The Therapy Alliance: A Moderator in Therapy Outcome for Families Dealing with Child Abuse and Neglect
Johnson, Lee N., Ketring, Scott A., Journal of Marital and Family Therapy
The role of the therapy alliance in therapy outcome for families dealing with child abuse and neglect was examined using the family as the unit of analysis. The alliance was tested as a moderator in relationship to posttreatment levels of symptom distress and physical violence. Results show that the bonds, goals, and tasks subscale scores are significantly related to posttreatment levels of symptom distress and that the goals subscale score is significantly related to posttreatment level of violence. There is an interaction between bonds and level of violence at intake, suggesting that the greater the level of violence at intake, the more important the bonds domain.
There is little doubt that the alliance between the therapist and family members is consistently related to therapy outcomes (e.g., Alexander, Barton, Schiavo, & Parsons, 1976; Bennun, 1989; Diamond, Liddle, Hogue, & Dakof, 1999; Green & Herget, 1991; Heatherington & Friedlander, 1990; Johnson, Wright, & Ketring, 2002; Shirk & Karver, 2003). Current alliance research typically focuses on individual family members as the unit of analysis. However, there is limited knowledge about how the alliance influences family therapy and how the alliance is formed in family therapy (Johnson & Wright, 2002). Specifically, no research has looked at the relationship between the alliance and outcome using the family as the unit of analysis. Thus, the purpose of this study is to examine the relationship between the severity of symptoms at intake, level of therapy alliance, and outcome using statistics that permit the family to be the unit of analysis. This will provide clinicians and researchers with information on the influence of the alliance in families. Prior to presenting the study a brief review of the alliance conceptual framework is necessary.
Prior to the work of Bordin (1979) therapists focused on the relationship between a client and therapist in terms of trust, transference, and countertransference. However, Bordin (1979) defined the relationship in terms of a working alliance comprising three domains: bonds, goals, and tasks. Bonds represents the trust, respect, and caring between a therapist and client. The tasks domain is the agreement and collaboration around the activities that occur during therapy, along with the timing and pacing of activities. Tasks also encompass the client's perception of the therapist's ability to help them. Goals focus on the mutual agreement about, and investment in, achieving set goals (Bordin, 1979). To conceptualize the alliance more consistently with family therapy, Pinsof and Catherall (1986) added the interpersonal dimension to Bordin's original conceptualization. The interpersonal dimension focuses on with whom the therapist may develop an alliance. Thus, in family therapy an alliance can exist between the therapist and individual family members, the therapist and subgroups of family members, or the therapist and the whole family. Although the framework proposed by Pinsof and Catherall provided an avenue for looking at the alliance with the whole family only a limited amount of research has looked at how the alliance between family members and the therapist interacts to influence therapy (Robbins, Turner, Alexander, & Ferez, 2003).
Clarifying the role of how the alliance influences treatment within the family as a whole will advance research in family therapy (Robbins et al., 2003) and provide clinicians with additional information on how the alliance affects family therapy. For example, there seems to be a profound relationship between the severity of the presenting problem and the importance of the therapy alliance, especially when considering therapy outcomes (Clarkin & Levy, 2004; Ketring, Johnson, Capers, & Salts, n.d.). One stigmatizing problem that may require that more emphasis be placed on specific domains of the alliance is child abuse. Parents who have abused their child need to trust their therapist enough to tell them about the past abuse and any ongoing occurrences of abuse. …