Pressure to Attend Therapy, Dyadic Adjustment, and Adverse Childhood Experiences: Direct and Indirect Effects on the Therapeutic Alliance in Couples Therapy

By Anderson, Shayne R.; Witting, Alyssa Banford et al. | Journal of Marital and Family Therapy, April 2020 | Go to article overview

Pressure to Attend Therapy, Dyadic Adjustment, and Adverse Childhood Experiences: Direct and Indirect Effects on the Therapeutic Alliance in Couples Therapy


Anderson, Shayne R., Witting, Alyssa Banford, Tambling, Rachel R., Ketring, Scott A., Johnson, Lee, Journal of Marital and Family Therapy


BACKGROUND AND SIGNIFICANCE

The therapeutic alliance is one of the most robust predictors of therapeutic outcomes across individual, couple, and family therapy (Barber et al., 2001; Friedlander, Escudero, Heatherington, & Diamond, 2011). A recent meta-analysis of the alliance-outcome link in couple and family therapy provides strong evidence for this relationship, with a medium effect size (d = 0.6; Friedlander, Escudero,Welmers-van de Poll, & Heatherington, 2018). Despite the importance of the alliance to successful therapeutic outcomes, we know surprisingly little about factors that predict successful alliance formation with couples. As a result of this knowledge gap, clinicians who hope to improve outcomes by improving the alliance have little guidance regarding how to do so, what elements of a client's individual history to pay attention to, or what elements of the client's relationship to address.

Developing an alliance in couple therapy is a complex process (Bartle-Haring et al., 2012; Knerr et al., 2011; Pinsof, 1994). The therapist must build an alliance with each partner, while also ensuring that these alliances are balanced to avoid problematic split alliances (Beck, Friedlander, & Escudero, 2006; Friedlander, Lambert, Escudero, & Cragun, 2008). When couples come in with differing goals or differing ideas of what tasks need to be done in therapy, this may become more challenging. The therapist must also pay attention to the extent to which the partners agree with each other on the goals and tasks of therapy (the within-system alliance; Pinsof, 1994) as well as monitor how safe therapy feels for each partner (Friedlander, Escudero, & Heatherington, 2006).

These various relationships are constructed during therapy sessions as clients and therapist establish goals for treatment and together negotiate the tasks of therapy. However, how clients and therapists behave in-session and how they perceive the behaviors of the other members of the therapy system are influenced not only by what is happening during the session but by what each member of the system brings to the therapeutic encounter. Each individual brings their past experiences and personal characteristics into the therapy room. These factors may influence how they behave in therapy and how they perceive the actions of the other members of the therapy system. Similarly, the characteristics of the couple relationship may also influence how each partner develops a relationship with the therapist and the collaborative relationship they bring to therapy.

Early forays into exploring client predictors of alliance formation have yielded mixed results. There is good evidence, for example, that characteristics of the relationship such as marital satisfaction and commitment are predictive of early alliance formation (Knerr et al., 2011; KnoblochFedders, Pinsof, & Mann, 2004). However, there are more ambiguous results when examining individual client characteristics. For example, researchers examining the connection between individual symptom distress and early alliance in couple therapy have found no correlation (KnoblochFedders, Pinsof, & Mann, 2004; Mamodhoussen, Wright, Tremblay, & Poitras-Wright, 2005), a positive correlation (Knerr et al., 2011), or a negative correlation with alliance (Kuhlmna, Tolvanen, & Seikkula, 2013). Others have examined the family of origin characteristics such as differentiation of self and found that certain aspects of differentiation were associated in various ways with initial alliance and how it developed over time (Knerr et al., 2011).

The sparse, and often conflicting, findings suggest that considerable work is needed to understand what client factors are associated with early alliance formation. The purpose of this study was to explore two client factors that have not been examined previously as predictors of the alliance in couple therapy: pressure to attend treatment and adverse childhood experiences (ACEs). …

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