"Education, Faculty of"@en . "Educational and Counselling Psychology, and Special Education (ECPS), Department of"@en . "DSpace"@en . "UBCV"@en . "Gruman, Mary"@en . "2010-07-15T02:20:41Z"@en . "1986"@en . "Master of Arts - MA"@en . "University of British Columbia"@en . "The present study was an exploratory process-outcome examination of the therapeutic alliance in couple therapy as measured by a generic measurement instrument of the alliance. Measures were taken on a sample of eighty-four subjects; fifty-six subjects received emotionally-focused couple therapy and twenty-eight subjects received interactional/systemic couple therapy. Three aspects of the alliance were investigated: (1) the power of the alliance in predicting outcome in the two models of couple therapy; (2) the characteristics of the alliance in terms of its content and interpersonal system dimensions; (3) the interaction of couple characteristics with alliance and style of therapy in effecting outcome. The content dimension refers to the (a) task, (b) goal, and (c) bond components of the alliance; the interpersonal system components consist of the client's perceptions of the alliance between the therapist and: (a) the client (self-therapist), (b) the client's partner (other-therapist), and (c) the couple (relationship-therapist). Results indicated that the other-therapist component of the alliance consistently correlated with outcome measures in the two therapies; that the alliance correlated differently with the three outcome measures, and that it correlated differently with the outcome measures for the two models of therapy; that the characteristics of the alliance remained stable across the therapies and over time; that the strength of the alliance increased over time in emotionally-focused therapy. No interactive effects of alliance and couple characteristics were discovered."@en . "https://circle.library.ubc.ca/rest/handle/2429/26480?expand=metadata"@en . "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 , 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 \u00E2\u0080\u0094 . 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; mutuality of goals of therapy; and 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 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). 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 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 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: 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 . In the content dimension, only the bond component correlated with CRS gain < = .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 . 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) 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: 6289.17 58.27 3144.58 .72 2 49 8.32 .00 ** EF Source of Variation SS MS DF F P Between Within 10039.46 123.94 81 CRS: Source of Variation SS MS DF F P Between 169.39 84.70 2 2.45 . 10 Within 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 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 <\u00C2\u00AB* =.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. 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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\u00E2\u0080\u0094 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 .\u00E2\u0080\u0094 cn o re o. re \u00E2\u0080\u00A2w \u00E2\u0080\u0094 o \u00E2\u0080\u0094 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 >-. r\u00E2\u0080\u0094 01 <\u00E2\u0080\u0094 a> Ot c n \u00C2\u00AB L_ c n i- OJ i-. \u00E2\u0080\u0094 QJ c : ai ai c n C C n . \u00E2\u0080\u0094 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> *^ ->\u00E2\u0080\u0094 o \u00E2\u0080\u00A2\u00E2\u0080\u0094 o \u00C2\u00ABs "Thesis/Dissertation"@en . "10.14288/1.0054229"@en . "eng"@en . "Counselling Psychology"@en . "Vancouver : University of British Columbia Library"@en . "University of British Columbia"@en . "For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use."@en . "Graduate"@en . "A study of the therapeutic alliance in couple therapy"@en . "Text"@en . "http://hdl.handle.net/2429/26480"@en .