/ systemic treatment group. Correlations of Termination Alliance with Outcome Correlation coefficients between the alliance variable and its component parts and the outcome measures were computed for the 52 subjects In the combined treatments who had been measured on the alliance scale following the tenth therapy session. The results appear In Table 5. These correlations were computed on a small sample of 26 subjects per group; however, the preliminary findings are promising. In the combined therapies sample, the .33 correlation of termination CTAS with DAS gain was significant at the .01 level. Of the component parts, a l l of which correlated significantly with the three outcome measures, the goal and self-therapist components were the only components that 74 TABLE 5 Pearson Correlation Coefficients for the Treatment Groups: Termination CTAS with DAS, CRS, TC DAS CRS TC Combined Combined Combined CN=52) (N= 52) CN= 52) CTAS Content: a) Task .35 ** .41 ** .52 ** b) Goal .23 * .40 ** .42 ** c) Bond .33 ** .53 ** .42 ** Interpersonal: i a) Self .28 * .44 ** .47 ** b) Other .35 ** .49 ** .49 ** c) Relation- .36 ** .46 ** .50 ** ship Total .33 ** .47 ** .49 ** EF IS EF IS EF IS Cn=26) <n=26) <n= 26) (n=26) (n= 26) Cn=26) CTAS Content: a) Task .40 * . 15 .25 .46 ** .45 ** .49 ** b) Goal .30 -.01 . 19 .43 ** .28 .37 * c) Bond .39 * . 17 .49 ** .50 ** .33 .34 * Interpersonal: a) Self .36 * .07 .30 .45 ** .34 * .45 ** b) Other .44 ** . 14 .38 * .50 ** .47 ** .38 * c) Relation- .37 * .24 .25 .54 ** .35 * .51 ** ship Total .40 * .13 .33 * .50 ** .41 * .44 * * p<.05 ** p<.01 75 did not correlate at the .01 level with DAS gain scores. The CTAS total and a l l the component parts correlated with CRS and TC at the .01 level of significance. In the emotionally-focused therapy group, the other-therapist component had a .44 correlation with DAS gain, significant at the .01 level; the overall termination alliance and the component parts of the alliance, with the exception of the goal component, had correlations with DAS gain ranging between r=.36 and r=.40 <«c=.05>. In the content dimension, only the bond component correlated with CRS gain <r=.49, »<=.01); in the interpersonal dimension, only the other-therapist component correlated significantly with CRS gain (r=.38,eK=.05). The termination alliance had a .41 <«=>< = .05) correlation wih TC; the task and other-therapist components had .45 and .47 correlations with TC significant at the .01 level. In the interactional/systemic therapy group, the termination alliance and its component parts did not correlate with DAS gain. The overall alliance had a .50 correlation with CRS gain, and its component parts had correlations ranging from .43 to .54 with CRS gain, significant at the .01 level. The alliance had a .44 correlation with TC, and al l the component parts correlated with TC; the task, self-therapist, and relationship-therapist components had correlations with TC significant at the .01 level. To summarize, across both treatment groups, the termination alliance, the bond component, and the other-therapist component correlated with the outcome measures, with the exception of non-significant correlation of alliance and its component parts with 76 DAS in the interactional/systemic group. As has been shown, the strength of the alliance over time changed differently in the two therapies. It appears as well that, within the two therapies, different relationships developed between the alliance and the different outcome measures. In the emotionally-focused group, correlations of alliance and outcome generally increased over time: correlations of alliance and its component parts with DAS and CRS developed. In the interactional/systemic group, the correlations of alliance with CRS and TC remained basically the same over time. The correlations of alliance with TC were low but steady over time for both groups. Correlations to Examine the Form of the Alliance Correlations were computed to see if the relative strengths of the task, goal and bond components in the alliance in the two treatment groups were equivalent. Since data on the interpersonal dimension was readily available, correlations were computed to examine the relative strengths of the self-therapist, other-therapist, and relatonshlp-therapist components as well. T-tests using Fisher's Z to compare the correlations of the component parts with the alliance in the two treatment groups found nonsignificant differences, Indicating that the form of the alliance was similar in the two therapies. The same procedure was applied to the termination alliance, with nonsignificant findings. Results appear In Table 6. Since the form of the alliance appeared similar in the two groups and over time, yet 77 Table 6 Pearson Correlation Coefficients and t-test values for the Treatment Groups: Initial CTAS Total with Component Parts and Termination CTAS Total with Component Parts Initial Total with/ Task Goal Bond Self-Therapist Other-Therapist Relationship-Therapist Emot ionally-Focused <n=56) .91 .85 .82 .93 .92 .90 Interact ional/ Systemic <n=28) .91 .84 .86 .93 .95 .93 t-value .03 .02 .57 .08 . 17 .61 Termination Total <n=26) with/ Task .97 Goal .88 Bond .87 Self- .98 Therapist Other- .97 Therapist Relationship- .95 Therapist <n=26) .95 .93 .95 .97 .97 .94 1.12 .79 1.62 .35 .29 .40 Note. Al l reported correlations are significantly different from 0 <<< =. 01 > . 78 the correlations with the different outcome measures differed for the treatment groups, it appears the change induced in therapy may be different, and the different outcome measures utilized reflect correlation of alliance with different aspects of change, as captured by the different outcome measures, within the two therapies. Further Tests to Examine Alliance Change It is apparent the alliance changed over time in the emotionally-focused group, between the init ial measure following the third therapy session and the termination measure following the tenth therapy session. The question arises as to how it changed. That is, does a high init ial alliance predict a high termination alliance? To answer this question, correlations of the init ial alliance with the termination alliance were computed; the results appear in Table 7. While the init ial alliance had a statistically significant correlation of .59 with the termination alliance in the sample of 52 subjects, the alliance did appear to vary somewhat over time. In both therapy groups and in the combined therapies sample, on correlations of init ial and termination alliance scores, the other-therapist component had high correlations, ranging between .64 and .66; the bond component had correlations ranging between .57 and .58; and the task component had correlations ranging between .53 and .59. These components remained consistent across the time of therapy. It appears that once the bond, task and other-therapist 79 Table 7 Pearson Correlation Coefficients and t-test values for Treatment Groups: Initial CTAS with Termination CTAS Combined EF IS t-value (N=52) (n=26) <n=26> Content: a) Task .55 b) Goal .43 c) Bond .57 Interpersonal: a) Self .46 b) Other .65 c) Relationship .53 Total .59 .53 .59 .28 .38 .42 .14 .57 .58 .04 .43 .54 .45 .66 .64 -.13 .47 .49 .11 .58 .61 .16 Note. All reported correlations are significantly different from 0 (oc =.01). 80 components develop, they remain relatively strong. High, Medium and Low Alliance Groups In an attempt to further explore the form and fluctuation of the alliance In couple therapy, further analysis was done on various groupings. The combined therapies sample of 84 subjects was grouped in three categories of high, medium and low alliance, with 28 subjects in each group. Means were calculated for the termination alliance for the three categories of alliance in the combined therapies sample. As Table 8 shows, the alliance remained stable in the high alliance group; in the low and medium alliance groups, the amount of increase in alliance was relatively equal. The high alliance group may have remained stable on alliance due to the ceiling effect; alternatively, the stability of the alliance in the high alliance group in the combined therapies sample may indicate that it did not Increase over time In the combined therapies group. Means for the termination alliance in the emotionally-focused therapy group were also calculated and appear in Table 8. Both the init ial alliance mean and the termination alliance mean were higher in this group, reflective of the increase in alliance in general in the emotionally-focused therapy group. Despite the celling effect, the high alliance group mean increased from the init ial to the termination alliance. The low and medium alliance group means increased dramatically; what is of Interest is that the medium alliance 81 Table 8 Means and Standard Deviations for High, Medium, and Low Initial Alliance Groups within the Combined Therapies and Emotionally-Focused Treatment Groups: Initial and Termination CTAS Initial Termlnat ion Mean S. D. Mean S. D, Combined Therapies: <n=28) High Medium Low 177.36 10.30 155.36 4.81 138.14 6.94 177.07 <n=15) 169.88 <n=16) 151.67 (n=2l) 17.98 16.95 22.01 Emot i onal1y-Focused; High Medium Low 180.37 <n=19) 158.28 (n=18) 140.53 <n=l9) 10.22 4.87 6.89 185.38 <n=8) 182.83 <n=6) 166.42 <n=12) 15.95 6.40 21.05 82 group was nearly as high on the termination alliance as the high Initial alliance group, and the low alliance group increased in termination alliance mean to the level of init ial alliance mean of the medium alliance group. It appears that within emotionally-focused therapy an extremely strong therapeutic alliance develops that increases relatively equally within high, medium and low init ial alliance groups over the time of therapy. In both the combined therapies sample and the emotionally-focused group, while the alliance mean Increased over time, the standard deviation did as well, indicating greater variance of termination alliance scores than init ial alliance scores within the high, medium and low alliance categories. ANOVAs for the termination alliance for the combined therapies sample and the emotionally-focused therapy group were conducted; the results appear in Table 9. It is evident that the strength of the termination alliance varied in relation to the strength of the init ial alliance. Table 10 shows means and standard deviations of DAS gain scores, CRS gain scores, and TC scores for the high, medium and low alliance groups in the sample. The outcome scores tended to increase from the low to medium to high alliance groups. On the CRS, there was a clear trend of outcome means increasing from the low to high alliance groups. Table 11 shows the Anova computed to test for differences on DAS, CRS, and TC among the three alliance categories in the combined therapies sample. The only significant difference that was found was on TC. The Duncan Multiple Comparisons Test was computed, resulting in Identifying 83 Table 9 Analysis of Variance Tests: Termination CTAS on High, Medium, and Low Initial Alliance Groups Combined Source of Variat ion SS MS DF F P Between Within <n=52> 6289.17 58.27 3144.58 .72 2 49 8.32 .00 ** EF Source of Variation SS MS DF F P Between Within <n=26) 2085.34 6857.63 1042.67 298. 16 2 23 3.50 .05 * * p<.05 ** p<.01 84 Table 10 Means and (Standard Deviations): DAS, CRS and TC for High, Medium and Low Alliance Groups in the Combined Therapies Sample Alliance Group: DAS CRS T.C. <n=28) <n=28) High 13.32 7.00 4.02 <11.80) <4.81) (.93) (n=17) Medium 14.18 5.89 3.73 <11.89) (6.00) (.71) (n=!8) Low 10.25 2.95 3.39 (9.56) (6.53) (.89) (n=21) 85 Table 11 Analysis of Variance Tests: DAS, CRS, and TC for High, Medium, and Low Initial Alliance Groups in the Sample DAS: Source of Variation SS MS DF F P Between 238.95 119.48 2 .96 .39 Within <N=82> 10039.46 123.94 81 CRS: Source of Variation SS MS DF F P Between 169.39 84.70 2 2.45 . 10 Within <N=56> 1834.73 34.62 53 TC: Source of Variation SS MS DF F P Between 5.67 2.83 2 3.94 .02 * Within 58.27 .72 81 <N=82) * p<.05 ** p<.01 86 significant differences between the high and low init ial alliance groups. pifferences on Alliance Between Couple Partners Preliminary examination of the alliance scores taken on the 84 subjects participating in the study indicated that there was a considerable difference In the alliance for the partners who formed the couple. The mean difference between the alliance scores for the couple partners was 14.57 with a standard deviation of 10.13* the difference scores on the alliance ranged between 2 and 45 points. Of the 42 couples, 15 had alliance scores within 10 points of each other; 8 had scores differing from each other by 20 points or more. Given this wide range on alliance that some couples displayed, the question arose whether couples where both partners scored high on alliance would differ significantly on the outcome measures from couples where both partners scored low. Five couples where both partners had high init ial alliance scores (above 163) were selected from the combined therapies sample and categorized as having high combined couples alliance scores. Five couples where both partners had low init ial alliance scores (below 148) were categorized as having low combined couples alliance scores. T-tests were computed on outcome measures for the low and high combined couples alliance groups; no significant differences were found. The means, standard deviations, and t-values appear in Table 12. 87 Table 12 Means, (Standard Deviations) and t-test values for High and Low Combined Alliance Couples and Similar and Split Alliance Couples: Initial CTAS, DAS, CRS, TC High CTAS Couples <n=10) Low CTAS Couples (n=10) t-value CTAS 183.50 (11.58) 135.70 (135.70) 10.62 ** DAS 16.60 (14.51) 12.20 (10.82) 0.77 CRS 8.25 (7.89) (n=4) 1.70 (7.09) 1.52 TC 4.20 ( .89) 3.55 (76) 1.76 Similar CTAS Couples (n=14) Split CTAS Couples (n=14> CTAS 150.43 (18.43) 167.00 (19.58) -2.31 * DAS 13.00 (10.53) 10.57 (13.00) 0.54 CRS 5.25 (4.33) (n=8) 11.13 (5.08) (n=8) -2.49 * TC 3.71 (1.09) 3.68 (0.90) 0.09 * p<.05 ** p<.01 88 A further question was whether couples who scored similarly on alliance would differ on outcome from couples who scored dissimilarly. Seven couples (14 subjects) from the combined therapies sample who had the least differences between them on alliance scores (differences of 5 points or less) were categorized in a similar-alliance group, and 7 couples who had the greatest differences between them on alliance scores (differences of 24 points or more), in a dissimilar or split alliance group. Table 12 shows the means and standard deviations on alliance and DAS, CRS, and TC. T-tests showed nonsignificant differences between these two groups on the outcome measures, except on the CRS. Given the low number of subjects, this finding is not reliable; however, as couples with split alliances improved on this measure, further inquiry may be warranted. Analyses on FACES II Categories Given the lack of clear correlation between alliance and the outcome measures, and the lack of correlation between FACES II and outcome, further statistical analysis to examine the interactive effects of alliance and couple configuration on outcome in the two treatment groups was not undertaken. However, because of the meaning of the FACES II scores, which may not be reflected in correlation, further examination of FACES II was undertaken. The cohesion dimension categorizes couples in four categories ranging from disengaged to enmeshed, with the two 89 middle categories representing healthy functioning. The adaptability dimension similarly categorizes couples, ranging from rigid to chaotic. When these two dimensions are combined, 16 quadrants are formed, with the four middle quadrants representing healthy functioning, the surrounding quadrants representing different types of moderate dysfunction, and the corner quadrants representing different types of extreme dysfunction. Interestingly, of the 84 subjects who sought couple counselling, over half fell in the rigid and disengaged quadrants. On the adaptability dimension, 32 subjects fel l in the healthy-functioning mid-range, and 51 fell in the rigid quadrant. On the cohesion dimension, 29 fel l in the healthy-functioning dimension, and 51 fell in the disengaged category. When the measures were combined, 45% of the individuals seeking couple therapy (38 subjects) could be categorized as dysfunctional in the rigid and disengaged quadrant; 27% (23 subjects) as moderately dysfunctional, toward the rigid/disengaged spectrum; 10% (8 subjects) as moderately dysfunctional in the enmeshed and/or chaotic spectrum; and 18% (15 subjects) as healthy-functioning. This is an incidental but interesting finding relating to characteristics of distressed couples seeking couple therapy who met the selection criteria of this study. Perhaps this skew of population accounts for the lack of clear results on the correlation of FACES II with outcome. However, ANOVAs computed on the different FACES II categories and 90 on the cohesion and adaptability dimensions showed no statistically significant differences between the groups on either dimension, nor on the combined groupings, in terms of outcome as measured by DAS gain, CRS gain, or TC. 91 CHAPTER FIVE SUMMARY AND DISCUSSION This study represents a beginning examination of the alliance in couple therapy. As such, It is a preliminary and exploratory study of the significance of the alliance in how it impacts outcome. A summary of the research results is presented in this chapter, followed by discussion of the implications of the findings, limitations of the study, and recommendations for further research. Summary The first hypothesis tested was that the strength of the alliance would not predict outcome in couple counselling. Certainly, no clear predictions can be made. In the sample studied, the CTAS total did not correlate with the DAS gain measure of outcome, the primary outcome measure utilized. The correlations of alliance and its component parts with TC and CRS were significant, but low, accounting for about 16% of the outcome variance. Overall, the other-therapist component consistently correlated with outcome. This is a significant finding in this preliminary study of alliance in couples therapy. The second hypothesis suggested that the strength of the alliance would not differentially predict outcome in the two 92 treatments. While the init ial alliance was strong ln both therapies, the correlations of alliance with outcome were different in the two groups. In both therapy groups, correlations of alliance with DAS gain were nonsignificant. The correlations with the outcome measures of CRS gain were stronger in the interactional/systemic therapy group than in the emotionally-focused group, where correlations were nonsignificant. The alliance in the interactional/systemic group had a correlation of .51 with TC, significant at the .01 level, as compared with .28 correlation with TC in the emotionally-focused group. It is apparent that the alliance in the two therapies differentially predicts outcome; while the alliance predicts outcome in the Interactional/systemic group on the CRS and TC measures, it falls to do so on any measures in the emotionally-focused group, except, to a slight degree, on the TC measure. Across the two therapies, as in the combined therapies sample, the other-therapist component consistently correlated with outcome, with one exception (the nonsignificant correlation between the other-therapist component and DAS in the interactional/systemic group). It appears the other-therapist component generally has predictive power of outcome early in therapy. The second hypothesis suggested as well that the alliance at the tenth therapy session would not correlate with outcome. The correlation of the alliance at termination with outcome was significant for DAS, CRS and TC at the .01 level. It is 93 noteworthy that In emotionally-focused therapy, the termination alliance had a significant correlation of .40 <«* =.05) with DAS gain, with the other-therapist component having a correlation of .44 <<=><=.01). Correlations of the termination alliance with outcome Increased In this group from correlations of the Initial alliance with outcome. In Interactlonal/systemic therapy, the termination alliance correlations with outcome measures were similar to the correlations of the init ial alliance with outcome. Both the init ial and termination alliance correlated differently with the various outcome measures in the two therapies. Across both therapies, the bond and other-therapist components correlated significantly with the outcome measures, with the exception of nonsignificant correlation between the bond and other-therapist components and DAS in the interactional/ systemic group. At termination of treatment, the bond and other-therapist components appear to have increased value as predictors of outcome. The third hypothesis stated that the component parts of the alliance would not differ in the two treatments. This hypothesis was born out by the statistical results. The interpersonal dimension was examined as well as the content dimension. No differences were found in either dimension. The form of the alliance as measured by CTAS appears to be the same in the two therapies. The fourth hypothesis stated that the different types of couple configuration would not relate to outcome. As this was born out by the lack of correlation between the FACES measure and 94 the outcome measures, the second part of the hypothesis was not tested. The fifth hypothesis stated that the init ial alliance would not differ from the termination alliance. This hypothesis was not supported. The alliance increased over the time of therapy in the sample. While it did not increase ln the interactional/ systemic group, it increased dramatically in the emotionally-focused group, with the greatest t-values on the component parts registered between the bond and other-therapist components. It appears these components are particularly important in the development of a strong alliance that has some relationship to outcome. Further questions about change in the alliance over time were investigated. The init ial alliance showed correlations ranging between .58 and .61 with the termination alliance for the sample and both treatment groups. The bond, task and other-therapist components had correlations of the init ial and termination alliance ranging between .53 and .66. Examination of the termination alliance in high, medium and low init ial alliance groupings showed that the strength of the init ial alliance did not impact outcome. The alliance changed over time. In the emotionally-focused group, where the alliance increased significantly over time, it increased relatively equally across the groupings, allowing for the ceiling effect. The termination alliance increased in relation to the strength of the init ial alliance. However, while the means of the termination alliance scores increased, the greater spread of 95 scores within the three groupings both In the sample and the emotionally-focused group indicates that the honeymoon effect of early therapy wears off, and there is variation within each grouping on the direction and amount of change in the alliance. While there was considerable variation on the alliance between the partners in a couple, couple differences did not impact outcome. In general, the alliance in couple therapy as measured by the CTAS has some value in predicting outcome. The other-therapist component generally correlated with the outcome measures. The strength of the alliance changed over time, but it remained constant in form over time and across therapies. It was stronger In emotionally-focused therapy than in interactional/ systemic therapy, particularly after ten therapy sessions. The Initial alliance indicated the strength of the termination alliance in emotionally-focused therapy, a therapy that develops a strong alliance. In emotionally-focused therapy, as the alliance increased, correlation with outcome increased. In interactional/systemic therapy, the strength of the alliance did not increase; correlations of alliance with outcome remained the same over time. Discussion As noted In the introduction, the present study was a process-outcome study with a focus on discovery. As such, It was a two-fold study. It was a preliminary examination of the 96 alliance in couple therapy and it's Impact on outcome, in order to identify factors that lead to greater efficacy in therapy. It was also a study of the uti l i ty of the Couple Therapy Alliance Scale, a recently developed Instrument, and how It relates to outcome measurement Instruments which are currently In use. The CTAS, while s t i l l in a developmental phase, is a state-of-the-art instrument for process measurement using generic, Integrative concepts. The development of a scale that captures the essence of Interaction In Interweaving component parts Is a difficult task. This study may contribute useful information to assist in the on-going refinement of the instrument. The alliance is theoretically and cl inical ly recognized as an essential vehicle for the work of therapy to be effectively undertaken. Clearly, in the two therapies, a strong alliance was developed early in treatment. This finding is consistent with theory about the importance of the alliance in the first therapy sess ions. In the two therapies, the alliance and the component parts correlated differently with different outcome measures. Overall, the other-therapist component most consistently correlated with outcome. A possible explanation for this finding is that the other-therapist component reflects how the mate perceives the partner's relationship with the therapist: the client sees the partner as primarily responsible for the marital distress, perceives the therapist to "understand" the partner in a way that matches his/her own world view, and perceives that the partner changes as a result of the therapy. The perception of the 97 partner's attitude to the therapy may actually reflect the client's changing perception of the partner. This kind of change would also be reflected in outcome measures. At the same time, the results of this study were such that Marmor's (in press) concern about the dangers of circularity in self-report measures of alliance and outcome were not justified. Although there was some correlation of alliance with outcome, it was apparent from investigation of differences on outcome measures among low to high alliance groups that alliance did not determine self-reported outcome to a degree where the validity of the alliance and outcome measures was doubtful. Paradoxically, the other-therapist component both remained consistent across the time of therapy, and increasesd over time. One possible explanation is that the other-therapist component is a vital component in couple therapy that, once developed, remains constant, but also continues to develop in alliances that increase over the time of therapy. Of interest Is the fact that the alliance correlated with different outcome measures in the two therapies. The outcome measures appear to measure different aspects of change, and the two therapies may incur different types of change. The alliance increased in strength in the emotionally-focused group. Correlation of the alliance with outcome measures also increased in this group. Bordln (1980) spoke of the differences in models of therapy being imbedded in the change goals sought. Very global categorization of what the outcome scales measure, and what actually occurs In the two therapies as demonstrative of 98 different change goals, are proposed as an explanation of the differential correlations of the alliance with different outcome measures in the two therapies. DAS measures marital satisfaction, an elusive quality which may not necessarily be closely linked to marital behaviour. Emotionally-focused therapy focuses on understanding and acceptance of oneself and one's partner as people with valid feelings and needs, and not on behavior change. Perhaps that elusive quality, reflected by the DAS measure, is developed in emotionally-focused therapy. Possibly, the modelling of empathy by the therapist assists in the development of empathy In the couple relationship. This is consistent with Bordin's theory that intensive therapies that explore inner experience require a strong bond; the strong bond in this style of therapy may effect a positive perception of the therapy, leading to a powerful overall alliance. Emotional and attitudlnal change takes longer to develop than behavioral change; perhaps, for this reason, the termination alliance, but not the Initial alliance, correlated with the DAS change measure. In contrast, InteractIonal/systemic therapy focuses on the Interaction that encompasses the marital dissatisfaction, and not the validation of emotion. It specifically addresses the marital conflict, and utilizes interventions to resolve it . The CRS, a measure of conflict resolution, correlated with the alliance formed in a therapy that addresses interactional behavior change. Interactional/systemic therapy is task focused, but the bond component also correlated highly with the CRS measure in this 99 therapy. The strong bond appears to be the element that allows the distressed couple to trust the therapeutic process. The above explanation suggests that therapeutic interventions play a major role in the development of the alliance. The differences in strengths of the alliance and correlations of the alliance with different outcome measures in the two therapies indicate that relationship and technique possibly interact in the development of the alliance. Limitations Given the exploratory nature of this research into the alliance in couple therapy, utilizing a developing Instrument within a recently established conceptual universe, the limitations of this study can best be seen as signposts to additional investigation of the alliance. The first limitation is universal to any experimental study: the constraints of the experimental situation. In this instance, a specific aspect of experimental constraints was the time-1imitedness of the therapy. Some couples would have continued in therapy beyond the tenth session, and outcome measures, although taken at the same chronological time, may not have been taken at the same psychological time for al l the couples. This may have affected the correlation reults; however, it seems unavoidable given the limitations of experimental design. Another limitation Is that the alliance was not measured 100 frequently enough to precisely examine the change that occurred in the alliance over time. Obviously, there was a change between the init ial and termination alliance. Correlation of the init ial alliance with the termination alliance, as well as means of the two alliance measurements, indicate that there was a fair amount of change in the alliance over time. In addition, a related limitation is that the events of therapy were not linked to measures of the alliance. It would be fruitful to know which therapeutic interactions strengthened the alliance, and which necessary therapeutic risks weakened i t . The "nodal points" of change s t i l l need to be examined. A further limitation is inherent in the scale itself. As Pinsof and Catherall (1986) point out, clients are reluctant to say anything negative about their therapy or therapist, resulting in a skew towards the positive end of the scale. Related to this is the actual skew of alliances developed in this study. Poor alliances lead to clients leaving therapy, making it Impossible to study the effects of poor alliance on outcome. This study in effect examined differences between good therapeutic alliances and better ones. Statistically, the greatest limitation of this study was the number of subjects-. While the sample group of 84 is large, differences between the two treatment groups both on the strength of the alliance and correlation of the alliance with outcome were evident, leading to a focus on comparative examination of the alliance in the two treatment groups, although there were too few subjects for a reliable comparative study. The interactional/ 101 systemic group, consisting of 28 subjects, is a small sample for correlation purposes. In addition, analysis on the termination alliance was done on samples of only 26 subjects. The findings must be read in the light of a preliminary study. Nonetheless, the findings hold promise for directions for future research. The differences in alliance and in correlation of alliance with outcome in the two therapies suggests that continued research could assist clinicians in developing alliances best suited to the kind of outcome desired. Recommendations Future research examining the therapeutic alliance and the relationship of alliance with outcome would add useful Information to the study of the power of the alliance as a vehicle for change In couple therapy. The termination alliance may be useful in predicting long-term outcome, and should be explored as well as a measure that potentially could assist the clinician in determining optimal timing of termination of therapy. An observer rating measure of the alliance in conjunction with the CTAS would be useful in order to fine-tune the instrument. This study utilized treatment models that were clearly delineated in terms of process and interventions, as recommended by Gurman (1981). What is s t i l l needed is to further illuminate the formation of the alliance, using observer ratings of the 102 therapeutic interactions ln couple therapy, conjointly with more frequent self-report measurements of the alliance. This would add information linking the formation of the alliance to therapeutic Interventions, and pinpointing the "critical change points" in the process of change. 103 REFERENCES Alexander, J . , Barton, C , Schlavo, R.S., & Parsons, B.V. (1976). Systems-behavioral interventions with families of delinquents: Therapist characteristics, family behavior and outcome. Journal of Consulting and Clinical Psychology, 44, 656-664. Alexander, L . B . , & Luborsky, L. (in press). The Penn Helping Alliance Scales. In L. Greenberg and W. Pinsof (Eds.), The  psychotherapeutic process: A research handbook. New York: Guilford Press. Barton, C , & Alexander, J . F . (1981). Functional family therapy. In A. Gurman & D. Knlskern (Eds.), Handbook of family therapy, (pp.403-443). New York: Brunner/Mazel. Battle, C .C. , Imber, S.D-., Hoehn-Sarlc, R., Stone, A.R., Nash, E.R., & Frank, J.D. (1966). Target Complaints as criteria of improvement. American Journal of Psychotherapy, 20, 184-192. Bordln, E.S. 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Jacobson, N.S. (1985). Toward a nonsectarian blueprint for the empirical study of family therapies. Journal of Marital and  Family Therapy, U(2), 163-165. Johnson, S. (1984). A comparative treatment study of experiential and behavioral approaches to marital therapy. Unpublished doctoral dissertation. University of British Columbia. Vancouver, B.C. Kiresuk, T . J . , & Sherman, R-.E. (1968). Goal attainment scaling: General method for evaluating comprehensive community mental health programs. Community Mental Health Journal, 4, 443-^ 453. Kniskern, D.P., & Gurman, A.S. (1983). Future directions for family therapy research. In D. Bagarozzi, A. Jurich & R. Jackson, (Eds.), Marital and family therapy: New perspectives  in theory, research and practice (pp. 209-235). New York: Human Sciences Press. Locke, H . J . , & Wallace, K.M. (1959). Short marital adjustment and prediction tests: Their rel iabi l i ty and validity. Marriage and Family Living, 8, 251-256. Luborsky, L. (1985). Psychotherapy integration is on Its way. The Counseling Psychologist, 13(2), 245-249. Marmor, C . , MarzlolI, E . , Horwltz, M., & Weiss, D. (In press). The development of the therapeutic alliance rating system. In L. Greenberg & W. Pinsof (Eds.) The psychotherapeutic process: A research handbook. New York: Guilford. Martin, P. (1976). A marital therapy manual. New York: Brunner/Mazel. Meninger, K.A. , & Holzman, P.S. (1973). Theory of psychoanalytic  technique (2nd Ed.). New York: Basic Books. McKie, D.C. , Prentice, B. & Reed, P. (1983). Pivorce: Law  and the family in Canada. Statistics Canada. Minister of Supply and Services, Canada. Ottawa. 106 Moras, K. , & Strupp, H. (1982). Pretherapy Interpersonal relations, patients' alliance, and outcome in brief therapy. Archives of General Psychiatry, 39, 405-409. Morgan, R., Luborsky, L . , Crlts-Chrlstoph. P. , Curtis, H . , & Solomon, J . (1982). Predicting the outcomes of psychotherapy by the Penn helping alliance rating method. Arch1ves of  General Psychiatry, 39, 397-402. Nadelson, C.C. (1978). Marital therapy from a psychoanalytic perspective. In T . J . Paolinl and B.8. McCrady (Eds.), Marriage and marital therapy: Psychoanalytic, behavioral, and system theory perspectives (pp. 89-164). New York: Brunner/Mazel. Olson, D.H., Bell , R., & Portner, J . (1979). Faces II Family  adaptability & cohesion evaluation scales. Unpublished manual. University of Minnesota, Family Social Science, St. Paul, Minnesota. Olson, D.H., & Portner, J . (1983). Family adaptability and coheslon e va1uat1on sea1es. In E.E. FiIsinger (Ed.), Marriage  and family assessments (pp. 299-250). Beverly Hi l l s , Ca.: Sage Publishing. Olson, D.H., Russell, C.S. , & Sprenkle, D.H. (1980). Circumplex model of marital and family systems: II. Empirical studies and clinical intervention. In John F. Vincent (Ed.), Advances in  family Intervention assessment and theory (Vol. I pp. 129-179). Greenwich, Conn.: JAI Press. Olson, D.H., Russell, C.S. , & Sprenkle, D.H. (1983). Circumplex model of marital and family systems: VI. Theoretical update. Family Process, 22(1), 69-83. Parioff, M.B., Waskow, I . E . , & Wolfe, B.E. (1978). Research on therapist variables In relation to process and outcome. In S. Garfield & A. Bergin (Eds.), Handbook of psychotherapy and  behavior change (2nd ed. pp. 233-282). New York: Wiley. Pinsof, W.M. (1981). Family therapy process research. In A. Gurman & D. Knlskern (Eds.), The handbook of fam11y therapy (pp.699-741). New York: Brunner/Mazel. Pinsof, W.M., & Catherall, D.R. (1984). The Integrative psychotherapy alliance: Family, couple and individual therapy  scales. Unpubl1shed manuscript. Northwestern University, Center for Family Studies/The Family Institute of Chicago, Chicago, 111. Pinsof, W.M., & Catherall, D.R. (1986). The Integrative psychotherapy al1 lance: Family, couple and Individual therapy scales. Journal of Marital and Family Therapy, 12(2), 137-151. 107 Rogers, C R . (1957). The necessary and sufficient conditions of therapeutic personallty change. Journal of Consulting  Psychology, 21, 95-103. Rogosa, D., Brandt, D., & Zlmowskl, M. (1982). A growth curve approach to the measurement of change. Psychological Bulletin, 92(3), 726-748. Rutan, J . S . , & Smith, J.W. (1985). Building therapeutic relationships with couples. Psychotherapy; Theory, Research  and Practice, 22(2), 194-200. Sager, C .J . (1981). Couples therapy and marriage contracts. In A. Gurman & D. Kniskern (Eds.), Handbook of family therapy (pp. 85-139). New York: Brunner/Mazel. Shapiro, R., & Budman, S. (1973). Defection, termination, and continuation in family and individual therapy. Family Process, 1_2, 55-67. Smith, J.W., & Gr une baum, H. (1976). The. therapeutic alliance in marital therapy. In H. Grunebaum and J . Christ (Eds.), Contemporary marriage; Structure, dynamics, and therapy (pp. 353-370). Boston: Li t t le , Brown. Spanler, G. (1976). Measuring dyadic adjustment. Journal of  Marriage and the,Family, 38, 15-28. Sterba, R. (1934). The fate of the ego in analytic therapy. The  International Journal of Psycho-AnalysIs, lj>, 117-126. Strupp, H.H. (1973). On the basic ingredients of psychotherapy. Journal of Consulting and Clinical Psychology, 41(1), 1-8. Suh, C.S, O'Malley, S.S., & Strupp, H.H. (in press). The VanderblIt process measures: The psychotherapy process scale (VPPS) and the negative Indicators scale (VNIS). In L. Greenberg & W. Pinsof (Eds.), The psychotherapeutlc process: A research handbook. New York: Guilford Press. Waskow, I . E . , & Parioff, M.B. (1975). Psychotherapy change  measures. Rockville, M.D.: National Institute of Mental Health. Whitaker, C.A. , & Keith, D.V. (1981). Symbolic-experiential family therapy. In A. Gurman & D. Kniskern (Eds.), Handbook of  family therapy (pp.187-225). New York: Brunner/Mazel. Wynne, L.C. (1983). Family research and family therapy: A reunion? Journal of Marital and Family Therapy, 9(2), 113-117. Zetzel, E. (1956). Current concepts of Transference. International Journal of Psycho-Analysis, 37, 369-376. 108 APPENDIX Couple Therapy Alliance Scale (CTAS) William M. Pin s o f , Ph.D. Donald R. Catherall CSAT-1 at en f— 01 C O ) 01 CL at O 01 01 E s- t. l_ J -o cn ^ s i cn at at > , QJ at at L at i -c: cn .— cn o re o. re •w — o — The therapi s t cares about me as a person. The therap i s t and I are not i n agreement about the goals f o r t h i s therapy. I t r u s t the ther a p i s t . The therapist lacks the s k i l l s and a b i l i t y to help my partner and myself with our r e l a t i o n s h i p . My partner f e e l s accepted by the t h e r a p i s t . The therapist does not understand the r e l a t i o n s h i p between my partner and myself. The therap i s t understands my goals i n therapy. The therapist and my partner are not i n agreement about the goals f o r t h i s therapy. My partner cares about the t h e r a p i s t as a person. The therapist does not understand the goals that my partner and I have for ourselves as a couple in t h i s therapy. My partner and the th e r a p i s t are in agreement about the way the therapy i s being conducted. The therap i s t does not understand me. The therapist i s helping my partner and me with our r e l a t i o n -ship. I am not s a t i s f i e d with the therapy. 6 6 6 6 6 6 6 6 6 6 6 6 Please Go On To The Next Page 109 CSAT-2 >> 03 >, 03 >-. <u OJ 0) 4-> r— 01 <— a> Ot c n « L_ c n i- OJ i-. — QJ c : ai ai c n C C n . — c n a. o> o a> t o O fO E i- 1- l_ t- 3 in S- VI e to o c n *J c n c n a> *^ ->— o •— o «s </) <C O (_) o The t h e r a p i s t understands my partner's qoals f o r t h i s therapy. 7 6 5 4 3 2 I do not f e e l accepted by the t h e r a p i s t . 7 6 5 4 3 2 The t h e r a p i s t and I are i n agreement about the way the therapy i s being conducted. 7 6 5 4 3 2 The t h e r a p i s t i s not helping me. 7 6 5 4 3 2 The t h e r a p i s t i s in agreement with the goals that my partner and I have f o r ourselves as a couple i n t h i s therapy. 7 6 5 4 3 2 The t h e r a p i s t does not care about my partner as a person. 7 6 5 4 3 2 The t h e r a p i s t has the s k i l l s and a b i l i t y to help me. 7 6 5 4 3 2 The t h e r a p i s t i s not helping my partner. 7 6 5 4 3 2 My partner i s s a t i s f i e d with the therapy. 7 6 5 4 3 2 I do not care about the therapist as a person. 7 6 5 4 3 2 The t h e r a p i s t has the s k i l l s and a b i l i t y to help my partner. 7 6 5 4 3 2 My partner d i s t r u s t s the t h e r a p i s t . 7 6 5 4 3 2 The therap i s t cares about the r e l a t i o n s h i p between my partner and myself. 7 6 5 4 3 2 The t h e r a p i s t does not understand my partner. 7 6 5 4 3 2 Thank You 

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