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Couple and Family Therapy: The challenge of dealing with multiple alliances

Jenny Sanbrook, Accredited Mental Health Social Worker

The Relationship as the Client

Anyone who has braved the elements of couple or family therapy can probably relate to the image of the Cat in the Hat, juggling the cup, the boat, the fish in a bowl and cake, while balancing on a ball.  

When difficulties are considered and treated in relational terms there are a different set of skills required by the therapist to that of individual work.  The goals of couple and family therapy (here on referred to as relational therapy) often centre on improving communication between people and inviting everyone to take some responsibility for the family/couple issue.  In order to be successful, the therapist is required to be “multi-positioned”, and to hold different family members in mind in order to include each persons point of view.  Additionally, the therapist is required to work with various subsystems and or “stakeholders”  both in and outside the room eg. family members not present.  

Why expand the system from an individual focus?  

Pinsof (1995) suggests that the therapist will learn more about a patient system by meeting as many key players as possible.  The therapist can develop a stronger therapeutic alliance if there is face-to-face contact with key players and there is a wider, more stable empathic understanding by the family of what is happening.  The therapist can also gain greater insight into problem maintaining behaviours.      

For example, in treating a couple/family who has a family member suffering from depression the goal would be to understand unhealthy family patterns and beliefs that may be contributing to the problem, and consider the possibility that the depression is embedded in an unhealthy relationship (parent/child/spousal etc). Therefore, the therapist will include a spouse or other family members in the room as part of the work. Commonly, this work may be done alongside individual work conducted by another therapist/psychiatrist who may focus on medication and/or more individual and internal thought patterns and beliefs.

The centrality of the therapeutic alliance 

In general terms an alliance is seen as a “union or association formed for mutual benefit” (Macquarie Dictionary). Sprenkle et.al. define the therapeutic alliance as “the quality and strength of the collaborative relationship (2009: 88).  It is generally accepted that successful therapeutic outcomes rely on the quality of the therapeutic alliance regardless of the therapists clinical orientation (see Lebow, J 1982, Horvath, A 2006, Rait, D 2000).  Given this, it is even more important to be mindful of several layers of behaviour and emotion simultaneously.  Surprisingly, the therapeutic alliance is much less studied in family therapy than in individual therapy.  Here are some ways the therapist can address the varying levels of commitment and differing motivations people inevitably bring to relational work. 

Ways to develop and maintain a strong therapeutic alliance in relationship work.

1.  Goals, Tasks and the Bond between the client and therapist.  

Bordin (1979) pointed out three elements to creating and maintaining a strong therapeutic alliance.  Sprenkle et al (2009) have developed this further in relational work.  Firstly, it is imperative to ensure there is a strong connection and level of agreement for each family member about the goals and where the therapy is going.  This can be achieved by having  a conversation in the room about what outcomes are hoped for and what each persons goal is.  This will help to maintain realistic and balanced expectations.

Checking in with the level of agreement there is between each family member about the tasks needed to accomplish the goals ie, the extent to which the clients find therapy appropriate, helpful and relevant.  

Lastly, attending to the bond between therapist and each individual ie. the connection to the therapist and the extent to which the clients and therapist feel engaged.  Ensuring the clients feel validated, respected and accepted by the therapist. 

2.  Track the alliances.

According to Horvath (2006),problems early in the therapeutic relationship predict greater drop out rates, thus tracking alliances can prevent problems before they arise.  Remaining focused on multiple individual alliances, monitoring and tracking the relative strength of those alliances and considering the alliance as a group is required.  

This may also involve attending to a family member who feels the goals are not being addressed and re-aligning the work to fit in with what is important to each person.  It may involve spending more or less time on one particular issue, apologising for mistakes or misunderstandings, and the therapist owning that they may have a different opinion on a particular matter.  Ultimately it will involve the therapist ensuring they are empathising with each individual family /couple member.   It is also valuable to track less direct signs of a problem, eg a person becoming increasingly defensive or withdrawn in a session. 

Additionally to a therapists own assessment, it is useful to point out that measures have been developed to aid this process.  One such measure is the System for Observing Family Therapy Alliances, (SOFTA-Friedlander and Heatherington 2006).  This is a set of tools both observational and self report that evaluate the strength of the therapeutic alliance.  They measure four components:  Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System and Shared Sense of Purpose within the Family.  The SOFTA -o (observation) is used by a supervisor analysing videotaped family sessions and the SOFTA -s (self report) is a questionnaire which can be used by the client and therapist.

3.  Use Joining Behaviours and Reframing 

Salvador Minuchin (1974) emphasised the importance of joining with families, suggesting behaviours such as pacing e.g. matching the behaviour of the family, tone of voice, speed of talking and types of wording used.  This may range from formal to more casual and informal depending on the family.  In the early stages of therapy accepting a family’s view of certain things, or perhaps expressing a lack of knowledge about certain things (eg a family  members job, music taste) etc and getting them to explain it to you.  

Taking a “one-down position” will facilitate rapport along with choosing language and behaviour that fits for clients.  These behaviours aim to have a calming effect and encourage the family to feel they are co-equal in the process.  Conveying optimism and reframing problems in a less pathologising way will also pave the way for a more positive climate in the room. 

Summary 

The quality of the therapeutic alliance is considered to be a reliable predictor of therapeutic outcome.  Ensuring clients experience the therapist as empathic and respectful, agreement on goals and how you to achieve them are key factors that deserve attention early in the process of therapy.  It is important to track alliances and attend to problems with the alliance along with using joining and reframing techniques.  

Assuming all of these factors are lining up at the same time with each person is where the relational therapist can feel more like the cat in the hat and find themselves dropping the ball, or the cake or the fish in the bowl.  

In the end, managing the alliances carefully will create a better capacity for the system to withstand the therapist challenging of roles and behaviour and greater likelihood of therapeutic success.  

References 

Barker, P (1988) Basic Family Therapy.  Blackwell Science. London.

Bordin, E. S (1979) The generalisability of the psychoanalytic concept of the working alliance.  Psychotherapy (Chic) 16, 252-260

Friedlander M, Escudero V, and Heatherington L, (2006)  Therapeutic Alliances in Couple and Family Therapy an Empirically Informed Guide to Practice.  Washington DC Australian Psychological Association.   

Friedlander and Heatherington (2006) System for Observing Family Therapy Alliances (SOFTA).   

Horvath, A (2006) The Alliance in Context.  Accomplishments, challenges and future directions.  Psychotherapy.  Theory, research, practice, training. 38 (4).   

Lebow, J (1982) Consumer Satisfaction with Mental Health Treatment. In Psychological Bulletin Vol 91 (2), 244-259. 

Minuchin (1974) Families and Family Therapy.  Cambridge Harvard University Press. 

Pinsof, W (1995).  Integrative Problem Centred Therapy.  A synthesis of family, individual and biological therapies. NY Basic Books.   

Rait, D (2000) The therapeutic alliance in couple and family therapy.  In Journal of Clinical Psychology Vol 56 (2).

Sprenkle (2009).  Common Factors in Couple and Family Therapy: The overlooked Foundation for Effective Practice.  Guilford Press NY. 

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